Should many IM subspecialties follow the neurology model?

[W19]

---

Members don't see this ad.

I just finished an away neuro rotation at a big academic center and I worked with an older doc who told me that neuro was an IM subspecialty like GI/Cardio?HemOnc/ID/AI etc... Then they switched to 1-year IM prelim or categorical with the 1-year IM prelim incorporated... (not sure when that happened though)

I might be wrong here, but do ID/GI/HemOnc etc.. docs require 3-year IM residency...? Cant it be only 1 or even 2 years and then they can sub-specialize.

 

[PlutoBoy]

Yes

 

[NeurologyHopeful2018]

I just finished an away neuro rotation at a big academic center and I worked with an older doc who told me that neuro was an IM subspecialty like GI/Cardio?HemOnc/ID/AI etc... Then they switched to 1-year IM prelim or categorical with the 1-year IM prelim incorporated... (not sure when that happened though)

I might be wrong here, but do ID/GI/HemOnc etc.. docs require 3-year IM residency? Cant it be only 1 or even 2 years and then they can sub-specialize.

Of course they should - you only need basic foundational IM to practice one organ system. That is why you have a primary care team (both inpatient and outpatient) and a specialist consult.

 

[ortnakas]

I get the argument, but one of the things I like about IM is that it gives me the option of subspecializing or not. I think a lot of people pick IM because it has that leeway. Picking a specialty after MS3 is hard enough— it would be even trickier to settle on a subspecialty.

Other factors:
—I’d be interested to hear from attendings on if they think PGY-2s are ready to train as sub-specialists in their fields
—I think you’d see a lot of unmatched applicants trying to go straight to GI and cardio

 

[W19]

I get the argument, but one of the things I like about IM is that it gives me the option of subspecializing or not. I think a lot of people pick IM because it has that leeway. Picking a specialty after MS3 is hard enough— it would be even trickier to settle on a subspecialty.

Other factors:
—I’d be interested to hear from attendings on if they think PGY-2s are ready to train as sub-specialists in their fields
—I think you’d see a lot of unmatched applicants trying to go straight to GI and cardio

I am as well.... But I saw early PGY-3 running the floor without attendings' input..

 

[Mad Jack]

You'd be surprised how much ordinary medicine a lot of subspecialists and specialists end up needing to know or do. There's been a lot of stuff that just would have been missed without that larger knowledge base that I've seen over the past year, it's crazy how useful general IM ends up being.

 

[W19]

The same was said for neurology...

I would love to hear what cardio/GI etc... docs have to say.

 

[Espressso]

I can see the argument for GI... but even that would really benefit with an solid IM base.

for heme/onc and ID.. microbes and infections can occur within any organ system and in any corner of the body. Cancers can metastasize basically anywhere. As a ID or heme/onc specialist, you should have an extremely strong IM base because these sub specialties are whole-body.

Just my opinion

 

[Lawpy]

I think cards, GI and heme/onc should become residencies and their subspecialties should become fellowships. A 1 year internal medicine internship is more than enough for their purposes.

 

[nanobot1]

I think cards, GI and heme/onc should become residencies and their subspecialties should become fellowships. A 1 year internal medicine internship is more than enough for their purposes.

I disagree. To practice any of those subspecialties you need to have a strong foundation in Internal Medicine. Plus there is a lot of overlap between all of the subspecialties. It would be hard to separate them out. All these organ systems closely interact with each other. Having a background in other fields would be helpful.

 

[AlbinoHawk DO]

I just finished an away neuro rotation at a big academic center and I worked with an older doc who told me that neuro was an IM subspecialty like GI/Cardio?HemOnc/ID/AI etc... Then they switched to 1-year IM prelim or categorical with the 1-year IM prelim incorporated... (not sure when that happened though)

I might be wrong here, but do ID/GI/HemOnc etc.. docs require 3-year IM residency...? Cant it be only 1 or even 2 years and then they can sub-specialize.

Absolutely. Someone correct me if I'm wrong, but I was under the impression at one point Cardiology was 1 year IM with 3-4 years cardio.

 

[Lawpy]

I disagree. To practice any of those subspecialties you need to have a strong foundation in Internal Medicine. Plus there is a lot of overlap between all of the subspecialties. It would be hard to separate them out. All these organ systems closely interact with each other. Having a background in other fields would be helpful.

You can make this argument for any specialty. I mean, a strong knowledge in IM also results in excellent performance in surgery shelf exams! And strong performance in Step 1 translates into doing well in IM. IM is already a foundation for medicine.

It's important to realize that those fellowships are the hardest to get and those who do get them already have a strong medical knowledge from medical school days. And these fellowships require a lot of productive research in their fields early on.

A one year IM internship is more than enough, and cards, GI and heme/onc can become residencies with competitiveness similar to neuro, if not closer to derm.

 

[nanobot1]

You can make this argument for any specialty. I mean, a strong knowledge in IM also results in excellent performance in surgery shelf exams! And strong performance in Step 1 translates into doing well in IM. IM is already a foundation for medicine.

It's important to realize that those fellowships are the hardest to get and those who do get them already have a strong medical knowledge from medical school days. And these fellowships require a lot of productive research in their fields early on.

A one year IM internship is more than enough, and cards, GI and heme/onc can become residencies with competitiveness similar to neuro, if not closer to derm.

^That's a stretch. You are assuming everyone who goes into those 3 subspecialties already have their strong foundation from medical school days. Therefore they are set on path to go straight into residencies of those particular subspecialties. Plus many do not get enough exposure to those subspecialties until 4th year electives and rotations during residency.

 

[SunsFun]

I am probably in the minority, but I am not a big fan of any early specialization. I like a system where you get trained and certified in some form of general medicine/surgery/peds and after spending couple of years practicing apply to subspecialty training.

 

[Lawpy]

^That's a stretch. You are assuming everyone who goes into those 3 subspecialties already have their strong foundation from medical school days. Therefore they are set on path to go straight into residencies of those particular subspecialties. Plus many do not get enough exposure to those subspecialties until 4th year electives and rotations during residency.

Right, but the problem lies at the medical school level that should be fixed. I don't think strong, clinically prepared students should be required to take a separate IM residency to do what they already want to do.

Consider an MD/PhD student focusing heavily on cancer research with plans to go onto oncology. Consider another MD/PhD student whose research was on neuroscience and wants to go into neurology. The neuroscience student has shorter overall training time than the oncology student. In a way, it feels like the oncology student is wasting 3 years before they can pursue what they want to do.

There is an advantage to IM residency but that's mainly for strong academic IM residency programs that allow for lots of productive research and networking opportunities to prepare their residents for excellent fellowships. Spending 3 years at MGH is definitely worth it to match into MSKCC even for MD/PhD oncology students.

Getting into those residencies is extremely difficult for most students but they also select for the strongest and most prepared students for further career development. That's a different reason entirely for what many seem to argue for IM residencies.

In theory, my only argument is if neuro/derm/anesthesia residents are fine with 1 year IM residency, I think so can those who want to do cards, GI or heme/onc. I mention those three mainly because they are the most competitive specialties to pursue and already selects for talented residents. Might as well try to narrow down the training time.

Another option is for every med school to adopt a 1 year preclinical/3 year clinical model, but that's a separate matter for another day.

 

[Redpancreas]

It should follow the integrated model of surgical subspecialties. Let us know we have matched Cardiology out of medical school. Complete 1 year of pure IM, a second year that’s similar to PGY-2 IM year but with a Cardiology focus (extra month in CICU or something), and then 3/4/5 should be fellowship. They’re actually starting this in some places but admission is given once in residency, not before. I think shaving two years off is harder.

 

[drdpmn]

I’m interested in Endocrinology but 3-4 years of residency plus 2-3 fellowship seems crazy, especially considering that the salary averages are lower than, or roughly equivalent to, primary care. I know the IM background is valuable for endo, but it really discourages me from pursuing it.

 

[W19]

It should follow the integrated model of surgical subspecialties. Let us know we have matched Cardiology out of medical school. Complete 1 year of pure IM, a second year that’s similar to PGY-2 IM year but with a Cardiology focus (extra month in CICU or something), and then 3/4/5 should be fellowship. They’re actually starting this in some places but admission is given once in residency, not before. I think shaving two years off is harder.

It's good there are a few places that started doing that... If enough places do it, that might push the people in charge to make some changes to the whole system. There is no reason for something like ID/AI/Rheum to be 5 years... 2-year IM and 2-year of these sub-specialties should be enough IMO.

 

[YoungDoc25]

Genuine question that may come across wrong, but how is it any different than surgical sub specialties (plastics, thoracic, vascular, etc) where you have the option to match integrated or pursue gen surg and then specialize? There’s not a difference in their skills pertaining to their sub specialty is there? They just have a more flexible career path from what I understand...?

 

[mehc012]

It should follow the integrated model of surgical subspecialties. Let us know we have matched Cardiology out of medical school. Complete 1 year of pure IM, a second year that’s similar to PGY-2 IM year but with a Cardiology focus (extra month in CICU or something), and then 3/4/5 should be fellowship. They’re actually starting this in some places but admission is given once in residency, not before. I think shaving two years off is harder.

As someone planning on going into surgery, I actually hate this setup. It's hard enough to settle on a specialty in med school, but for surgical subs, you have to somehow find your own experience of them (if you want to decide early enough to actually prepare an app), you're limited in what you get to actually rotate through before you apply, and it just generally fragments everything and makes it more of a pain. The early specialization of surgical subspecialties is basically the biggest drawback of deciding you want to do surgery.

 

[mehc012]

Genuine question that may come across wrong, but how is it any different than surgical sub specialties (plastics, thoracic, vascular, etc) where you have the option to match integrated or pursue gen surg and then specialize? There’s not a difference in their skills pertaining to their sub specialty is there? They just have a more flexible career path from what I understand...?

Most of the ones that have integrated match end up converting almost entirely over pretty quickly...it's almost less flexible, because you have to decide earlier (in med school) because the gen surg → fellowship pathways eventually disappear.

 

[Anti-PD1]

Wasn't cardiothoracic surgery previously 5+ years of gen surg + 3 years of fellowship? Could take a decade.

Now it's integrated to 6 years. Doesn't seem too much of a leap for heart surgery:

Integrated Thoracic Surgery Residency Programs | TSDA

I'd argue most neurosurgery programs have enough volume and autonomy to be 5 years. But some don't, and there's the ACGME research requirement so, it's 7 years.

 

[YoungDoc25]

Most of the ones that have integrated match end up converting almost entirely over pretty quickly...it's almost less flexible, because you have to decide earlier (in med school) because the gen surg → fellowship pathways eventually disappear.

Gotcha. That makes sense. I guess my the flip side to that is that there’s a decent number of applicants though that would not do their surgical subspecialty if they had to do gen surg first. I feel like that’s pretty similar to some potential applicants on having to do IM for 3 years before getting to do cards/GI/whatever.

 

[sliceofbread136]

In my opinion the neurology model sucks balls. Many neurologists I know certainly could have used an extra year of that generalist training and mis-manage non neuro issues badly. I also wish neuro was open to me after finishing my categorical training however that is actually difficult to accomplish

 

[Redpancreas]

As someone planning on going into surgery, I actually hate this setup. It's hard enough to settle on a specialty in med school, but for surgical subs, you have to somehow find your own experience of them (if you want to decide early enough to actually prepare an app), you're limited in what you get to actually rotate through before you apply, and it just generally fragments everything and makes it more of a pain. The early specialization of surgical subspecialties is basically the biggest drawback of deciding you want to do surgery.

If you don’t want to do it, you could still apply the normal way instead of making everyone do it per your preferences. I’ve known I’ve wanted to do IM and subspecialize for a while.

 

[mehc012]

If you don’t want to do it, you could still apply the normal way instead of making everyone do it per your preferences. I’ve known I’ve wanted to do IM and subspecialize for a while.

The 'normal way' is the integrated pathways. And it's not such a simple switch as you're trying to make it sound. Neuro, ENT, Uro...all but impossible to change to later. Plastics, Cards, Vascular...getting harder every year. You generally can't just apply the old way.

If you don't want to have a discussion about how people have different preferences and how there are pros and cons to each, don't participate in a thread about 'is option 1 better than option 2'. It's great that you know exactly which subspecialty you want, but many people don't. So the pros are, with the integrated model, some people save a few years. The cons are that it adds more stress and uncertainty into choosing a specialty. Both are valid; you can weigh them differently, but they're both worth bringing up in the thread.

TL;DR there are pros and cons to each; please try not to make it personal. My pointing out the cons doesn't mean I'm 'making everyone do it per my preferences', anymore than you wanting to save a few years means the converse.

 

[sliceofbread136]

The 'normal way' is the integrated pathways. And it's not such a simple switch as you're trying to make it sound. Neuro, ENT, Uro...all but impossible to change to later. Plastics, Cards, Vascular...getting harder every year. You generally can't just apply the old way.

If you don't want to have a discussion about how people have different preferences and how there are pros and cons to each, don't participate in a thread about 'is option 1 better than option 2'. It's great that you know exactly which subspecialty you want, but many people don't. So the pros are, with the integrated model, some people save a few years. The cons are that it adds more stress and uncertainty into choosing a specialty. Both are valid; you can weigh them differently, but they're both worth bringing up in the thread.

TL;DR there are pros and cons to each; please try not to make it personal. My pointing out the cons doesn't mean I'm 'making everyone do it per my preferences', anymore than you wanting to save a few years means the converse.

Switching to neuro is possible following a categorical, I’d put it in the getting harder every year category

 

[Redpancreas]

The 'normal way' is the integrated pathways. And it's not such a simple switch as you're trying to make it sound. Neuro, ENT, Uro...all but impossible to change to later. Plastics, Cards, Vascular...getting harder every year. You generally can't just apply the old way.

If you don't want to have a discussion about how people have different preferences and how there are pros and cons to each, don't participate in a thread about 'is option 1 better than option 2'. It's great that you know exactly which subspecialty you want, but many people don't. So the pros are, with the integrated model, some people save a few years. The cons are that it adds more stress and uncertainty into choosing a specialty. Both are valid; you can weigh them differently, but they're both worth bringing up in the thread.

TL;DR there are pros and cons to each; please try not to make it personal. My pointing out the cons doesn't mean I'm 'making everyone do it per my preferences', anymore than you wanting to save a few years means the converse.

This thread was about IM subspecialties and the ‘normal’ way I am referring to is the current IM PGY3+3 being converted to PGY-5 and I guess made a comparison you latched onto. I don’t really know much about surgery and hardships you face, but that’s hardly the point here. Voicing opposition to an efficient model based on your preferences in addition to the fact that you’re talking about a different field doesn’t make sense.

 

[sliceofbread136]

If you don’t want to do it, you could still apply the normal way instead of making everyone do it per your preferences. I’ve known I’ve wanted to do IM and subspecialize for a while.

The thing is that a lot of us don’t know, and when a field switches to the pgy-5 then the amount of programs offering a 3 year fellowship starts to dwindle. I wish ideally we could offer both routes, but seems like the way things end up shaking out it stays one way or the other

 

[Redpancreas]

The thing is that a lot of us don’t know, and when a field switches to the pgy-5 then the amount of programs offering a 3 year fellowship starts to dwindle. I wish ideally we could offer both routes, but seems like the way things end up shaking out it stays one way or the other

That’s a good point actually.

 

[YoungDoc25]

The thing is that a lot of us don’t know, and when a field switches to the pgy-5 then the amount of programs offering a 3 year fellowship starts to dwindle. I wish ideally we could offer both routes, but seems like the way things end up shaking out it stays one way or the other

Do you think something like what IR has with ESIR would work? Allow applications during second year, start a 3 year cardiology “fellowship” pgy-3 through pgy-5, and then get out a year early. If you still don’t know or don’t get a spot, you could still reapply the following year.

 

[sliceofbread136]

Do you think something like what IR has with ESIR would work? Allow applications during second year, start a 3 year cardiology “fellowship” pgy-3 through pgy-5, and then get out a year early. If you still don’t know or don’t get a spot, you could still reapply the following year.

I think it would be great, and to my knowledge pedi neuro used to have this however as each year goes by fewer and fewer non-5 year program spots go out (whether to upcoming pgy-3s or 4s).

I also think a big problem with people leaving a program before pgy-3 is that residency loses a senior resident which can be tough.

So places do offer straight to a fellowship after 2 years for people with strong research backgrounds in a certain subject, so maybe this could be expanded on?

Honestly there isn’t a great answer, I like the 3+3 system but I can see why it’s frustrating for someone who is already set on a specialty

 

[mehc012]

This thread was about IM subspecialties and the ‘normal’ way I am referring to is the current IM PGY3+3 being converted to PGY-5 and I guess made a comparison you latched onto. I don’t really know much about surgery and hardships you face, but that’s hardly the point here. Voicing opposition to an efficient model based on your preferences in addition to the fact that you’re talking about a different field doesn’t make sense.

It's a direct analogy given that surgical subspecialties used to be set up as "residency + fellowship → subspecialty" and now it has largely converted to an integrated "intern year + subspecialty training" model...exactly the same transition that is being talked about in this thread for IM subspecialties. It is exactly the point here, as was brought up by another poster earlier (the one I was responding to originally).

Voicing opposition to the 'efficient model' makes perfect sense in a thread that is essentially titled "should IM specialties follow the efficient model?" The OP asked a question, and discussing the cons of the 'efficient model' is a perfectly valid response to that.

You haven't made a comparison yet; you've just thrown a tantrum about other people having opinions rather than actually taking other perspectives into consideration like an adult.

 

[mehc012]

That’s a good point actually.

This is exactly the point I was making in my posts, if you'd bothered to comprehend the parallels.

 

[YoungDoc25]

I think it would be great, and to my knowledge pedi neuro used to have this however as each year goes by fewer and fewer non-5 year program spots go out (whether to upcoming pgy-3s or 4s).

I also think a big problem with people leaving a program before pgy-3 is that residency loses a senior resident which can be tough.

So places do offer straight to a fellowship after 2 years for people with strong research backgrounds in a certain subject, so maybe this could be expanded on?

Honestly there isn’t a great answer, I like the 3+3 system but I can see why it’s frustrating for someone who is already set on a specialty

Good point. Especially losing senior residents. I’m not sure hospitals would be too fond of that. Definitely no easy answer!

 

[nanobot1]

I’m interested in Endocrinology but 3-4 years of residency plus 2-3 fellowship seems crazy, especially considering that the salary averages are lower than, or roughly equivalent to, primary care. I know the IM background is valuable for endo, but it really discourages me from pursuing it.

LOL. That is like saying I want to do Pediatric Cardiology minus the pediatrics residency part.

 

[mcloaf]

As someone planning on going into surgery, I actually hate this setup. It's hard enough to settle on a specialty in med school, but for surgical subs, you have to somehow find your own experience of them (if you want to decide early enough to actually prepare an app), you're limited in what you get to actually rotate through before you apply, and it just generally fragments everything and makes it more of a pain. The early specialization of surgical subspecialties is basically the biggest drawback of deciding you want to do surgery.

Gotcha. That makes sense. I guess my the flip side to that is that there’s a decent number of applicants though that would not do their surgical subspecialty if they had to do gen surg first. I feel like that’s pretty similar to some potential applicants on having to do IM for 3 years before getting to do cards/GI/whatever.

This. Many of the people I know going into categorical surgical subs realized pretty early that they did not have much interest in doing general surgery. If I had to do 5+ years of general surgery before I could start doing the stuff I'm actually interested in I probably would've just said **** it and applied to something else in medicine--a sentiment I think is pretty common among people doing surgical subs. Learning to manage sick general surgery patients as an intern on the floor is going be useful, but I don't see a lot of value in spending years learning operations I will never perform again for pathology I don't find interesting.

 

[mehc012]

This. Many of the people I know going into categorical surgical subs realized pretty early that they did not have much interest in doing general surgery. If I had to do 5+ years of general surgery before I could start doing the stuff I'm actually interested in I probably would've just said **** it and applied to something else in medicine--a sentiment I think is pretty common among people doing surgical subs. Learning to manage sick general surgery patients as an intern on the floor is going be useful, but I don't see a lot of value in spending years learning operations I will never perform again for pathology I don't find interesting.

Right...as I said, there are pros and cons. I'm currently stuck here with no idea what I want to do with my life and no prospect of actually getting any experience in the subspecialties I think might interest me, and even if I take my time and find a way to half-assedly explore the top 3 or 4 subspecialties, that leaves 5 or so where I don't even have that much exposure, never mind the actual Gen Surg fellowships I'd love to explore. And I've spent more time shadowing and in the OR than anyone else I know in my class. So I'm glad that a lot of people are happy enough jumping in blind, but I'd rather spend the extra years getting myself to somewhere I know I want to go than make an ill informed decision based on gut feeling and no experience, and then spend half as much time training in a specialty I may or may not actually end up liking at the end of the day when I see reality. I've seen so many people change their minds about what they like throughout med school, and honestly even that is usually heavily biased just based on the culture of the rotations at one particular institution. Then you throw in the surgical subs where they often never end up seeing it at all and it's utterly terrifying.


Now, that's surgery. The training is pretty damn long, and includes a lot of specific procedures that as you said, you won't need to know in your subspecialty. But for IM? Where even the 'long' option isn't as long, and the foundation you're laying is 'how to medically manage patients'? Sorry, but that con isn't weighing as hard, imo.

 

[DoctwoB]

The problem with this idea of making IM subspecialties totally separate is that the patients in said fields are highly complex not just in one particular organ system. Cancer patients often have multi-system organ problems related to their disease and underlying medical conditions. Patients with renal failure or severe CAD or heart failure almost by definition have many other medical problems. Given that most medical subspecialties admit their own patients (with some exceptions), saying 1 year of medicine is enough to handle all of that seems misguided. The alternative approach would be to have IM admit all these patients with subspecialists as consultants only, but that runs into major communication problems when someone is admitted to a service who isn't driving the primary focus of their care.

The increased specialization of medicine is a negative thing in many ways, and in my experience a patient is better served by one or a few doctors who have general training and can meet their needs reasonably well then by a team of subspecialists for every organ system.

 

[Wordead]

Neuro residents have dog**** medical knowledge. Which is fine for them but I dont think would translate well for cards id onc etc

 

[siliso]

I’m interested in Endocrinology but 3-4 years of residency plus 2-3 fellowship seems crazy, especially considering that the salary averages are lower than, or roughly equivalent to, primary care. I know the IM background is valuable for endo, but it really discourages me from pursuing it.

So the benefit isn’t more money, it’s being an endocrinologist (or nephrologist or geriatrician or ID doc) instead of a general internist if you like that option better. 5 years in total not half bad. I can’t imagine all these subspecialty departments wanting to take on the general medical training of their now-fellows with all the attendant administrative and organizational tasks, but who knows what the future could hold. Also being on the other end of training I just don’t see many folks finishing intern year ready to go be a fellow.

Also it seems that dedicated neurology residency programs have existed since at the 1940s, not that there has been any recent decoupling. The separate board of psych and neuro formed 1934.

 

[Drrrrrr. Celty]

I think having something similar to what psych has for child psychiatry i.e 3 years of adult psych then do 2 years of child psych and get dual boarded should be an option tbh. Ex 2 years IM + 2 years of endo for 4 years instead of 3 years IM + 2 years endo.

 

[LebronManning]

I think a better alternative would be to keep the 3 year IM residency but allow the 3rd year to be flexible in that you can start fellowship that year. If one does not choose to do fellowship the 3rd year would be required but if one is doing fellowship the leadership skills and IM 6th sense learned in 3rd year IM is not necessary.

I do however think 2 years of IM is required for Cards, H/O, and GI because even with their specific focus they are much more dependent on full body physiology than is Neurology.

 

[W19]

I think a better alternative would be to keep the 3 year IM residency but allow the 3rd year to be flexible in that you can start fellowship that year. If one does not choose to do fellowship the 3rd year would be required but if one is doing fellowship the leadership skills and IM 6th sense learned in 3rd year IM is not necessary.

I do however think 2 years of IM is required for Cards, H/O, and GI because even with their specific focus they are much more dependent on full body physiology than is Neurology.

I agree... Some people in this thread are only focusing in 1-yr IM preliminary... But the other alternative can be that they can make the system more flexible by giving people the option of starting their fellowship as PGY3 and let residents who want to do IM to complete their IM PGY3.

 

[raiderette]

So the benefit isn’t more money, it’s being an endocrinologist (or nephrologist or geriatrician or ID doc) instead of a general internist if you like that option better. 5 years in total not half bad. I can’t imagine all these subspecialty departments wanting to take on the general medical training of their now-fellows with all the attendant administrative and organizational tasks, but who knows what the future could hold. Also being on the other end of training I just don’t see many folks finishing intern year ready to go be a fellow.

Also it seems that dedicated neurology residency programs have existed since at the 1940s, not that there has been any recent decoupling. The separate board of psych and neuro formed 1934.

Considering that Endo, rheum, nephrology often have unfilled spots, the switch would make those fields more desirable.

 

[drdpmn]

So the benefit isn’t more money, it’s being an endocrinologist (or nephrologist or geriatrician or ID doc) instead of a general internist if you like that option better. 5 years in total not half bad. I can’t imagine all these subspecialty departments wanting to take on the general medical training of their now-fellows with all the attendant administrative and organizational tasks, but who knows what the future could hold. Also being on the other end of training I just don’t see many folks finishing intern year ready to go be a fellow.

Perhaps, but in most specialties there’s some degree of additional compensation for additional training and delayed earnings. Considering that there seems to be a shortage of endocrinologists, at least in my area, I think making a modest change to maybe 4 years total would make the field a lot more desirable.

 

[siliso]

The additional compensation I think comes from reimbursement structures for procedural vs E&M billing, under present payment models at least. Thus why you can (for now) bank more driving scopes than managing T1DM, not because it takes an extra 1 year (it’s nothing in the scheme of things) to finish GI than endo.

But if you don’t want to drive scopes and you don’t want to practice GIM (why not ) but you do want to be an endocrinologist - the baseline of a more than decent living is there for any and all of them. Long term satisfaction counts as much or more if the baseline is there and there are still plenty willing to defer gratification for a year or two for satisfaction’s sake.

 

[AthleteDoc7]

It should follow the integrated model of surgical subspecialties. Let us know we have matched Cardiology out of medical school. Complete 1 year of pure IM, a second year that’s similar to PGY-2 IM year but with a Cardiology focus (extra month in CICU or something), and then 3/4/5 should be fellowship. They’re actually starting this in some places but admission is given once in residency, not before. I think shaving two years off is harder.

Does anyone know which programs currently exist that do this?! Mainly wondering about cardio

 

[MSTP18]

IM-Research track residencies already have people starting their fellowships in PGY-3 so it seems pretty reasonable from a clinical competency standpoint to only require 2 years of IM residency. You could have either "non-research short tracks," or as someone else suggested, making it a flexible, post-match decision with IM w/o fellowship requiring a 3rd year of supervised general IM practice prior to board certification and IM + fellowship being 2 years of IM + fellowship which would mean >3 years of supervised practice so it feels like there's an obvious consistency in requiring at least 3 years of supervised practice to be board certified in internal medicine. If someone completes one year of fellowship and then decides not to continue for any reason they could still sit for IM boards but not the fellowship one obviously.

 

[Money Moniker]

I guess placing stents is literally the hardest task any human can ever hope to accomplish, as it takes an insane 16 years* of post high school "education" before one is allowed to do it for a living.

With that said, I can completely understand why the people who've gone through the traditional pipeline have no interest in changing it for the benefit of medical students. Length of training is one of the factors used to justify reimbursement, and cuts in training length would surely be used to justify cuts in reimbursement. If you're a practicing physician who had to throw away years of his life under the existing system, why would you want to eat the reimbursement cuts that would follow shortening the pathway when you'd not benefit from said shortening? I sure wouldn't.

Hell, you better believe I'm completely opposed to shortening the length of medical school to 3 years or doing away with the college requirement, for that very same reason. I already paid full price for this sheit. I don't want the deal to be renegotiated so that the "cost" of pursuing medicine is lowered at the expense of lessening the financial reward, since I'd only eat the latter and not benefit from the former.

*(4 college+4 med school +3 IM +3 cards +2 interventional cards).