What do you like/dislike the most about general internal medicine?

[CTR]

I would appreciate comments from anyone, whether or not they are interested in (or practicing) general IM. Thanks!

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[drfunktacular]

One of the major downsides IMO: it is harder to be a good general internist than to be a competent subspecialist, BUT the perception is that it is easy so you get much less respect and $$$.

Hence nurse practitioners think they can do what a general internist does as well or better for $90k, and insurance companies like the sound of that; bad recipe for the future of general medicine.

 

[CTR]

I'm asking because I may possibly go into general IM and was curious to know what others may like (or not like) about this line of work. Personally I think it would be nice because there is a wide variety of cases you can see, and you don't have to do pediatrics or obstetrics like you would in FM. Before committing to any specialty, though, I'd like to know both the good and the bad associated with that area of medicine. I know a lot of internists like to subspecialize, but if anyone here knows anything about general IM I'd love to hear from you!

 

[jdh71]

Out patient work ups are a pain in the ass.

Noncompliance. Most of our new "quality" measures ate completely dependent on the patient being a good boy.

Documentation for billing is killing medicine.

Problem personality types you have to keep seeing again and again and again because you are the doorway to everyone else.

I also agree with the above, it's simply easier to be a competent, even good, or excellent sub specialist than it is to be a good general internist.

 

[gutonc]

I also agree with the above, it's simply easier to be a competent, even good, or excellent sub specialist than it is to be a good general internist.

True 'dat. There are several reasons I went for the research pathway and one of them is that it took me about 3 months to be as good of a sub-specialist as I had become a generalist in 2 years of IM training. General IM is hard and the fact that it gets paid less than sub-specialties is borderline criminal.

Many is the time I wish it was kosher for an IM sub-specialty service to call an IM generalist consult to ask, "WTF is up with this case? I can explain A, B and most of C but D-R are a total mystery to me."

Instead, I wind up asking 5 other sub-specialists to weigh in on D-R while the folks who are really good at seeing A-R (not to mention S-Z which I've been ignoring to this point since they're stable) are sitting around dealing with yet another boring COPD exacerbation.

 

[lipstikisntfood]

For me the most frustrating thing about inpatient IM is that it tends to serve as a dumping ground, usually inappropriately so. This may vary by institution, but I think it is relatively common for patients whose primary issue is surgical/orthopedic/neurologic/neurosurgical to be admitted to medicine after the appropriate service is consulted and refuses primary responsibility for the patient. IM residents are stuck doing a lot of scut while the actual patient management is run by the consulting service. Obviously this is not ideal for patient care, and takes time and attention away from patients with actual IM problems. Although I would still choose IM again, I wish someone had told me about this ongoing problem earlier in my career.

 

[drfunktacular]

It's a shame how things change... internists nowadays are what GP's were 30 years ago. An internist back in the day was the master of the difficult case, and often functioned as a consultant who was only turned to when a patient was extremely sick or complicated or baffling.

Now they're just trying to grind out 40+ patients a day in clinic (the simpler the better) to stay afloat--and meanwhile spending hours per day on the phone with insurance cos, consultants, patients, etc, all of which is unpaid.

 

[drfunktacular]

For me the most frustrating thing about inpatient IM is that it tends to serve as a dumping ground, usually inappropriately so. This may vary by institution, but I think it is relatively common for patients whose primary issue is surgical/orthopedic/neurologic/neurosurgical to be admitted to medicine after the appropriate service is consulted and refuses primary responsibility for the patient. IM residents are stuck doing a lot of scut while the actual patient management is run by the consulting service. Obviously this is not ideal for patient care, and takes time and attention away from patients with actual IM problems. Although I would still choose IM again, I wish someone had told me about this ongoing problem earlier in my career.

This is true, but it's only annoying in residency, when you are wasting your time on non-medicine cases you don't learn anything from. In practice it's great because you are just babysitting while the urologist gets around to doing what they want to do, and each day you write the same progress note is more $$$. Also, for many of our patients nowadays who have multiple ongoing medical comorbidities (DM, CAD, HTN, COPD, etc), they really are probably better off being managed by an internist while the technicians come in to do what they're trained to do and then get their hands off.

 

[drfunktacular]

Documentation for billing is killing medicine.

This is so true. I weep for this.

 

[Music MD]

Documentation for billing is killing medicine.

Which specialties have limited amounts of paperwork? I really hate filling out useless forms that no one will ever care about.

 

[jdh71]

Which specialties have limited amounts of paperwork? I really hate filling out useless forms that no one will ever care about.

You can't get out of paperwork anywhere in medicine. But surgical specialties don't have the same documentation issues that medicine does since they get paid as a package deal for an entire procedure (ie. cholecystetomy for one example) as opposed to medicine which has to document pretty specifically to get maximal billing.

 

[WorkaholicsAnon]

It's a shame how things change... internists nowadays are what GP's were 30 years ago. An internist back in the day was the master of the difficult case, and often functioned as a consultant who was only turned to when a patient was extremely sick or complicated or baffling.

Now they're just trying to grind out 40+ patients a day in clinic (the simpler the better) to stay afloat--and meanwhile spending hours per day on the phone with insurance cos, consultants, patients, etc, all of which is unpaid.

Yeah it's crazy, this has always been a huge pet peeve of mine. That sort of practice does not lend itself to thoughtful work or quality medicine. Something has got to change with the system--I know people dont really want to work this way but ultimately are compelled to by the system, in order to meet their overhead costs and make at least a little money to support their families. As such, residency training has evolved to encourage and reward this sort of thinking (or rather lack thereof 😛) and this sort of conveyer belt, checklist practice style.

This is not the kind of medicine I envisioned practicing when I decided to become a physician, and I REFUSE to succumb. And thus will not under any circumstance in this day and age do primary care (even though I'd enjoy it--the way I would have wanted to practice). Even hospitalist work is keeping me on edge that way, constantly having to fight the pressure to do quick superficial work.