Why or why not internal medicine?

[remedy23]

Just curious what other people's reasons were for doing or not doing IM!

Things I like
- cerebralness of internal medicine: you really have to think critically
- team-based: frequently going over cases with your colleagues
- procedural & hands-on: you can do many procedures like lines, intubating patients, ultrasounds

Things I don't like

- lifestyle: being on call/paged frequently can interfere with your personal life, if you want to go on vacation, it'll depend on the hospital's schedule
- long histories: you probably end up seeing 10-12 patients per day for 0.5 - 1 hours which is draining
- acuity: you're mainly going to be seeing sick patients
- high stress - I imagine it's stressful seeing crashing patients all the time, especially when you're the only one covering the floor at night!
- subspecialties are competitive (other than geriatrics perhaps but slaving away for 3 years doing GIM isn't worth it in my opinion)

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[Oso]

IM is a very broad field and depending on your sub-specialty and practice, your lifestyle and level of acuity can differ drastically (ex. outpatient allergy/immuno vs ICU, outpatient endo vs cards, hospitalist vs internist, etc.). Some sub-specialties are really not that competitive, for example ID, nephrology, rheum, etc (except for maybe at top programs).

I am going into peds. I just couldn't deal with always seeing the long histories of/medications for HTN, DM, HLD, CAD, CHF, OSA, obesity, etc. + people refusing to take their medications for no good reason + trying to get people to quit smoking, drinking, drugs

Adults just suck (myself included), but to each their own.. someone's gotta deal with 'em. Overall, IM is a good field with a ton of great options available after residency.

 

[NITRAS]

IM is really broad, there is no one way to practice. The number and acuity of patients, the number of procedures you do, really is up to you.

 

[Redpancreas]

Just curious what other people's reasons were for doing or not doing IM!

Things I like
- cerebralness of internal medicine: you really have to think critically
- team-based: frequently going over cases with your colleagues
- procedural & hands-on: you can do many procedures like lines, intubating patients, ultrasounds

Things I don't like

- lifestyle: being on call/paged frequently can interfere with your personal life, if you want to go on vacation, it'll depend on the hospital's schedule
- long histories: you probably end up seeing 10-12 patients per day for 0.5 - 1 hours which is draining
- acuity: you're mainly going to be seeing sick patients
- high stress - I imagine it's stressful seeing crashing patients all the time, especially when you're the only one covering the floor at night!
- subspecialties are competitive (other than geriatrics perhaps but slaving away for 3 years doing GIM isn't worth it in my opinion)

You’ve got a good handle on the pros/cons from a student perspective. Other cons are the competitiveness of top 20 residencies which kind of fits into your competitiveness section. Another one is the length of training of subspecialists as most of us will have families if we get to fellowship and getting paid 60K to while performing nearly at the level of an attending is kind of ridiculous. That said, like you’ve said the ability to reason through things and diagnose in a setting where you’re directly talking with patients, etc. is what I’ve always wanted to do and I’ve wanted a decent income while working with my hands too.

If you’re interested, here’s my lengthy decision making logic. You first have to decide surgery vs. medicine. While shadowing I already began to realize surgery wasn’t my favorite thing as I’d start to fall asleep during the longer ones and honestly my rotation confirmed my suspicion that it wasn’t the right culture for me even though I do love working with my hands. Then it’s Anesthesiology, Dermatology, EM, Family Medicine, IM, Neurology, Pathology, Pediatrics, PM&R, Psychiatry, and Radiology. Derm, though appealing, (may have considered it more if competitive) was out because of the laser-focus on skin which I can see is important but it didn’t seem interesting enough. Rads/Path were out because I wanted patient contact. Anesthesiology was out because it seemed very monotonous for the most part, but then BAM do something or patient dies which seems to high stress for me. In retrospect, it’s not too bad and you work with your hands and I do like to check on things a lot and think I could have enjoyed anesthesiology and don’t think CRNAs are huge deal. Pediatrics was out partly due to the culture and because I’m not really fond of kids, but the pathology played to my strong suits (biochem, ID, genetics, etc.). Family was out partly due to Peds/OB as well as an exclusively being a primary care role but I realized during my rotation that I did like an ambulatory setting more than inpatient. PM&R/Psych are interesting fields, but were just never my idea of the medicine I wanted to practice. That left EM/Neurology/IM. Neurology was cerebral and I thought I’d like it more but the imaging played a larger role than I thought and the MRI usually held the answer. Also the salary was a bit of a turn off. EM was perfect for the short residency/salary/time-off etc. but I didn’t like the quick thinking/stabilizing, and not treating nature of the field and the lack of ambulatory interaction over time was a turn off. Heck in inpatient IM rotations, I’m already too willing to do “ambulatory things” and EM is the opposite. Also the whole circadian rhythm thing, lack of a exit strategy/hospital ties without an exit strategy, and no PP options drove me away. Lastly, EM is not an expert at anything which I feel would lead to lack of fulfillment for me. I did consider switching rotations to make it easier to apply EM, but then realized it was better to do something I personally had a genuinely interest in.

 

[PTPoeny]

Adults smell bad. You get all the same pros but better smelling patients in Peds

Plus most kids admitted to the hospital you can actually save. Much cooler to save someone's life when they can go on to to live another 80 or 90 years than when they are going to die in the next few years no matter what you do.

The lifestyle concerns you raise can be mitigated in either field by carefully choosing your practice setting.

If higher acuity is stressful for you and a con on your list you may prefer outpatient medicine no matter what fields you are in. This would also take care of your concerns regarding length of history as you wouldn't have anywhere near that amount of time with each patient.

 

[Moose A Moose]

If they make me ‘run the list’ one more time I’m going to have a conniption.

 

[Cyphix]

I did enjoy the cerebral nature of thinking about complex medical problems and differentials in IM -- to an extent. On some days, after hours of rounding and note-writing, I found myself wanting the team to get to the point, make a plan, and execute it in a definitive way. I felt like part of the day was missing when I wasn't going to the operating room. Chose a surgical subspecialty!

 

[libertyyne]

Just curious what other people's reasons were for doing or not doing IM!

Things I like
- cerebralness of internal medicine: you really have to think critically
- team-based: frequently going over cases with your colleagues
- procedural & hands-on: you can do many procedures like lines, intubating patients, ultrasounds

Things I don't like

- lifestyle: being on call/paged frequently can interfere with your personal life, if you want to go on vacation, it'll depend on the hospital's schedule
- long histories: you probably end up seeing 10-12 patients per day for 0.5 - 1 hours which is draining
- acuity: you're mainly going to be seeing sick patients
- high stress - I imagine it's stressful seeing crashing patients all the time, especially when you're the only one covering the floor at night!
- subspecialties are competitive (other than geriatrics perhaps but slaving away for 3 years doing GIM isn't worth it in my opinion)

7 on7 off no call.
Acuity varies greatly, usually patients requiring one to one nursing get transferred to ICU. Where intensivists take over.
When a patient crashes the same happens and rapid teams and ICU teams become involved.
Something's you haven't touched on is being the dumping grounds for specialties ,ICU , and etc.
Dealing with the social issues for the patients.
Generally low on procedures unless you are in a subspecialty.

 

[remedy23]

If you’re interested, here’s my lengthy decision making logic. You first have to decide surgery vs. medicine. While shadowing I already began to realize surgery wasn’t my favorite thing as I’d start to fall asleep during the longer ones and honestly my rotation confirmed my suspicion that it wasn’t the right culture for me even though I do love working with my hands. Then it’s Anesthesiology, Dermatology, EM, Family Medicine, IM, Neurology, Pathology, Pediatrics, PM&R, Psychiatry, and Radiology. Derm, though appealing, (may have considered it more if competitive) was out because of the laser-focus on skin which I can see is important but it didn’t seem interesting enough. Rads/Path were out because I wanted patient contact. Anesthesiology was out because it seemed very monotonous for the most part, but then BAM do something or patient dies which seems to high stress for me. In retrospect, it’s not too bad and you work with your hands and I do like to check on things a lot and think I could have enjoyed anesthesiology and don’t think CRNAs are huge deal. Pediatrics was out partly due to the culture and because I’m not really fond of kids, but the pathology played to my strong suits (biochem, ID, genetics, etc.). Family was out partly due to Peds/OB as well as an exclusively being a primary care role but I realized during my rotation that I did like an ambulatory setting more than inpatient. PM&R/Psych are interesting fields, but were just never my idea of the medicine I wanted to practice. That left EM/Neurology/IM. Neurology was cerebral and I thought I’d like it more but the imaging played a larger role than I thought and the MRI usually held the answer. Also the salary was a bit of a turn off. EM was perfect for the short residency/salary/time-off etc. but I didn’t like the quick thinking/stabilizing, and not treating nature of the field and the lack of ambulatory interaction over time was a turn off. Heck in inpatient IM rotations, I’m already too willing to do “ambulatory things” and EM is the opposite. Also the whole circadian rhythm thing, lack of a exit strategy/hospital ties without an exit strategy, and no PP options drove me away. I did consider switching rotations to make it easier to apply EM, but then realized it was better to do something I personally had a genuinely interest in.

Thanks for this! I feel like I have a similar thought process to you! I've eliminated surgery, and I want to be a generalist (kind of like a little bit of everything!) vs. a specialist! So basically, I'm down to FM & IM

I thought about physiatry, psychiatry, and neurology but those are too specialized and I would prefer something more broad! Pediatrics, I don't want to deal with only kids, and anesthesiology might be great until you have a crashing patient. Dermatology not really interested in skin and I'm not a visual person in general. EM would be way too stressful when you're the only EM doc covering the floor. And I want patient interaction, so eliminate pathology, radiology and public health!

I really want to be a jack of all trades kind of guy - so IM & FM seem to be a good fit, but the lifestyle of FM is pushing me towards that haha

 

[Redpancreas]

Thanks for this! I feel like I have a similar thought process to you! I've eliminated surgery, and I want to be a generalist (kind of like a little bit of everything!) vs. a specialist! So basically, I'm down to FM & IM

I thought about physiatry, psychiatry, and neurology but those are too specialized and I would prefer something more broad! Pediatrics, I don't want to deal with only kids, and anesthesiology might be great until you have a crashing patient. Dermatology not really interested in skin and I'm not a visual person in general. EM would be way too stressful when you're the only EM doc covering the floor. And I want patient interaction, so eliminate pathology, radiology and public health!

I really want to be a jack of all trades kind of guy - so IM & FM seem to be a good fit, but the lifestyle of FM is pushing me towards that haha

Family’s gots its pros and cons . Keep in mind you’ll be expected to see kids and pregnancy issues. For one, it’s the most 9-5 job out there. With good business acumen, you should be able to make a decent amount too no matter what everyone says. Consider if you want to do family with heavy OB training integrated into residency. With that, you can go to more less urban settings and do a lot more stuff related to delivery. Despite the creation EM residency, they’ll still let family’s practice in ERs in places too.

 

[Neopolymath]

Social issues, dumping ground, unlimited notes and rounding, hardly any procedures, lots of mental masturbation, slow progress... WHAT'S NOT TO LIKE?!

 

[Spodermin]

cerebralness of internal medicine: you really have to think critically

Its really not that "cerebral" for 95% of patients. Antibiotics, fluid management, CHF and COPD medications become second nature after a few months on IM service.

team-based: frequently going over cases with your colleagues

These can, and do, turn into useless discussions quite often

procedural & hands-on: you can do many procedures like lines, intubating patients, ultrasounds

unless you're in the ICU, you won't be doing these

 

[Lexdiamondz]

Its really not that "cerebral" for 95% of patients. Antibiotics, fluid management, CHF and COPD medications become second nature after a few months on IM service.

These can, and do, turn into useless discussions quite often
unless you're in the ICU, you won't be doing these

Even if you’re in the ICU it’s more often ICU fellows doing those interventions

 

[CherryRedDracul]

Its really not that "cerebral" for 95% of patients. Antibiotics, fluid management, CHF and COPD medications become second nature after a few months on IM service.

Every field has its routines that can become autopilot.

The internist, however, needs to put his/her brain to task for that 5%. That 5% was the fun stuff for me during intern year.

 

[bonemann]

glorified flow chart

 

[Money Moniker]

Its really not that "cerebral" for 95% of patients. Antibiotics, fluid management, CHF and COPD medications become second nature after a few months on IM service.

These can, and do, turn into useless discussions quite often
unless you're in the ICU, you won't be doing these

glorified flow chart

Which field of medicine isn't mindless rote repetition though? For all the wishful talk among doctors and med students about how medicine will be the last profession to be automated, there is a reason healthcare is the #1 target of machine learning development efforts. That reason is that the practice of medicine really is a repetitive, algorithmic slogfest where you do the same thing over and over and over again with very little creative thinking involved.

It's not restricted to IM, the other specialties are even more mind numbingly repetitive. GI and its butt piracy? Cards and its artery plumbing? EM and its shotgun labs +admit? Surgery, with its emphasis on honing a few procedures via obscene volume? Let's face it, medicine is not something that requires deep or original thought and that's why tech companies and their algorithms and hospital admin and their online-trained NPs are gonna tear it a new one.

 

[Moose A Moose]

Which field of medicine isn't mindless rote repetition though? For all the wishful talk among doctors and med students about how medicine will be the last profession to be automated, there is a reason healthcare is the #1 target of machine learning development efforts. That reason is that the practice of medicine really is a repetitive, algorithmic slogfest where you do the same thing over and over and over again with very little creative thinking involved.

It's not restricted to IM, the other specialties are even more mind numbingly repetitive. GI and its butt piracy? Cards and its artery plumbing? EM and its shotgun labs +admit? Surgery, with its emphasis on honing a few procedures via obscene volume? Let's face it, medicine is not something that requires deep or original thought and that's why tech companies and their algorithms and hospital admin and their online-trained NPs are gonna tear it a new one.

Easy, Tex. Surgery is going to be a safe haven for a lot longer than any other specialty. Even if the tech exists, the lawyers are gonna needs someone with hands to scrape that malpractice money from, and hospitals will always need that fall guy. It’s the same deal with pilots - you need a man (or woman) to answer to.

 

[bonemann]

Which field of medicine isn't mindless rote repetition though? For all the wishful talk among doctors and med students about how medicine will be the last profession to be automated, there is a reason healthcare is the #1 target of machine learning development efforts. That reason is that the practice of medicine really is a repetitive, algorithmic slogfest where you do the same thing over and over and over again with very little creative thinking involved.

It's not restricted to IM, the other specialties are even more mind numbingly repetitive. GI and its butt piracy? Cards and its artery plumbing? EM and its shotgun labs +admit? Surgery, with its emphasis on honing a few procedures via obscene volume? Let's face it, medicine is not something that requires deep or original thought and that's why tech companies and their algorithms and hospital admin and their online-trained NPs are gonna tear it a new one.

I'd rather be a gloried flow chart + work with my hands, instead of just a flow chart.
My post was basically in response to the people who think IM is 'intellectually stimulating" and "diagnostically challenging" - i think its only very rarely these things.

 

[curiousneuro]

I think AI is going to make a dent in all specialties in the future - but the question really is just how much and when.

Call me biased or just a naive resident, but I just can't imagine that it will happen anytime soon in the field of neurology. Sure, there are basic patients that can be managed somewhat algorithmically (such as routine strokes or run-of-the-mill headache patients), but for the most part, every patient, their story, and physical exam findings are so different and can send you on different paths completely. And in neuro, the physical exam is key - everything else (including imaging) is 'supportive evidence'.

For example, we had a patient recently on the service with recent-onset spastic dysarthria. Everything came back normal (including MRI with thin-cuts through the brainstem, brainstem evoked potentials, lumbar puncture with autoimmune panels, etc.). All of those tests didn't change our management though...we still treated her. And we do see MRI-negative strokes from time-to-time, for example.

Probably the biggest skill we learn in neurology residency is how to really tease out a physical exam. I just don't see that happening with AI and midlevels, just yet.

 

[Atom612]

IM is a very broad field and depending on your sub-specialty and practice, your lifestyle and level of acuity can differ drastically (ex. outpatient allergy/immuno vs ICU, outpatient endo vs cards, hospitalist vs internist, etc.). Some sub-specialties are really not that competitive, for example ID, nephrology, rheum, etc (except for maybe at top programs).

I am going into peds. I just couldn't deal with always seeing the long histories of/medications for HTN, DM, HLD, CAD, CHF, OSA, obesity, etc. + people refusing to take their medications for no good reason + trying to get people to quit smoking, drinking, drugs

Adults just suck (myself included), but to each their own.. someone's gotta deal with 'em. Overall, IM is a good field with a ton of great options available after residency.

Adults smell bad. You get all the same pros but better smelling patients in Peds

Plus most kids admitted to the hospital you can actually save. Much cooler to save someone's life when they can go on to to live another 80 or 90 years than when they are going to die in the next few years no matter what you do.

The lifestyle concerns you raise can be mitigated in either field by carefully choosing your practice setting.

If higher acuity is stressful for you and a con on your list you may prefer outpatient medicine no matter what fields you are in. This would also take care of your concerns regarding length of history as you wouldn't have anywhere near that amount of time with each patient.

Yeah, but what about dealing with parents though? How much of your day is spent negotiating with a difficult mom/dad?

 

[ortnakas]

I think every specialty, like just about every job that exists and everything else in life, has the ability to get mundane when you're doing the same thing every day. Some of the best advice I got going into medical school was to pick what you can best picture doing the bread and butter of every day vs. picking something for its zebras. And remember that what you find exciting and boring might be completely different than somebody else.

@Oso taking you for an example-- props for going into peds, good pediatricians are awesome. Personally, I find nothing more mind-numbing than well-child visits, but I'm really glad there are people like you and my in-real-life future pediatrician friends to take care of sick kids and make sure the healthy ones are growing properly, because I sure couldn't do it. Meanwhile, I actually enjoy dealing with multiple comorbidities and polypharmacy and figuring out if my little old peoples' SOB is due to their COPD vs ischemia vs fluid overload vs whatever, enough so that dealing with the social issues is okay with me, but I totally understand that it isn't everyone's cup of tea.

 

[Oso]

Yeah, but what about dealing with parents though? How much of your day is spent negotiating with a difficult mom/dad?

Not a lot of it. Of course, I'm an M4 so have yet to go through residency, fellowship, and actually work, but here are my thoughts:

- most parents sincerely want what is best for their child, so often, any disagreements or tensions that develop are due to a lack of understanding on the parents' end. For example, thinking that putting a baby on an NGT means they will become 'dependent' on it forever, so they may resist its placement, despite us knowing it's in the patient's best interest.
- sometimes we just take things for granted and we don't explain things well to parents. Using the NG example, sometimes a baby is weaned off the tube but then needs to get back on it for whatever reason. I've seen a few parents think that this is a big step backwards and become very stressed and dismayed and don't want it placed again, so we had to explain that it wasn't really a step backwards and that overall the patient was making big improvements in other areas
- sometimes parents are just really stressed and exhausted. I've seen patients stay in the hospital for weeks to months, and parents have to be switching off who is visiting and/or spending the night in the hospital, meanwhile they still have to juggle caring for their other children and their day jobs. This stress can make things stressful for everyone in the team. I've found it can be helpful to sometimes say something like "this is a ****ty situation, you guys are exhausted, I'm sorry. let us know if there's anything else we can do" and parents will appreciate it a lot and it can help relieve tensions.
- the patient is the child! Regardless of the parents, it's much easier for me to maintain empathy and compassion towards the patient (as opposed to when the patient is a difficult adult who refuses to take their medication for no reason or continues to smoke or yells at you all day long -- I just find it harder to continue to give a **** in these cases).

Caveats:
- I have seen some difficult social cases and child abuse cases
- ****ty adults exist, so sometimes those people become parents and become a pain in the ass to deal with regardless of the situation
- sometimes teenagers can be the worrrssstttttt
- I'm sure I will become more cynical as my training goes on

Cheers

 

[Lnsean]

I think every field has its own gripes. Some of the smartest people I know love IM.

 

[WingedOx]

Rounding sucks.

 

[spacegun]

I've been told rounding in a university or academic place isn't like rounding in PP. Rounding in PP is supposed to be much better and faster. I guess if you're the IM attending in PP, then you can go as fast or as slow as you are able.

 

[ndafife]

I've been told rounding in a university or academic place isn't like rounding in PP. Rounding in PP is supposed to be much better and faster. I guess if you're the IM attending in PP, then you can go as fast or as slow as you are able.

Still takes forever to round on 25 people

 

[cbrons]

7 on7 off no call.
Acuity varies greatly, usually patients requiring one to one nursing get transferred to ICU. Where intensivists take over.
When a patient crashes the same happens and rapid teams and ICU teams become involved.
Something's you haven't touched on is being the dumping grounds for specialties ,ICU , and etc.
Dealing with the social issues for the patients.
Generally low on procedures unless you are in a subspecialty.

- Intensevists are only in a minority of hospitals.
- When a patient crashes it is usually internists who run the stat teams, even in big academic hospitals.
- Being the dumping grounds is a problem, but often these dumps come from services who have very seriously mismanaged the care and gives you the opportunity to correct things
- Social issues are dealt with by social workers. To the extent the doctors have to deal with people who are using the hospital as a hotel/homeless shelter, that is something other specialties have to deal with as well, e.g. EM, FM, pediatrics, psychiatry. The ICU has its own class of seriously soul-crushing situations, e.g. seriously demented people without surrogate decision makers not being allowed to die with dignity, disabled people in the same situation stuck on ventilators, etc (ICU is one of the worst specialties to go into if you want to avoid social work nightmares). Half of all neurology inpatients are insanely high-need and have a primarily psychiatric issue; there is also a fair amount of ICU-level hopeless cases (TBI patients in the neuro ICU for example). General surgeons are "dumping" ground for wound care management. Interventional radiology is a "dumping ground" for simple procedures that no one else has time or gets paid to do. Anesthesiology is often subservient to their surgical colleagues and treated like garbage, not to mention CRNA nightmares, etc. Point is these problems exist everywhere to some to degree, and to the extent that they don't, there are other problems.

 

[cbrons]

Its really not that "cerebral" for 95% of patients. Antibiotics, fluid management, CHF and COPD medications become second nature after a few months on IM service.

This is far too cynical. There is a great deal of nuance in each of the things you mentioned, and "CHF" (a dumb and outdated term) and COPD are far from the only problems that an inpatient internist will see.

These can, and do, turn into useless discussions quite often

Academic rounds are often a big waste of time. Definitely a weakness of IM residency.

unless you're in the ICU, you won't be doing these

You can do a lot of procedures on the floor if you want. They just take up a lot of time and you don't get well-compensated for them, so they aren't worth it in private practice.
Attending ICU doctors will do a varying amount of procedures. Often the same issue of time and compensation comes up, and so they hire mid-levels to do it. None of those procedures are difficult (though while endotracheal intubation is very easy, its extremely dangerous and a cluster if you screw it up), so they won't be doing all of them. Also, as an academic intensevist you'll be doing almost no procedures in the Unit, but will be supervising fellows and residents who get to do them. Oftentimes this means yawning in the back of the room and looking at your watch. The times you get actively involved usually means stuff has gone badly wrong.

 

[cbrons]

Which field of medicine isn't mindless rote repetition though? For all the wishful talk among doctors and med students about how medicine will be the last profession to be automated, there is a reason healthcare is the #1 target of machine learning development efforts. That reason is that the practice of medicine really is a repetitive, algorithmic slogfest where you do the same thing over and over and over again with very little creative thinking involved.

This is absurd. Mindless rote repetition is working on an assembly line or flipping burgers or sweeping floors or selling movie tickets and popcorn. Being a physician in any specialty is far more complex and nuanced in almost every way than virtually every other profession.

The reason medicine is the target for machine learning is not because it is mindless but because it is extraordinarily complex.

 

[NITRAS]

Rounding sucks.

Other specialties don’t see their patients?