Straight up IM or subspecialize

[jpro]

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It seems like everyone I know that is interested in IM is really just interested in a specific IM specialty. Who actually wants to do straight up IM? The only thing that would discourage me from going into this field is not being sure I could secure the specialty I wanted. How many people seeking IM feel this way? My guess is most.

 

[doc05]

as a 1st-year student, you have plenty of time to figure this out. as for general IM vs. specialty, the question of being able to get the fellowship of your choice is a good one. general IM sucks. but if you get into a good subspecialty you'll be set. take some time to figure this one out. good luck.

 

[ntmed]

general IM sucks

Maybe you should get a little more prespective before demonstrating your ignorance and insulting other people's choice.

 

[heech]

Uh, I believe you misread doc05's post. He's not the 1st-year student; doc05's referring to the original poster jpro (UT Houston class of 2008). Looking at doc05's past posts, he's probably a surgical resident (or beyond).

 

[jpro]

I am a 1st year, but I still would like to know if people go into IM primarily for the subspecialties because I have yet to meet anyone that wants to do straight up IM.

Maybe its time to take off that UT Houston c/o 2008 sig?

 

[SmallTownGuy]

It would certainly be risky to go for somethings super competitive like cards or GI if you would not be happy in general IM. I myself am debating between specialty and general now. I always wanted cards, but I am recently engaged and a ready to get out there, make some bucks, and get on with my life.

I would also encourage you to investigate what specialties are like in private practice, especially before you listen to general statements such as "general IM sucks". For example, many people at my school told me that family medicine had a horrible lifestyle, with 12 hour days and lots of call. When I did my rotation at a hospital based practice, however, the docs worked 8-5 M-Th and did not take call, since a hospitalist program was in place. They were paid about 130,000 plus bonuses for this. Not too bad!

I think that many people (not necessarily saying you doc05) who say that IM is bad do so because of the endless rounding, long days, etc that they see on rotations. Private practice is not like this, necessarily. Perhaps they just want more money, but this is relative. Just my two cents.

BTW, there are people out there who actually want to do general IM. In the future, I may be one of them. 🙂

 

[doc05]

I think that many people (not necessarily saying you doc05) who say that IM is bad do so because of the endless rounding, long days, etc that they see on rotations. Private practice is not like this, necessarily. Perhaps they just want more money, but this is relative. Just my two cents.

actually, the academic focus of rounding is one of the few good things about IM. Private practice general IM is incredibly boring. And the patients' incedible lack of respect toward their docs is striking. Not to mention the fact that HMOs put the squeeze on anyone who's a PCP, which limits their ability to actually help their patients. Many of my friends and classmates are going into IM; and every single one of them is looking toward a fellowship.

 

[cubby]

I'm planning, at least for now, on doing general IM. Yeah, so it may not be considered a hot shot field, but it all depends on what you are looking for in a career. I get a bit weary sometimes of short-sighted people bagging on other fields of medicine. They can do it if they choose, it's no skin of my back, but in my judgment it just isn't very professional. Everybody has different interests, different backgrounds, and sees the world through a different lens...so how can a reasonable person generalize and bag on another field just because it isn't right for him or her?

Anyways, enough on that. I like general IM because it's what I've always seen myself doing, ie my "mentor" MD prior to medical school was a wonderful general internist who I really looked up to, I wanted to become a physician like him, and medical school did not deter me from that. I place a high value on long term relationships with patients, and think that a good primary care doc can make a load of difference in the lives of individuals, not only from a treatment standpoint, but especially from a preventive medicine standpoint. General IM docs also have a great opportunity to serve underserved populations (like many specialties, for that matter), both abroad but also at here at home, which is a big interest of mine. Yes, general internists can work very hard, and don't get paid as much as others, and may not have the respect as a specialties as do other. If those things bother you, you may want to choose a different field. Yes, they often tend to take care of sick, older people, who are often on lots of meds...but think that over..."sick, older people, who are often on lots of meds"...who else needs a careful, caring MD more than those people? There's something fulfilling to me about helping someone "coast into the port" gracefully. IMO, I think there are some great things about being a general internist. The bottom line...do what is best for you, talk to lots people about it both in and out of the field, and be careful whose opinions you listen to--only consider those from people you know and trust.

 

[AJM]

I've noticed that there's been a lot of hating on general IM on this board recently, and that may have caused you to think that it's a terrible field. In fact, I think that a lot of the negative posts about it are way off from actual reality.

There will always be bitter physicians that you meet in every specialty. That's never going to change. However, if you meet more than one bitter physician in a single specialty, you may have a tendency to think that everyone in that specialty hates their field. This in fact is a huge overgeneralization.

I know tons of general internists, and the vast majority of them are very happy and satisfied with their work. In fact, the only really bitter ones I've come across have been the older physicians, because they've had the hardest adjustment to all the HMOs, PPOs, etc. The younger internists don't notice this as much because they were trained in this kind of atmosphere from the beginning of med school, and don't know any different. Now the personality of general internists as a whole tend to be a bit different than the subspecialists as a group. (yes, I know, now I'm the one about to make a huge generalization...). As a group, internists tend not to have much of a need to feed their egos, they like to establish and build long-term relationships with their patients, and they really enjoy the intellectual and academic aspects of medicine.

As far as the previous comment about patients not respecting their primary care doctor, that is very far from the truth. Sure, there are patients who don't respect their PCP, but for every 1 of those, you have 10 that do respect their internist. Often, they will respect their PCP more than subspecialists that they see because they get to know their PCP so much better, and develop a stable relationship. This builds trust, which is very important in health care delivery. In fact, on many occasions, I've had my primary care continuity patients see me in clinic and say, "I saw this cardiologist/vascular surgeon/rheumatologist/(fill in the blank), and he said x, y, z. But I'm not sure I believe them -- what do you think, doctor?" I usually agree with the subspecialists, but it's funny - only after they hear me give my approval would they think the subspecialist knew what they were talking about! 🙂 Sometimes they will even wait to fill out the prescriptions the subspecialists gave them until they get the thumbs up from me. I actually had one patient who I sent to a neurosurgeon for a certain problem. The neurosurgeon wanted to operate, but the patient put off the surgery for a month until he saw me back in clinic to see if I would approve of going ahead with the surgery!


But the original question was if anyone does IM residency with plans to be a generalist. The answer is yes. Lots of people do. There are many people in my residency program who are planning on doing general IM, and I'm at a specialist-heavy program. Nationwide, only about 40% of IM residents go on to subspeicalty fellowships, which means that 60% don't. There are lots of people out there who start their IM residency with plans to do primary care. As it is in medical school, though, people's preferences change with time and experience. I have classmates who started out in the primary care track, who are now going into GI, and classmates who thought they wanted to do cards who have since decided to be generalists.

Don't worry too much about what your fellowship chances would be in IM. If you are at a reputable program and do well, you would be able to get into a fellowship.

 

[cubby]

A very good post, AJM. Articulate and spot on. Thanks.

 

[SmallTownGuy]

actually, the academic focus of rounding is one of the few good things about IM. Private practice general IM is incredibly boring. And the patients' incedible lack of respect toward their docs is striking. Not to mention the fact that HMOs put the squeeze on anyone who's a PCP, which limits their ability to actually help their patients. Many of my friends and classmates are going into IM; and every single one of them is looking toward a fellowship.

I would say that private practice IM is boring TO YOU, doc05. Some may enjoy it. Different strokes for different folks, agreed?

I brought up the rounding issue, because many students (especially those going it more acute fields like anesthesiology and EM) tell me that they could not be a internist because of the constant rounding that they do. Very few internists round in the way that we do in medical school.

BTW, just out of curiousity, what is your level of experience? Student? Resident? Have you had any exposure to IM other your med school rotation? Have you worked in a private internist office? How do you know that it is boring and that all the patients don't respect the internists?

 

[Hova2005]

AJM and Cubby - great posts! 👍

 

[jpro]

The only problem I have with general IM is that most patients are reffered to speciallists if there is a major problem. Now I don't have a lot of experience with general IM being an MS1, but so far that is my impression. I came into medicine to help people not to refer them to someone that can help them. I guess my original point would be that I want to be the physician that patients rely on for treatment and not for a referal. That is why I don't think I would be happy if I didn't get into Heme/Onc, Cards, Nephrology, ect... or some subspecialty where I was the one providing the treatment for major problems. This has been my impression from most people interested in IM, myself included.

 

[v-tach]

The only problem I have with general IM is that most patients are reffered to speciallists if there is a major problem. Now I don't have a lot of experience with general IM being an MS1, but so far that is my impression. I came into medicine to help people not to refer them to someone that can help them. I guess my original point would be that I want to be the physician that patients rely on for treatment and not for a referal. That is why I don't think I would be happy if I didn't get into Heme/Onc, Cards, Nephrology, ect... or some subspecialty where I was the one providing the treatment for major problems. This has been my impression from most people interested in IM, myself included.

That's the impression I get as well. However, I've heard that if you go to a more rural area you get to do a lot more because the specialists aren't as readily available.

 

[cubby]

The only problem I have with general IM is that most patients are reffered to speciallists if there is a major problem. Now I don't have a lot of experience with general IM being an MS1, but so far that is my impression. I came into medicine to help people not to refer them to someone that can help them. I guess my original point would be that I want to be the physician that patients rely on for treatment and not for a referal. That is why I don't think I would be happy if I didn't get into Heme/Onc, Cards, Nephrology, ect... or some subspecialty where I was the one providing the treatment for major problems. This has been my impression from most people interested in IM, myself included.

You are right, jpro, that general IM docs do make a lot of referrals when certain problems come up that are more "complicated," that's just the medical culture we're in today...a lot of experts. The definition of "major problem," to use your term, is very relative though...it sounds like your definition of a "major problem" is in terms of degree of complication, or need for referal; but a "major problem" could also be defined based on prevalence (ie HTN), chronicity (ie DM), long-term disability, cost, etc.

I think this general doc/subspecialty set-up is both good and a bad for various reasons--it does break up the consistency of care that most patients and many docs value. But, according to me, thank goodness that subspecialties exist! People, even MD's, are only so smart, especially with all of the new knowledge and technology pouring into all fields of medicine today. How could a general IM doc, or any doc for that matter, possibly stay current with the latest and greatest, not to mention detailed and complicated, research in cardiology and heme/onc and nephrology and GI and critical care and geriatrics all at the same time? It's just not possible--we'd do nothing but read. So we refer. One of my mentors gave me this useful perspective...docs in each field are only trained to handle about 20 medical problems really, really well. They just don't have the mental and intellectual capacity, nor the time to stay current, to handle more than 20 problems REALLY WELL (meaning current, evidence-based, standard-of-care practice). This mentor is a world-renowned GI doc. He said that he has a great handle on his 20 problems, just as cardiology buddies have a great handle on their 20 different problems, just as general IM docs have a great handle on their 20 problems. So between all of the subspecialties and their "20 problems," we can as a whole pretty much cover everything. But we need each other...subspecialists need general docs, and general docs need subspecialists. And, yes, general IM docs, like all subspecialties, do have their own set of problems that they are pretty much better at addressing than anyone else, such as hypertension, hyperlipidemia, diabetes, CHF, mild/moderate depression, etc. Important, very prevalent problems that may not be "major," per se, in the sense that they require referral, but they may indeed be "major" in terms of prevalence, cost to the health care system, and life-threatening consequences if not managed appropriately. Sure, each of these "general" problems could technically be treated by a subspecialist, but not everybody can see a subspecialist for everything--that's why we need good, competent general IM docs to take care of the bulk of common illness, and even some mild/moderate cases of the more difficult illnesses, prior to referral to a subspecialist. Also, it's often general docs that serve the needs of the underserved, as many of the underserved have basic primary care needs.

So my point in this ramble--know that general IM docs are not just referral machines...they do treat patients. They just are experts at treating different problems than a cardiologist or gastroenterologist is. And they need to have a good handle on all of the subspecialties so that they can know when to refer for certain illnesses in order to provide more expert care. So...use medical school (2nd year, wards, mentors, etc.) to pick the "20 problems" that most interest you, that give you the biggest "buzz"...then go with it!

 

[ReMD]

One of the fastest growing specialties in medicine is being a hospitalist. Many of my collegues are getting offers up to $200,000 to start, not including bonuses, straight after 3 yrs of IM. They work 5 days on and 5 days off, 12 hour shifts, with up to 10 weeks vacation time. No clinic, no overhead, no worry about pts showing up to clinic appts, a never-ending supply of business, no staff members calling in sick, etc, etc. And having the ability to refer is a good thing. That takes away a lot of liability issues. If someone has CP you consult Cards. Now they are responsbile. Same for GI bleed. It's nice to have those options. Gen Internal med has many more options than you think.

 

[Informer]

What do you all think if FP then? If someone decides to stay general, why not hit FP, that way you can see peds AND OB while being a hospitalist at the same time.

 

[AJM]

What do you all think if FP then? If someone decides to stay general, why not hit FP, that way you can see peds AND OB while being a hospitalist at the same time.

Not everyone wants to see kids and OB. Many people in IM, like me, are much more comfortable treating patients over the age of about 40, and don't even want to touch the OB or pediatric patients. It's all a question of which patient population you prefer.

Plus, one of the draws of IM over FP is that because you are focusing on a single patient population, you gain a much better in-depth knowledge of how to deal with their medical conditions, and you become much more adept and comfortable with dealing with the highly complicated patients. This is especially an advantage if you want to be a hospitalist - IM docs have much more inpatient training than FP.

 

[augmel]

This is a great thread. I have a couple thoughts. This discussion has focused on what a general internist can treat, but a lot of folks like IM for the diagnostic work. A general internist can have a lot more fun than most subspecialists in that respect. I'd rather diagnose the vasculitis than be the rheumatologist figuring out the cytoxan, prednisone, whatever else regimen. Of course, the really rare stuff will be diagnosed by the rheum folks or whoever but the generalist gets first crack at it. A great IM guy at my school says "sure we can use the GI guys to do our scope for us but we can do everything else for the patient." Slight exageration and granted he is smarter than most, but you get the point. I love medicine cause no matter what subspecialty you do, everyone is an internist at the core and shares a common knowledge base. And remember, you decide what to refer. Take everything you are comfortable with and refer the rest.