Like GI, not IM

[Jaspreed24]

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So M3 year is winding down, and I'm still struggling with specialty decisions.

Right now I'm between EM, PICU, and Adult GI. I think I would be a great fit for any of these specialties, but I've been really feeling adult GI lately because I like the mixture of clinic days and procedure days, and I find the medicine interesting. However, my biggest concern is that internal medicine residency fills me with dread. I like adults in specialty clinics, and I interact with them well, but in clinic they're usually in a better mood and I feel like I'm actually helping them (vs inpatient, where you just make them good enough to leave). Inpatient, they're pretty nasty. I had great interactions with patients/families in inpatient Peds, but I shadowed a peds GI clinic and it was all vomiting, diarrhea, constipation, and EOE, with markedly fewer procedures.

I have been very gung-ho EM for a while, but after during surgery, it is quite nice to actually fix a problem and see a result (hence PICU, with the lower mortality rate and complex problems, and GI--I don't love surgery enough to go into it). I worry that in EM, I will just run patients through the system and never get to see anything good come of my work.

So basically....has anyone else been in this situation, and have any insight?

 

[FlameBroiledDoc]

Any internal medicine residency is 2 1/2 years of scut work, then the subspecialty match. If you really love GI, remember that not all of your IM years are inpatient hell. You get some elective time, some consult-only rotations (like ID), procedure-rich ICU, and rotations like Cardiology which are nowhere near as soul-sucking as general IM.

If you really feel a need to "fix" your patients, GI is not the field to go into. Setting aside the IBS cases for which there's really no treatment, IBD can be difficult and even heartbreaking to manage. And you need a lot of patience for alcoholics and IV drug users. If that's you, fantastic.

 

[Ismet]

I shadowed a peds GI clinic and it was all vomiting, diarrhea, constipation, and EOE, with markedly fewer procedures.

Depends on where you train. Peds GI at my med school and my residency institution do a ton of procedures. But then you also have to deal with functional abdominal pain and that's no fun 😛

 

[Tenk]

I have been very gung-ho EM for a while, but after during surgery, it is quite nice to actually fix a problem and see a result (hence PICU, with the lower mortality rate and complex problems, and GI--I don't love surgery enough to go into it). I worry that in EM, I will just run patients through the system and never get to see anything good come of my work.

That is literally one of my favorite parts about EM. No long term contact. No pager. Work hard. Play hard. No mix. The best.

 

[tennislover1989]

I'm also an M3 so take my opinion with a grain of salt. One of my advisors recently told me that it's potentially a huge risk to do a residency in a specialty that you're not willing to practice. Cardiology and GI are the most competitive IM fellowships to match into. I was considering GI as well, but I'm pretty sure I would be miserable if I didn't match into fellowship and was forced to do IM. It's not a risk that I'm willing to take, but I'm pretty risk averse. If you're comfortable with that, you should go for it!

 

[GadRads]

One of my good friends was meh about general IM, but is currently a GI fellow after doing IM at a top program.

It is not necessary to do IM at a top program to match into GI, however. Match into a good IM program, do some GI research, and you will match somewhere. That said general IM sucks but it won't kill you, at least so I think.

 

[DNM]

I'm also an M3 so take my opinion with a grain of salt. One of my advisors recently told me that it's potentially a huge risk to do a residency in a specialty that you're not willing to practice. Cardiology and GI are the most competitive IM fellowships to match into. I was considering GI as well, but I'm pretty sure I would be miserable if I didn't match into fellowship and was forced to do IM. It's not a risk that I'm willing to take, but I'm pretty risk averse. If you're comfortable with that, you should go for it!

I think in general that is good advice to follow. GI is competitive, but not quite so bad as people think. Based on the last charting the outcomes, while the fellowship had roughly a ~50-60% overall match rate, it was around 85% for AMG MD's.

 

[general admission]

I'm also an M3 so take my opinion with a grain of salt. One of my advisors recently told me that it's potentially a huge risk to do a residency in a specialty that you're not willing to practice. Cardiology and GI are the most competitive IM fellowships to match into. I was considering GI as well, but I'm pretty sure I would be miserable if I didn't match into fellowship and was forced to do IM. It's not a risk that I'm willing to take, but I'm pretty risk averse. If you're comfortable with that, you should go for it!

If you're a US MD w/ no red flags and go to an academic institution w/ a home GI for residency, you're pretty much set. Work hard during residency, show your face to your dept and publish some things in GI. If you go to a community program, are an IMG, or have big red flags on your record, that's where things start to get hazy.

In reality, there's nothing wrong with going into medicine with the mind to specialize. Plenty of people do that. General IM sucks man.

 

[Polonium-210]

Same. History of IBD as well so I know how much fun it's management can be. Cool medicine, cool drugs, cool procedures. But IM...

 

[hello1234!]

are u concerned that patients on the inpatient side are nasty compared to outpatient? I'm in IM, and I never found that to be the case. if anything, I have heard the opposite. Also, getting patients to the point where they can safely leave the hospital and preventing readmission is a big deal and is helping patients.

 

[Jaspreed24]

Any internal medicine residency is 2 1/2 years of scut work, then the subspecialty match. If you really love GI, remember that not all of your IM years are inpatient hell. You get some elective time, some consult-only rotations (like ID), procedure-rich ICU, and rotations like Cardiology which are nowhere near as soul-sucking as general IM.

If you really feel a need to "fix" your patients, GI is not the field to go into. Setting aside the IBS cases for which there's really no treatment, IBD can be difficult and even heartbreaking to manage. And you need a lot of patience for alcoholics and IV drug users. If that's you, fantastic.

That's a good perspective on IM residency! I think I imagine it all being like the patients I'm seeing on vascular surgery (albeit they're surgical patients) with gangrenous toes. I definitely like medicine and physiology, which obviously there's a ton of in IM

Unfortunately, all the fields I want to go into have some aspect of heartbreak (traumas gone wrong, dead PICU children, chronic IBD/cirrhosis complications).

 

[Jaspreed24]

Depends on where you train. Peds GI at my med school and my residency institution do a ton of procedures. But then you also have to deal with functional abdominal pain and that's no fun 😛

True, that was a big negative for pediatric GI--I would feel the need to tack on another year for hepatology or IBD to keep things more interesting. But I've also heard my hospital isn't the best when it comes to GI. We don't have ERCP at children's 🙁 They get shipped to the main university hospital

 

[Jaspreed24]

If you're a US MD w/ no red flags and go to an academic institution w/ a home GI for residency, you're pretty much set. Work hard during residency, show your face to your dept and publish some things in GI. If you go to a community program, are an IMG, or have big red flags on your record, that's where things start to get hazy.

In reality, there's nothing wrong with going into medicine with the mind to specialize. Plenty of people do that. General IM sucks man.

I agree, I am honestly not that worried about getting into a GI program, it's more just putting your cards in order and applying smart/broad

 

[Jaspreed24]

are u concerned that patients on the inpatient side are nasty compared to outpatient? I'm in IM, and I never found that to be the case. if anything, I have heard the opposite. Also, getting patients to the point where they can safely leave the hospital and preventing readmission is a big deal and is helping patients.

Yes, that was my concern. Tbh I haven't seen true adult inpatient medicine since summer (I've only seen inpatient surgery , OB/Gyn, and EM on the adult side these past few months)

 

[Jaspreed24]

That is literally one of my favorite parts about EM. No long term contact. No pager. Work hard. Play hard. No mix. The best.

Wait so just to clarify, you like just moving the meat? I'm mainly asking because I am trying to figure out if my temperament is just not meant for EM. I loved my 2-week rotation in EM because I love diagnosis, seeing every organ system/age range, using test results right then and there to diagnose/determine initial management, and then leaving the actual "boring" aspects of management to the inpatient team (fluids, giving Abx, discharge planning and all its social concerns). But it also matters to me that I make a real impact on my patients and their care in the ED, as opposed to just handing them off as soon as I can.

Oh yes, and procedures. All the fields I like have an aspect of procedures to them.

 

[Jaspreed24]

These threads about med students bashing IM should be banned...

I am in no way bashing IM. Medicine is a huge field, and everyone finds different passions and ways they feel they make a difference. My limited experience with inpatient general IM felt like just getting patients back to their baseline, which was often pretty low. If I feel passionate about GI, but have misgivings about IM, it is pretty important to determine if I just had a faulty perspective due to inexperience, or if going into IM could actually be a mistake. If that's not politically correct...I can't help that.

 

[67552931811]

So M3 year is winding down, and I'm still struggling with specialty decisions.

Right now I'm between EM, PICU, and Adult GI. I think I would be a great fit for any of these specialties, but I've been really feeling adult GI lately because I like the mixture of clinic days and procedure days, and I find the medicine interesting. However, my biggest concern is that internal medicine residency fills me with dread. I like adults in specialty clinics, and I interact with them well, but in clinic they're usually in a better mood and I feel like I'm actually helping them (vs inpatient, where you just make them good enough to leave). Inpatient, they're pretty nasty. I had great interactions with patients/families in inpatient Peds, but I shadowed a peds GI clinic and it was all vomiting, diarrhea, constipation, and EOE, with markedly fewer procedures.

I have been very gung-ho EM for a while, but after during surgery, it is quite nice to actually fix a problem and see a result (hence PICU, with the lower mortality rate and complex problems, and GI--I don't love surgery enough to go into it). I worry that in EM, I will just run patients through the system and never get to see anything good come of my work.

So basically....has anyone else been in this situation, and have any insight?

In my VERY limited experience the interesting peds GI cases end up in the unit. Of course I want to do PICU or NICU so I'm *slightly* biased 😉

 

[Jaspreed24]

In my VERY limited experience the interesting peds GI cases end up in the unit. Of course I want to do PICU or NICU so I'm *slightly* biased 😉

I am trying to set up shadowing in the PICU just to see it again, since we don't do ICU until 4th year here, and PICU has been pretty competitive to get before apps are due! I shadowed PICU for a day as an M1, but tbh my fund of knowledge was so low it was all a different language to me. From what you saw, were things mainly diagnosed in the ED, then transferred to the ICU where basically the patient's vent settings were managed (the stereotype I've heard), or does diagnosis continue on the unit? I guess just...how was your experience? 🙂

 

[hello1234!]

Saying you like diagnosis I don't really think is the best way to think about it because there is monotony to every field of medicine and the diagnosis aspect will get actually pretty simple for you by the time you're done with residency.

*this is coming from someone who hates working in the ER and absolutely loves IM.

 

[Tenk]

Wait so just to clarify, you like just moving the meat? I'm mainly asking because I am trying to figure out if my temperament is just not meant for EM. I loved my 2-week rotation in EM because I love diagnosis, seeing every organ system/age range, using test results right then and there to diagnose/determine initial management, and then leaving the actual "boring" aspects of management to the inpatient team (fluids, giving Abx, discharge planning and all its social concerns). But it also matters to me that I make a real impact on my patients and their care in the ED, as opposed to just handing them off as soon as I can.

Oh yes, and procedures. All the fields I like have an aspect of procedures to them.

Only about 20% of ED patients give or take some will be admitted to the hospital. That means the other 80ish% will be discharged. You will be treating them as outpatients. I treat plenty of diseases. My overall job though is simple: I don't let people die under my watch and if you are dead I try to make you not dead (unless you are very old then I am ok with you being dead). I just love the fact that I don't have to deal with people calling me when I am on the slopes snowboarding, at the range shooting, at the gym lifting, or on the mountains biking. Work is work. Life is life. I do not mix the two.