Which Internal Medicine subspecialty offers the most individual decision making opportunities?

[deleted1016251]

I guess what I’m looking for in a subspecialty is the chance to practice the art of medicine where I can make my own decisions for the patient based on my own experience/knowledge and decide the best course of action, rather than strictly adhering to protocols or algorithms.

which specialty is the most like that?

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[gutonc]

The one you like the most. Practice setting likely has more to do with protocolization than specialty does.

 

[DrMetal]

I guess what I’m looking for in a subspecialty is the chance to practice the art of medicine where I can make my own decisions for the patient based on my own experience/knowledge and decide the best course of action, rather than strictly adhering to protocols or algorithms.

which specialty is the most like that?

None of them. Nobody practices medicine in a bubble any more. It's a team sport.

 

[Animalcules]

Rheum

 

[Doctor Bob]

Critical care... if you choose to exercise your perogative.
I've seen some intensivists who won't make any decisions without a bunch of consultants. And then some who refuse to bring anyone else in unless the patient needs a procedure that the intensivist isn't credentialled to do.
Usually the ICU environment will allow you to be wherever along that spectrum you prefer to be.

 

[DrMetal]

Critical care... if you choose to exercise your perogative.
I've seen some intensivists who won't make any decisions without a bunch of consultants. And then some who refuse to bring anyone else in unless the patient needs a procedure that the intensivist isn't credentialled to do.
Usually the ICU environment will allow you to be wherever along that spectrum you prefer to be.

There should be a happy middle ground. Don't consult cards for the HR 140 before you've tried something.....do consult for the HR 180 that's not responding to initial drips and you're worried about ensuing Vtach/Vfib.

 

[Doctor Bob]

There should be a happy middle ground. Don't consult cards for the HR 140 before you've tried something.....do consult for the HR 180 that's not responding to initial drips and you're worried about ensuing Vtach/Vfib.

Exactly... you can be as independent as you feel comfortable being.

 

[tantacles]

Literally every single one once you finish fellowship, including general internal medicine. You make the rules and use the guidelines to practice appropriately.

 

[CCM-MD]

Critical care... if you choose to exercise your perogative.
I've seen some intensivists who won't make any decisions without a bunch of consultants. And then some who refuse to bring anyone else in unless the patient needs a procedure that the intensivist isn't credentialled to do.
Usually the ICU environment will allow you to be wherever along that spectrum you prefer to be.

This is true in a closed ICU. Not true in open ICU.

But open has its own advantages 😉 and I still get to do pretty much whatever I want in the sickest of the sick, no one gets in my way.

 

[smartparts]

There's a great perspective piece in NEJM from a few months ago called "Moving On" where a retiring ID doc reflects on this question a bit. I thought it was a good read and you might find it interesting too. Like others have said, you can do whatever you want once you're done training (barring objections from your employer). It's simultaneously liberating and terrifying.