Mostly elderly patients in IM?

[zeppelinpage4]

Hey guys!

So, we're making our 4th year schedules and I've been getting to thinking about specialty interests.

One thing I'm a bit confused about in particular is the patient population in IM.

I had my medicine rotation a few months back and to my surprise, 80% of our floor were elderly patients in very bad health, hearing problems, dementia etc. I rarely connected with the patients, more often than not I was quite detached, and all in all I wasn't a fan. I expect a decent amount of elderly patients, but it seemed that almost all of the patients were elderly and most of them I could not talk to or properly interact with. Some were in such bad health, I just felt like we were fighting a losing battle. I was seriously considering IM before third year started, but this experience was enough for me to not want to do IM at all. I just did not enjoy the patient population. I def prefer seeing a wide age range, which IM did not have.

But before ruling it out, I just wanted to confirm, since I only experienced one hospital.
If I did internal medicine, would the majority of my patients be like this?
Or does the outpatient environment have more alert and healthy adults across a wider age range?
I'm happy caring for elderly patients, but I just didn't expect to just be caring for elderly patients...it felt a bit like geriatrics.

On the other hand, I loved surgery (took care of kids and adults, most of whom were recovering and getting better quick. I felt like we were actually making a different in their health, not just doing damage control like in IM) and am really enjoying pediatrics (also a wide age range, and here we are trying to prevent a lot of the diseases from the start).
Truth be told, I think I enjoy seeing kids, adults AND elderly patients. I just think I'd enjoy dealing with a wide age range. But, I don't like just seeing elderly patients, which is what IM felt like.
Regardless, I have a lot more rotations ahead, so I'm still figuring out what I might like. But I wanted to ask about IM before ruling it out completely.

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[HelpPleaseMD]

Hey guys!

So, we're making our 4th year schedules and I've been getting to thinking about specialty interests.

One thing I'm a bit confused about in particular is the patient population in IM.

I had my medicine rotation a few months back and to my surprise, 80% of our floor were elderly patients in very bad health, hearing problems, dementia etc. I rarely connected with the patients, more often than not I was quite detached, and all in all I wasn't a fan. I expect a decent amount of elderly patients, but it seemed that almost all of the patients were elderly and most of them I could not talk to or properly interact with. Some were in such bad health, I just felt like we were fighting a losing battle. I was seriously considering IM before third year started, but this experience was enough for me to not want to do IM at all. I just did not enjoy the patient population. I def prefer seeing a wide age range, which IM did not have.

But before ruling it out, I just wanted to confirm, since I only experienced one hospital.
If I did internal medicine, would the majority of my patients be like this?
Or does the outpatient environment have more alert and healthy adults across a wider age range?
I'm happy caring for elderly patients, but I just didn't expect to just be caring for elderly patients...it felt a bit like geriatrics.

On the other hand, I loved surgery (took care of kids and adults, most of whom were recovering and getting better quick. I felt like we were actually making a different in their health, not just doing damage control like in IM) and am really enjoying pediatrics (also a wide age range, and here we were trying to prevent a lot of the diseases from the start). Again, I think I enjoy seeing kids, adults and elderly patients. I really think I'd enjoy dealing with a wide age range (though my best experiences across multiple rotations we were kids, and young adults). But, I don't like just seeing elderly patients, which is what IM felt like.
Regardless, I have a lot more rotations ahead, so I'm still figuring out what I might like. But I wanted to ask about IM before ruling it out completely.

It really depends on where your hospital is located. If its the inner city county hospital you will get a lot more of a mix between the old/young. if its a community hospital in a rich area of the suburbs the elderly are probably who you will mostly see.

It is true that IM deals with a lot of chronic diseases, but if you do it well it really makes a huge difference in their quality of life. It is not just damage control.

 

[zeppelinpage4]

It really depends on where your hospital is located. If its the inner city county hospital you will get a lot more of a mix between the old/young. if its a community hospital in a rich area of the suburbs the elderly are probably who you will mostly see.

Thanks, my rotation was definitely at a community hospital in a suburban area. So, maybe that was why.

Yes, the elderly are more likely to be sick than the young

Hahaha, this is true, and probably should have been obvious to me from the start.

I guess I was expecting more 40% elderly, rather than 80-90%.
But this probably varies by type of hospital and location like HelpPleaseMD said.

I just wanted to know if it would be almost only elderly patients (which was my experience in IM) in other hospitals and practice settings.

 

[solitarius]

Elderly, then obese ppl.

 

[Psai]

You get a lot of old people to practice on so that when someone comes through those doors that you can actually help, you will be trained and ready. The amount of money this country spends on geriatric care is insane. Just look at any icu and you'll find multiple examples of incredibly expensive and useless "care". One time we had an old homeless guy with no family come in with a basilar artery thrombosis. He was gone but the icu team decided to do a million dollar hypercoagulability workup. Not sure why because it doesn't help anybody, least of all the patient who basically had no brainstem

If you want younger people you can help think of allergy rheum fammed ob derm ent etc

 

[HelpPleaseMD]

Thanks, my rotation was definitely at a community hospital in a suburban area. So, maybe that was why.


Hahaha, this is true, and probably should have been obvious to me from the start.

I guess I was expecting more 40% elderly, rather than 80-90%.
But this probably varies by type of hospital and location like HelpPleaseMD said.

I just wanted to know if it would be almost only elderly patients (which was my experience in IM) in other hospitals and practice settings.

Select an inner city program and you will see closer to a 50/50 split. If you are thinking of IM, I'd recommend looking for high volume places with more than 1 hospital with one of them being a county hospital. A closed ICU and one that doesnt have the half a day of clinic a week during inpatient month schedule. It sounds like you are leaning towards surgery though.

 

[organdonor]

If only there were a specialty that lined up well with your interests that include seeing all ages and sexes, inpatient, outpatient, many young healthy patients, and in office procedures.

Says the family medicine resident. Don't write it off 😉

 

[Mad Jack]

Thanks, my rotation was definitely at a community hospital in a suburban area. So, maybe that was why.


Hahaha, this is true, and probably should have been obvious to me from the start.

I guess I was expecting more 40% elderly, rather than 80-90%.
But this probably varies by type of hospital and location like HelpPleaseMD said.

I just wanted to know if it would be almost only elderly patients (which was my experience in IM) in other hospitals and practice settings.

You're in the hospital. Not a lot of young people end up admitted to the hospital for medical reasons, particularly outside the inner city.

Now, if you're in the inner city, and particularly a more diverse inner city, you end up with a lot of certain types of younger patients. Asthma. Sickle cell. CF, if you're in a big enough city or are a referral center. Alcohol withdrawal on occasion. Complications of poorly managed diabetes. Occasionally you might get a GI obstruction here and there that hasn't yet become a surgical consult. Outpatient, I have no idea. Probably depends on where you choose to work. If you work in a vibrant suburb, I'd imagine you'd have a more diverse mix. Plus many of your elderly patients will be more vibrant than the sort that frequently end up in the hospital, and are actually much more interesting and enjoyable to interact with than severely demented patients from ECFs with urosepsis and the like.

 

[Moko]

If only there were a specialty that lined up well with your interests that include seeing all ages and sexes, inpatient, outpatient, many young healthy patients, and in office procedures.

Says the family medicine resident. Don't write it off 😉

No thanks, I'll stick with syncope work-ups.

 

[tick_tock400]

The internal medicine doctors who lead one of my medical courses said that a general rule where they practice (we're in a well-off city btw) is that internal medicine doctors ONLY see the elderly. Family med doctors see people of all ages. Of course, this might be a general (take that general to be very "loose") statement towards which way the IM field is heading in non rural-ish/non inner-city areas, but I don't know for sure of course.

 

[organdonor]

No thanks, I'll stick with syncope work-ups.

Sounds fulfilling.

 

[Moko]

Sounds fulfilling.

Totally not questioning my career choices right now.

 

[Crayola227]

OMG.
Smh.

The whole point of having FM, peds, and IM, is that the easy outpatient stuff goes to FM, the harder stuff with kids goes to Peds, IM can theoretically see age 12 and up, usually doesn't I won't get into when that does happen. So the best use of an IM doc will be more complicated patients over FM's head, diagnostic challenges. Most of IM by definition have complicated chronic illness usually secondary to lifestyle factors. Most of that stuff is accumulated with time, hence old people.

Be ready for COPDiabesity, smokers, drinkers, IVDU and EtOH/hep C liver cirrhotics. Diabetes, cardiac conditions, obesity related stuff.

It is outside scope of practice to do any preggos (not allowed) and you don't do much gyn or prenatal counseling, so that cuts out a lot of healthy people you might otherwise see.

Exposure to young in IM is mostly through outpt, some programs are PC oriented with special tracks, otherwise you spend 90% of your time inpt with the gomers.

 

[ACSurgeon]

Hey guys!

So, we're making our 4th year schedules and I've been getting to thinking about specialty interests.

One thing I'm a bit confused about in particular is the patient population in IM.

I had my medicine rotation a few months back and to my surprise, 80% of our floor were elderly patients in very bad health, hearing problems, dementia etc. I rarely connected with the patients, more often than not I was quite detached, and all in all I wasn't a fan. I expect a decent amount of elderly patients, but it seemed that almost all of the patients were elderly and most of them I could not talk to or properly interact with. Some were in such bad health, I just felt like we were fighting a losing battle. I was seriously considering IM before third year started, but this experience was enough for me to not want to do IM at all. I just did not enjoy the patient population. I def prefer seeing a wide age range, which IM did not have.

But before ruling it out, I just wanted to confirm, since I only experienced one hospital.
If I did internal medicine, would the majority of my patients be like this?
Or does the outpatient environment have more alert and healthy adults across a wider age range?
I'm happy caring for elderly patients, but I just didn't expect to just be caring for elderly patients...it felt a bit like geriatrics.

On the other hand, I loved surgery (took care of kids and adults, most of whom were recovering and getting better quick. I felt like we were actually making a different in their health, not just doing damage control like in IM) and am really enjoying pediatrics (also a wide age range, and here we are trying to prevent a lot of the diseases from the start).
Truth be told, I think I enjoy seeing kids, adults AND elderly patients. I just think I'd enjoy dealing with a wide age range. But, I don't like just seeing elderly patients, which is what IM felt like.
Regardless, I have a lot more rotations ahead, so I'm still figuring out what I might like. But I wanted to ask about IM before ruling it out completely.

You mention that you love surgery and then don't elaborate any further. I guess I'm wondering why you're not considering it instead of IM.

Most surgical and procedural specialties will have a significant percentage of their patients have an anatomically correctable problem, which is very gratifying. The training is longer, harder, etc and the lifestyle afterwards is also more difficult but reasonable.

No matter what, you'll have a lot of old people in your practice (except Peds).

 

[alpinism]

If you don't like gomers, don't do IM.

 

[zeppelinpage4]

Wow thank you for all the responses and insightful posts guys! Truly, this was very helpful and eye opening. I needed some other perspectives.

First off, if I am understanding everyone's posts right.
Seems, most of IM are older patients who have complications from lifestyle influenced diseases (COPD, DM2 etc) and my experience is fairly accurate of what most of inpatient IM is like.
However, if in certain locations, like diverse inner cities, or outpatient settings I am likely to see a greater diversity of age, and the elderly patients I would see would be healthier and more interactive with me. Yes?

This actually helps a lot. I don't inherently dislike seeing elderly patients, just not the ones that are so far gone, which the inpatient setting has more of. The older surgical patients I had in good health were great, I talked to them often and saw them get better and it was gratifying.

So I could like IM in certain settings, like the inner city, or outpatient clinics (where there are healthier elderly patients, and a wider age range of patients in general). However, since I'm not sure what practice setting I'll ultimately be in, I feel it's a bit risky to choose IM knowing I might only like it in certain settings?

If only there were a specialty that lined up well with your interests that include seeing all ages and sexes, inpatient, outpatient, many young healthy patients, and in office procedures.

Says the family medicine resident. Don't write it off 😉

Hahaha, so to be 100% honest, I was seriously considering Family Medicine.
My only concern is that I am in the North East and hope to stay here.

I was told Family Medicine sees mostly adults in the North East because most parents here would prefer sending their kids to pediatricians. So, if that's the case, I feel I could just do solely IM, or solely peds, since it would leave the options open to specialize, and I could decide to work inpatient or outpatient hospital settings afterwards.

I honestly thought family med would be ideal for me. I like patient continuity, seeing a varied age group, and I seem to prefer being in outpatient settings (though this could change as I progress in the process). Only, I feel being in the north east, I'd be more limited in the type of patients I saw, and the settings I could work in as a family med doc. But I could be wrong, so if anyone can confirm if my concerns are true or not, I'd appreciate it.

Basically, I need to decide whether to go IM, Peds, or Family Med. I like peds patients more now, but it's partially cause I'm young and relate to the kids a lot now, not sure if I'll feel the same when I'm older. But I think I like interacting with family members, and peds seems to have more of that.
I considered med/peds, but it seems after the all the work, they end up seing mostly IM or mostly peds. And the options to work with both populations are limited, unless they're at a family practice setting.

You mention that you love surgery and then don't elaborate any further. I guess I'm wondering why you're not considering it instead of IM.

Most surgical and procedural specialties will have a significant percentage of their patients have an anatomically correctable problem, which is very gratifying. The training is longer, harder, etc and the lifestyle afterwards is also more difficult but reasonable.

No matter what, you'll have a lot of old people in your practice (except Peds).

Hey lazymed, good observation. So, I was very conflicted with surgery, it was my favorite clerkship so far, but as you mentioned the difficult training and demanding lifestyle is a big factor and I'm not sure if I'm willing to take those on. Surgery had some of my highest most exciting moments of med school, but also some of my toughest. Each day flew by, I felt a rush and sense of excitement that my other clerkships didn't have. But it was also taxing physically and mentally.
I also felt that a lot of what I liked about surgery had to do with the awesome people I was working with and less the surgeries themselves. I had two strong role models and mentors, and actually felt like I bonded with the residents.
I really liked scrubbing into cases, again, it's exciting and I got a rush each time. It felt cool I guess, and getting in there and fixing someone with our own hands was satisfying. But doctors told me that excitement can wear off after the 50th gall bladder running on 4 hours of sleep. And I should only do surgery if it's the only thing I can see myself doing, which is not the case.

Also, the truth is, I don't think I would be competitive for any of the subspecialties. I'm below average in my class, all of my grades are passes (no honors, and my step score is very low (well below average).

But again, I did like it a lot. As you said, solving correctable problems and seeing the results of your work is very gratifying and I really liked that aspect of surgery. Plus, we saw kids, adults, and elderly patients, so there was a good variety of patients. There also seemed to be a sense of comraderie among the surgeons that I didn't quite feel in my other clerkships. They said things like it was, and I felt people were more themselves, so I felt like I fit in with that personality. But much of my good experience was because of the people, which can be different at every hospital.

 

[doc05]

you need to go into family medicine.

and since my advice is so good....

your welcome.

 

[zeppelinpage4]

Update. So....a pediatric resident I spoke with told me that peds heme/onc, or peds cardio doctors are able to follow their child patients into adulthood.
It piqued my interest, since that might give me the continuity of care I like, and I could technically see adults if some of my peds patients stayed long enough.

Is this a fairly common thing? Or do I need to do something like med/peds to follow a patient into adulthood?

Are there other peds specialties aside from heme/onc and cardiology that allow for this type of continuity into adulthood?

If it's feasible, this could be something I'd quite like. I could see kids, and have the opportunity to see a few into adulthood, thus seeing a wide age range.

 

[Psai]

It piqued your interest

 

[zeppelinpage4]

It piqued your interest

Corrected. Thanks.

 

[Siggy]

I just calculated the average age of my program's inpatient list and it came out to 59.

 

[Crayola227]

Just that if your peds adults are complicated enough no one will really want to accept them from you even when you try to pass them off, then you can justify continuing to see them as a pediatrician despite that they are an adult

Conditions that start in early peds are sorta a mystery for a lot of FM'er & IM'ers taking over care, there were some cases I saw of Rett syndrome with a developmental peds doc on rotation, those girls don't live long into adulthood usually but handful do, in any case since he was developmental peds guy he could look at one girl's hand gesturing and tone and say she's not a very bad case, I've had her since she was 4, and "the botox is doing good, time for another round" whereas any FM or IM doc would just have to take his word for it, most docs have never even seen Retts

and you would just be doing heme-onc management, if the kid is 40 and gets an MI you will be consulting out or going outside scope of practice
not every doctor does everything
some heme-onc doctors start to approach being a PCP but it's bad care
same thing happens in ob-gyn

 

[Rocher]

As an IM resident, I would say most of my patients are 60+ but I do see many that are younger, especially on specialty services like GI. I wouldn't say that I'm not able to connect with my old patients though, they are often my favorite patients. Many have some level of dementia but I would say those with deficits so bad that I can't communicate with them are the minority. I'm sure it may vary by hospital though.

I wouldnt say that it is true that family med sees younger patients while IM only sees the elderly. In real life I'd say they are more similar than different. Sure you can see children an a FP but in my experience they still see more elderly patients.

 

[familyaerospace]

Elderly, then obese ppl.

I am neither elderly nor obese.

The internal medicine doctors who lead one of my medical courses said that a general rule where they practice (we're in a well-off city btw) is that internal medicine doctors ONLY see the elderly. Family med doctors see people of all ages. Of course, this might be a general (take that general to be very "loose") statement towards which way the IM field is heading in non rural-ish/non inner-city areas, but I don't know for sure of course.

My general internist in Atlanta who I see as my PCP mostly sees 20s-50s. Not elderly, not obese. A ton of my friends go there. If I end up in internal medicine, I am planning to base my practice off of his since he serves the same underserved community I wish to serve.

 

[Crayola227]

OK, let's make this clear:

With general internal medicine residency training, you CANNOT do obstetrics or see anyone under the age of 12. Period. Unless you had additional training, certification, fellowship, dual boarded, blah blah.

So it's not a question of ONLY seeing elderly, but anyone technically young is out. Once you have eliminated 12 and younger from your clinic as a hard rule, it is sorta hard to recruit the 12-18 yo bracket.

This came up in my FM rotations. How does a young FM attending build a practice? The number one thing that brings young healthy women to the doc is pregnancy, planned or otherwise. The number two thing that brings in young healthy men to a practice? Said female partners. The number three thing that brings young healthy children to a practice? Delivering those babies and seeing them. Outside of those with health literacy doing their duty of yearly preventative PEs or doing health maintenance, most people come to the doctor because something ails them.

As an adolescent I ended up being seen by an internist because my parent was too ill for FM and it was their PCP. Internists try to treat families too. Just not children or preggos. In general adolenscents wasn't a population they advertised for or got referrals for.

Once you understand what the hard rules are, that internists don't do obstetrics or peds, it starts to become a little more apparent that the path of least resistance in an IM practice is going to be older sick people.

To be fair, location and insurance really shapes your patient population outside of what I've mentioned. VA? Keizer? There you go.

Tomorrow I'll post about how billing plays into this.