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Discussion in 'Medical Students - MD' started by DrShelmonMD, Dec 7, 2008.
Disadvantage would be it takes longer to do two fellowships vs one.
Why don't you ask yourself this question after your first set of ABIM in-training exam scores come back after you take this exam your first year of Internal Medicine Residency? Also, be sure that your Internal Medicine Residency Match is high-caliber university too. GI is one of the most competitive IM fellowships out there and community programs are not going to get you into GI. Also, be aware endo is not a "chip shot" either. Before you start looking at practice options, lets see what you bring to the table in terms of where you match and how you do in residency.
I've thought of doing a double fellowship too (except in ID and heme-onc). Of course, there's more time spent on doing the fellowships as opposed to practicing and earning money. Why are you interested in combining GI and endocrine? GI is highly procedural whereas endocrine is not so much.
If, in the end, you end up wanting to do both, try to match in the most high caliber academic IM residency, then GI, then endocrine.
technically, hemeonc docs are double boarded so that's 3 fellowships.
since GI is so competitive, if OP doesn't match into a competitive IM program, could he could use the endocrine fellowship as a springboard into GI?
I'm not an attending, but I think it would be like a nurse applying to medical school. The GI fellowship would want to have some explanation of "why GI," especially since diabetes management and research is more within endocrine's purview. It would probably be easier to go from GI to endocrine because of lower level of competition.
Then again, as others have said, this whole discussion is premature and the op, should he be in a position to do so will probably be sick at that point of further education and will stick to just the one fellowship and go from there.
I think at some point you may realize that you want to be a GI doc with endo knowledge or an endocrinologist with GI knowledge. Once you figure that out, do a fellowship in whatever you want "to be" and just focus your independent learning (reading, conferences and collaborations through research or multidisciplinary clinics) in the other field of medicine you want to compliment your practice.
It would be hard to get PCPs to send you referrals for both.. plus GI is more procedure oriented and thus one would want to focus on that to make $$$$$...
If you want to manage both sets of patients, why not skip both fellowships and be a generalist?
I think it would be hard to maintain both knowledge bases in practice.
Agree. I think it will be plenty challenging to be a good internist and then be one or the other than trying to be all three. Keep in mind that if your focus is on DM than a GI fellowship isn't nec going to add all that much to your expertise.
Keeping up on the current literature would be a 1/4 time job in and of itself if you really wanted to be good, nevermind doing enough GI procedures (EGD, cscope, ERCP) so as to stay good at them.
Endo and GI also tend to attract different people. There's a sort of GI/Cards/Pulmonary crowd (proceduralists, interventionalists) and a Rheum/Endo/ID/Allergy crowd. So hearing someone saying they are interested in both is a bit like listening to an M3 saying, "I am either going to do Pathology or Emergency Medicine" -- it seems to reflect a lack of either self-knowledge or knowledge about the fields at hand.
Plus there is the whole issue of being PGY-9 and not being about to do a craniectomy...
Hey! Some of us are actually having this internal debate. Maybe I lack a little more than a bit of both?
Well I certainly didn't mean to be rude or caustic but I do stand by my statement!
On the one hand you have what is basically a 8-5 career immersed in basic science, molecular techniques, methodical activity, and the very minimum of patient contact. On the other you have a nights-and-weekends, procedurally oriented, relatively fast-paced, heavily patient-centered field.
It's less surprising to see someone be
Surg vs. EM
Ortho vs. EM
even IM vs. EM
Rads vs. Path
Derm vs Path
Path and EM are actually both great fields with relatively high job satisfaction and income for hours worked (path > EM in terms of $). I just think that the student who is torn between them needs to do some soul-searching (preferably with the help of trusted faculty mentors) to answer the question "what I am really looking for in a career?"
Thanks for your responses everyone. I think that I'll apply to both, and if I get into the GI fellowship, I'll take that one. Otherwise, endo it is!
Once you finish one subspecialty fellowship, the draw to actually go out and practice and earn a nice living will probably outweigh any interest in going back for another multi-year fellowship. So most people wouldn't do it. Your life will change in the 5+ years it's going to take post-med school to get through one field, and you can only speculate what life draws will be pulling you to be in the work force already by that point. So it is perhaps doable, but few would do it because most people have non-academic reasons to be in the work force by the time they get through a fellowship.
I disagree with this idea...somewhat.
I think for a lot of people (probably the vast majority) the decision IS between to very similar fields, like your path vs. radiology example or picking between two surgical subspecialties.
However, I think there are certainly some multifaceted individuals out there who would indeed be exceptional in two completely separate fields because they play to different aspects of their personality. Take a friend of mine. Going into anesthesia. However, he was a psychology major in college, enjoyed psych both in the classroom and clinically, and it was a big decision to choose between these two vastly different fields.
That's not to say I'm not skeptical when somebody tells me "I either really want to do radiology or dermatology" because the people I've met who are interested in both only care about money and vacation, but I think it is possible for a lot of people to choose between really different fields because they play to the persons two different strengths.
So the OP can't consider his career options ahead of time? When IS the precise moment that we students are permitted to consider fellowships of interest? Is it after we match our residency? Is it after we get our scores back on inservice exams? Is it after we get letters of rec? Be precise as I don't want to think about this prematurely!
I mean geez, why shouldn't the OP look ahead? What if he's making his match list and is torn between that high powered academic program and a little more laid back community program. Maybe knowing his fellowship goals ahead of time might help with the decision, eh? Besides that, when did people on SDN decide that it was 'imprudent' or in fact 'wrongheaded' to aim at a goal until AFTER one had already cleared the hurdles to achieving the goal? Are we afraid of failure around here, or is it something else? It reminds me of the threads on pre-allo where the pre-med will mention being interested in ortho, or derm, or whatever, and then immediately all the naysayers will jump on him about not even thinking about that until he gets into med school, aces his classes, and scores a 397 on Step 1. The kid's not going to med school to become a generic fill in the blank doc, he's going with the idea of working as a specific type of doc, just like EVERY ONE OF US DID.
Let people dream. Let them imagine their futures. Quit trying to get in their way. If you think someone's dream is not feasible, mention the pitfalls you see and allow them to consider your comments and, if necessary, adjust their vision. But quit griping at people for looking ahead to a career they think they'll find enjoyable just because YOU think they might now be able to make it.
Sorry I just find it sad how much negativity flies around this place.
I agree with MattD.
I can see Path vs. EM as being a very insightful internal debate.
Both fields have a predictable lifestyle, and can easly fit into a ~40 hour work week. Neither have "emergencies" when you're off the job (unless something really bad is goin' down), and you can leave your job at work.
Both are concerned with making THE diagnosis, and both can leave the management to the medicine or surgery guys. Both can have routine cases, or workdays, and once in a while have a particulary interesting or mindbending case. Both can choose to work in a hospital which will keep them on their toes all day. Neither needs to be overly concerned with getting to know the patient, or their family. Neither has to worry if the patient is going to be compliant with their medications, or if maybe they'll quit smoking this time around.
Both can do fellowships which will allow them to work the streets, (EMS, or Forensic Path), or to a fellowship that allows them to work with law enforcement (EMS fellowship concentrating on SWAT, or again, Forensic Path), or EM physicians can do a fellowship in toxicology, and I would think that theres something similar in Path.
And on, and on...
So, anyway... maybe Pathology vs, EM is a bad example. But, there is something to the idea that students should have some idea of what they want to go into before they even get to med school, and that the options should have something tying them together. But, we should accept that we cant always see the same connections that others can.
Having some idea of what you want to go into is tied to why you want to be a doctor in the first place. Whether that is that you want to be able to study science and apply it, or you want to help people... or you want to diagnose diseases, or you want to treat them, or if you want to save lives, or you want to improve quality of life.... or you want to treat disease, or you want to prevent it, and help people stay healthy...
Whatever the case, you should have some idea of, a) why you want to be a doctor and b) some reason for thinking that the reality of medical practice will fit with "point a", and c)which fields of medicine fit your reality of medical practice.
I have never met an ER doctor who was concerned with making a diagnosis.
Unless you consider "hyponatremia" and "altered mental status" diagnoses.
Yeah, I have to agree with tired here, in my admittedly limited experience, the ER guys are concerned with making THE dispo, not so much the diagnosis. The question is "Will this person die or irrecoverably lose function within the next hour?", "Is this patient sick enough to be admitted?", and "Which service do we turf this patient to?" Which is fine, because that's their job. Triage, stabilize, and direct the patient to the appropriate care provider. In tired's example the flow goes like this: Patient has AMS -> patient has hyponatremia per chem7, this is the most likely cause of the AMS -> hyponatremia is most likely a result of a process IM docs deal with -> call admitting IM resident.
That's it. And the IM resident is simply hoping the ER doesn't do something silly like try to treat with hot salt before he can get down there and take over care.
two against one? i could be wrong...
Having a patient who comes in with a vague, generic complaint like chest pain, or SOB, and then being the one to diagnose the MI, PE, pneumonia, etc, or to confirm the lack thereof, is one of the things I like about EM. If they admit the patient with a hokey diagnosis of "chest pain", they've presumably thought of, looked for, and ruled out an MI, PE, dissection, etc. etc.
On Medicine, if you want to make a diagnosis, just look at the last page of the H&P. Pre-diagnosed For Your Convenience.
Actually, what you guys are missing, and what I'd think is the larger fraction of patients, are the ones that are treated and streeted. In those patients, the ER doc certainly makes a diagnosis.
Of course, Im over-simplifying the chest pain example, but I always like the chance to have somone come in with some random signs and symptoms, and just a two page chart, and I get to figure out what he does or doesnt have.
I dont know... maybe this too, shall pass.
Dude, this kid IS a premed.
I mean, yeah it's true, but at the same time, it's not really fair to blame the EM docs for the fact that the general public uses them for primary care and not for emergencies. If someone wants a fullblown dx workup for a problem that's been going on for weeks --> months --> years and is NOT life threatening, the ED is not the appropriate place to go (hence the "emergency" in "emergency department"). So yes it's unfortunate that other services have to deal with the backlash (not safe to go home --> admit) but it's not totally their fault. Also, if someone came in with AMS, the ED often runs multiple tests at once and diagnoses based on what comes back positive... but they can't exactly sit there are correct the hyponatremia to make sure that's the cause of the AMS when they have a waiting room full of "chest pain" and "abdominal pain" and "vaginal bleeding" and a limited number of beds.
This reason, for me at least, is at the root of my dilemma. The Dr. Jekyll in me wants to be involved in molecular diagnostics and basic science as it is applied to medical practice, while Mr. Hyde wants to be in the center of the drama, doing procedures and handling emergencies.
Why can't I find a career path that combines all the aspects of everything I like about medicine? The closest I have come thus far is family med. (Unfortunately, the bulk of the "pathology" I experienced on my FM rotation was looking at endless vaginal discharge smears for yeast and clue cells. Not particularly exciting.)
For the record, it is never advantageous to be an endocrinologist.
Unless you really like Diabetes and Thyroid. It seems that all the interesting endocrine stuff presents to Neurology, Nephrology, and OB/Gyn, and stays there.
How 'bout derm? As hands on as you want to be, lots of looking at slides and histology. Focus on skin cancer and you'll have plenty of both.
Or maybe oncology? Those guys know a ton about the cellular and molecular basis of disease, actually know what they are looking at when the pathologist shows them slides.....and their clinical work is pretty intense.
yeah, I know. Your point?
Oh sure, I wasn't bagging on the EM guys, I understand the reason that they operate the way they do. And it's true that they diagnose lots of things and send patients home, and that's totally appropriate. All I was getting at was that if there was some fascinating medical mystery, it wouldn't be solved in the ER, it would be stabilized, initial labs drawn, and turfed to the appropriate service. If someone wants to solve those mysteries, they need to be on the admitting service. There's no time to indulge in real in depth detective work in the ED.
Hah. I'm primarily interested in surgery, but I have to admit I enjoy endocrinology a lot. Of course I was a control systems guy in eng. school, so perhaps that's where it comes from. I could NOT, however, see myself managing 35 diabetes patients per day in clinic
I dunno -- the couple I've worked with say they love their job, do a lot of clinical research on a handful of patients who will never be "cured" (steady flow of repeat business), and don't seem to work too hard compared to some of the other medicine subspecialties.
What if your main area of interest is obesity? Endo has diabetes, GI has hepatology and fat storage. Which specialty do you think is more relevant if you want to be an obesity specialist or pursue clinical obesity research?
By word of mouth from those looking at the field or already in it, there are several reasons why endocrinology is a suckers bet:
- it's actually somewhat competitive
- you take a suprising amount of inpatient call, but when you get called it's for things that are only peripherally related to the field or minor things any Medicine doc could do ("Please do stim test on ICU patient" or "Please help with synthroid adjustments")
- (this is the biggest one) most endocrinologists I have encountered don't get enough volume to sustain an all-endo practice, and usually have to do general Internal Medicine as well
Obviously if you're one of the lucky few who can work their way into a group at a tertiary care center or one of the big name Endocrine groups/hospitals, this doesn't apply. But for your average endocrinologist . . .
About 0.01% of GI training would help you above and beyond what you would get out of endo training.
You could also consider, and hear me out before laughing at me, family practice if you're interested in obesity. At least 50% of your patients will be obese, and you'll see the gamut of reasons for it. Or you could hang your shingle as an obesity specialist, do the weight loss clinic type stuff, there's plenty of opportunity for academic research. I dunno, I feel like if you're REALLY into obesity, you may be able to get down to it quicker that way than with an IM+Endo route. I don't know how much volume you'd get thru that route vs. an endo practice, so the dollars and cents would have to be worked out. If you can't get enough volume doing full time obesity work though, the route you take would likely depend on what OTHER types of patients you'd like to work with in addition to the obese ones.
Well here's my predicament: I spent a summer doing clinical endocrinology research at the NIH. I really enjoyed it because the focus of my unit was obesity. However, of all the rounds I went on I found lipid metabolism rounds to be the most interesting and exciting. Endocrine rounds were alright when there were obese patients, but for the most part we talked about hypo or hyperthyroidisms, hypo or hypergonadisms, etc. In lipid metabolism rounds we had patients who may or may not have been obese, but had unusual dyslipidemias. I enjoy learning about the mechanisms behind glucose tolerance and diabetes, as well as dyslipidemias associated with obesity.
Just a thought: which specialty or route would I benefit most from if I wanted to become a lipid specialist?
Whatever you want