Primary Care Internal Medicine

[sys71082]

Why go into Internal Medicine Primary care instead of Family Medicine? I understand that IM PC focuses on adults while FM sees all patients but in an interview when asked this question, what is a good way to answer without putting down other specialties. Can I simply say I would prefer to gain in depth knowledge of adult medicine in a primary care setting. or is that too general of an answer?

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[jdh71]

Why go into Internal Medicine Primary care instead of Family Medicine? I understand that IM PC focuses on adults while FM sees all patients but in an interview when asked this question, what is a good way to answer without putting down other specialties. Can I simply say I would prefer to gain in depth knowledge of adult medicine in a primary care setting. or is that too general of an answer?

That seems like a reasonable explanation, I might also add that since your interest is the adult population would get MORE formal training in adults doing IM, than having to dilute your adult training with pediatrics and obstetrics.

 

[IM2GI]

That seems like a reasonable explanation, I might also add that since your interest is the adult population would get MORE formal training in adults doing IM, than having to dilute your adult training with pediatrics and obstetrics.

You also have the option to subspecialize when you realize how much primary care sucks.

 

[jdh71]

You also have the option to subspecialize when you realize how much primary care sucks.

True. Though some people do like primary care. With the right set up could be a decent gig.

 

[IM2GI]

True. Though some people do like primary care. With the right set up could be a decent gig.

I didnt mind having a half day a week of it, but full-time primary care, seeing 20-30 patients a day, would be instant burn out to me. I give good PCPs all the credit in the world, very hard job. Much harder than being a sub specialist.

 

[Raryn]

IM gives you a lot more training in how to care for sick (as opposed to well) patients. And you don't spend significant portions of your residency doing things like peds, Ob, surgery electives.

And you have the option to change your mind. As opposed to family med, who really don't have fellowship opportunities (except a few very specific cases).

 

[CarlATHF]

I am going into IM with the intent of going into outpatient primary care. I chose IM over FM because I knew I never wanted to see kids or do OB stuff anymore, as well as the fact that you will get more exposure to the subspecialties of IM and provide you with the ability to take care of more complex patients as their PCP. You can use your elective time to "make up" some of the outpatient experiences that FM usually gets, like outpatient GYN, derm, etc.

 

[sys71082]

Thanks for the responses! I agree with everything being said, but to word it in a way that an interviewer will like and that doesnt put other specialties down, I really like what CarlATHF said about getting more exposure to the subspecialties of IM so that I can care for more complex adult patient cases . jdh71 also made a point along the same line. thanks again everyone

 

[trickster123]

personally, I think FM would be better if you FOR SURE wanted to do primary care...as this gives exposure to peds, ob/gyn, and DERM, plus maybe some sports med...because primary care are gate keepers to the specialists, you'll probably make urself more marketable in the private practice world having a more general knowledge base --> have a larger POTENTIAL patient base to take care of...idk just some information I got from many friends who chose FM instead of primary IM for these reasons

 

[235009]

personally, I think FM would be better if you FOR SURE wanted to do primary care...as this gives exposure to peds, ob/gyn, and DERM, plus maybe some sports med...because primary care are gate keepers to the specialists, you'll probably make urself more marketable in the private practice world having a more general knowledge base --> have a larger POTENTIAL patient base to take care of...idk just some information I got from many friends who chose FM instead of primary IM for these reasons

the reimbursements are much lower for treating kids than they are for treating adults and OB so time consuming (running to the hospital to do deliveries). You can get all the derm exposure you want at a good IM residency (ex: do an elective in it). FM is only a good choice if you REALLY can't decide between IM and peds ....and even then you should probably do med-peds instead. From the OB standpoint your scope of practice is the same as that of a midwife and in IM you can do all the GYN you're comfortable doing. There is more of a focus on minor procedures in FM but if you want to you can get that training in IM too.

to answer the original question: you almost certainly will not be asked "why not FM" ....you will however be asked "why IM"

 

[jdh71]

personally, I think FM would be better if you FOR SURE wanted to do primary care...as this gives exposure to peds, ob/gyn, and DERM, plus maybe some sports med...because primary care are gate keepers to the specialists, you'll probably make urself more marketable in the private practice world having a more general knowledge base --> have a larger POTENTIAL patient base to take care of...idk just some information I got from many friends who chose FM instead of primary IM for these reasons

No. All of that DILUTES your training in ADULT primary care.

Primary care physician are in DEMAND, so all you need a is pulse, a desire to do primary care, and record that is reasonably clean of hookers and cocaine

Also, God made dermatologists to diagnose and treat skin disease. That's why they exist.

 

[keindo]

No. All of that DILUTES your training in ADULT primary care.

Primary care physician are in DEMAND, so all you need a is pulse, a desire to do primary care, and record that is reasonably clean of hookers and cocaine

Also, God made dermatologists to diagnose and treat skin disease. That's why they exist.

One should not exceed two (2) hookers and three (3) cocaines monthly, averaged over any twelve (12) month period. Of note, this should be no problem because on a PCP salary one can rarely afford more than 1 hooker OR 1.5 cocaines.

 

[babdoc]

Something that I didn't see above: hospital privileges. Most don't/can't see pts in the hospital after FM residency--whether it's the hospital's decision or their own. Though it's becoming more uncommon, traditional IM (hospital + clinic) can be very interesting and rewarding...but also very tiring

 

[WaylonS]

The way it was pitched to me, in an unopposed FM residency, you'll learn more procedures than you would as an IM who does primary care

 

[IM2GI]

The way it was pitched to me, in an unopposed FM residency, you'll learn more procedures than you would as an IM who does primary care

Unopposed? You mean a place with only FM and no IM? Probably a pretty weak hospital if that is the setup.

What procedures? Vasectomy? You really want to be doing those in your outpatient office as a PCP?

 

[WaylonS]

Unopposed? You mean a place with only FM and no IM? Probably a pretty weak hospital if that is the setup.

What procedures? Vasectomy? You really want to be doing those in your outpatient office as a PCP?

I'm not going into primary care, but at the unopposed residency I did my rotation at, yeah, vasectomies, colonoscopies (yes, I'm serious), derm biopsies, joint injections, IUD/implanon insertions, c-sections (again, I'm not joking). Also, while not a procedure, the FM residents got a lot of specific psych training

The issue of the inpatient training not being good misses the point: if you want to be a hospitalist, you should go into IM. If you want to have the opportunity to spend several months doing inpatient peds, IM, and CCM, FM may be a better option. Let's be honest: an FM is not going to manage the high risk OB patient, the pt with a weird derm condition, or the post-BMT pt with a mystery fever, however, by having a broad knowledge, the FM should develop the intuition of when to pass a patient off to a specialist.

 

[IM2GI]

I'm not going into primary care, but at the unopposed residency I did my rotation at, yeah, vasectomies, colonoscopies (yes, I'm serious), derm biopsies, joint injections, IUD/implanon insertions, c-sections (again, I'm not joking). Also, while not a procedure, the FM residents got a lot of specific psych training

The issue of the inpatient training not being good misses the point: if you want to be a hospitalist, you should go into IM. If you want to have the opportunity to spend several months doing inpatient peds, IM, and CCM, FM may be a better option. Let's be honest: an FM is not going to manage the high risk OB patient, the pt with a weird derm condition, or the post-BMT pt with a mystery fever, however, by having a broad knowledge, the FM should develop the intuition of when to pass a patient off to a specialist.

Interesting. I think the parts of the country where a FM doc would be able to perform C-sections and Colonoscopies would be very limited. In todays medicolegal climate, Im not sure I would be comfortable doing such procedures without subspecialty training. Complications happen...

In a very rural area without local access to specialists, I could see that being valuable.

 

[WaylonS]

Interesting. I think the parts of the country where a FM doc would be able to perform C-sections and Colonoscopies would be very limited. In todays medicolegal climate, Im not sure I would be comfortable doing such procedures without subspecialty training. Complications happen...

In a very rural area without local access to specialists, I could see that being valuable.

Exactly, the program I rotated at was a rural program that was interested in training FM docs to work in rural areas where specialists don't want to live. I realize that this is by no means typical of FM training, but opportunities to have a relatively broad scope of practice in FM are possible in the right circumstances

 

[VA Hopeful Dr]

Unopposed? You mean a place with only FM and no IM? Probably a pretty weak hospital if that is the setup.

What procedures? Vasectomy? You really want to be doing those in your outpatient office as a PCP?

Incorrect. What that means is that the residents usually get more exposure to the sicker patients because there's no medicine team to take them instead. The majority of family doctors are trained in such places.

And, generally speaking, FM residencies have better training at outpatient procedures just like IM residencies do more inpatient procedures than FM. Compared to my internist wife, I did much more minor skin stuff, joint injections, and GYN procedures while she did many more central lines, intubations, and various centesises (is that the correct plural of centesis?)

 

[babdoc]

and various centesises (is that the correct plural of centesis?)

I think you forgot the silent q



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[xenotype]

Also, God made dermatologists to diagnose and treat skin disease. That's why they exist.

They frequently take months to actually take a referral appt due to insufficient numbers, frequently do not accept your patient's insurance, or don't exist at all in more rural areas.

Many FM docs cannot get their patients derm referrals, so they handle the issues themselves. This is commonplace, and most FM residencies emphasize taking care of 80-90% of dermatologic issues yourself.

As much as you might hate it or refuse to believe it, there are FM docs that are fulltime hospitalists, doing colonsocopies, handling high risk surgical OB, and managing their patients in community ICUs.

Not being able to do routine gyn procedures, handle common derm complaints, and do non-operative management of common orthopedic problems are serious detractors from doing an IM PC residency. Especially with the current trend of concierge clinics- you need to be able to handle issues in-house as much as possible to provide value for your patients.

 

[jdh71]

They frequently take months to actually take a referral appt due to insufficient numbers, frequently do not accept your patient's insurance, or don't exist at all in more rural areas.

Many FM docs cannot get their patients derm referrals, so they handle the issues themselves. This is commonplace, and most FM residencies emphasize taking care of 80-90% of dermatologic issues yourself.

As much as you might hate it or refuse to believe it, there are FM docs that are fulltime hospitalists, doing colonsocopies, handling high risk surgical OB, and managing their patients in community ICUs.

Not being able to do routine gyn procedures, handle common derm complaints, and do non-operative management of common orthopedic problems are serious detractors from doing an IM PC residency. Especially with the current trend of concierge clinics- you need to be able to handle issues in-house as much as possible to provide value for your patients.

I don't know why I'd hate any of that. You can train anybody to do just about anything. So what. I guess it's game time to name some outliers and declare then victory? If you don't want to dilute your adult training with kids and pregnancy, you're going to want to do IM. The FP's elbow deep in anus notwithstanding.

 

[rokshana]

As much as you might hate it or refuse to believe it, there are FM docs that are fulltime hospitalists, doing colonsocopies, handling high risk surgical OB, and managing their patients in community ICUs.

.

sorry, i have seen this and its a bit scary…most FMs (at least on the east coast) get very little training in the way of ICU (where i trained, the FM residents did one month of MICU and one month of SICU, that's it) and unless they have done a hospital medicine fellowship, don't seem to be that prepared to handle the icu and very keen on consulting practically every subspecialty for an inpt admission.

 

[VA Hopeful Dr]

sorry, i have seen this and its a bit scary…most FMs (at least on the east coast) get very little training in the way of ICU (where i trained, the FM residents did one month of MICU and one month of SICU, that's it) and unless they have done a hospital medicine fellowship, don't seem to be that prepared to handle the icu and very keen on consulting practically every subspecialty for an inpt admission.

It is very program dependent, there's no doubt about that. My admittedly biased experience has been that unopposed FM residencies tend to be heavier on the inpatient/ICU than opposed ones. In my 3 years, I did 13 months of inpatient where we followed all our of own ICU patients - I think my final talley was over 150 ICU patients. Now I know that's nothing compared to what you IM folks do, but its generally a lot more than what the FMs as the opposed programs I interviewed at were doing.

As for pan consulting, the IM hospitalists at my current gig do the same thing so that's hardly a unique FM problem.

 

[VA Hopeful Dr]

I don't know why I'd hate any of that. You can train anybody to do just about anything. So what. I guess it's game time to name some outliers and declare then victory? If you don't want to dilute your adult training with kids and pregnancy, you're going to want to do IM. The FP's elbow deep in anus notwithstanding.

The question then becomes, are we losing enough adult training to make any appreciable difference? I think in the outpatient world the answer is a resounding no. Inpatient is a different story.

 

[jdh71]

The question then becomes, are we losing enough adult training to make any appreciable difference? I think in the outpatient world the answer is a resounding no. Inpatient is a different story.

Again. If you don't want to deal with kids and pregnancy? Just out patient adults . . .

Let's me just beg the question that when it comes to the out-patient adult population, the ambulatory training is the same, if this is the case and a person doesn't want to have to deal also with kids and pregnancy, then the answer is easy.

 

[WaylonS]

Again. If you don't want to deal with kids and pregnancy? Just out patient adults . . .

Let's me just beg the question that when it comes to the out-patient adult population, the ambulatory training is the same, if this is the case and a person doesn't want to have to deal also with kids and pregnancy, then the answer is easy.

There actually are FM programs that contain the minimum amount of peds and OB/GYN required for accreditation so that the residents can focus on adults and still get exposed to outpatient procedures/psych.

 

[VA Hopeful Dr]

Again. If you don't want to deal with kids and pregnancy? Just out patient adults . . .

Let's me just beg the question that when it comes to the out-patient adult population, the ambulatory training is the same, if this is the case and a person doesn't want to have to deal also with kids and pregnancy, then the answer is easy.

Well sure, if you don't want to take care of kids or OB ever again than doing an FM residency is just stupid.

 

[gutonc]

Well sure, if you don't want to take care of kids or OB ever again than doing an FM residency is just stupid.

Which has been jdh's point all along. But all the replies are "but you can do a butt-o-scope, C-section and cirumcision if you train in FM instead". Screw that...I got people for that crap.

 

[VA Hopeful Dr]

Which has been jdh's point all along. But all the replies are "but you can do a butt-o-scope, C-section and cirumcision if you train in FM instead". Screw that...I got people for that crap.

Well there is, at least in my geographical area, a trend towards more experience in FM residencies in terms out outpatient procedures - even minor stuff like joint injections and skin stuff so one could make the argument that (at least in the Southeast) an FM trained doc is able to do more for his/her adult patients without referrals.

That said, its certainly not worth doing peds and OB in residency just to get a little better at shooting up knees and shoulders.

 

[DIce3]

Young medical students are drawn like flies to a bug light to the allure of "do it all."


1a.) An FP can only do OB well if the practice is mostly OB. To remain solid in operative obstetrics, which is required to really do obstetrics safely, the case load must remain high. Period. There is no getting around this.
1b.) If the OB case load is high, the internal medicine case load will be low, resulting in a weaker skill set in internal medicine. The only way around this is to work 80 hours a week in practice, but your spouse will divorce you.
1c.) Doing FP to do obstetrics makes very little sense as long as a residency in obstetrics exists.

2.) Doing FP instead of med/peds to practice med/peds is a proclamation that you are much smarter than a med/peds resident, who really does need the 4 years to become competent at the practice of med/peds.
You are so good that you can do it in 2.5 years and be just as competent.

3a.) The average end of year PGY3 internal medicine resident will crush the average end of year PGY1 internal medicine resident in the ability to manage the complicated adult patient.
3b.) The average end of year PGY3 internal medicine resident will crush the average end of year PGY3 family medicine resident in the ability to manage the complicated adult patient.
3c.) The average end of year PGY3 pediatric resident will crush the average end of year PGY3 family medicine resident in the ability to manage the complicated pediatric patient.
3d.) The average end of year PGY4 obstetrics resident will crush the average end of year PGY3 family medicine resident in the ability to manage the complicated obstetric patient.
3e.) If you disagree with this logic, the average end of year PGY3 family medicine resident may be equally able to manage complicated patient compared to a PA or ARNP.

4.) Choosing FP to shave off a skin tag or inject a knee is nonsense as ARPNs and PAs are truly capable of these tasks, as opposed to managing complicated patients.

5.) You care because you will compete with midlevels for patients and need a skill set that is superior to theirs. Taking care of the nearly healthy patient with skin tags is done by midlevels.

 

[VA Hopeful Dr]

The ignorance of this post is astounding. My comments in bold...

Young medical students are drawn like flies to a bug light to the allure of "do it all."


1a.) An FP can only do OB well if the practice is mostly OB. To remain solid in operative obstetrics, which is required to really do obstetrics safely, the case load must remain high. Period. There is no getting around this.
1b.) If the OB case load is high, the internal medicine case load will be low, resulting in a weaker skill set in internal medicine. The only way around this is to work 80 hours a week in practice, but your spouse will divorce you.
1c.) Doing FP to do obstetrics makes very little sense as long as a residency in obstetrics exists.
This is patently untrue. Most rural FPs do obstetrics, adult medicine inpatient and outpatient, and a reasonable number do peds and they do it all fairly well. Now, even as an FP I would rather my wife have her OB care with an OB but that's not always possible. In fact, most of the FPs that still deliver babies do so because there isn't enough of a need for a full time OB/GYN.

2.) Doing FP instead of med/peds to practice med/peds is a proclamation that you are much smarter than a med/peds resident, who really does need the 4 years to become competent at the practice of med/peds.
You are so good that you can do it in 2.5 years and be just as competent.
I don't think very many FPs will argue that med/peds have us beat in certain areas. Those areas are usually inpatient for both adults and kids, especially ICU.
3a.) The average end of year PGY3 internal medicine resident will crush the average end of year PGY1 internal medicine resident in the ability to manage the complicated adult patient. I would certainly hope so
3b.) The average end of year PGY3 internal medicine resident will crush the average end of year PGY3 family medicine resident in the ability to manage the complicated adult patient. Crush? No, I don't think so. 3rd year IM residents will obviously have a deeper understanding of adult medicine but I don't think the gap is as wide as you think it is.
3c.) The average end of year PGY3 pediatric resident will crush the average end of year PGY3 family medicine resident in the ability to manage the complicated pediatric patient. I won't argue this one, but then very few general pediatricians handle much on their own once things get complicated anyway. Their referral threshold is much much lower than an equally experienced internist.
3d.) The average end of year PGY4 obstetrics resident will crush the average end of year PGY3 family medicine resident in the ability to manage the complicated obstetric patient. Agreed
3e.) If you disagree with this logic, the average end of year PGY3 family medicine resident may be equally able to manage complicated patient compared to a PA or ARNP. That's just pure horse****, and I find the fact that you think this quite insulting. I have worked with a decent number of midlevels between residency and practice and I have yet to meet one that has anywhere close to my knowledge and skills, and I don't even think I'm in the top 3rd of family doctors out there.

4.) Choosing FP to shave off a skin tag or inject a knee is nonsense as ARPNs and PAs are truly capable of these tasks, as opposed to managing complicated patients.
You can train a monkey to do most procedures in medicine, its knowing when/when not to do it and managing complications that sets MDs apart from midlevels
5.) You care because you will compete with midlevels for patients and need a skill set that is superior to theirs. Taking care of the nearly healthy patient with skin tags is done by midlevels.

If a patient would rather have a midlevel than a physician, keeping in mind that the fee is usually the same, that's perfectly fine with me. There are more than enough patients to go around.

 

[IM2GI]

The ignorance of this post is astounding. My comments in bold...


If a patient would rather have a midlevel than a physician, keeping in mind that the fee is usually the same, that's perfectly fine with me. There are more than enough patients to go around.

I think the problem is that most of us have trained at large academic University hospitals with both IM and FM departments, as well as every subspecialty. In this environment, FM really does suffer. The FM department will refuse admissions that are "too complicated" and push them to IM, and with so many other subspecialties their exposure really hurts. Sure you can do a month with OB, a month in the ICU, etc, but is that really any better than a glorified sub-I?

FM really shines as you mentioned, in hospitals with no IM department, in small rural communities. That is the only practice environment where having a jack of all trades really can be useful to the community.

 

[VA Hopeful Dr]

I think the problem is that most of us have trained at large academic University hospitals with both IM and FM departments, as well as every subspecialty. In this environment, FM really does suffer. The FM department will refuse admissions that are "too complicated" and push them to IM, and with so many other subspecialties their exposure really hurts. Sure you can do a month with OB, a month in the ICU, etc, but is that really any better than a glorified sub-I?

FM really shines as you mentioned, in hospitals with no IM department, in small rural communities. That is the only practice environment where having a jack of all trades really can be useful to the community.

I can definitely get behind that idea. My wife, as I've mentioned before, is an IM resident at university-affiliated community shop with the basic residencies (IM, FM, peds, surgery, OB, ortho, psych, med/peds). She'll come home from a night on call with some story about what their FM residents did and I'm always blown away by some of the crap they pull - like refusing admissions as you pointed out. I actually get a little bit self-conscious at residency events with her because I know what everyone there is used to seeing from family medicine.

 

[rokshana]

Well there is, at least in my geographical area, a trend towards more experience in FM residencies in terms out outpatient procedures - even minor stuff like joint injections and skin stuff so one could make the argument that (at least in the Southeast) an FM trained doc is able to do more for his/her adult patients without referrals.

That said, its certainly not worth doing peds and OB in residency just to get a little better at shooting up knees and shoulders.

just an fyi..in IM residencies…you are required to do joint injections (as well as LPs, paracenteses, thorocenteses, a lines as well as central lines)…don't really think its an advantage of FM to do these procedures.

 

[IM2GI]

just an fyi..in IM residencies…you are required to do joint injections (as well as LPs, paracenteses, thorocenteses, a lines as well as central lines)…don't really think its an advantage of FM to do these procedures.

Can we stop beating up on this poor guy? Im sure he knows what procedures IM docs do. Are there unique situations where FM might make sense for someone? Sure. Let's leave it at that.

 

[jdh71]

I think VA already admitted that there is probably a palpable difference in the in-patient side of the equation with regard to adults. But he also probably also had a legitimate claim that in the out-patient setting FP is just as good and perhaps at times arguably "better".

Anyone can get good at what they do.

My point that got the the whole argument started, was simply that all things bring equal, if you don't want to see the kids or the OB it was an easy choice.

 

[jdh71]

And in my humble opinion ambulatory medicine is God's work. I'm always blessed the presence of good out patient docs from either IM or FP and I've seen non-thinking idiots from both as well. A good primary care physician is worth their weight in gold, twice. And we all know it too.

 

[VA Hopeful Dr]

just an fyi..in IM residencies…you are required to do joint injections (as well as LPs, paracenteses, thorocenteses, a lines as well as central lines)…don't really think its an advantage of FM to do these procedures.

I am aware of that. I'm also aware, again at least in my geographical area, that FM residents do lots more of the outpatient procedures like joint injections compared to the IM residents. Conversely, the IM residents do lots more of the inpatient procedures.

The end result: I can out joint injection 90+% of IM residents but you guys can out central line and intubate me easily.

 

[VA Hopeful Dr]

And in my humble opinion ambulatory medicine is God's work. I'm always blessed the presence of good out patient docs from either IM or FP and I've seen non-thinking idiots from both as well. A good primary care physician is worth their weight in gold, twice. And we all know it too.

Ugh, I wish everyone thought that. My wife's hospitalist job for this fall is paying her 80k more than I'm pulling doing outpatient.

 

[jdh71]

Ugh, I wish everyone thought that. My wife's hospitalist job for this fall is paying her 80k more than I'm pulling doing outpatient.

I think we all think it, it just becomes so much more hard to compensate for it. Hospital stays are much bigger bills as we all know. Hospitalists are just getting a small piece of that action for another relatively thankless job. Out patient you really gotta hustle.