Advice on IM vs FM

[sterntaler]

I'm currently in 4th year of medical school and will be applying through CaRMs this cycle.

I'm still having a a very difficult time deciding between IM (I'm more interested in the outpatient specialties, e.g., endo, rheum, geriatrics) versus family medicine. I have been talking to many Internal medicine residents (R1s to R3s, many of them are interested in the same specialties), and many of them are telling me that if I can see myself being a family doc, I should just go for Family Medicine due to the better lifestyle/flexibility and ability to practice earlier (and they said I will do well in an IM program, so it's not because they have no confidence in me lol). Some of them even went as far as saying that they wish they had gone into Family Medicine instead. 

I wonder how much of this is just "grass is greener on the other side", especially because they're in the middle of arguably some of the toughest years of an IM program. Does anyone know of any unhappy internal/family staff physician who wish they had gone into another specialty instead? 

[chateau22]

It will be 5 hard years in Internal vs. 2 years in FM (not to say FM residency / studying is rosy and easy), but many people say Royal College is something that takes about a year to prepare for and your life is almost on pause at that point

In addition, FM has an excellent lifestyle, you're out sooner

Also, you'll have to consider if you don't match to endo, rheum, geri, etc. (probably unlikely but it happens) and if you'd be happy with GIM. Because if you're not happy with GIM, then internal would be a risk imo.

 

[offmychestplease]

^

[coolestman]

As someone at the start of Internal Medicine residency right now who applied to both FM and IM, this question has definitely been on my mind a lot!

My advice would be to think about your experiences in both electives and to weigh what you like and dislike about each. If you can't imagine yourself doing one of the specialties then its obviously an easy decision.

For sure IM residency will be a lot more busy than FM residency with the call schedule (1 in 4 for at least half the year and probably at least 1 in 7 for the rest) and later the stress of the subspecialty match. I would be lying if I said I was never jealous when talking to some of my friends in FM and hearing that they have so much more free time than me. But you have to take into account IM residency is just a short part of your much longer career. 

I think right now you're weighing (endo, rheum, geriatrics) vs FM. It basically boils down to would you see yourself enjoying those subspecs more than FM that you are willing to sacrifice a busier residency along with a longer training time. Different people will have different answers to this question so even if you talk to a lot of people in IM who wish they switched to FM, there are definitely people in FM who wish to switch to IM too. I've honestly seen people go both ways so far in my training.

You might not know the answer now, you might even rank between the two based on location. But after doing all your electives and interviews, when push comes to shove - I'm sure you'll be able to make the best choice for yourself then.

Wish you the best of luck in fourth year and with figuring out your career goals!

[sterntaler]

Thank you all of your responses! I also realized that I haven't done any FM rotations for 1 year now, so hopefully my electives/interviews will help a bit with the decision haha.

[MedZZZ]

I am kinda in the same boat and I think about the FM versus IM dilemma on a regular basis. I have a mix of IM and FM electives. I really enjoy IM and I actually like CTU. I really like rheumatology but I am also OK with GIM; however, the only concern for me is the long duration of IM residency and the stress of second round of CaRMS and I wouldn't really start making money until after 5 years ... 

FM is great with shorter duration of residency, great lifestyle, flexibility, and decent income. It would be nice to hear from people who were in the same situation and how did they choose their path

[unmatch]

I'm in the boat of having applied and matched to FM as a back-up from a different specialty (not IM). I haven't really enjoyed my program, just find the work in FM to be unfulfilling. There are a lot of conditions which are very prominent but have no good treatments and patients are very upset (bad backs, bad knees, etc), it often times feels like you're being more of a counsellor than a doctor, and there's so much paperwork that specialists don't have to deal with (refills, consultant notes, etc). I feel like a baby sitter for a lot of my complex patients who have multiple specialists - trying to coordinate complex conditions without having the training or skills to do so.  Specialists have the ability to choose their patients and discharge them when the medical question is answered, whereas in family it doesn't feel like there's a medical question at all a lot of the time. If you find it rewarding to develop relationships with patients, know them over several years, and don't necessarily want to always be practicing from strict evidence based medicine (a lot of your judgement is based off of gestalt and intuition), then you'll probably enjoy family medicine. If you want to be a doctor in the strictest sense then IM is probably better for you. 

They also get paid a lot more for ultimately doing less work (assuming you work similar hours as you would in rheum/endo/etc). The residency is harder in IM but I think the trade off is worth it for a lifetime of a potentially more fulfilling career. 

My thoughts are echoed by a lot of my friends who only wanted family medicine and found that the career wasn't all that it was cracked up to be. Medical students are often shielded from the reality of family medicine because a large amount of your time will be unpaid scutwork, and not true medicine. 

[gogogo]

10 hours ago, unmatch said:

I'm in the boat of having applied and matched to FM as a back-up from a different specialty (not IM). I haven't really enjoyed my program, just find the work in FM to be unfulfilling. There are a lot of conditions which are very prominent but have no good treatments and patients are very upset (bad backs, bad knees, etc), it often times feels like you're being more of a counsellor than a doctor, and there's so much paperwork that specialists don't have to deal with (refills, consultant notes, etc). I feel like a baby sitter for a lot of my complex patients who have multiple specialists - trying to coordinate complex conditions without having the training or skills to do so.  Specialists have the ability to choose their patients and discharge them when the medical question is answered, whereas in family it doesn't feel like there's a medical question at all a lot of the time. If you find it rewarding to develop relationships with patients, know them over several years, and don't necessarily want to always be practicing from strict evidence based medicine (a lot of your judgement is based off of gestalt and intuition), then you'll probably enjoy family medicine. If you want to be a doctor in the strictest sense then IM is probably better for you. 

They also get paid a lot more for ultimately doing less work (assuming you work similar hours as you would in rheum/endo/etc). The residency is harder in IM but I think the trade off is worth it for a lifetime of a potentially more fulfilling career. 

My thoughts are echoed by a lot of my friends who only wanted family medicine and found that the career wasn't all that it was cracked up to be. Medical students are often shielded from the reality of family medicine because a large amount of your time will be unpaid scutwork, and not true medicine. 

I agree with some of the things you said, like how specialists can just discharge patients ("you should ask your family doctor about that"). And the degree of paperwork in FM is staggering.

...But some of the things you said seem like they apply to a lot of medicine. For instance, isn't most of what we do in medicine not curative (unless you're in surgery)? This came as a surprise to me when I entered med school, but looking across specialties, I feel that much of medicine is management or monitoring or ruling out/avoiding the worst case scenario rather than "fixing" (again, unless you do surgery). This seems to especially apply to the fields the OP is interested in. Endo is a lot of diabetes (no cure), rheum deals with finicky autoimmune conditions and their flare ups, and geriatrics is probably just as focused on complex comorbidity management and psychosocial issues as FM is. And apart from cardio and GI (which seem to require much more training and hours), I thought the outpatient specialties (like rheum, endo, and geriatrics) make similarly to FM? 

You're much farther along than I am, so please let me know if I'm wrong in these assessments.

 

 

[Jarisch]

On 11/15/2020 at 2:41 PM, difficultdecisions said:

I'm currently in 4th year of medical school and will be applying through CaRMs this cycle.

I'm still having a a very difficult time deciding between IM (I'm more interested in the outpatient specialties, e.g., endo, rheum, geriatrics) versus family medicine. I have been talking to many Internal medicine residents (R1s to R3s, many of them are interested in the same specialties), and many of them are telling me that if I can see myself being a family doc, I should just go for Family Medicine due to the better lifestyle/flexibility and ability to practice earlier (and they said I will do well in an IM program, so it's not because they have no confidence in me lol). Some of them even went as far as saying that they wish they had gone into Family Medicine instead. 

I wonder how much of this is just "grass is greener on the other side", especially because they're in the middle of arguably some of the toughest years of an IM program. Does anyone know of any unhappy internal/family staff physician who wish they had gone into another specialty instead? 

I'm going to provide my opinion on this, perhaps in a roundabout sort of way. You are asking about unhappy internists or family doctors and if there is a grass if greener on the other side phenomenon. I am not an attending and cannot comment. But I will give you my perspective on what I wish I knew more about IM before I matched to it in medical school. For context, I am a current PGY3 Internal Medicine Resident who matched to a Cardiology fellowship for 2021. I have about six more months in my IM residency before I successfully complete it, and will be challenging the Royal College in-between.

My experience now at the tail end of my Internal Medicine Residency is that it was tough with frequent and stressful call, but still a highly rewarding period of time from an educational point of view. My medicine subspecialty rotations were like being immersed into a completely different world of practice and patient care that was uniquely rewarding, each in different respects. The pathology across different specialties (hematology, oncology, cardiology, respirology etc) was fascinating at an academic centre. I especially felt this way as a junior medical resident. Learning pace is fast, and getting to learn from experts in each field was like sinking your teeth into a different meal every day... you really do grow a lot! 

When I become senior, a lot of the novelty of these different fields wore off. There was more a focus on your overnight senior call and generalist skills. Often the on-call nights could be acute and busy. With critical care rotations, you become fairly adept at procedures and managing the 'sick patient'.

The downside, which is where many of my colleagues experienced burnout, was that senior call brings with it the politics of the hospital, which you are largely protected from as a junior medical resident and a medical student. Some of my on-call nights were stressful not necessarily because of patient care, but because of fighting administrative battles. Why is ED giving me this patient for medicine admission when it sounds like they just need ICU? Because the intensivist gave pushback...so it becomes my job to call them and have the conversation when the invariably need pressors a few hours later, or intubation. Why does IM have to admit patients with marginal/soft social issues, when realistically ED could tackle these problems and prevent an admission if there was even slightly more robust social support structures in place? Why am I admitting a hip fracture as a single-issue for ortho because "if it wasn't for the social issues, ortho would have done this as an outpatient"? (Not ripping on any specialties - just providing examples of some of the things we deal with in medicine that decrease job satisfaction) I was frustrated that IM was the dumping ground so to speak, such that patients with multiple issues that did not crisply fall under one domain defaulted to medicine. Chronicity on the medicine wards is high. My passion for medicine as a "diagnostician" and "problem solver" was often not utilized. Sometimes I felt like a secretary, with moments of medicine and magic punctuated in-between. 

 While in PGY1 the novelty of the clinical problems kept me interested, in PGY2 and PGY3 my knowledge growth flattened and I focused on more administrative and managerial duties as a senior of a team. When I did my junior attending rotations in PGY3, I DID feel that the job in the community setting was more acute focused and I did 'more' as I had less subspecialty support. A robust knowledge base was valued. Community internists likely have a wider repertoire of knowledge and skills in general, especially before many community ICUs moved to closed unit models. Still then, in my brief experience we still dealt with many social admits, administrative quarrels and sometimes I felt like someone who coordinated care, and that my medical knowledge was not being applied to patients in a meaningful way. That made my satisfaction feel low. You often work the hardest in the hospital but are remunerated the least for the hours you put in (as an attending). 

I cannot comment on how this compares to family medicine. For me, my experience in mid-to-late PGY2 solidified my interest in Cardiology because of differences in satisfaction I experienced in that field, and when I got to PGY3 I felt frankly relieved to have matched to my subspecialty. I enjoyed internal medicine residency because it was my gateway to my specialty of choice, because of the immense medicine I learned there, and because managing a team was incredibly fun for the comrardie aspect and the soft-skills I developed. By this point of residency however, I realized that while IM residency was great, that a IM career for me would likely have left me unhappy for many of the reasons above. This is coming from someone who initially planned to do a GIM fellowship. I still strongly believe a good internist is worth their weight in gold so this is in no way a rip on the specialty, just a commentary on sone of the challenges my colleagues and I experienced throughout residency.  If there is something you wish to do in IM that is a specialty route, then I think the three years of IM residency are certainly worth it and these variables are really not that important overall. it will be a stressful 3 years, but once you're in your fellowship you don't necessarily need to practice more internal medicine. 

 

 

 

[MedZZZ]

On 1/4/2021 at 12:19 AM, Jarisch said:

I'm going to provide my opinion on this, perhaps in a roundabout sort of way. You are asking about unhappy internists or family doctors and if there is a grass if greener on the other side phenomenon. I am not an attending and cannot comment. But I will give you my perspective on what I wish I knew more about IM before I matched to it in medical school. For context, I am a current PGY3 Internal Medicine Resident who matched to a Cardiology fellowship for 2021. I have about six more months in my IM residency before I successfully complete it, and will be challenging the Royal College in-between.

My experience now at the tail end of my Internal Medicine Residency is that it was tough with frequent and stressful call, but still a highly rewarding period of time from an educational point of view. My medicine subspecialty rotations were like being immersed into a completely different world of practice and patient care that was uniquely rewarding, each in different respects. The pathology across different specialties (hematology, oncology, cardiology, respirology etc) was fascinating at an academic centre. I especially felt this way as a junior medical resident. Learning pace is fast, and getting to learn from experts in each field was like sinking your teeth into a different meal every day... you really do grow a lot! 

When I become senior, a lot of the novelty of these different fields wore off. There was more a focus on your overnight senior call and generalist skills. Often the on-call nights could be acute and busy. With critical care rotations, you become fairly adept at procedures and managing the 'sick patient'.

The downside, which is where many of my colleagues experienced burnout, was that senior call brings with it the politics of the hospital, which you are largely protected from as a junior medical resident and a medical student. Some of my on-call nights were stressful not necessarily because of patient care, but because of fighting administrative battles. Why is ED giving me this patient for medicine admission when it sounds like they just need ICU? Because the intensivist gave pushback...so it becomes my job to call them and have the conversation when the invariably need pressors a few hours later, or intubation. Why does IM have to admit patients with marginal/soft social issues, when realistically ED could tackle these problems and prevent an admission if there was even slightly more robust social support structures in place? Why am I admitting a hip fracture as a single-issue for ortho because "if it wasn't for the social issues, ortho would have done this as an outpatient"? (Not ripping on any specialties - just providing examples of some of the things we deal with in medicine that decrease job satisfaction) I was frustrated that IM was the dumping ground so to speak, such that patients with multiple issues that did not crisply fall under one domain defaulted to medicine. Chronicity on the medicine wards is high. My passion for medicine as a "diagnostician" and "problem solver" was often not utilized. Sometimes I felt like a secretary, with moments of medicine and magic punctuated in-between. 

 While in PGY1 the novelty of the clinical problems kept me interested, in PGY2 and PGY3 my knowledge growth flattened and I focused on more administrative and managerial duties as a senior of a team. When I did my junior attending rotations in PGY3, I DID feel that the job in the community setting was more acute focused and I did 'more' as I had less subspecialty support. A robust knowledge base was valued. Community internists likely have a wider repertoire of knowledge and skills in general, especially before many community ICUs moved to closed unit models. Still then, in my brief experience we still dealt with many social admits, administrative quarrels and sometimes I felt like someone who coordinated care, and that my medical knowledge was not being applied to patients in a meaningful way. That made my satisfaction feel low. You often work the hardest in the hospital but are remunerated the least for the hours you put in (as an attending). 

I cannot comment on how this compares to family medicine. For me, my experience in mid-to-late PGY2 solidified my interest in Cardiology because of differences in satisfaction I experienced in that field, and when I got to PGY3 I felt frankly relieved to have matched to my subspecialty. I enjoyed internal medicine residency because it was my gateway to my specialty of choice, because of the immense medicine I learned there, and because managing a team was incredibly fun for the comrardie aspect and the soft-skills I developed. By this point of residency however, I realized that while IM residency was great, that a IM career for me would likely have left me unhappy for many of the reasons above. This is coming from someone who initially planned to do a GIM fellowship. I still strongly believe a good internist is worth their weight in gold so this is in no way a rip on the specialty, just a commentary on sone of the challenges my colleagues and I experienced throughout residency.  If there is something you wish to do in IM that is a specialty route, then I think the three years of IM residency are certainly worth it and these variables are really not that important overall. it will be a stressful 3 years, but once you're in your fellowship you don't necessarily need to practice more internal medicine. 

 

 

 

Congratulations on matching to a competitive program and thank you so much for your very thorough input! It is very helpful to hear this from someone who has been through the process already. I have done most of my electives now including FM and IM. Going to the 4th year, I had all my eyes set on IM and decided to do 14 IM electives and 6 FM electives; however, as the CaRMS is approaching and really reflecting on my experiences during the 4th year, I realize that perhaps FM is a better option for me individually given my personal situation. I have 6 weeks of FM (4 wks hospitalist ad 2 wks rural) and a lot of my IM electives are also applicable to FM including addiction med, geriatrics, rural GIM. I am wondering if someone can share their experience (personal and anectodal) what would be my chances of matching to FM since at this point, I am thinking of ranking it higher ... Any suggestions would be appreciated.

[unmatch]

2 hours ago, MedZZZ said:

Congratulations on matching to a competitive program and thank you so much for your very thorough input! It is very helpful to hear this from someone who has been through the process already. I have done most of my electives now including FM and IM. Going to the 4th year, I had all my eyes set on IM and decided to do 14 IM electives and 6 FM electives; however, as the CaRMS is approaching and really reflecting on my experiences during the 4th year, I realize that perhaps FM is a better option for me individually given my personal situation. I have 6 weeks of FM (4 wks hospitalist ad 2 wks rural) and a lot of my IM electives are also applicable to FM including addiction med, geriatrics, rural GIM. I am wondering if someone can share their experience (personal and anectodal) what would be my chances of matching to FM since at this point, I am thinking of ranking it higher ... Any suggestions would be appreciated.

Lots of people match to competitive family medicine programs after doing a very IM-focused elective season. Most things in IM are related to family. You'll get a school or two who will think you're backing up but just explain the situation in your letter. My application was very hard towards a different specialty and I matched well within family. Similar stories for my friends who did IM, psych, etc