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  • Opinion on choosing Internal Medicine as a specialty

    Hello there,

    I'd like your opinions on pursuing Internal Medicine. It's been years since I've posted here. I think my last post was prior to beginning medical school. I'm now at the point in M3 where I'm preparing my application for residency. Internal medicine is the most appealing specialty to me given its broad knowledge base and versatility with practice types. In an ideal world, I'd like to practice the old model of outpatient clinic with admitting privileges that allows me to round on my patients in the local hospital. My PCP still does this but I'm aware that this model is all but missing the final nail in the coffin.

    I'm reaching out to you all who have further experience to hear your opinions on the future of internal medicine and primary care. Whether you think that it's worth pursuing or if I should strongly consider something else?

  • #2
    Not IM. I am retired OB/GYN. I liked taking care of patients over decades. It also seems to me that IM gives you many options. You can fall in love with one of the specialities like cards or do hospitalist work. Plenty of patients desire an IM who will round on them in the hospital and direct their care. My thinking is this is concierge medicine. Hopefully someone who is doing this will respond to you.

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    • #3
      If you want to practice only outpatient, choose family medicine. If you want options, choose internal medicine.

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      • #4
        I’m FM, outpatient only. As you hinted, it’s rare for someone these days to round at hospital then have a full clinic day. . I don’t think that lifestyle is sustainable long term.

        pretend you chose to do this path(gen IM outpatient and admit your patients)…a typical day would require you to round in am likely atleast by 7am then attend your clinic by 9am -12pm. Maybe you could go back to hospital at lunch and get some more things done. Then rush back to clinic 1-5pm or later. Also, who covers you at night ? Weekends? Holidays? You wouldn’t be able to shut off your phone at night etc. you’d need to arrange call coverage for nights weekends etc. you’d likely need to team up with other local pcps who do the same traditional practice and share call with them so you don’t have to be on call every single day for your patients but you’d have to cover their patients when on call also.

        I wouldn’t recommend FM..seems to be taken over w midlevels etc. If you don’t mind not seeing all ages then IM would be the way to go, this would leave you options to do strictly outpatient vs hospitalist vs specialty.
        recommend you shadow more to get an idea of what it’s like. Focus on what life is like after residency, not so much on the residency itself which is temporary

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        • #5
          Are you competitive enough to match into a surgical specialty?

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          • #6
            What’s the specialty you enjoy most? Also, do your research on the day to day downsides of the specialties you enjoy and pick the one with the issues that bother you the least.

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            • #7
              Originally posted by Hank View Post
              Are you competitive enough to match into a surgical specialty?
              I am competitive for surgery but truly detest it. I’m just finishing up surgery right now. The vascular surgeon I’m with is pushing me to apply but I just don’t like it. The atmosphere is too toxic. I did enjoy surgery clinic days though

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              • #8
                I think IM is a great specialty that gives you a ton of options and job opportunities. Inpatient, outpatient, urgent care, subspecialties, employed, private, etc. Admitting your own patients is rare and likely a pain. I wouldn't do that. I'm not doom and gloom about primary care, lots of need for doctor PCPs and they feed the rest of us. You'll likely find a job wherever you want and the money and lifestyle can be pretty good. As long as you know what you're getting into.

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                • #9
                  Do IM followed by a subspeciality to future proof yourself.

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                  • #10
                    IM keeps the option doors open for another three years. I went IM after end of 3rd year. Didn't decide for outpatient until 2nd year residency when I said 20 years of education was enough -- ready to start 'life'.

                    There are some groups that maintain both inpatient and outpatient combo practices where they rotate in each month to care for their group. You'll find this is larger metro for birds-of-the-feather and they tend to skew younger docs. -- it's not quite dead yet.

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                    • #11
                      Originally posted by Greendogs19 View Post

                      I am competitive for surgery but truly detest it. I’m just finishing up surgery right now. The vascular surgeon I’m with is pushing me to apply but I just don’t like it. The atmosphere is too toxic. I did enjoy surgery clinic days though
                      Define “toxic”, if you are comfortable doing so? Once you are an attending, you'll sail the ship how you want to, while still being able to have enjoyable experiences in surgery clinic.

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                      • #12
                        Sounds like IM is a good choice for you. I wouldn’t bank on doing in and outpatient unless you’re willing to work somewhere fairly rural.

                        I did EM->CCM. If I had to do it again, I’d probably do IM. More options. A lot of good sub specialties - can do something procedural or no procedures, all inpatient or all outpatient, hospitalist with shift work or have your own patient panel, employed or on your own, very lifestyle friendly or high comp.

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                        • #13
                          IM is a great field, challenging and lots of options.

                          i do a ton of counseling on specialty selection fyi.

                          one of the best pieces of advice i ever got (this was from a doc who was IM/Pulm-crit) was "don't go into a field to change it, it will change you."

                          with that in mind, remember that the model of primary care docs admitting their own pts is dying all over the place, probably for good reason. i have worked in this model before and tbh it's kind of a mess imho. you tend to wait a long time to hear back from someone, you have no other options for admission (god help the ER doc who admits a pt to the wrong doctor), the docs tend to be pissed to hear from you after hours since they've already worked all day, etc.

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                          • #14
                            I've been at my institution for nine years. On the hospitalist side, there's a mix of private hospitalist groups, a resident teaching service, and a few private docs, some of which are only hospitalists and some of which do an outpatient/inpatient mix. When I started, we had a few docs that did the model you're talking about, having their own clinic and then rounding on their own patients in the hospital. None of them had regular coverage; they were essentially on call 24/7, with the occasional coverage for vacations or such. There ended up being too many problems with being able to reach those docs in a timely manner, and the hospital system has phased in a few rule changes over the past few years that have essentially phased out that model. Now, there is only one doc who still practices that way; he is about 1000 years old and could probably get away with murder at our hospital. The other doctors who used to do that have either joined together to make an informal group where they cover each other patients, or have stopped doing the hybrid model altogether.

                            While complaints from the ED ultimately make little difference in policy given how little political power we have, I will say that those docs were a flipping nightmare to admit to. They basically only took admits during a couple hours in the morning and then a ~4h block in the evening. Now we have a policy where admitting doctors have to call back within an hour of getting the page for admission, it's mostly adhered to, and flow through the department is a lot better. (If only we had a policy where surgical services were required to make up their minds as to whether they're going to admit a patient or punt to medicine within a reasonable time frame..... But I know better than to wish for impossibilities.)

                            Anyway, for the bigger question, I think IM is a great specialty. It gives you probably more options than any other specialty, and you have a lot of opportunities for crafting a career into what you want. Unless you have a burning passion for another specialty, I'd say go for it. You can do a lot of things from IM.

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                            • #15
                              Be careful about conflating a toxic atmosphere in one rotation, perhaps only one or a handful of people, with a toxic field. You may be right that an entire field operates such that you want no part of it. But you need to look far beyond one service. Do a rotation in a different surgical specialty at a different institution. Talk to people at other places. If there is anyone you trust at your place in a different surgical.field, ask them. Ask your classmates who have worked with other surgeons at your school. Ask
                              ​​​your 4th years.

                              This is a big decision and you want to have good information.

                              I am happy with the choice I made but looking back, it is clear that I paid more attention than I should have to local issues that were not representative of fields as a whole. I went to a school with excellent hospitals but a long tradition of weakness in one field that interested me. I let that incline me away.when it should not have done so.

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