Is it unwise to pursue IM simply for fellowship?

[Doctor_Strange]

USDO, 243/237. App is otherwise average.

I sent in my app to EM and IM programs, mostly university and some community university programs. On the EM side of things, I enjoyed my rotations but some of the effects on my sleep cycle and the scary job market in the future (even post-COVID) had me weary. I also did a few IM months and while it did not get my juices flowing as much, I walked away enjoying the workflow and having a bit more meaningful relationship with patients on the inpatient side of things. That being said, if I end up deciding on IM I'm hoping to match somewhere nice and then fellowship into either PCCM or maybe Cards (most of my programs have in-house fellowships). But I wanted to query this thread, did anyone here pursue or are pursuing IM simply for fellowship? How common is this mindset? And for those currently in residency, how has it changed your mindset either towards pursuing fellowship or pushing you away and wanting to finally be an attending (I don't want to underestimate the brutal hours residency has which would continue of course in fellowship)?

Thank you

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[tantacles]

Lots of people do IM thinking they’ll do fellowship. Subsequently, many eggs up not doing fellowship, either because they want a shorter training window or they like general medicine.

 

[HemeOncHopeful19]

Applying to IM simply for PCCM, Heme/Onc and/or Cards fellowship is not a terrible idea for an AMG with those stats, IMO. IMG and Cards may be a bit more of a gamble but I feel like there is an overabundance of IMGs interested in Cards for what I think are probably cultural reasons which ramps up the applicant pool a bit.

The big caveat is you can’t be that guy/girl that slacks off or doesn’t work hard and tries to dump work on their peers EXCEPT when it involves XYZ department. Nobody likes that guy and they become the people who learn that word gets around when it comes time to match for fellowship. You gotta bust your *** to really make sure you end up where you want.

I might not say the same thing about GI.

 

[wamcp]

USDO, 243/237. App is otherwise average.

I sent in my app to EM and IM programs, mostly university and some community university programs. On the EM side of things, I enjoyed my rotations but some of the effects on my sleep cycle and the scary job market in the future (even post-COVID) had me weary. I also did a few IM months and while it did not get my juices flowing as much, I walked away enjoying the workflow and having a bit more meaningful relationship with patients on the inpatient side of things. That being said, if I end up deciding on IM I'm hoping to match somewhere nice and then fellowship into either PCCM or maybe Cards (most of my programs have in-house fellowships). But I wanted to query this thread, did anyone here pursue or are pursuing IM simply for fellowship? How common is this mindset? And for those currently in residency, how has it changed your mindset either towards pursuing fellowship or pushing you away and wanting to finally be an attending (I don't want to underestimate the brutal hours residency has which would continue of course in fellowship)?

Thank you

This was my mindset and it worked well for me and i am sure many others. It is pragmatic and logical. IM is flexible, if you change your mind on fellowship you have PCP and hospitalist work to fallback on, both of which are far less brutal than EM work.

I started residency desiring pulm/ccm but realized how burnt out I would be and chose hospitalist work and I could not be happier.

 

[Doctor_Strange]

Applying to IM simply for PCCM, Heme/Onc and/or Cards fellowship is not a terrible idea for an AMG with those stats, IMO. IMG and Cards may be a bit more of a gamble but I feel like there is an overabundance of IMGs interested in Cards for what I think are probably cultural reasons which ramps up the applicant pool a bit.

The big caveat is you can’t be that guy/girl that slacks off or doesn’t work hard and tries to dump work on their peers EXCEPT when it involves XYZ department. Nobody likes that guy and they become the people who learn that word gets around when it comes time to match for fellowship. You gotta bust your *** to really make sure you end up where you want.

I might not say the same thing about GI.

Because GI fellowship is that much to get into? I suppose I viewed the competitiveness as GI = Cards > Heme/Onc > PCCM, but that is based only on my recollection of the fellowship match #s. I could be off.

And I agree, the number one theme on reddit and SDN about matching into a good fellowship is first and foremost being a strong internist. I recognize Cards is basically still 70% IM. So it is not that I dislike Internal Medicine, but the workflow and the nature of being a hospitalist seems less appealing to me as a career.

Edit: Also I am glad someone said it about IMGs and Cards -- it seemed an inordinate amount of IMGs I know wanted to pursue Cards the moment they left the womb lol

 

[Doctor_Strange]

This was my mindset and it worked well for me and i am sure many others. It is pragmatic and logical. IM is flexible, if you change your mind on fellowship you have PCP and hospitalist work to fallback on, both of which are far less brutal than EM work.

I started residency desiring pulm/ccm but realized how burnt out I would be and chose hospitalist work and I could not be happier.

Thank you for your reply. I 100% concede that residency could cause me to simply want to get a job and be done with training (that was part of the allure of EM to me as well frankly, ie 3 year residency -> go out to community practice). I actually hope I enjoy residency and won't find myself overly burned out and/or not wanting to pursue further education. I probably should have mentioned in my initial post, but I will be graduating with zero debt as my family has graciously been able to afford my medical school education (one of the more cheaper DO schools in the country). I did have a few questions if you could mind sharing your perspective:

1) Do you think having zero debt would have altered your own decision-making process, or did you just want to get out of residency regardless?
2) Speaking only for yourself, is there anything on the EM side of things you wish you could practice?
3) Is there any worry that several years down the line hospital medicine will bore you? That the lifestyle of 7on/7off gets tiring (or not conducive to family life)? A big warning sign for me was that the hospitalist I precepted with -- a really really nice and popular doc -- was apparently trying to get facetime with the local dermatology residency to try and see if he could match. I really lingered on that experience for some time afterwards, probably why I defaulted to EM for several months.

Thank you so much for your time!

Thanks for any comments or insight you can provide!

 

[rokshana]

Frankly, i think most people go into IM planning on doing fellowship and along the way many decide against it.
At the end of my 3rd year in med school I had to make a decision of whether to peruse a REI vs gen endo fellowship...I had to think that if I did not get the fellowship...which would I be happier doing...ob/gyn or IM? i am currently an endocrinologist... it’s fine to do a core specialty with the goal of fellowship...but be comfortable about the potential that you may end up doing the core specialty

 

[wamcp]

Thank you for your reply. I 100% concede that residency could cause me to simply want to get a job and be done with training (that was part of the allure of EM to me as well frankly, ie 3 year residency -> go out to community practice). I actually hope I enjoy residency and won't find myself overly burned out and/or not wanting to pursue further education. I probably should have mentioned in my initial post, but I will be graduating with zero debt as my family has graciously been able to afford my medical school education (one of the more cheaper DO schools in the country). I did have a few questions if you could mind sharing your perspective:

1) Do you think having zero debt would have altered your own decision-making process, or did you just want to get out of residency regardless?
2) Speaking only for yourself, is there anything on the EM side of things you wish you could practice?
3) Is there any worry that several years down the line hospital medicine will bore you? That the lifestyle of 7on/7off gets tiring (or not conducive to family life)? A big warning sign for me was that the hospitalist I precepted with -- a really really nice and popular doc -- was apparently trying to get facetime with the local dermatology residency to try and see if he could match. I really lingered on that experience for some time afterwards, probably why I defaulted to EM for several months.

Thank you so much for your time!

Thanks for any comments or insight you can provide!

1) If I knew I had zero debt I probably would have thought more carefully about the specialty I wanted. In med school I chose to limit myself to 3 year residencies partly because of the huge debt burden at the time. For example I might have explored interests in ophtho or radiology. Or in residency, I would have seriously considered other fellowships in IM when I realized CCM would burn me out

2) When I was in IM residency I felt hospitalist work would miss out on procedures and getting to see undifferentiated patients/critical stabilization of patients. Now as a hospitalist attending I am so glad I rarely have to deal with intubations, vents, lines. They will burn you out quick. You could still do them in open ICUs as a hospitalist anyway.

3) I feel bored with hospital medicine already and I like it that way. Boring is good, I've accumulated a ton of experience working 20+ shifts a month for the last 3-ish years, so that the job has become easy to me. Boring means more efficiency in work flow, and so I get more free time at work to watch TV or play video games , which are activities I have less time to do at home from spending time with my family.
Everyone is different though, some people live to go to work and want to genuinely enjoy the job. For me, my priorities are family time. I've cut back this summer and no longer moonlight now (since I'm nearing financial independence already)

7 on and 7 off in anything, will no doubt tire you out. I don't think it's sustainable by the sheer number of hours you have to work; UNLESS the job allows you round and go home. 7 on 7 off nocturnist lifestyle is suicide, because that's literally 84 hours work week ( you can't really go home early as a nocturnist).

There are many hospitalist jobs that don't follow that model and do 4 or 5 on/4 off or 5 off for days, or 7 on 14 off nocturnist gigs. Those are far more sustainable.

Other things to consider, is that if your priority in life is time with family and home, think carefully about the fellowship or speicalty you end up in. As a hospitalist it's shift work and you can't be bothered when you're off. But for like cards or GI, having to take call looks like it really sucks. Answering patient nonsense or getting consult calls or needing to drive to the hospital urgently overnight when you're trying to sleep or have dinner with family is terrible, especially if it's something you must do regularly for like 30 years of your career.

 

[Gastrapathy]

Its unwise to choose IM unless you want to do fellowship

 

[collegestud2013]

USDO, 243/237. App is otherwise average.

I sent in my app to EM and IM programs, mostly university and some community university programs. On the EM side of things, I enjoyed my rotations but some of the effects on my sleep cycle and the scary job market in the future (even post-COVID) had me weary. I also did a few IM months and while it did not get my juices flowing as much, I walked away enjoying the workflow and having a bit more meaningful relationship with patients on the inpatient side of things. That being said, if I end up deciding on IM I'm hoping to match somewhere nice and then fellowship into either PCCM or maybe Cards (most of my programs have in-house fellowships). But I wanted to query this thread, did anyone here pursue or are pursuing IM simply for fellowship? How common is this mindset? And for those currently in residency, how has it changed your mindset either towards pursuing fellowship or pushing you away and wanting to finally be an attending (I don't want to underestimate the brutal hours residency has which would continue of course in fellowship)?

Thank you

As mentioned above most people, especially U.S. grads, go into IM with the intent of doing fellowship. A lot of it comes from perceptions in med school that general IM, whether it's PCP or hospitalist, are not only the least paid, but also the least respected and you're essentially looked down by the specialists and in some cases you're the "super-senior resident" for the specialists, and in in the inpatient setting have to deal with the patients no one else wants to take. The prestige aspect is still true these days and as hospitalists and PCP there's still a lot more scut, but the pay difference between hospitalist and specialties like pulm-crit and non-interventional cards is much narrower than you think once you factor in the long hours you need to work as a cardiologist and the 3 extra years of training).

Many people will change their mind during residency and not pursue fellowship or switch to a different fellowship. Besides the shorter training period and true change of interest, another common reason is that residents find that they're simply not competitive for the subspecialty they're going for or apply and don't match so are essentially forced into doing general IM (even if they don't like it, since many have loans to pay off). Remember that any IM subspecialty that on average pays more than general IM will be competitive to get into with far more applicants each year than spots. Cards, Heme-onc, and Pulm/Crit all have match rates in the 70s% and for GI it's in the 60s% overall, but for DOs those numbers are much lower. DO with a 243/237 is decent but far from certain into matching into cards or pulm/crit and for GI the match rate is around 42%. If you're a D.O. and want to ensure getting into a competitive fellowship after IM, the strategy that many take is to go to an IM program with that respective in-house fellowship and try to do a chief resident year, since at most programs being a chief nearly guarantees you an in-house fellowship spot. Of course the 2 major downsides of being chief is that you need to be well liked at your residency program to get it, and you're taking a huge paycut during chief year (even if your program allows you do do some more moonlighting) compared to being a full-year attending

So bottom line is: as a DO, go into IM only if you're okay if you end up not matching into a competitive fellowship and have to do hospitalist or primary care, or are okay with a non-competitive IM fellowship like Palliative Care, Geriatrics, ID, or Nephrology.

 

[shouldigomd]

I disagree. With those scores a DO can match into any IM specialty with a little effort.

I think most IM residents start out wanting / thinking about fellowship. People change their minds for various reasons (tired of training / not making $$, don't want to invest the extra effort for research, enjoy IM, don't match, want the lifestyle of IM, etc etc).

One of the attractive things about IM is that it offers a wide variety of careers and you will change as you go through training. I am a cardio fellow and wanted to do cardio from day 1 and I will tell you my outlook definitely changed in my 3 years of residency.

 

[Doctor_Strange]

I disagree. With those scores a DO can match into any IM specialty with a little effort.

I think most IM residents start out wanting / thinking about fellowship. People change their minds for various reasons (tired of training / not making $$, don't want to invest the extra effort for research, enjoy IM, don't match, want the lifestyle of IM, etc etc).

One of the attractive things about IM is that it offers a wide variety of careers and you will change as you go through training. I am a cardio fellow and wanted to do cardio from day 1 and I will tell you my outlook definitely changed in my 3 years of residency.

Would you care to expound on this? Reading that sentence I assumed you would say you would not have ended up in cardio lol since your outlook had changed? What exactly changed and how did that affect your outlook?

Thanks!

 

[Chemist0157]

No. I think a lot of people do IM with the intention of fellowship. Just make sure you would still be satisfied with IM in case it does not work out.

 

[shouldigomd]

Would you care to expound on this? Reading that sentence I assumed you would say you would not have ended up in cardio lol since your outlook had changed? What exactly changed and how did that affect your outlook?

Thanks!

My point is that the 3 years of residency will change you more than perhaps any other period in your life. Priorities may shift (or stay the same) as lifestyle, finances, family, location, personal fulfillment, etc etc all play a role.

 

[Drrrrrr. Celty]

Most of residency is going to do bad things to your sleep wake cycle. IM or EM.

I honestly went into IM to subspecialize. I like general medicine. But I think the lifestyle of a hospitalist would burn me out.

 

[Redpancreas]

As mentioned above most people, especially U.S. grads, go into IM with the intent of doing fellowship. A lot of it comes from perceptions in med school that general IM, whether it's PCP or hospitalist, are not only the least paid, but also the least respected and you're essentially looked down by the specialists and in some cases you're the "super-senior resident" for the specialists, and in in the inpatient setting have to deal with the patients no one else wants to take. The prestige aspect is still true these days and as hospitalists and PCP there's still a lot more scut, but the pay difference between hospitalist and specialties like pulm-crit and non-interventional cards is much narrower than you think once you factor in the long hours you need to work as a cardiologist and the 3 extra years of training).

Many people will change their mind during residency and not pursue fellowship or switch to a different fellowship. Besides the shorter training period and true change of interest, another common reason is that residents find that they're simply not competitive for the subspecialty they're going for or apply and don't match so are essentially forced into doing general IM (even if they don't like it, since many have loans to pay off). Remember that any IM subspecialty that on average pays more than general IM will be competitive to get into with far more applicants each year than spots. Cards, Heme-onc, and Pulm/Crit all have match rates in the 70s% and for GI it's in the 60s% overall, but for DOs those numbers are much lower. DO with a 243/237 is decent but far from certain into matching into cards or pulm/crit and for GI the match rate is around 42%. If you're a D.O. and want to ensure getting into a competitive fellowship after IM, the strategy that many take is to go to an IM program with that respective in-house fellowship and try to do a chief resident year, since at most programs being a chief nearly guarantees you an in-house fellowship spot. Of course the 2 major downsides of being chief is that you need to be well liked at your residency program to get it, and you're taking a huge paycut during chief year (even if your program allows you do do some more moonlighting) compared to being a full-year attending

So bottom line is: as a DO, go into IM only if you're okay if you end up not matching into a competitive fellowship and have to do hospitalist or primary care, or are okay with a non-competitive IM fellowship like Palliative Care, Geriatrics, ID, or Nephrology.

I disagree with this take. While it is true many IM residents end up choosing IM when their intention was GI/Cards, etc. for various situations, if your heart is truly set on fellowship, I know you'll make it there with persistence and don't let SDN tell you otherwise. It sounds like you're between IM+fellowship vs. EM which is extremely common because they both offer a competitive salary. Factors you need to consider are predictability of schedule (EM physicians work a variety of shift whereas IM is a bit more predictable unless you're doing a lot of procedural call), preference for shift work, whether you enjoy continuity of care, whether you want to pursue 3 additional years of training, etc. EM is very different from IM even if salary is similar to IM subspecialties. Pick what you tolerate on a daily basis and where you can do the most good because that will allow you to remain happiest/healthiest version of yourself over the next 30-40 years.

 

[rokshana]

I disagree with this take. While it is true many IM residents end up settling for IM when their intention was GI/Cards, etc. for various situations, if your heart is truly set on fellowship, I know you'll make it there with persistence and don't let SDN tell you otherwise. It sounds like you're between IM+fellowship vs. EM which is extremely common because they both offer a competitive salary. Factors you need to consider are predictability of schedule (EM physicians work a variety of shift whereas IM is a bit more predictable unless you're doing a lot of procedural call), preference for shift work, whether you enjoy continuity of care, whether you want to pursue 3 additional years of training, etc. EM is very different from IM even if salary is similar to IM subspecialties. Pick what is going to keep you the happiest/healthiest version of yourself in 30 years.

its not a settling for IM, but things change...some realize they actually like general medicine, some have changes in their status...they get married, have kids, etc...realize that hospitalist can make the same amount of money with less training ...or when they actually DO cards or GI, they realize that the don't like Cards or GI... I think half my resident class wanted to do cards...i think 2 ended up doing it.

 

[InternistDO]

Plenty of people go into IM for the fellowships, i don't think there's anything wrong with that.

I do think, however, that you need to enjoy a good majority of general internal medicine to go into IM, because most of the subspecialties day to day is still similar to general medicine (a cardiologist has a more similar workflow to a hospitalist or PCP than they do to an anesthesiologist or EM physician for example). If you absolutely hate floor rounding with every fiber of your being, are you really going to like ICU rounding in pulm/crit? Or if you hate outpatient clinic are you really going to enjoy being a cardiologist who spends a big chunk of time in the cards office?

The nice thing about IM is that as long as you don't mind inpatient workflow or clinic (its ok to not like one...if you don't like both you're in trouble) you have a huge amount of options open to you for future career goals between general medicine and the fellowships. So I wouldn't stress about what fellowship you want to do right now, I'd just decide if you like internal medicine and then go from there.

 

[Redpancreas]

its not a settling for IM, but things change...some realize they actually like general medicine, some have changes in their status...they get married, have kids, etc...realize that hospitalist can make the same amount of money with less training ...or when they actually DO cards or GI, they realize that the don't like Cards or GI... I think half my resident class wanted to do cards...i think 2 ended up doing it.

Agreed. Poor word choice.

 

[Doctor_Strange]

Plenty of people go into IM for the fellowships, i don't think there's anything wrong with that.

I do think, however, that you need to enjoy a good majority of general internal medicine to go into IM, because most of the subspecialties day to day is still similar to general medicine (a cardiologist has a more similar workflow to a hospitalist or PCP than they do to an anesthesiologist or EM physician for example). If you absolutely hate floor rounding with every fiber of your being, are you really going to like ICU rounding in pulm/crit? Or if you hate outpatient clinic are you really going to enjoy being a cardiologist who spends a big chunk of time in the cards office?

The nice thing about IM is that as long as you don't mind inpatient workflow or clinic (its ok to not like one...if you don't like both you're in trouble) you have a huge amount of options open to you for future career goals between general medicine and the fellowships. So I wouldn't stress about what fellowship you want to do right now, I'd just decide if you like internal medicine and then go from there.

As a third year, I really harped on the fact that I found inpatient work inefficient but still clinically engaging most of the time. I always saw a bunch of hospitalists sitting in the physicians lounge on their phone or something waiting or a call back or lab or what have you -- and this was at a community hospital. It struck me as a waste of time. Or to put it another way, I thought "I just would like to come in and work and then leave" and EM fit the bill. Now as 4th year, I am beginning to see that well waiting 30 minutes or so in the physician's lounge actually is not a bad deal at all. Do hospitalists work more hours than EM docs? For sure. Is the intensity the same? No way. That's how I justify why EM docs get paid slightly more than hospitalists. Like I said now that I am a 4th year I am beginning to change my tune. I suspect consultant specialties are even busier than hospitalists but I am less sure if that is accurate.

I also think I initially got worked up about the fact that during my one rotation I had to pre-round like at 530 before the doc came in at 7 and that bothered me, but again in hindsight I understand why the system is designed like that even if I am not a big fan of pre-rounding lol

 

[MLNS]

As a third year, I really harped on the fact that I found inpatient work inefficient but still clinically engaging most of the time. I always saw a bunch of hospitalists sitting in the physicians lounge on their phone or something waiting or a call back or lab or what have you -- and this was at a community hospital. It struck me as a waste of time. Or to put it another way, I thought "I just would like to come in and work and then leave" and EM fit the bill. Now as 4th year, I am beginning to see that well waiting 30 minutes or so in the physician's lounge actually is not a bad deal at all. Do hospitalists work more hours than EM docs? For sure. Is the intensity the same? No way. That's how I justify why EM docs get paid slightly more than hospitalists. Like I said now that I am a 4th year I am beginning to change my tune. I suspect consultant specialties are even busier than hospitalists but I am less sure if that is accurate.

I also think I initially got worked up about the fact that during my one rotation I had to pre-round like at 530 before the doc came in at 7 and that bothered me, but again in hindsight I understand why the system is designed like that even if I am not a big fan of pre-rounding lol

What do you think residents do? We pre-round. Often even pre pre-round (ie interns will round before the seniors if said senior wants to round together before the attending or fellow gets there). So, if something this minor bothers you you’re gonna stroke out during IM residency

 

[wamcp]

As a third year, I really harped on the fact that I found inpatient work inefficient but still clinically engaging most of the time. I always saw a bunch of hospitalists sitting in the physicians lounge on their phone or something waiting or a call back or lab or what have you -- and this was at a community hospital. It struck me as a waste of time. Or to put it another way, I thought "I just would like to come in and work and then leave" and EM fit the bill. Now as 4th year, I am beginning to see that well waiting 30 minutes or so in the physician's lounge actually is not a bad deal at all. Do hospitalists work more hours than EM docs? For sure. Is the intensity the same? No way. That's how I justify why EM docs get paid slightly more than hospitalists. Like I said now that I am a 4th year I am beginning to change my tune. I suspect consultant specialties are even busier than hospitalists but I am less sure if that is accurate.

I also think I initially got worked up about the fact that during my one rotation I had to pre-round like at 530 before the doc came in at 7 and that bothered me, but again in hindsight I understand why the system is designed like that even if I am not a big fan of pre-rounding lol

You are spot on - I used to think the same, that EM work seemed better than hospitalisit work because you're almost always doing something, an endless stream of patients at 2-3 per hour. Now as an attending hospitalist, eff that! I liked admitting only 6 patients and being able to rewatch Saving private ryan and mad max fury road at work yesterday night (as a nocturnist) and put in a couple hours of COD:MW. Sure I get 20% less hourly pay than the ER doc downstairs but I'm doing less than 50% of the work.

Also I don't think hospitalists with at least a tinge of experience bother prerounding before shift. Most of us just show up and pick up the list, open the chart and go at it.

 

[Osteoth]

You are spot on - I used to think the same, that EM work seemed better than hospitalisit work because you're almost always doing something, an endless stream of patients at 2-3 per hour. Now as an attending hospitalist, eff that! I liked admitting only 6 patients and being able to rewatch Saving private ryan and mad max fury road at work yesterday night (as a nocturnist) and put in a couple hours of COD:MW. Sure I get 20% less hourly pay than the ER doc downstairs but I'm doing less than 50% of the work.

Also I don't think hospitalists with at least a tinge of experience bother prerounding before shift. Most of us just show up and pick up the list, open the chart and go at it.

Also in hospitalist medicine pts rarely yell, pee, poop, or even bleed on you without you being aware of what is about to happen...

 

[Doctor_Strange]

What do you think residents do? We pre-round. Often even pre pre-round (ie interns will round before the seniors if said senior wants to round together before the attending or fellow gets there). So, if something this minor bothers you you’re gonna stroke out during IM residency

I guess bothered is not the right word. Honestly, maybe it was just annoying because it seemed excessive, but I certainly did not see the big picture. In fact, there was a recent Twitter thread on the merits of forgoing pre-rounding and having the whole team review a patient at the same time to allow for more conversation of the patient (the thread was more of a thought experiment but the comments were nonetheless interesting).

Plus I also doubt anyone necessarily enjoys pre-rounding either.

 

[Drrrrrr. Celty]

Also in hospitalist medicine pts rarely yell, pee, poop, or even bleed on you without you being aware of what is about to happen...

Some degree of stabilization or a fluid trial for a few hours before they go up to the floor really changes the world. That being said some do slip through.

I think in the end if you love the rush of doing things you could be happy in either EM or IM. A hospitalist isn't going to be in an adrenaline rush unless they're running a code, intubating someone on the floor, or running a rapid by chance because they're close by to a patient. But you can absolutely feel the rush in cardio, critical care, sometimes gi.

Alternatively I want to just calmly think about my patients and their weird diseases and not have to rush over and run a rapid.

 

[Drrrrrr. Celty]

I guess bothered is not the right word. Honestly, maybe it was just annoying because it seemed excessive, but I certainly did not see the big picture. In fact, there was a recent Twitter thread on the merits of forgoing pre-rounding and having the whole team review a patient at the same time to allow for more conversation of the patient (the thread was more of a thought experiment but the comments were nonetheless interesting).

Plus I also doubt anyone necessarily enjoys pre-rounding either.

Pre-rounding is important because it lets me let my interns actually work through a patient before I see them. I need them to learn how to think on their own and on their feet because next year it's on them. It has nothing to do with what we talk about on rounds, it's not about teaching facts, it's about learning how to be an independent senior and not **** up massively.

 

[Drrrrrr. Celty]

Like I could very easily just tell my interns what it is. But then they never grow. I could save their asses from ****ing up and just do the job. But then they never realize how close they got to messing up. etc.

The most educational times of residency were when I screwed up.

 

[scoopdaboop]

its not a settling for IM, but things change...some realize they actually like general medicine, some have changes in their status...they get married, have kids, etc...realize that hospitalist can make the same amount of money with less training ...or when they actually DO cards or GI, they realize that the don't like Cards or GI... I think half my resident class wanted to do cards...i think 2 ended up doing it.

How does a hospitalist make a mill a year like in I-cards?

 

[Drrrrrr. Celty]

How does a hospitalist make a mill a year like in I-cards?

They don't. But they can hit similar earning to a general cardiologist. Also being an interventional cardiologist is far more stressful, far less forgiving, and your patients are a lot sicker.

I've flirted with general or heart failure cardiology for a a hot second. They have better lifestyle and while also as interesting. But EP and Interventional just sound like you're always working and your patients half the time are in cardiogenic shock or on the edge of a ventricular rhythm. Also mind you that intervention is literally 2-3 more years of superfellowship on top of fellowship. A hospitalist will have had over 6 years of earnings by the time they left residency on you.

 

[scoopdaboop]

They don't. But they can hit similar earning to a general cardiologist. Also being an interventional cardiologist is far more stressful, far less forgiving, and your patients are a lot sicker.

I've flirted with general or heart failure cardiology for a a hot second. They have better lifestyle and while also as interesting. But EP and Interventional just sound like you're always working and your patients half the time are in cardiogenic shock or on the edge of a ventricular rhythm.

Yeah general cards seems pretty cool. 4 day work weeks available... salaries are good etc. Also, I don't understand how I/EP always works? Yeah, they can take call, but if your call structure is 1:4 or better, seems pretty doable. Are they often working past their scheduled times; for example if your schedule is a 7-5, are they often in the hospital till 7-8?

 

[Drrrrrr. Celty]

Yeah general cards seems pretty cool. 4 day work weeks available... salaries are good etc. Also, I don't understand how I/EP always works? Yeah, they can take call, but if your call structure is 1:4 or better, seems pretty doable. Are they often working past their scheduled times; for example if your schedule is a 7-5, are they often in the hospital till 7-8?

It probably depends on whether there are residents or fellows. But like if you get a STEMI alert and the guy is in cardiogenic shock, you're going to be down there longer, if they go into arrhythmia you'll be there longer, if they arrest it'll be longer and so on. So the job can be erratic.
Likewise if you're going home at 5 and you get a call about someone with weird ekg changes and a positive troponin you're not going home.

 

[Doctor_Strange]

They don't. But they can hit similar earning to a general cardiologist. Also being an interventional cardiologist is far more stressful, far less forgiving, and your patients are a lot sicker.

I've flirted with general or heart failure cardiology for a a hot second. They have better lifestyle and while also as interesting. But EP and Interventional just sound like you're always working and your patients half the time are in cardiogenic shock or on the edge of a ventricular rhythm. Also mind you that intervention is literally 2-3 more years of superfellowship on top of fellowship. A hospitalist will have had over 6 years of earnings by the time they left residency on you.

What are reasons that you have seen or heard for why a resident would forgo seeking a fellowship? Does it mostly come down to either lack of interest, not competitive enough, or the desire to become an attending? As an aside, I have thought that the "not competitive enough" argument holds true if coming from a community IM program without much in the way of research, but if coming from an academic university program one is in good shape.

 

[Drrrrrr. Celty]

What are reasons that you have seen or heard for why a resident would forgo seeking a fellowship? Does it mostly come down to either lack of interest, not competitive enough, or the desire to become an attending? As an aside, I have thought that the "not competitive enough" argument holds true if coming from a community IM program without much in the way of research, but if coming from an academic university program one is in good shape.

Idk, I go to a community IM program. Pretty much everyone matches into a fellowship including cards, gi, heme onc, etc thanks to having in house and decent portfolios and letters that get them outside matches including university programs.

There's a lot of reasons for it. One of the smartest guys in my program didn't want to do it because he was set on a specialty and then when he finally did it he didn't like it. Another guy had a kid and wanted to be a father more than he wanted to be a specialist. A lot of other people honestly just don't want to be students anymore and want to go work and have a life.

My dream is to continue being involved in academia and resident teaching after I finish. So I'm willing to continue putting in the time and effort. But I also recognize that if after finishing residency I could easily start with a 250k +starting bonus contract as a PCP in a good suburb and have a very solid 4.5 day schedule.

 

[Drrrrrr. Celty]

It's also worth mentioning that truthfully even being a DO coming from a university program may gimp your odds of matching into a competitive fellowship more than going to a community program with a high rate of matching into their own in house fellowships though. It's not a fair race, but DO prejudices still exist.

 

[bobow98]

It's also worth mentioning that truthfully even being a DO coming from a university program may gimp your odds of matching into a competitive fellowship more than going to a community program with a high rate of matching into their own in house fellowships though. It's not a fair race, but DO prejudices still exist.

Biases are present certainly but if you are a lone DO coming out of a well regarded residency program, that itself is enough validation to usually give you a fair shot at all but the most competitive institutions. An old colleague of mine went to DO school, then a philly based university IM program and is now a practicing GI doc.

 

[VA Hopeful Dr]

What are reasons that you have seen or heard for why a resident would forgo seeking a fellowship? Does it mostly come down to either lack of interest, not competitive enough, or the desire to become an attending? As an aside, I have thought that the "not competitive enough" argument holds true if coming from a community IM program without much in the way of research, but if coming from an academic university program one is in good shape.

My wife started her IM residency super gung-ho heme/onc. Between dreading another 3 years of training and not wanting to lose lots of her generalist skills, she decided to stick with general IM.

 

[rokshana]

What are reasons that you have seen or heard for why a resident would forgo seeking a fellowship? Does it mostly come down to either lack of interest, not competitive enough, or the desire to become an attending? As an aside, I have thought that the "not competitive enough" argument holds true if coming from a community IM program without much in the way of research, but if coming from an academic university program one is in good shape.

Yes.

 

[rokshana]

Biases are present certainly but if you are a lone DO coming out of a well regarded residency program, that itself is enough validation to usually give you a fair shot at all but the most competitive institutions. An old colleague of mine went to DO school, then a philly based university IM program and is now a practicing GI doc.

Your anecdote of 1 not withstanding, DO representation in ACGME fellowships is not as high as you wa t to think and more prestigious programs even less. Just check out the nrmp for the data... facts are facts.

 

[wamcp]

Your anecdote of 1 not withstanding, DO representation in ACGME fellowships is not as high as you wa t to think and more prestigious programs even less. Just check out the nrmp for the data... facts are facts.

I'm bored at work and decided to google NRMP data, I come across this.

Donna L. Lamb, D.HSc., M.B.A., B.S.N., President and CEO National Resident Matching Program

Not trying to derail the thread but wut?

 

[rokshana]

I'm bored at work and decided to google NRMP data, I come across this.

Donna L. Lamb, D.HSc., M.B.A., B.S.N., President and CEO National Resident Matching Program

Not trying to derail the thread but wut?

Didn’t you post this a few months ago? There was a thread on this....

 

[wamcp]

Didn’t you post this a few months ago? There was a thread on this....

Huh, maybe? Forgot all about it. Better take my donepezil

 

[AlteredScale]

Your anecdote of 1 not withstanding, DO representation in ACGME fellowships is not as high as you wa t to think and more prestigious programs even less. Just check out the nrmp for the data... facts are facts.

Yep. You go through the majority of residency grad placement matches you’ll see most DOs are going hospitalist or non competitive fellowships. And personally, I think the reason is multifaceted: most DOs are unable to participate in research and succeed because of the previous lack of exposure to it as a medical student, where DO schools have laughable resources for research (and a tiny sliver of nih funding). Secondly, a good proportion of DOs (compared to MDs) are non traditional and older, and realize in residency they’d rather just get out to the work force to support their family.

 

[bobow98]

Your anecdote of 1 not withstanding, DO representation in ACGME fellowships is not as high as you wa t to think and more prestigious programs even less. Just check out the nrmp for the data... facts are facts.

I'm not talking about overall DO representation. I am suggesting as written that if you are a lone DO that makes it into a real university residency program, someone clearly thinks you have potential, and that itself lends credibility to your application to most fellowships. I am not trying to argue that DOs match equally well in NRMP fellowship match, because they do not.

 

[tantacles]

You are spot on - I used to think the same, that EM work seemed better than hospitalisit work because you're almost always doing something, an endless stream of patients at 2-3 per hour. Now as an attending hospitalist, eff that! I liked admitting only 6 patients and being able to rewatch Saving private ryan and mad max fury road at work yesterday night (as a nocturnist) and put in a couple hours of COD:MW. Sure I get 20% less hourly pay than the ER doc downstairs but I'm doing less than 50% of the work.

Also I don't think hospitalists with at least a tinge of experience bother prerounding before shift. Most of us just show up and pick up the list, open the chart and go at it.

Yup, as nocturnists we still have the best job.

 

[Kaustikos]

Yup, as nocturnists we still have the best job.

Well,
You can be a specialist and a hospitalist at the same time. Even a Nocturnist and Specialist. Seen several Fellows and Attendings do it.
So, if nocturnist lifestyle is so great, one could realistically do both and make a comfortable lifestyle early in their career.

 

[Nespresso]

I’ll jump in as the devils advocate. Looking back to medical school, I’d say if you despise internal medicine but want GI or Cards, think very hard before pursuing IM just for the fellowship. It may not be worth the risk if you want to settle into a specialty that you like more than General IM. Lots of people across the nation end up 1) persuaded against applying to GI/Cards due to not being a competitive applicant 2) trying to bluntly do well in a specialty they don’t like (IM) and fall short of their competition 3) fall into life events that prevent them from going through fellowship app cycles and they end up doing hospitalist or PCP which they may have not liked as much as another specialty to begin with. It’s a gamble anyhow.

 

[Doctor_Strange]

I’ll jump in as the devils advocate. Looking back to medical school, I’d say if you despise internal medicine but want GI or Cards, think very hard before pursuing IM just for the fellowship. It may not be worth the risk if you want to settle into a specialty that you like more than General IM. Lots of people across the nation end up 1) persuaded against applying to GI/Cards due to not being a competitive applicant 2) trying to bluntly do well in a specialty they don’t like (IM) and fall short of their competition 3) fall into life events that prevent them from going through fellowship app cycles and they end up doing hospitalist or PCP which they may have not liked as much as another specialty to begin with. It’s a gamble anyhow.

I was a bit curt in my initial posts. The truth is I do enjoy inpatient medicine; I do not enjoy outpatient medicine whatsoever. That being said, if I were to match at a program that had multiple in-house fellowships, I likely would strive to match into a competitive specialty if the resources were available to me, specifically some of the more procedural specialties like Cardiology and PCCM.

Is it really a gamble if one can get into a reputable program w/ good fellowship match? I mean, I guess anything thing is a gamble in this world but I often hear that the number one reason is less about competitiveness and more about residents having a stronger desire to becoming an attending.

 

[Drrrrrr. Celty]

I was a bit curt in my initial posts. The truth is I do enjoy inpatient medicine; I do not enjoy outpatient medicine whatsoever. That being said, if I were to match at a program that had multiple in-house fellowships, I likely would strive to match into a competitive specialty if the resources were available to me, specifically some of the more procedural specialties like Cardiology and PCCM.

Is it really a gamble if one can get into a reputable program w/ good fellowship match? I mean, I guess anything thing is a gamble in this world but I often hear that the number one reason is less about competitiveness and more about residents having a stronger desire to becoming an attending.

Subspecialty clinic is basically the gem of IM. Also most subspecialties are still really outpatient intensive. Like 1-2 weeks a month is clinic for our general cardiologists here. You can be very heavily inpatient, but you're not going to be able to do that for >40 weeks a year.

Honestly you need to decide not whether you like inpatient medicine, but whether you enjoy what internal medicine is. Do you think that working up hyponatremia is akin to nails on chalkboard? Because you're going to be doing that more than you'll be putting in central lines and procedures or chest tubes. I mean it's hard to do IM if you're not interested in medicine and working up weird **** to ad nauseum. This is not like EM where it's diagnostic big picture.

Like I'm an internal medicine resident. I can tell you that I think inpatient kind of sucks, but I also think that it's horribly interesting and intellectually stimulating. Furthermore I'm at very much a community program, albeit one with a decent sized hospital system and a good academic environment, but our match rate for fellowships are very good. We have in house and we usually have a preference for our own graduates. So while we aren't quote on quote prestigious, there are a few applicants here who ranked bigger and more established programs because they probably have a better shot at matching a fellowship here.

 

[Kaustikos]

Subspecialty clinic is basically the gem of IM. Also most subspecialties are still really outpatient intensive. Like 1-2 weeks a month is clinic for our general cardiologists here. You can be very heavily inpatient, but you're not going to be able to do that for >40 weeks a year.

Honestly you need to decide not whether you like inpatient medicine, but whether you enjoy what internal medicine is. Do you think that working up hyponatremia is akin to nails on chalkboard? Because you're going to be doing that more than you'll be putting in central lines and procedures or chest tubes. I mean it's hard to do IM if you're not interested in medicine and working up weird **** to ad nauseum. This is not like EM where it's diagnostic big picture.

Like I'm an internal medicine resident. I can tell you that I think inpatient kind of sucks, but I also think that it's horribly interesting and intellectually stimulating. Furthermore I'm at very much a community program, albeit one with a decent sized hospital system and a good academic environment, but our match rate for fellowships are very good. We have in house and we usually have a preference for our own graduates. So while we aren't quote on quote prestigious, there are a few applicants here who ranked bigger and more established programs because they probably have a better shot at matching a fellowship here.

Love inpatient. Hate outpatient but there's a caveat - I'm sure doing outpatient as an Attending is a lot better because you can set your own pace about managing patients instead of waiting to present to the Attending.

 

[Deecee2DO]

1000% only doing IM in order to do fellowship (GI). I know GI is a gamble but thats why I busted my ass on boards to do well knowing this going in. I wouldnt mind H/O either or A/I for the lifestyle so either way im good with any of those 3. I have too much debt from chiro school to be a GP and i would hate hospitalist work lol my personal opinion