What made you decide internal med instead of family med?

[novacek88]

I think we're all in agreement on that.

I'm not going to turn your "quantity" argument around and suggest that FM can take better care of outpatients because we spend more time doing that in residency compared to IM, because that would be wrong. I don't really think one can accurately make blanket statements that apply to inpatients, either, based solely on whether one trained in IM or FM. There are too many individual variables.

So it's wrong to suggest that one has more expertise in something because they have more experience doing it? If that's a blanket statement then yes I'm making one.

FM can also function as ER physicians. Do you also feel it's possible for FM to be as adept as physicians who completed a formal residency in emergency medicine despite spending significantly less time in the emergency room during residency?

And yes, as an example, I do think FM are more proficient in dealing with OB/GYN related cases than IM because they have more experience with that. I don't have anything against Family Medicine. My only argument is with those who feel Family Medicine specialists have the same expertise and training regarding inpatient care as Internal Medicine specialists. You have your own set of unique skills and so do we.

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[Mumpu]

Let's not forget that most internists are coming out of academic programs. Most FPs are coming out of private hospital settings. I'm sure a major tertiary center exposes its trainees to more acute, sick, and rare cases than Mom's Diner and Hospital.

Given the costs of OB malpractice insurance, I wonder what the true take-home is for FPs catching babies.

Like Novacek said, the professions have their unique skillselts.

 

[deleted87716]

Given the costs of OB malpractice insurance, I wonder what the true take-home is for FPs catching babies.

Most of the income figures you've seen quoted are after expenses, which would include malpractice insurance.

 

[sophiejane]

Most of the income figures you've seen quoted are after expenses, which would include malpractice insurance.

I know an FP who was recently offered a starting salary of $200K by a regional healthcare system in an underserved area because he has strong OB skills. The hospital pays his malpractice.

It's economics, supply and demand. A lot less people are going into FM, and as the demand grows, so will the reimbursement.

 

[novacek88]

Let's not forget that most internists are coming out of academic programs. Most FPs are coming out of private hospital settings. I'm sure a major tertiary center exposes its trainees to more acute, sick, and rare cases than Mom's Diner and Hospital.Given the costs of OB malpractice insurance, I wonder what the true take-home is for FPs catching babies.

Good point, I actually saw a patient with necrotizing fasciitis. Are you telling me that a FP resident at Mom's Diner and Hospital has seen anything close to something as obscure as that outside of a Robbins text. Maybe FM resident at unopposed programs engage in much inpatient care but these programs are not held at large academic tertiary centers that provide the same level of acute and diverse patients.

In regards to your second part, What hasn't been mentioned is that most FP with OB/GYN practice in rural areas. In the last decade, a significant number of FP in metropolitan areas have dropped OB from their practice because the demand wasn't there to justify the cost of paying the hefty malpractice insurance. Specialists tend to congregate in large cities so FP face an uphill battle in trying to establish a successfull OB practice due to the competition from OB/GYN groups. Now, I'm sure Sophie will mention an FP who does OB in Beverly Hills that earns 500K but the general principle still stands. Yes, there are FP who practice OB in large cities but many of these physicians are older and established their practice a long time ago and the relatively young FP/OB took significant risk and time to establish the OB facet of their practice. So if you are considering living in a major metropolitan city, realize that practicing OB as an FP is not a very realistic option/

 

[zippy81]

Good point, I actually saw a patient with necrotizing fasciitis. Are you telling me that a FP resident at Mom's Diner and Hospital has seen anything close to something as obscure as that outside of a Robbins text. Maybe FM resident at unopposed programs engage in much inpatient care but these programs are not held at large academic tertiary centers that provide the same level of acute and diverse patients.
/

Actually saw a case of it a few weeks ago. I'm at a large regional hospital that gets a variety of diseases in an unopposed FM program. I've quickly learned you don't have to be in academia tripping over fellows and dealing with rude nurses to be trained well. Whether its FM, IM or peds you can get a quality education from community programs if you do your research and find the good ones.

 

[deleted87716]

Good point, I actually saw a patient with necrotizing fasciitis. Are you telling me that a FP resident at Mom's Diner and Hospital has seen anything close to something as obscure as that outside of a Robbins text.

I saw three cases in residency, actually. Which proves...nothing.

Regional medical center, unopposed FM program.

One of 'em was Fournier's...really nasty.

I've also diagnosed a case of Addison's disease, which means I'll probably never see another one.

Still haven't found a pheo yet, but not for lack of trying.

Sounds like you'd enjoy Zebra Cards...got a birthday coming up?

 

[AJM]

Good point, I actually saw a patient with necrotizing fasciitis. Are you telling me that a FP resident at Mom's Diner and Hospital has seen anything close to something as obscure as that outside of a Robbins text. Maybe FM resident at unopposed programs engage in much inpatient care but these programs are not held at large academic tertiary centers that provide the same level of acute and diverse patients.

Nec fasc is actually not that obscure -- while uncommon, it's seen relatively regularly, both in community hospitals and major academic centers, and the incidence is growing. The initial management has to be done at the center the patient presents to, so a lot of these patients don't get transferred to academic centers. BTW, I usually see a case of nec fasc in the ICU every couple of months. Granted, I'm at an academic medical center, but many, if not most, of our patients with nec fasc are not transfers from outside hospitals, implying that community hospitals see these patients pretty regularly as well.

But I generally agree with your point -- while I valued the months I spent training at a county hospital, I felt like I got more out of my training at academic centers as far as diversity of cases, number of rare and unusual cases, and very sick patients. But then again, I'm now doing a subspecialty, so I don't really know how someone focused on primary care would feel....

 

[sophiejane]

I'm now doing a subspecialty, so I don't really know how someone focused on primary care would feel....

I think you bring up a good point. I haven't started residency, but I hear from some that the problem with "major academic centers" and tertiary referral hospitals for training as a generalist is that you may see a lot of interesting cases, but how many of those do you really get to work up and follow as a resident? I would think at a hospital with lots of fellowships that the fellows would get these cases more often than a resident. I'm sure someone will tell me I'm wrong, but I'm just going from what I've heard and observed thus far.

The other issue is that of outpatient care. I think IM offers great training for hospitalists, but at least in the programs where I've rotated so far, the outpatient training for general IM is pretty dismal. Does anyone else see a problem with that model, since most general internists will have mostly office-based practices? Or do you think you can learn outpatient medicine just as well by seeing patients in the hospital?

 

[Mumpu]

The reason NPs and PAs are growing in numbers is precisely because the OP practice does not require training. A nurse with a college degree will do as well as an MD 99.9% of the time because most of what comes through the door is complete bull****.

 

[deleted87716]

OP practice does not require training.

Um...yeeeeeah.

Where do you think all of your hospital patients go when you discharge them? They go back to the offices of physicians (general internists and family physicians...very few, if any, go back to an NP) who do everything they can to keep them out of the hospital. Same patient, same diseases, but with the added challenges afforded by the uncontrolled environment outside the hospital. No training required?

 

[sophiejane]

The reason NPs and PAs are growing in numbers is precisely because the OP practice does not require training. A nurse with a college degree will do as well as an MD 99.9% of the time because most of what comes through the door is complete bull****.

Wow, that's a lot of "bull****"....99.9%? Then how do hospitals ever fill up?

 

[RuralMedicine]

Nec fasc is actually not that obscure -- while uncommon, it's seen relatively regularly, both in community hospitals and major academic centers, and the incidence is growing. The initial management has to be done at the center the patient presents to, so a lot of these patients don't get transferred to academic centers. BTW, I usually see a case of nec fasc in the ICU every couple of months. Granted, I'm at an academic medical center, but many, if not most, of our patients with nec fasc are not transfers from outside hospitals, implying that community hospitals see these patients pretty regularly as well.

But I generally agree with your point -- while I valued the months I spent training at a county hospital, I felt like I got more out of my training at academic centers as far as diversity of cases, number of rare and unusual cases, and very sick patients. But then again, I'm now doing a subspecialty, so I don't really know how someone focused on primary care would feel....

As a primary care provider in a rural area I've diagnosed necrotizing fasciitis twice in the past year so unfortunately it's not that uncommon. Interestingly both cases were community aquired MRSA (which we have way too much of here ) I know training at the only tertiary care "standalone" children's hospital in the state was touted as a major advantage when I was a resident and I definitely saw a lot of zebras. I think it gives me a slightly different approach to practice now. Admittedly one that my colleagues mock at times because if I have concerns and the consequences of missing the diagnosis are great then I do pursue a workup. One of my first cases of necrotizing fasciitis actually presented/ was diagnosed this way. I also pushed for a cardiac catheterization on a patient (soft EKG changes and strong cocaine history--yes I know it's often vasospasm but cocaine addicts get accelerated atherosclerosis too) that one of my colleagues wanted to discharge without further workup (and case management harassed me about how we weren't going to get paid) on cardiac catheterization the patient was right dominant with a 90% occlusion of the RCA with plaque rupture. She was successfully stented and actually has been abstinent from cocaine for nearly 4 months now. I realize that if I was a little less conservative I could probably see more patients in less time, and make more money on some DRGs or under certain capitated plans and often times I (and the patient) would get away with it. But I wouldn't want a doctor who practiced that way and I don't want to practice that way. I sort of figure that the reality is that no one can make the diagnosis or save the day all the time, and life and medicine are not fair so when you have an opportunity you have to do the right thing.

 

[RuralMedicine]

I think you bring up a good point. I haven't started residency, but I hear from some that the problem with "major academic centers" and tertiary referral hospitals for training as a generalist is that you may see a lot of interesting cases, but how many of those do you really get to work up and follow as a resident? I would think at a hospital with lots of fellowships that the fellows would get these cases more often than a resident. I'm sure someone will tell me I'm wrong, but I'm just going from what I've heard and observed thus far.

I trained at an academic tertiary care center with excellent fellowship programs in pretty much all of the IM and pediatric subspecialties. At no time did I feel like my education was inhibited by fellows. Several of our hospitals still operated with a general IM team carrying all the patients (subspecialists consult only--this actually set up a great opportunity for the fellows to function as liason educators in the consultant role). Even at hospitals in the system where subspecialty teams existed residents led the teams and fellows took more of an adjunctive role.

The other issue is that of outpatient care. I think IM offers great training for hospitalists, but at least in the programs where I've rotated so far, the outpatient training for general IM is pretty dismal. Does anyone else see a problem with that model, since most general internists will have mostly office-based practices? Or do you think you can learn outpatient medicine just as well by seeing patients in the hospital?

I suppose I can't really compare and contrast IM vs FP to train for outpatient medicine from personal experience because I never did an FP residency. I think that outpatient training in IM varies from program to program. I don't see a lot of difference between what I do now and what I did as a resident in continuity clinic with the exception of the volume of hospital patients I carry now being less which affords me more time to be in my office. If I look at my practice now common adult problems include DM, CAD, HTN, COPD (with a little asthma thrown in for fun), CRI, those are probably the big 5 in my practice (and yes I inherited a ton of patients with all 5). After that another biggy seems to be musculoskeletal/ low acuity trauma/GYN issues galore and then I get random and sometimes interesting a little off the wall stuff. I think my residency trained me pretty well for that. I mean when you discharge the patient from the hospital you have a plan for outpatient followup. I don't know maybe there is some magic stuff I missed out on that happened in the FP clinic on our campus but I kind of don't think so. (The preventive stuff is very cookbook no offense). One thing FP may do a better job of is the business aspect of medicine (that probably was downplayed in our program--but I think that's a lot easier to learn through books/courses etc so if you have to leave out something that isn't a bad thing to sacrifice in a program and plan to supplement on your own).

 

[Mumpu]

I'll admit, the beauty of hospital medicine is that it lets me stay somewhat sheltered from the real world of non-compliant (scotch tape that doesn't stick is non-adherent, a patient who doesn't take charge of their own health is non-compliant) self-destructive behavior (yes, true, I don't see the 99 good patients whose toes don't fall off from A1C of 16, so my perspective is skewed). And yes, I have very little faith in patients. I do not trust them to follow up. I do not trust them to follow any of my advice or take any of the meds. Therefore, the only way for me to feel like I'm not just wanking around pretending to be saving the world for my own feelgood is to take care of people in a controlled environment where interventions and meds I want are guaranteed to make their way to the patient. It was hard enough to start feeling comfortable with discharging someone home on warfarin and not staying up all night worrying that they will bleed to death because they ignore your warning to follow up within 3 days with someone who'll check the INR... :\

 

[augmel]

There is a great deal of variability in residency training. Residency is not near as standardized as med school. I get the feeling that a lot of people view university programs like us med schools with good standardized training and community programs like carribean med schools. You can get good training in a variety of settings. Whether or not you come out as an exceptional physician has more to do with your intelligence and your work ethic than the US News ranking of your hospital. No doubt that most of the folks from MGH and UCSF are good, but that has some to do with the programs, a lot to do with competition and doctor's being status driven to a fault. If you look at the CV's of your best attendings, I'm betting that you will see some of the usual big names, but a lot of lesser known places as well.

 

[augmel]

And by the way, during my intern year at a community IM program I saw familial mediterrainian fever, pulmonary kaposi's, oriental cholangiohepatitis, neurocistecircosis, relapsing polychondritis, LOTS of nec fasc. and too many other things to have time to read about. (forgive my spelling, I'm not looking it up at this time of night.)

 

[Old_Mil]

The advantage of family practice is the lifestyle. You will be much less stressed both mentally and physically as an FP resident versus a medicine.

...in what way? The FP residencies that report hours to Freida all seem to be 70 hrs/week plus.

 

[Gastrapathy]

...in what way? The FP residencies that report hours to Freida all seem to be 70 hrs/week plus.

Agree with this. FPs can work plenty hard in residency and after. IMHO, IM is incredibly difficult to do well, given the breadth of knowledge required. FP...well, its a lot to ask of anyone to know enough about every specialty not to be dangerous.

Major advantage of IM over FP: the IM subs. I know, I know, there are FP subs but its not the same. You can flee primary care after an IM residency.

 

[DrWBD]

Not to add flames to the fire, but during my IM residency (in a university hospital with both IM and FP residencies) we often received requests for transfers from the FP service to us because the patients were "too complicated" (their words, not ours). In my three years as a resident there, the number of times the reverse happened=0.

That's not to say they always did well on our service, though.

 

[ocean11]

I'm going to actually address the OP in this post:

The reason I chose IM over FM is because of the opportunity to specialize! it is true that if you are am IM doc and go into primary care, you will see the same patients as an FM (minus the kids and OB) THAT being said, you STILL have option of specializing later on. IM docs who get cards or GI fellowship can make close to half a million a year. So if you look at salaries alone, IM wins hands down.

In addition, although I enjoyed my third year FM rotation, I felt that most of the patients were coming in for really simple things like URI, UTI, physicals, headache. I got bored after two weeks! ofcourse you see the odd zebra, but those usually got referred to someone else. In addition, I really would rather NOT treat kids, I don't mind teenagers, but I got so sick of trying to pry a kid's mouth open to check for strep pharyngitis. I got SO sick of checking the immunization status of kids and dealing with crying toddlers who did not like to be examined (can't blame them though). I did NOT like peds, I did NOT like OB/GYN... but did enjoy IM.... so IM was the choice for me....

I honestly feel that the case you see in IM are MUCH more complex, IM offers you opportunities to specialize and finally there are NO kids! and no pregnant women.... and I believe you have much more flexibility in IM, career wise!

So there you have it.... that being said.... if u love FM go for it! but IM was more my thing!

 

[Old_Mil]

For those of you who don't plan on specializing (no fellowship) after IM residency: what thing(s) made you decide to do internal med instead of family med?

One more question: is there such a thing as a relatively friendly IM program in a non-metropolitan setting? Something without the angst, miserableness, look down your nose, ivory-tower snobbery that seems to characterize some segments of the IM world?

 

[DarthNeurology]

No (alhtought a literal interpretation of the parent statement would assume that). IM = medicine for adults and most IM docs either prefer not to do, don't know how to do or completely forget to do routine GYN screening and care for their female patients. HTN, DM, cardiac, GI and pulmonary issues are no problem (regardless of the gender of the patient) but most internists don't even think about going "down there" let alone doing routine breast exams or counseling. All too often that part of the H&P boils down to "when was the last time you saw your OB/GYN? you should make an appointment soon.". It's not something we're routinely trained in.
BE (now PE)

When I did ambulatory medicine we always asked about important screening like mammograms and pap smears and such, . . . it seems like such an important part of the annual physical for women and for any patient in general is screening for common cancers, I am really surprised that there are IM doctors who don't do this!

 

[DarthNeurology]

One more question: is there such a thing as a relatively friendly IM program in a non-metropolitan setting? Something without the angst, miserableness, look down your nose, ivory-tower snobbery that seems to characterize some segments of the IM world?

There are IM programs that are "primary care" tracks so I would hope they aren't as malignant as some of the other pseudo-top tier IM programs that feel inferior