Which patients get admitted to general IM inpatient service?

[deleted1095841]

I know this is a really, really basic question, but for some reason I don't know.
I start my IM rotation soon (most students at my school get assigned to a specialty service) and would like to know what to expect.

Like if a patient came in to the ED with shortness of breath, the ED doctor would get their history, do a physical exam, and then I guess do a chest x-ray and get some labs, and then admit them to one of the inpatient services.
If the patient's shortness of breath is worse with exertion and they have swollen legs and jugular venous distention, they would probably get admitted to the cardiology service.
If the patient's hemoglobin is 6 and they have all sorts of weird cells on their peripheral blood smear, they would probably get admitted to the hematology service.
If the patient is unvaccinated and their friends just had COVID and their pulse ox is 85% and chest x-ray shows bilateral infiltrates like ARDS, they would probably get admitted to the pulmonology/critical care service.

What kind of patient/chief complaint would lead to admission to the general IM service?

---

Members don't see this ad.

 

[GoSpursGo]

It depends on the institution. However, I actually suspect that all of those patients that you list would get admitted to the general IM service and the appropriate subspecialties would be consulted if it was beyond the scope of what the hospitalist was comfortable with dealing with on their own. In general, the patient with COVID would definitely be on the general service (unless they are in the ICU), CHF would probably be on the general service, and the patient with leukemia either could probably go right to hematology or could go to the general service pending a bone marrow/formal diagnosis.

ED is really there to stabilize the patient and start a workup, and then if they believe the patient requires further inpatient management they can hand it off to the inpatient team.

 

[obiwan]

At our hospital (which happens to one of the biggest hospitals in all of Texas), its pretty much everyone unless you've been shot or hit by a car with poly-trauma

 

[cj_cregg]

This may differ from hospital to hospital, but with the exception of perhaps large academic centers, many specialists do not admit their own patients, they only serve as consultants.

All of the patients you described would get admitted to the hospitalists at my shop, with consults if/when needed. Heme-onc doesn't admit their own. Cardiology will basically only admit STEMIs who don't have non-cardiac comorbidities or patients there overnight after an elective procedure. There is no pulm service, and we have an open ICU so the hospitalists actually still admit ICU patients with pulm/CC acting more as a consultant.

Only admitting teams at my hospital are: adult/peds hospitalists, gen surg/trauma, neurosurg and ortho (but neurosurg/ortho will often turf admits to the hospitalists and just consult if the patient has comorbidities), and OBGYN.

Things that commonly get admitted to our FM hospitalist team just for some examples...heart failure, a fib, stroke, ACS, PE, GI bleeds, pancreatitis, gall bladder stuff, decompensated cirrhosis, electrolyte abnormalities/AKI, COPD, cancer patients, sepsis of any flavor, COVID, pneumonia, sickle cell pain episode, pregnant patients who are admitted for non-pregnancy things and are previable and/or too sick to be cared for by the OB team, DKA, EtOH withdrawal, drug overdoses, chest pain workup, hypertensive crisis...the list goes on.

 

[mrbreakfast]

Highly dependent on your institution, but in your examples above, for instance, all three would probably be admitted to general medicine where I work (with the possible exception of the third patient).

If the first patient had an EF of 5%, they might get admitted to cardiology (as we have a heart failure service)
If the second patient's weird cells included a WBC of 100K, they might get admitted to hematology
If the third patient had ILD instead of COVID, they might go to pulm, or if they had aspergillosis, they might go to ID. Etc.

The behind-the-scenes workings of this is that many hospitals maintain a long list of diagnoses that determine to which service the patient goes. For example: if a patient has seizures due to alcohol withdraw, they go to medicine; if their seizures are due to a subdural hematoma, they go to neurosurgery, unless it's traumatic, in which case they go to trauma; if they have seizures for another reason (or unclear reason), they go to neurology. Etc.

At a smaller hospital, even an academic one, you should expect a very wide range of complaints to go to medicine. In my field (neuro), only large academic centers are going to have an admitting service, and only the largest are going to admit anything neuro that isn't a stroke.

 

[Tenk]

GOMERS.

 

[Miles Gloriosus]

The hospitals I work at: geriatric ortho fx patients

 

[Redpancreas]

I know this is a really, really basic question, but for some reason I don't know.
I start my IM rotation soon (most students at my school get assigned to a specialty service) and would like to know what to expect.

Like if a patient came in to the ED with shortness of breath, the ED doctor would get their history, do a physical exam, and then I guess do a chest x-ray and get some labs, and then admit them to one of the inpatient services.
If the patient's shortness of breath is worse with exertion and they have swollen legs and jugular venous distention, they would probably get admitted to the cardiology service.
If the patient's hemoglobin is 6 and they have all sorts of weird cells on their peripheral blood smear, they would probably get admitted to the hematology service.
If the patient is unvaccinated and their friends just had COVID and their pulse ox is 85% and chest x-ray shows bilateral infiltrates like ARDS, they would probably get admitted to the pulmonology/critical care service.

What kind of patient/chief complaint would lead to admission to the general IM service?

the answer will vary per hospital/center. That said, where your example goes awry in practice most of those patients you listed will get admitted, at least initially, to the general internal medicine service even at the most subspecialty driven academic hospitals. Going by organ system, heart failure, NSTEMI, COPD exacerbation, viral infections with complications, AKI, Electrolyte Issues, Anemias, Pneumonia, Cellulitis, Diverticulitis, Acute Pancreatitis, Decompensated Cirrhosis, GI bleeds, Uncontrolled DM, DKA, etc. can all be managed on the general medical floors. Some quarternary teaching hospitals have subspecialty floors. For example, where I trained we had floors specifically for liquid oncology, solid tumor, cirrhosis, CF, HF/ACS, pulmonary HTN. The key though is that a lot of patients with these conditions could also be managed by the general internal medicine floor. The way to determine where they're triaged with depend on the complexity/severity of their condition. For example, if their cirrhosis was not decompensated, they may end up on general internal medicine if their issue is cellulitis. Similarly, if a patient has heart failure, but they haven't been given all the medications, LVAD, and aren't end-stage, they may not need to be on the HF service. Usually each floor has a set of nurses trained to do a specific set of things (neuro checks every 2 hrs on stroke) and the physicians are often used to seeing and treating the same things.

Some example of specialty diagnoses IM can manage fairly easily are:
HF: Lasix, ECHO if needed. Add medications. Daily weights/IOs/Labs, Discharge.
COPD Ex: 40 mg Prednisone x5D, Antibiotics if indicated, oxygen therapy spectrum, Discharge.
COVID+Hypoxia: Decadron, Remdesivir, Respiratory monitoring/O2, discharge.

An unfortunate truth is that IM often gets the most undifferentiated, complex, socially-challenging patients, not to mention many patients with primarily surgical issues that happen to have medical comorbidities. There are the patients you will see on the IM service.

 

[whoknows2012]

At my large academic center it’s actually pretty simple. All non surgical patients get admitted to medicine except;

Ongoing cardiac event, possibility of intervention, cardiac step down or ccu
New hematologic malignancy that is obvious (ie leukemia or myeloma or coming with dx) goes to whichever malignant heme service (ie leukemia service). If significant work up needed and unclear what is going on, medicine
New liver failure or significant liver issue, hepatology service
All other patients with renal, hematologic, oncologic (ie solid tumors) GI rheum Endo etc get admitted to medicine
(Unless critically I’ll then icu of course)

Otherwise established patients from transplant leukemia lymphoma myeloma cardiology hepatology are admitted to those services off the bat

 

[deleted1095841]

Thanks for all your helpful responses! It seems like the general IM service would get a lot more patients that any other service. But at my school there seem to be way more specialist physicians than general IM hospitalists. Do IM generalists see way more patients than anyone else? Or is it that IM subspecialists see most of their patients in outpatient clinics and therefore hospital work is only a small fraction of what they do?

 

[mrbreakfast]

Do IM generalists see way more patients than anyone else?

No. Many subspecialty consult services (generally non-IM ones) will see way more patients than a generalist service. Of course, they aren't managing the whole patient, just one problem, so it's much less work per patient.

Also, keep in mind you aren't considering the other major "primary service" in the hospital, which is ED. A large proportion of consults placed in a hospital come from the ED, though that doesn't necessarily apply to subspecialty IM.