Which specialty under IM would allow the most freedom to be able to practice as a PCP while utilizing your specialist skills?

[KeikoTanaka]

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Title says it all. Wondering to hear what people think. Also, what opportunities exist for during fellowship to practice general medicine more frequently, like moonlighting? Hospitalist work? etc. etc.

 

[jurassicpark]

Nephrologists OWN their patients, especially when they go onto hemodialysis and for most parts seem to supplant their actual PCPs. They are the ones managing their medical issues, blood pressure, etc and of course still following them if they land up in the hospital. Also, many nephrologists moonlight as hospitalists to increase their pay.

 

[KeikoTanaka]

Nephrologists OWN their patients, especially when they go onto hemodialysis and for most parts seem to supplant their actual PCPs. They are the ones managing their medical issues, blood pressure, etc and of course still following them if they land up in the hospital. Also, many nephrologists moonlight as hospitalists to increase their pay.

Interesting, thanks for this opinion. I heard Nephrology as a field was dead, however, do you foresee a potential rise in salary for nephrologists if more and more people avoid this field, decreasing the supply, and increasing the demand?

 

[KeikoTanaka]

What about Rheumatology? I know this is a more competitive field now-a-days, but it seems like a lot of in-office procedures that can be done in conjunction with normal IM.

 

[rokshana]

If you want to be a pcp, be a pcp... people who specialize are not looking to be pcps...why on earth would you do another 2-5 years of subspecialty training to then plan to go back to do something you could have done straight out of residency ??

My 10 yr old niece told me the other day she wants to be a dermatologist....and an oncologist...I’ll tell you the same thing I told her...you will eventually need to pick one...

 

[wamcp]

Uh, geriatrician?

 

[KeikoTanaka]

If you want to be a pcp, be a pcp... people who specialize are not looking to be pcps...why on earth would you do another 2-5 years of subspecialty training to then plan to go back to do something you could have done straight out of residency ??

My 10 yr old niece told me the other day she wants to be a dermatologist....and an oncologist...I’ll tell you the same thing I told her...you will eventually need to pick one...

Maybe some people have aspirations outside of pure financial gain and are willing to put in time for educational purposes if that's what brings them self-fulfillment while still providing services that are in critical need in many communities across the country

 

[KeikoTanaka]

Uh, geriatrician?

Is Geriatrics actually like a specialty specialty within IM? I thought IM just naturally prepared people to be geriatricians vs FMs or Peds who focus more on families/younger people

 

[rokshana]

Maybe some people have aspirations outside of pure financial gain and are willing to put in time for educational purposes if that's what brings them self-fulfillment while still providing services that are in critical need in many communities across the country

Do you live in the US? Or in med school here? Or even in med school?

US healthcare doesn’t work that way...

And,hon, I’m an endocrinologist...if you know anything about US medicine, financial gain is not the motivation for any endo...

 

[rokshana]

Is Geriatrics actually like a specialty specialty within IM? I thought IM just naturally prepared people to be geriatricians vs FMs or Peds who focus more on families/younger people

You really don’t know the US system...IM is medicine for adults...they are trained to take care of anyone over the age of 18, generally the focus is inpatient medicine, but have outpt responsibilities as well .

Geriatrics is a one yr fellowship after an IM residency. Do you need it to see pts >65? No... but if you want BC , then you will need to do the fellowship.

 

[KeikoTanaka]

Do you live in the US? Or in med school here? Or even in med school?

US healthcare doesn’t work that way...

And,honey, I’m an endocrinologist...if you know anything about US medicine, financial gain is not the motivation for any endo...

I'm a 2nd year with lots of pre-med shadowing experience. I understand how a lot of healthcare works. I also have worked with a Cardiologist who also practiced General Internal Medicine in a rural community.. No need to act so haughty for someone asking general hypothetical questions.

 

[KeikoTanaka]

You really don’t know the US system...IM is medicine for adults...they are trained to take care of anyone over the age of 18, generally the focus is inpatient medicine, but have outpt responsibilities as well .

Geriatrics is a one yr fellowship after an IM residency. Do you need it to see pts >65? No... but if you want BC , then you will need to do the fellowship.

Thank you, that's why I was confused about the need for a Geriatrics fellowship if your training was already very much catered to adults. But I assume this fellowship prepares one for more outpatient geriatric responsibilities and management?

 

[rokshana]

I'm a 2nd year with lots of pre-med shadowing experience. I understand how a lot of healthcare works. I also have worked with a Cardiologist who also practiced General Internal Medicine in a rural community.. No need to act so haughty for someone asking general hypothetical questions.

You are a 2nd year...in the US?

Rural areas are different... there may simply have not been enough of a pt load to be established as subspecialist and he had to take on some GM... or may have started a solo practice and, again, did not have the patient panel to support his sub specialty...

Your “premedical shadowing” is the equivalent to spending the night at a holiday inn... it gives little knowledge to real world medicine.

Once you are in residency, you will gain some insight and even then it’s really once you are an attending will reality hit...

 

[KeikoTanaka]

You are a 2nd year...in the US?

Rural areas are different... there may simply have not been enough of a pt load to be established as subspecialist and he had to take on some GM... or may have started a solo practice and, again, did not have the patient panel to support his sub specialty...

Your “premedical shadowing” is the equivalent to spending the night at a holiday inn... it gives little knowledge to real world medicine.

Once you are in residency, you will gain some insight and even then it’s really once you are an attending will reality hit...

It was more than just shadowing - I've scribed for several physicians. That included inputting billing codes, diagnosis codes, and being in the same room with the physician and management meetings for a year straight. You don't know anything about me and come here, don't answer my question initially, and try to insult me, "honey". Thank you for the information you have contributed, but the other aspects of what you said weren't really welcome and unnecessary.

 

[yakattack16]

It was more than just shadowing - I've scribed for several physicians. That included inputting billing codes, diagnosis codes, and being in the same room with the physician and management meetings for a year straight. You don't know anything about me and come here, don't answer my question initially, and try to insult me, "honey". Thank you for the information you have contributed, but the other aspects of what you said weren't really welcome and unnecessary.

Shadowing isn't the same as being a physician, while it certainly gives you more insight than the average person, don't assume you understand the deeper intricacies of the profession. What Rokshana said is true as far as rural specialists practicing general IM. The reason it's uncommon is because in most settings, you'd have to be crazy to do both.

 

[KeikoTanaka]

Shadowing isn't the same as being a physician, while it certainly gives you more insight than the average person, don't assume you understand the deeper intricacies of the profession. What Rokshana said is true as far as rural specialists practicing general IM. The reason it's uncommon is because in most settings, you'd have to be crazy to do both.

I'm crazy. I also want to live in a very rural area.. I know, how "out of generation" of me. *Shrugs*

I'm not here defending that I am some omniscient healthcare guru from scribing - I asked a question, I understand the downsides to it as I've heard it before. I'd appreciate anyone that responds to just go along with it, assuming time and money aren't factors. The nephrology comment was surprisingly insightful.

 

[yakattack16]

I'm crazy. I also want to live in a very rural area.. I know, how "out of generation" of me. *Shrugs*

I'm not here defending that I am some omniscient healthcare guru from scribing - I asked a question, I understand the downsides to it as I've heard it before. I'd appreciate anyone that responds to just go along with it, assuming time and money aren't factors. The nephrology comment was surprisingly insightful.

Not sure why the chip on your shoulder for wanting to live rural. You can essentially practice GIM while being boarded in any subspecialty, but it's not common and you know the reasons why. Nephrology is certainly one. Geriatrics will often have some younger patients as well, since for the majority of people, there isn't a reason to be seen by a geri doc as opposed to a IM or FM doc.

 

[KeikoTanaka]

Not sure why the chip on your shoulder for wanting to live rural. You can essentially practice GIM while being boarded in any subspecialty, but it's not common and you know the reasons why. Nephrology is certainly one. Geriatrics will often have some younger patients as well, since for the majority of people, there isn't a reason to be seen by a geri doc as opposed to a IM or FM doc.

No chip on my shoulder, sorry, the other poster made me get defensive after her belittling comments. Thanks for your input though. I'm definitely going to look more into geriatric fellowships

 

[hotsaws]

A major factor to consider is that, for the vast majority of practices, practice infrastructure is a major player. Rheumatology practices are going to have some portion of staff and overhead dedicated to establishing patients on biologics or perhaps providing infusions, Allergy practices will have a similar infrastructure geared toward shots/testing/possibly infusions, pulmonologists will be set up for PFTs/bronchs, cardiologists with their various diagnostic tests, etc. You have to fuel this machine to keep the practice afloat, if you start taking over PCP duties, you're taking away from the rest of it. Also, being a good PCP also relies on having a good infrastructure in place. Not sure if you've ever scribed/shadowed at a well run PCP office but they have their own version of a well oiled machine -- you have complete ownership of the patient, so you have to have staff dedicated to following up on all the various results that need to be reported, you need to have a referral network of sub specialists and ancillary services, you practically need someone dedicated to managing all the various authorizations for things. Also, if you start stealing patients from PCPs, you risk hurting your referral base. PCPs will stop referring patients to you if you start stealing or trying to co-manage their patients.

The system does not facilitate double dipping well. You're probably better off being a PCP, either FM or IM, and then dabbling in a particular subspecialty that interests you. If you go to a rural area, it's more feasible for you to do more MSK and skin procedures or maybe even diagnostics like ECHO or scopes.

 

[NERDY]

ID is often the primary care for HIV patients (managing the HIV plus DM/HTN/etc along with cancer screening).

 

[CCM-MD]

General Internal Medicine would be the best specialty under the umbrella of Internal Medicine that would allow you to practice as a PCP while utilizing your special internist skills.

 

[rokshana]

It was more than just shadowing - I've scribed for several physicians. That included inputting billing codes, diagnosis codes, and being in the same room with the physician and management meetings for a year straight. You don't know anything about me and come here, don't answer my question initially, and try to insult me, "honey". Thank you for the information you have contributed, but the other aspects of what you said weren't really welcome and unnecessary.

I’m so sorry! I didn’t realize you were SO experienced!!smh

 

[mszzeta]

Title says it all. Wondering to hear what people think. Also, what opportunities exist for during fellowship to practice general medicine more frequently, like moonlighting? Hospitalist work? etc. etc.

You are legally permitted to practice any IM subspecialty and PCP at the same time and I have even seen some pulmnologist doing PCP at the same time. If you take part the financial part (lots of people say it may hurt money practicing both primary care and subspecialty)

From the specialty perspective, most of the IM subspecialty which dose not focus on single organ system may promote the mutual clinical skills for both practice, such as rheumatology, endocrinology and ID. I do feel physicians need to know the even subspecialties beyond regular GIM to be good rheumatologists, for example complex glomerular disease, ILD, pulmonary hypertension, complicated neuro/muscle diseases......And good GIM skills are always the foundation

 

[KeikoTanaka]

I’m so sorry! I didn’t realize you were SO experienced!!smh

I'm sorry too. Sorry that you feel the need to come onto forums to attack posters without even addressing their questions and bringing nothing but haughty negativity. Luckily there are people who did post valuable information and definitely helped answer my question. Goodbye 🙂

 

[KeikoTanaka]

You are legally permitted to practice any IM subspecialty and PCP at the same time and I have even seen some pulmnologist doing PCP at the same time. If you take part the financial part (lots of people say it may hurt money practicing both primary care and subspecialty)

From the specialty perspective, most of the IM subspecialty which dose not focus on single organ system may promote the mutual clinical skills for both practice, such as rheumatology, endocrinology and ID. I do feel physicians need to know the even subspecialties beyond regular GIM to be good rheumatologists, for example complex glomerular disease, ILD, pulmonary hypertension, complicated neuro/muscle diseases......And good GIM skills are always the foundation

That's funny, there's actually a pulmonologist in the city that I'm attending school, and I spoke with someone who sees them for all their complaints as he also practices GIM and Pulmonology. Perhaps this is a coincidence, or does that subspecialty lend itself more to dealing with general problems also?

 

[xoggyux]

I have seen a few general cardiologists and pulmonologists transition into PCP role, often (but not always) under the umbrella of concierge service or some other pseudo-VIP system. The irony is that they no longer practice cardiology, not really. Apart from doing frequent stress tests in patients that might not even need them, when they actually need cardiology stuff they end up referring their patients to other cardiologists "heart failure specialist" "EP" etc. On the other hand, they are not great PCPs either.

And just because someone did an internal medicine residency does not automatically mean that they will be competent life-long to do IM doctor's job. After 3 years of fellowship, a cardiologist or GI has spent as much time out of IM practice as they have been in practice, not a recipe to make a great PCP if you ask me.

It is not a great idea, it is simply not practical.

 

[Instatewaiter]

I'm a 2nd year with lots of pre-med shadowing experience. I understand how a lot of healthcare works. I also have worked with a Cardiologist who also practiced General Internal Medicine in a rural community.. No need to act so haughty for someone asking general hypothetical questions.

I had to chuckle at this. Similarly, I understand how to build an airplane. I've seen a bunch take off.


Also any cardiologist that has to do general medicine to fill his/her schedule, probably isn't a very good cardiologist

 

[Kakoy]

What about Rheumatology? I know this is a more competitive field now-a-days, but it seems like a lot of in-office procedures that can be done in conjunction with normal IM.

To be a good rheumatologist, you will need excellent general internal medicine knowledge since our disease affect all the organ systems. Some patient would like to treat us as their PCP. However, there is such a shortage of rheumatologist currently that it's difficult to have enough appointments/time slot to accommodate non-rheumatological issues. Most of our disease are complex and just explaining the rheum diseases, it's pathophys, mediations, side effects, yada yada takes up most of the visit. I can't imagine trying to squeezing DM management, blood pressure management, screening test, etc in that visit.

Personal belief here: I don't want to miss anything rheumatological by focusing too much. Their other doctors are not going to focus on the labs indicating lupus progression/flare or that the development of lung dz in an RA pt or that bump in Cr ( with an unusually elevated BP) for a systemic scleroderma pt. They expect me to be on top of those ( as they should, since I am the rheumatologist). If I start doing a PCP's job, it's too easy to miss what I am suppose to be doing. It is also, IMHO, a sure way of burning out. I will stay in my lane and provide the best rheumatological care for my patient. I had a pt "fire" me for not taking care of their chronic issues in addition to their rheum issues. Honestly, I was ok with that.

If you plan on going to a rural area, I am sure they would love to have a rheumatologist ( been offer 300-400K in rural areas, but no money is worth it for me) and they would love a rheumatologist who will practice as a PCP. I suspect a rural rheumatologist will have more straightforward rheum patients as oppose the complex patient at an academic setting, maybe practicing both ( PCP + rheum) is possible? I am not trying to insult rural rheumatologist with the above statement but I honestly believe that a complex rheum patient need a multidisciplinary team in an academic setting with all it's resources ( Systemic scleroderma: rheum, pulm for ILD/PAH, GI for esophageal dysmotility &/ SBO, etc).

Hope this was somewhat helpful...

ETD: correct stuff... tapping on phone is hard

EETD: I had a rural PCP message me on Social media few months ago asking about whether their pt had lupus ( no rheum around that part apparently), so they would LOVE a rural rheumatologist.

 

[KeikoTanaka]

To be a good rheumatologist, you will need excellent general internal medicine knowledge since our disease affect all the organ systems. Some patient would like to treat us as their PCP. However, there is such a shortage of rheumatologist currently that it's difficult to have enough appointments/time slot to accommodate non-rheumatological issues. Most of our disease are complex and just explaining the rheum diseases, it's pathophys, mediations, side effects, yada yada takes up most of the visit. I can't imagine trying to squeezing DM management, blood pressure management, screening test, etc in that visit.

Personal belief here: I don't want to miss anything rheumatological by focusing too much. Their other doctors are not going to focus on the labs indicating lupus progression/flare or that the development of lung dz in an RA pt or that bump in Cr ( with an unusually elevated BP) for a systemic scleroderma pt. They expect me to be on top of those ( as they should, since I am the rheumatologist). If I start doing a PCP's job, it's too easy to miss what I am suppose to be doing. It is also, IMHO, a sure way of burning out. I will stay in my lane and provide the best rheumatological care for my patient. I had a pt "fire" me for not taking care of their chronic issues in addition to their rheum issues. Honestly, I was ok with that.

If you plan on going to a rural area, I am sure they would love to have a rheumatologist ( been offer 300-400K in rural areas, but no money is worth it for me) and they would love a rheumatologist who will practice as a PCP. I suspect a rural rheumatologist will have more straightforward rheum patients as oppose the complex patient at an academic setting, maybe practicing both ( PCP + rheum) is possible? I am not trying to insult rural rheumatologist with the above statement but I honestly believe that a complex rheum patient need a multidisciplinary team in an academic setting with all it's resources ( Systemic scleroderma: rheum, pulm for ILD/PAH, GI for esophageal dysmotility &/ SBO, etc).

Hope this was somewhat helpful...

ETD: correct stuff... tapping on phone is hard

EETD: I had a rural PCP message me on Social media few months ago asking about whether their pt had lupus ( no rheum around that part apparently), so they would LOVE a rural rheumatologist.

Thank you! This was an amazing breakdown, and makes sense that there will be differences between academic vs rural in terms of their capabilities and expectations. It makes me excited in general that rural areas might have more variety in opportunities.

Also, side note, I think it's sad that in this 21st century we have to resort to Social Media as a way of making contact with physicians to get second opinions! It would open up so many doors for rural physicians to be able to seamlessly share notes and video chat/picture share with specialists. The technology is definitely available.

 

[cardsguy2017]

You can be PCP and practice any specialty you want. If you own your own practice this is easier to do, if you're employed it's up to your employer on what they allow you to do. There are often opportunities to moonlight as hospitalist during fellowship.

 

[siliso]

Several of my partners in primary care also have endo training/bc.. There’s plenty of opportunity for using that in PC.

 

[gutonc]

Also any cardiologist that has to do general medicine to fill his/her schedule, probably isn't a very good cardiologist

Or probably a very good PCP.

 

[shiftingmirage]

I'm going to add H/O as if you are getting active treatment and in H/O office q2W, you likely won't have time for other doc appointments. Now once/if they cure you, you'll have to find a PCP.

I think a lot of it will depend on the group and patient load. I feel like most of the subspecialists in my area are so busy with their specialty that they don't have time for PCP work.

 

[jdh71]

Title says it all. Wondering to hear what people think. Also, what opportunities exist for during fellowship to practice general medicine more frequently, like moonlighting? Hospitalist work? etc. etc.

I would say basically NONE of them. You’ll only end up mediocre at both. Nephro will allow you often to manage hypertension along with kidney disease. Endocrine obviously could (if they wanted) manage all the easy diabetics and hyperlipid. Cards will also often manage hypertension and hyperlipid meds. But you don’t want to also be doing rectal and vaginal exams. Diagnosing rashes. Treating toenail fungus. And deciding what to do about shoulder pain. While trying to practice the nuance of a subspecialty. You’ll like end up being kind of bad at all of if. If you can’t see enough cases and complaints so that the regular things become a personal algorithm then you’ll be spending a lot of time trying to figure everything out all of the time. You won’t have the time or energy for that. And maybe most importantly in many ways it will make you an inefficient employee or partner and will impact your production and eventually your pay.

 

[KeikoTanaka]

I think a lot of it will depend on the group and patient load. I feel like most of the subspecialists in my area are so busy with their specialty that they don't have time for PCP work.

The specialists are also receiving tons of referrals to fill up their schedules. I'm assuming in this hypothetical situation (Yes, this is a hypothetical situation so I don't need to hear the same reasons over and over from various posters that you'd just be a horrible doctor trying to do both) that I would only use the specialist knowledge to supplement the care I'm giving to the people who are already my patients from a primary care lens. I would not be trying to steal patients or receive referrals for my specialist knowledge. Now, if I happened to be the ONLY specialist of that kind in a small town, sure, I could always open up time slots solely for new patients referrals on a specific afternoon/morning since they will require more time.

To be a good rheumatologist, you will need excellent general internal medicine knowledge since our disease affect all the organ systems. Some patient would like to treat us as their PCP. However, there is such a shortage of rheumatologist currently that it's difficult to have enough appointments/time slot to accommodate non-rheumatological issues. Most of our disease are complex and just explaining the rheum diseases, it's pathophys, mediations, side effects, yada yada takes up most of the visit. I can't imagine trying to squeezing DM management, blood pressure management, screening test, etc in that visit.

This is true, but based on what I said above, if I wasn't inundated and only dealing with my patients, I wouldn't need to deal with every single thing at one appointment. For example if a patient had HTN and DM but also SLE, they could come in one day for their Primary Care complaints and come back the next week for their Rheumatologic concerns, right?

Like I said, this is purely hypothetical, but people have shared examples above exemplifying that its possible, albeit very difficult, especially at first, and most likely in rural areas.

 

[rokshana]

Since this is a hypothetical and not wanting real world input, can we move this to the medical school forum? The IM forum is for IM residents, fellows, attendings and clinical medical student that are looking at IM as a realistic career choice.

@gutonc ? @Winged Scapula

 

[mdjo]

I think once you start your clinical training, the idea of spending 2-3 extra years in training just to be a smarter PCP is going to seem extremely unappealing. I'm a fellow and I guess it mostly feels worth it, but my fellowship is not even that hard and I'm actually training for something I'd like to do full time. I literally can't imagine an IM resident deciding to do a fellowship just so they can be a smarter PCP. Like, if you want to do knee injections, find a weekend conference on knee injections, don't do a whole rheumatology fellowship ffs.

I know this is just a naive hypothetical from a medical student, but the idea of someone frittering away 2-3 extra years of their life in medical education just for funsies is giving me palpitations. There should be a trigger warning on this thread for burnt out trainees!

 

[xoggyux]

The specialists are also receiving tons of referrals to fill up their schedules. I'm assuming in this hypothetical situation (Yes, this is a hypothetical situation so I don't need to hear the same reasons over and over from various posters that you'd just be a horrible doctor trying to do both) that I would only use the specialist knowledge to supplement the care I'm giving to the people who are already my patients from a primary care lens. I would not be trying to steal patients or receive referrals for my specialist knowledge. Now, if I happened to be the ONLY specialist of that kind in a small town, sure, I could always open up time slots solely for new patients referrals on a specific afternoon/morning since they will require more time.



This is true, but based on what I said above, if I wasn't inundated and only dealing with my patients, I wouldn't need to deal with every single thing at one appointment. For example if a patient had HTN and DM but also SLE, they could come in one day for their Primary Care complaints and come back the next week for their Rheumatologic concerns, right?

Like I said, this is purely hypothetical, but people have shared examples above exemplifying that its possible, albeit very difficult, especially at first, and most likely in rural areas.

The problem is, that the moment you finish the IM residency if you don't immediately start practicing, you will start forgetting more and more. You will start being more and more outdated when you don't keep up with medical journals/conferences/etc and you will flat out lose a large portion of your training in a short period of time. Certainly, 3 years is too much. You might get away with a 1 year palliative/sleep medicine/sports/etc, but once you start talking about 3-4 years fellowship you are losing a great deal of what would otherwise make you a good/decent doctor. Even for that matter, if you are an IM that practice hospital medicine, you would find that after a few years, transitioning to outpatient might be a bit of a hassle. Some of my colleagues just found out this the hard way and I reckon going from a specialty to IM is even worse than from IM inpatient to IM outpatient.
Furthermore, there is no guarantee that you will be any better at managing the "simple" specialty stuff. And like many have said, chances are you will in fact end up being mediocre at this also, especially if you don't get enough exposure due to low volumes in rural areas.
If you don't believe me... just wait until your last year of IM residency, get together with one of your old med-school pals that went into pediatrics or psych and try to keep up with that medical knowledge. We all got trained in psych and peds... we simply forget 90% after just a couple years, just remember the bare basic. Something similar will happen for IM once you go into specialty, every year out of practice you forget a little bit and miss 1 full year of journal info, next years compounds into previous, and so on. After 3 years you are at the brink of being mediocre.

The most troublesome of your query is that you don't even have a particular path in mind. It is not that you are telling us that you are in love with specialty X but also want to do some PCP work and you are torn between two options. It seems that you don't even care what specialty.... you just want "a specialty" as if you are simply chasing a tittle more than a career path. I don't want to make assumptions, but think about it, if you are chasing a tittle (whether for $$ or for a false illusion that you will get more respect or people will think more highly of you or some other idea), this is a terrible idea.