M4 strongly considering IM - still have a few questions regarding IM however

[okudasai]

Hey all,
I was all in for EM for most of my pre-med/med school life but recently have been re-thinking that decision. The jobs report was what initially prompted me to think about alternatives to EM for sure, but I've had a few weeks as an M4 on an EM sub-i and am starting to think I might like IM more than EM. I would probably do a CC or pulm CC fellowship afterwards if i went IM.

Initially, I think I didn't mind the non-sick patients in the ED, but the amount of just plain "don't need to be here" people have been getting to me, especially when you also have much more sick people that require more attention and resources. I would say the split is maybe 80/20 on a good a day in terms of not sick vs sick, and 90/10 most other days which I didn't really realize until M4 year. And of course, if you are working in the pit you will see almost no acuity or even medical complaints. The pit is fast-paced, but is mostly just a logistical nightmare and seems to have very little to do with medicine. I could very well be wrong about these impressions but that has been my experience so far.
I've also started to realize that I don't enjoy the H&P/early workup portion of medicine as much as I thought I did. I am finding the more complex, sicker patients interesting, whereas more "simpler" or slam dunk cases of appendicitis or cholecystitis less so. Alot of the most complex patients spend very little time in the ED and most of them go to the floors or ICU. I still very much enjoy being the first one to get to talk to the patient and figure out the story, but I am starting to think that the actual "medicine" where you get to sit down and figure out whats actually going on, what you can do to fix their pathology, actually getting the chance to fix whats wrong with them, etc. to be more compelling; this was something I had dismissed outright as an M3 but am beginning to appreciate as an M4.
My concerns about IM are the following:

1. I'm pretty much a textbook EM personality person; I like a fast-pace, hate long rounds and notes, have a short attention span, and no patience for academic discussions. I am concerned that I would not fit the culture at a typical IM program as a resident/attending, in that my only focus would be to fix the immediate thing thats keeping someone in the hospital and move on to the next patient. I have to say, alot of my IM attendings would spend several hours consulting and discussing every problem a patient had, and some of these patients had tons of problems. If all of IM ends up being like that, not sure I'd survive it.

1. I would very much miss fixing the acute crashing undifferentiated patient. I feel like EM is very good at resuscitation and EM people have very good instincts when it comes to knowing who is sick vs not sick. I feel that I would miss the codes and the stabilizing crashing patients, and am not sure that I would have the same opportunities going into IM. There is a level of chaos that I really enjoy coming from EM, and it would be pretty dull for me if all or most of my patients were stable rocks that I would do little to no interventions for.

Any and all advice from IM people or otherwise is very appreciated!

TLR Used to like EM, now thinking IM, worried cause heard IM has long rounds/notes/academic discussions/extreme focus on chronic issues/tons of consultations which I hate, worried that I would have much fewer opportunities to fix crashing patients anymore or run codes.

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[IMGASMD]

Hey all,
I was all in for EM for most of my pre-med/med school life but recently have been re-thinking that decision. The jobs report was what initially prompted me to think about alternatives to EM for sure, but I've had a few weeks as an M4 on an EM sub-i and am starting to think I might like IM more than EM. I would probably do a CC or pulm CC fellowship afterwards if i went IM.

Initially, I think I didn't mind the non-sick patients in the ED, but the amount of just plain "don't need to be here" people have been getting to me, especially when you also have much more sick people that require more attention and resources. I would say the split is maybe 80/20 on a good a day in terms of not sick vs sick, and 90/10 most other days which I didn't really realize until M4 year. And of course, if you are working in the pit you will see almost no acuity or even medical complaints. The pit is fast-paced, but is mostly just a logistical nightmare and seems to have very little to do with medicine. I could very well be wrong about these impressions but that has been my experience so far.
I've also started to realize that I don't enjoy the H&P/early workup portion of medicine as much as I thought I did. I am finding the more complex, sicker patients interesting, whereas more "simpler" or slam dunk cases of appendicitis or cholecystitis less so. Alot of the most complex patients spend very little time in the ED and most of them go to the floors or ICU. I still very much enjoy being the first one to get to talk to the patient and figure out the story, but I am starting to think that the actual "medicine" where you get to sit down and figure out whats actually going on, what you can do to fix their pathology, actually getting the chance to fix whats wrong with them, etc. to be more compelling; this was something I had dismissed outright as an M3 but am beginning to appreciate as an M4.
My concerns about IM are the following:

1. I'm pretty much a textbook EM personality person; I like a fast-pace, hate long rounds and notes, have a short attention span, and no patience for academic discussions. I am concerned that I would not fit the culture at a typical IM program as a resident/attending, in that my only focus would be to fix the immediate thing thats keeping someone in the hospital and move on to the next patient. I have to say, alot of my IM attendings would spend several hours consulting and discussing every problem a patient had, and some of these patients had tons of problems. If all of IM ends up being like that, not sure I'd survive it.

1. I would very much miss fixing the acute crashing undifferentiated patient. I feel like EM is very good at resuscitation and EM people have very good instincts when it comes to knowing who is sick vs not sick. I feel that I would miss the codes and the stabilizing crashing patients, and am not sure that I would have the same opportunities going into IM. There is a level of chaos that I really enjoy coming from EM, and it would be pretty dull for me if all or most of my patients were stable rocks that I would do little to no interventions for.

Any and all advice from IM people or otherwise is very appreciated!

TLR Used to like EM, now thinking IM, worried cause heard IM has long rounds/notes/academic discussions/extreme focus on chronic issues/tons of consultations which I hate, worried that I would have much fewer opportunities to fix crashing patients anymore or run codes.

Considered anesthesia? Don’t think you will really “enjoy” IM either from what you’re saying.
Part of the “problem” is if you cannot do general medicine and if you didn’t get into Pulm/crit then what?
Moreover, at some point everything “exciting” about IM/EM/Anes will wear off. It all becomes a “job” 90% of the time, if you cannot endure the daily grind of your chosen field, it may not be for you.

Just some thoughts. Good luck.

 

[okudasai]

I did do anesthesia, and unfourtanetly didn't enjoy the lack of patient interaction. I should be more speicifc, I did enjoy my IM rotations as well, in terms of managing the bread and butter cases, pt's acute exacerbations, talking to them and seeing them get better over time, etc. I did hope to still retain some acuity in the practice of general medicine/ICU medicine, where I could still get unstable and sick patients and manage their care.

 

[Natremia]

Hey all,
I was all in for EM for most of my pre-med/med school life but recently have been re-thinking that decision. The jobs report was what initially prompted me to think about alternatives to EM for sure, but I've had a few weeks as an M4 on an EM sub-i and am starting to think I might like IM more than EM. I would probably do a CC or pulm CC fellowship afterwards if i went IM.

Initially, I think I didn't mind the non-sick patients in the ED, but the amount of just plain "don't need to be here" people have been getting to me, especially when you also have much more sick people that require more attention and resources. I would say the split is maybe 80/20 on a good a day in terms of not sick vs sick, and 90/10 most other days which I didn't really realize until M4 year. And of course, if you are working in the pit you will see almost no acuity or even medical complaints. The pit is fast-paced, but is mostly just a logistical nightmare and seems to have very little to do with medicine. I could very well be wrong about these impressions but that has been my experience so far.
I've also started to realize that I don't enjoy the H&P/early workup portion of medicine as much as I thought I did. I am finding the more complex, sicker patients interesting, whereas more "simpler" or slam dunk cases of appendicitis or cholecystitis less so. Alot of the most complex patients spend very little time in the ED and most of them go to the floors or ICU. I still very much enjoy being the first one to get to talk to the patient and figure out the story, but I am starting to think that the actual "medicine" where you get to sit down and figure out whats actually going on, what you can do to fix their pathology, actually getting the chance to fix whats wrong with them, etc. to be more compelling; this was something I had dismissed outright as an M3 but am beginning to appreciate as an M4.
My concerns about IM are the following:

1. I'm pretty much a textbook EM personality person; I like a fast-pace, hate long rounds and notes, have a short attention span, and no patience for academic discussions. I am concerned that I would not fit the culture at a typical IM program as a resident/attending, in that my only focus would be to fix the immediate thing thats keeping someone in the hospital and move on to the next patient. I have to say, alot of my IM attendings would spend several hours consulting and discussing every problem a patient had, and some of these patients had tons of problems. If all of IM ends up being like that, not sure I'd survive it.

1. I would very much miss fixing the acute crashing undifferentiated patient. I feel like EM is very good at resuscitation and EM people have very good instincts when it comes to knowing who is sick vs not sick. I feel that I would miss the codes and the stabilizing crashing patients, and am not sure that I would have the same opportunities going into IM. There is a level of chaos that I really enjoy coming from EM, and it would be pretty dull for me if all or most of my patients were stable rocks that I would do little to no interventions for.

Any and all advice from IM people or otherwise is very appreciated!

TLR Used to like EM, now thinking IM, worried cause heard IM has long rounds/notes/academic discussions/extreme focus on chronic issues/tons of consultations which I hate, worried that I would have much fewer opportunities to fix crashing patients anymore or run codes.

? Probably should avoid a field to which you actively hate what they do 90% of the time. Only trying to fix the acute issues won’t get you very far in an IM residency..

Honestly, from your posts it sounds like trauma surgery or some kind of surgical field would be best for you. Now if you can pivot from EM to that is anyone’s guess.

 

[IMGASMD]

?

Honestly, from your posts it sounds like trauma surgery...

I think that’s a bit extreme…..

 

[okudasai]

? Probably should avoid a field to which you actively hate what they do 90% of the time. Only trying to fix the acute issues won’t get you very far in an IM residency..

Honestly, from your posts it sounds like trauma surgery or some kind of surgical field would be best for you. Now if you can pivot from EM to that is anyone’s guess.

I should have been more specific in my original post; I unfortunately really did not enjoy my surgery rotation. With regards to chronic stuff, I don't mind doing outpatient work in a residency, but would probably stick to inpatient as an attending. My understanding is that hospital patients are generally sicker, and I find myself fairly interested in fixing those patients issues, i.e.acute on chronic CHF, etc.

 

[NewYorkDoctors]

Cant go wrong with cardiology - full time Ccu or interventional is literally fix up the acute issues without frequent palliative care end of life micu cases
- general cards can always follow up longitudinally .

 

[okudasai]

Cant go wrong with cardiology - full time Ccu or interventional is literally fix up the acute issues without frequent palliative care end of life micu cases
- general cards can always follow up longitudinally .

I've definitely thought about it, I'm sure I'd get a decent amount of exposure to cards during an IM residency. I am pretty interested in crit care also; would there be any opportunities to fix acute issues in an ICU setting? I don't mind the palliative/goals of care discussions with families, or at the very least don't actively dislike them.

 

[IMGASMD]

I've definitely thought about it, I'm sure I'd get a decent amount of exposure to cards during an IM residency. I am pretty interested in crit care also; would there be any opportunities to fix acute issues in an ICU setting? I don't mind the palliative/goals of care discussions with families, or at the very least don't actively dislike them.

Just make sure you’re not getting cold feet…. And/or do a few more medicine sub-I.

 

[tylerb1800]

u/okudasai good luck with figuring out what you want to do.

I don't want you to come away thinking that we can most patient's problems in IM. We definitely cannot. Hard to fix the socioeconomic issues that plaque our patients as well as people not taking care of themselves. I do traditional IM. I am primarily in clinic but round daily on my patients in the hospital. The few fields that can fix things are primarily surgical. In the real world, IM doctors are not spending exorbitant amount of time rounding and what not. Time is money

​

 

[okudasai]

u/okudasai good luck with figuring out what you want to do.

I don't want you to come away thinking that we can most patient's problems in IM. We definitely cannot. Hard to fix the socioeconomic issues that plaque our patients as well as people not taking care of themselves. I do traditional IM. I am primarily in clinic but round daily on my patients in the hospital. The few fields that can fix things are primarily surgical. In the real world, IM doctors are not spending exorbitant amount of time rounding and what not. Time is money

​

Thank you for the reply! I'm glad to hear that rounding in the real world is much more efficient than what I've experienced so far. I'm very much okay with not addressing the chronic SES stuff that alot of hospital patients come in with, fixing the acute exacerbation of their chronic problem is pretty satisfying to me, at least at this stage anyway.

 

[Natremia]

I think that’s a bit extreme…..

I disagree

 

[Natremia]

I should have been more specific in my original post; I unfortunately really did not enjoy my surgery rotation. With regards to chronic stuff, I don't mind doing outpatient work in a residency, but would probably stick to inpatient as an attending. My understanding is that hospital patients are generally sicker, and I find myself fairly interested in fixing those patients issues, i.e.acute on chronic CHF, etc.

My point is that lots of inpatient general medicine fall under what you describe you hate: long notes, rounds forever, care coordination, chronic care. That IS inpatient general medicine in the United States. Up to you if you can stomach it. Cards and Pulm CC are competitive fields. Good luck to you dude.

 

[PugsAndHugs]

You sound like you would enjoy EM residency a lot and not enjoy IM at all. Another option would be EM/IM. This is a 5 year combined residency, and the critical care fellowship is only 1 year after EM/IM vs 3 years after IM.

 

[okudasai]

You sound like you would enjoy EM residency a lot and not enjoy IM at all. Another option would be EM/IM. This is a 5 year combined residency, and the critical care fellowship is only 1 year after EM/IM vs 3 years after IM.

I actually did not realize that CC ends up being one year if I went with the combined EM/IM pathway; I was planning to apply to the combined programs regardless but this is good to hear, thank you for the info!

 

[okudasai]

My point is that lots of inpatient general medicine fall under what you describe you hate: long notes, rounds forever, care coordination, chronic care. That IS inpatient general medicine in the United States. Up to you if you can stomach it. Cards and Pulm CC are competitive fields. Good luck to you dude.

Gotcha, I found the care coordination aspects to be okay but rounds till the late afternoon were pretty brutal for me. My understanding was that while pulm CC was competitive, it wasn't prohibitively so, i.e. if you did well on your ICU rotations, had good letters, etc. you would have a decent chance of matching. I wouldn't be averse to doing just a CC fellowship either; are both pulm CC as well as CC similarly extremely competitive?

 

[NewYorkDoctors]

I've definitely thought about it, I'm sure I'd get a decent amount of exposure to cards during an IM residency. I am pretty interested in crit care also; would there be any opportunities to fix acute issues in an ICU setting? I don't mind the palliative/goals of care discussions with families, or at the very least don't actively dislike them.

im a part time intensivist (mostly outpatient now). I gotta say in standard MICU the only routine few cases that get fixed up and patient has some semblance of recovery to baseline would be the DKA patients, the need urgent HD in MICU situation, and the ischemic CVA That need tPA and thrombectomy. I might be missing a few.

Otherwise all the septic shocks, COVIDs, massive PEs, end of life malignancy care, all really have no end in sight until they finally get downgraded to the floors in a very debilitated state.

Again I am generalizing. But there are a lot of "no end in sight" MICU cases out there. Definitely no one else to "admit the patient to" like in EM.

 

[okudasai]

im a part time intensivist (mostly outpatient now). I gotta say in standard MICU the only routine few cases that get fixed up and patient has some semblance of recovery to baseline would be the DKA patients, the need urgent HD in MICU situation, and the ischemic CVA That need tPA and thrombectomy. I might be missing a few.

Otherwise all the septic shocks, COVIDs, massive PEs, end of life malignancy care, all really have no end in sight until they finally get downgraded to the floors in a very debilitated state.

Again I am generalizing. But there are a lot of "no end in sight" MICU cases out there. Definitely no one else to "admit the patient to" like in EM.

Understood, I think I find the medicine aspect of taking care of sicker, complex patients more interesting, even if the end goal is a pretty bad outcome. Or put another way, just having the knowledge to manage patients of that complexity is interesting in and out of itself to me. I think perhaps just being able to try interventions and then having some effect occasionally (such as in the DKA patients, etc.) might be enough for me.

That being said, that's something to think about, I initially almost saw being able to downgrade to the floors as a "win" but I imagine the majority of people who go through the ICU don't do so great afterwards. I can't say it would be a dealbreaker if alot of my patients were sick/had bad outcomes, in that I'd still be able to contribute to helping them pass, goals of care, etc. if I could still have the occasional good outcome. I've also thought about working in a SICU which I've been told people tend to have better outcomes.

 

[InternistDO]

I actually did not realize that CC ends up being one year if I went with the combined EM/IM pathway; I was planning to apply to the combined programs regardless but this is good to hear, thank you for the info!

This actually not true. If you match into a triple combined EM/IM/CC program it's 6 years. However, if you do EM/IM and then later apply to critical care it's 2 more years, so 7 in total. I have no idea why.

I agree with NewYorkDoctors that the MICU is not a place for quick fixes or for people who need to see concrete benefit to their actions. Most patients in an academic MICU are going to die in the next few days to months regardless of what you do, with a smaller portion that have straightforward correctable issues (COPD requiring intubation, DKA, young person with a random sepsis) that will do well but usually aren't terribly complicated.

To answer your original question, I was in a similar boat as you (wanted EM since day 1, actually rotated in EM and realized there's no way I could enjoy 25 years of American emergency medicine) and ended up switching to IM. I enjoy it, while long rounds suck, they're at least better when you actually understand whats going on. There's still plenty of acuity in the ICU and PCU/SDU and on rapid responses/codes, though it's slower paced than the ER. I personally ended up enjoying clinic more than I expected in residency--it has the faster workflow of the ER, but you actually feel like you're helping 90% of your patients--and I ended up hating the ICU (for reasons stated above, outcomes were too terrible and it felt like you invested tons of work into hopeless patients). I don't think IM and EM are so incredibly different that you can't find something you like in IM if you have more of an EM personality, but that's just my opinion. If nothing else, IM is probably the most flexible residency you can do.

 

[okudasai]

This actually not true. If you match into a triple combined EM/IM/CC program it's 6 years. However, if you do EM/IM and then later apply to critical care it's 2 more years, so 7 in total. I have no idea why.

I agree with NewYorkDoctors that the MICU is not a place for quick fixes or for people who need to see concrete benefit to their actions. Most patients in an academic MICU are going to die in the next few days to months regardless of what you do, with a smaller portion that have straightforward correctable issues (COPD requiring intubation, DKA, young person with a random sepsis) that will do well but usually aren't terribly complicated.

To answer your original question, I was in a similar boat as you (wanted EM since day 1, actually rotated in EM and realized there's no way I could enjoy 25 years of American emergency medicine) and ended up switching to IM. I enjoy it, while long rounds suck, they're at least better when you actually understand whats going on. There's still plenty of acuity in the ICU and PCU/SDU and on rapid responses/codes, though it's slower paced than the ER. I personally ended up enjoying clinic more than I expected in residency--it has the faster workflow of the ER, but you actually feel like you're helping 90% of your patients--and I ended up hating the ICU (for reasons stated above, outcomes were too terrible and it felt like you invested tons of work into hopeless patients). I don't think IM and EM are so incredibly different that you can't find something you like in IM if you have more of an EM personality, but that's just my opinion. If nothing else, IM is probably the most flexible residency you can do.

This is very helpful information! I was told pretty much the same thing by some IM residents; while slower paced, there was enough acuity there that I think I would be satisfied with it, especially with being able to offer a little more continuity and definitive care. I'm glad to hear my personality may not be so different from IM people, it was something I was wondering about. The flexibility also feels like a breath of fresh air coming from EM, where options to work outside of the ER are very limited.

 

[NewYorkDoctors]

This is very helpful information! I was told pretty much the same thing by some IM residents; while slower paced, there was enough acuity there that I think I would be satisfied with it, especially with being able to offer a little more continuity and definitive care. I'm glad to hear my personality may not be so different from IM people, it was something I was wondering about. The flexibility also feels like a breath of fresh air coming from EM, where options to work outside of the ER are very limited.

Hospital Medicine, even Internal Medicine non ICU, can have some fairly acute patients in the stepdown units (or MICU rejects who can become MICU patients shortly) that will cause you quite a bit of anxiety. Sepsis but no hypotension so MICU reject. You'll be quite busy with that one. Cardiorenal syndrome - besides calling all the consults you'll be busy with that one also. A borderline GI bleeder that MICU wants nothing to do with and EGD cannot be done for a while in a patient who also has AKI and hyperkalemia. Just to name a few

It's really the outpatient subspecialties that are more long term, no imminent urgency, let's plan an academic discussion and go over randomized controlled trials for the best long term therapy, kind of discussions. This exists inpatient as well but it is more pronounced as an outpatient consultation,

 

[okudasai]

Hospital Medicine, even Internal Medicine non ICU, can have some fairly acute patients in the stepdown units (or MICU rejects who can become MICU patients shortly) that will cause you quite a bit of anxiety. Sepsis but no hypotension so MICU reject. You'll be quite busy with that one. Cardiorenal syndrome - besides calling all the consults you'll be busy with that one also. A borderline GI bleeder that MICU wants nothing to do with and EGD cannot be done for a while in a patient who also has AKI and hyperkalemia. Just to name a few

It's really the outpatient subspecialties that are more long term, no imminent urgency, let's plan an academic discussion and go over randomized controlled trials for the best long term therapy, kind of discussions. This exists inpatient as well but it is more pronounced as an outpatient consultation,

Ngl, hearing all the cases you outlined as causing you anxiety gives me a great deal of excitement, though I'm sure that might change when I'm actually in charge of dealing with it lol. Essentially, as long as I can still some acuity as you describe it, I think I'd be pretty satisfied as a IM doc. Thanks so much for the info!

 

[IMGASMD]

I disagree

No no no. Put whatever you said before back. I liked that better.

Can I ask how far along are you in your training? I am only asking because I think you’re still young and romanticize medicine, which are both good things.

I graduated more than 10 years ago, and when I finished, my academic designation was PGY9. Just a roundabout way to say I am a little jaded, but perhaps have a little broader perspectives than someone who may not have so much “training”. (Training in quotes, because a lot of wasted time in life…)

Trauma surgeons don’t have any personal interactions the op is seeking. If criticism for anesthesia is too little patient interactions, I don’t think op is right for trauma. Trauma surgery, just like any surgeries, you need to practice constantly to be good. Most if not all trauma surgeons prefer to spend time in the OR, even if most are capable of running a decent sicu. Last reason is more of a selfish and personal reason why I think trauma surgery is extreme for op. None of the very good/successful trauma surgeons I’ve met have a good home life. They are your stereotypical workaholic and adrenaline junkies who have difficult time holding onto relationships. What people say about surgery is also true, don’t be a surgeon unless you cannot imagine life without surgeries.

@okidasai CC is 2 years after IM. Pulm/Crit is usually 3 years after IM. It maybe a better investment of your time. It may also be easier to find a job with PCCM than CC alone. You can also get to CC from EM. I also want to sound like a broken record, just make sure you’re not getting cold feet from committing to EM and finding reasons not to apply. You can always apply to both and see where you end up…. Good luck, I think you’re thoughtful enough to find what you really want.

 

[okudasai]

No no no. Put whatever you said before back. I liked that better.

Can I ask how far along are you in your training? I am only asking because I think you’re still young and romanticize medicine, which are both good things.

I graduated more than 10 years ago, and when I finished, my academic designation was PGY9. Just a roundabout way to say I am a little jaded, but perhaps have a little broader perspectives than someone who may not have so much “training”. (Training in quotes, because a lot of wasted time in life…)

Trauma surgeons don’t have any personal interactions the op is seeking. If criticism for anesthesia is too little patient interactions, I don’t think op is right for trauma. Trauma surgery, just like any surgeries, you need to practice constantly to be good. Most if not all trauma surgeons prefer to spend time in the OR, even if most are capable of running a decent sicu. Last reason is more of a selfish and personal reason why I think trauma surgery is extreme for op. None of the very good/successful trauma surgeons I’ve met have a good home life. They are your stereotypical workaholic and adrenaline junkies who have difficult time holding onto relationships. What people say about surgery is also true, don’t be a surgeon unless you cannot imagine life without surgeries.

@okidasai CC is 2 years after IM. Pulm/Crit is usually 3 years after IM. It maybe a better investment of your time. It may also be easier to find a job with PCCM than CC alone. You can also get to CC from EM. I also want to sound like a broken record, just make sure you’re not getting cold feet from committing to EM and finding reasons not to apply. You can always apply to both and see where you end up…. Good luck, I think you’re thoughtful enough to find what you really want.

Thank you so much for this detailed reply, I will definitely be keeping this advice in mind moving forward! I have certainly considered that I might be getting cold feet with regards to EM, but I'm a bit more inclined to think that the rose colored glasses I had on during 3rd year are coming off a bit. I will definitely not be making any final desicions without some more introspection.

 

[Natremia]

No no no. Put whatever you said before back. I liked that better.

Can I ask how far along are you in your training? I am only asking because I think you’re still young and romanticize medicine, which are both good things.

I graduated more than 10 years ago, and when I finished, my academic designation was PGY9. Just a roundabout way to say I am a little jaded, but perhaps have a little broader perspectives than someone who may not have so much “training”. (Training in quotes, because a lot of wasted time in life…)

Trauma surgeons don’t have any personal interactions the op is seeking. If criticism for anesthesia is too little patient interactions, I don’t think op is right for trauma. Trauma surgery, just like any surgeries, you need to practice constantly to be good. Most if not all trauma surgeons prefer to spend time in the OR, even if most are capable of running a decent sicu. Last reason is more of a selfish and personal reason why I think trauma surgery is extreme for op. None of the very good/successful trauma surgeons I’ve met have a good home life. They are your stereotypical workaholic and adrenaline junkies who have difficult time holding onto relationships. What people say about surgery is also true, don’t be a surgeon unless you cannot imagine life without surgeries.

@okidasai CC is 2 years after IM. Pulm/Crit is usually 3 years after IM. It maybe a better investment of your time. It may also be easier to find a job with PCCM than CC alone. You can also get to CC from EM. I also want to sound like a broken record, just make sure you’re not getting cold feet from committing to EM and finding reasons not to apply. You can always apply to both and see where you end up…. Good luck, I think you’re thoughtful enough to find what you really want.

I had to edit it. I’m on probation

I’m a senior resident applying to fellowship rn

You deal more with trauma surgeons than me as I’m Med/Peds not anesthesia

I think he’ll hate IM tho

 

[okudasai]

I had to edit it. I’m on probation

I’m a senior resident applying to fellowship rn

You deal more with trauma surgeons than me as I’m Med/Peds not anesthesia

I think he’ll hate IM tho

Very possible, I did think about surgery for a bit (fixing things definitively is cool) but ultimately decided against it since I really did not enjoy the OR or surgery culture for the most part. I certainly appreciate the suggestion!

 

[Nespresso]

Hey all,
I was all in for EM for most of my pre-med/med school life but recently have been re-thinking that decision. The jobs report was what initially prompted me to think about alternatives to EM for sure, but I've had a few weeks as an M4 on an EM sub-i and am starting to think I might like IM more than EM. I would probably do a CC or pulm CC fellowship afterwards if i went IM.

Initially, I think I didn't mind the non-sick patients in the ED, but the amount of just plain "don't need to be here" people have been getting to me, especially when you also have much more sick people that require more attention and resources. I would say the split is maybe 80/20 on a good a day in terms of not sick vs sick, and 90/10 most other days which I didn't really realize until M4 year. And of course, if you are working in the pit you will see almost no acuity or even medical complaints. The pit is fast-paced, but is mostly just a logistical nightmare and seems to have very little to do with medicine. I could very well be wrong about these impressions but that has been my experience so far.
I've also started to realize that I don't enjoy the H&P/early workup portion of medicine as much as I thought I did. I am finding the more complex, sicker patients interesting, whereas more "simpler" or slam dunk cases of appendicitis or cholecystitis less so. Alot of the most complex patients spend very little time in the ED and most of them go to the floors or ICU. I still very much enjoy being the first one to get to talk to the patient and figure out the story, but I am starting to think that the actual "medicine" where you get to sit down and figure out whats actually going on, what you can do to fix their pathology, actually getting the chance to fix whats wrong with them, etc. to be more compelling; this was something I had dismissed outright as an M3 but am beginning to appreciate as an M4.
My concerns about IM are the following:

1. I'm pretty much a textbook EM personality person; I like a fast-pace, hate long rounds and notes, have a short attention span, and no patience for academic discussions. I am concerned that I would not fit the culture at a typical IM program as a resident/attending, in that my only focus would be to fix the immediate thing thats keeping someone in the hospital and move on to the next patient. I have to say, alot of my IM attendings would spend several hours consulting and discussing every problem a patient had, and some of these patients had tons of problems. If all of IM ends up being like that, not sure I'd survive it.

1. I would very much miss fixing the acute crashing undifferentiated patient. I feel like EM is very good at resuscitation and EM people have very good instincts when it comes to knowing who is sick vs not sick. I feel that I would miss the codes and the stabilizing crashing patients, and am not sure that I would have the same opportunities going into IM. There is a level of chaos that I really enjoy coming from EM, and it would be pretty dull for me if all or most of my patients were stable rocks that I would do little to no interventions for.

Any and all advice from IM people or otherwise is very appreciated!

TLR Used to like EM, now thinking IM, worried cause heard IM has long rounds/notes/academic discussions/extreme focus on chronic issues/tons of consultations which I hate, worried that I would have much fewer opportunities to fix crashing patients anymore or run codes.

When I say the words
“Patient is here to see you for pinky pain and demands pain meds”
“Patient is here to see you for arm pain” in the IM clinic how does that make you feel?

when I say the words
“Patient admitted for rehab placement”
“Patient admitted for question of delirium”

if any of the above make you want to stab yourself then don’t go into IM.

 

[IMGASMD]

When I say the words
“Patient is here to see you for pinky pain and demands pain meds”
“Patient is here to see you for arm pain” in the IM clinic how does that make you feel?

when I say the words
“Patient admitted for rehab placement”
“Patient admitted for question of delirium”

if any of the above make you want to stab yourself then don’t go into IM.

“It’s a social admission, and you know we can’t hold him in the ED for more than six hours. It ****s with our throughput numbers….”

“It’s Friday night, social work is not here until tomorrow morning, I need the bed in triage….”

 

[okudasai]

When I say the words
“Patient is here to see you for pinky pain and demands pain meds”
“Patient is here to see you for arm pain” in the IM clinic how does that make you feel?

when I say the words
“Patient admitted for rehab placement”
“Patient admitted for question of delirium”

if any of the above make you want to stab yourself then don’t go into IM.

That's actually a pretty good description of the kinds of cases I have heard many IM folks be pretty unhappy about lol. I have had a few dementia/delirium patients while on inpatient service, while not the most pleasant, it wasn't bad enough to the degree of wanting to do self-harm. The rehab placement case is obnoxious but I did have a few patients who had to wait several extra days for placement - pretty annoying but not to to where I couldn't bear it.

I would say maybe the demanding pain meds patient is probably the one that annoys me the most personally, because at least the other scenarios have some legitimate concerns, comparatively speaking anyway. Thank you for succinctly putting together the most exhausting parts of IM, these are the scenarios that I should definetly make my peace in dealing with since I'm sure I'll have plenty of them.

 

[okudasai]

When I say the words
“Patient is here to see you for pinky pain and demands pain meds”
“Patient is here to see you for arm pain” in the IM clinic how does that make you feel?

when I say the words
“Patient admitted for rehab placement”
“Patient admitted for question of delirium”

if any of the above make you want to stab yourself then don’t go into IM.

I guess I should also say the way I look at it, every specialty, EM certainly included, has these sorts of cases that no one enjoys taking care of but you have to deal with from time to time. I would say in EM its alot of the "med refills" or demanding patients who want pain meds/attention for issues that aren't real emergencies or issues that would have been solved in a more timely fashion had they gone to a PCP. And of course, the alcoholic/addict patients; I feel bad for them but they can be emotionally exhausting to deal with in my experience.

In my mind anyway, my experience with dealing with the "annoyances" of IM was easier for me to deal with personally than with what I saw in the ED, since whether this is actually true or not, I generally saw the annoying cases of IM as still being a slightly more legitimate problem to solve, whereas I saw the annoyances of the ED more as non-issues that took up resources away from the truly sick. I could be very wrong about this latter impression, but that has been my experience so far.

 

[Meerkatology]

coming from perspective of IM nocturnist. my job involves taking admit consults from ER docs.

i think if you like working nights - IM nocturnist is much better than being a nightshift ER person. ( i think most ER jobs require you to work a substantial # of nights as well? theres alot of ER visits in the evening)

unless of course u truly enjoy managing the emergent stuff like intubating people etc.
its just much better working conditions and less BS to deal with.

i dont know how the pay compares though

 

[Questionsaboutmedicine]

That being said, that's something to think about, I initially almost saw being able to downgrade to the floors as a "win" but I imagine the majority of people who go through the ICU don't do so great afterwards.

That isn't necessarily true. At some hospitals (even some big brand name ones that you have heard of), some floor pts get moved to the ICU when they don't need to be in the icu in the first place. This can happen for a variety of reasons that I won't get into (others can feel free to do so, but I am not going to litigate that). Not every pt tfx or admitted the ICU really needs ICU care. Some people get very frustrated when that happens, esp when you have no idea why they were moved to the ICU. But it doesn't bother me bc I just tfx the pt back to the floor.

 

[Questionsaboutmedicine]

I also hated rounding all day and missing lunch. We've all been there. I once rounded with the med/peds PD from 8 am to 5 pm on a Saturday as a med student and I hated my life.

But if you truly want to competently manage complex pts with tons of comorbidities, you have to delve into the nitty gritty details and learn to problem solve. That's where those long rounds come into play, bc the attending is trying to guide you on their thought process step-by-step. Certainly, they can be more efficient. But they are to give you a chance to grow and learn (and for attendings to flex). After you gain more knowledge, you can answer questions faster and push rounds forward, so that they last 3 hours instead of 6, lol.

Those rounds give you a chance to build your DDx, something EM is very adept at too. You have to sometimes sit there and think carefully when expanding your DDx when managing complex pts that aren't responding the way you think they should. Medicine can be humbling and Hickam's dictum is something that you should keep in mind. As a med student, I had a pt that came in to the ICU that was tx with tons of abx and basically everything. He sat in the ICU for 3-4 weeks. Turns out the pt had malignant catatonia and responded to benzos quickly. IDK if pontificating during bedside rounds helped us to get to the answer any faster, but it did certainly help us to think things through and r/o things. Rounding for hours sometimes is just a part of the process, esp when you have pts that are not doing well and you are stumped.

 

[okudasai]

I also hated rounding all day and missing lunch. We've all been there. I once rounded with the med/peds PD from 8 am to 5 pm on a Saturday as a med student and I hated my life.

But if you truly want to competently manage complex pts with tons of comorbidities, you have to delve into the nitty gritty details and learn to problem solve. That's where those long rounds come into play, bc the attending is trying to guide you on their thought process step-by-step. Certainly, they can be more efficient. But they are to give you a chance to grow and learn (and for attendings to flex). After you gain more knowledge, you can answer questions faster and push rounds forward, so that they last 3 hours instead of 6, lol.

Those rounds give you a chance to build your DDx, something EM is very adept at too. You have to sometimes sit there and think carefully when expanding your DDx when managing complex pts that aren't responding the way you think they should. Medicine can be humbling and Hickam's dictum is something that you should keep in mind. As a med student, I had a pt that came in to the ICU that was tx with tons of abx and basically everything. He sat in the ICU for 3-4 weeks. Turns out the pt had malignant catatonia and responded to benzos quickly. IDK if pontificating during bedside rounds helped us to get to the answer any faster, but it did certainly help us to think things through and r/o things. Rounding for hours sometimes is just a part of the process, esp when you have pts that are not doing well and you are stumped.

I think while the long rounds were not the most fun for me, I do understand why they happen during residency or for especially complex patients. I think I would be able to get through the long rounding during my residency, as they would probably help at least somewhat with learning how to build a better differential, etc. My hope is that I can graduate to the 3 hour rounds as an attending and be more efficient when I am practicing in the community, etc.

 

[Questionsaboutmedicine]

I think while the long rounds were not the most fun for me, I do understand why they happen during residency or for especially complex patients. I think I would be able to get through the long rounding during my residency, as they would probably help at least somewhat with learning how to build a better differential, etc. My hope is that I can graduate to the 3 hour rounds as an attending and be more efficient when I am practicing in the community, etc.

Didn't mean to belabor the point.

Lastly, as someone said, they are different when you are a resident vs a med student.

There are programs that round in 2 hours on 16 pts. IDK if they learned, but not all IM programs are built the same. There is variability within ea program too. There was an attending in my med school that did lightning rounds in less than an hour. We spent more time walking to the pt's room

Food for thought

 

[NewYorkDoctors]

Unclear what the point of long rounds serve if the attending and residents are not also doing mini presentations and review of literature . Bedside rounds serve few purposes other than engaging in patient communication and showing residents how to communicate effectively . Physical exam ? Well aside from edema what can be palpated in most patients that is of interest beyond the first day of admission ? I will say using something like the Eko duo stethoscope would be useful for auscultatory teaching (I don’t get paid for this statement I just use their product when I teach housestaff / fellows ) or using pocus PNA parient . If it’s a social dispo patient dunno wh I need to waste residents time on rounds . I’ll round myself and if something of interest is present bedside I would page text the hlusestaff to come in person for learning .