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Nearing end of IM/CTU rotation and unsure if I like it enough or good enough at it.


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Hello, 

I'm in the first half of Clerkship nearing the end of CTU, and previously had 3 months of Surgery. CTU has been my favourite rotation by far, and surgery wasn't really my jam but I get the feeling that my CTU experience wasn't very typical. Ours was run a bit more on the informal side, I was never carrying close to as many patients/tasks as the MSI4s and residents and the patients I were assigned tended to be quite stable and had prolonged hospital stays for other reasons so I didn't get much variety and was sort of just rounding on these patients over and over again for weeks. Similarly, the consults I had overnight tended to be more worked up and less acute than the MSI4 and resident ones. I did express that I would be like to try having more patients and more variety but I don't think that will happen by the end of the rotation. Again, this was still my favourite rotation by far (really enjoyed it in fact) so I don't want to sound ungrateful as I understand that the team/patients come first. I'm just unsure if I can see myself liking/being good enough at CTU to actually do electives in it (since I never performed close to the level of an MSI4 in my opinion). 

Part of what I loved about CTU was the reading before/after seeing patients/consults. So I was wondering if a more diagnostic specialty like pathology would be good, but I don't know if I would like the microscopic/histological side of things (i'm very unfamiliar with pathology though so I could have it all wrong). 

Would be open to hearing thoughts! I won't have family medicine before elective selection which is something else I am considering (i'm basically open to most non surgical fields at this point). 

Thanks!

 

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I mean........you would be good enough for the field. That probably shouldn't be a consideration in your thought process (that way madness lies....ha). You passed your premed classes? Your staff you are working with don't think you are an idiot? Then you have the capacity. They vowed to train you, and you have been trained.

I am a diagnostician - a radiologist - and that has overlap in some ways with pathology. If you like reading around the complexities of each case and deep diving into the pathology of things about a patient you may be disappointed in my side of the fence. If it is isn't obvious I really really like what I do - I solve problems all day, and often am the first person that knows what is "wrong" but I solve them quickly. I don't, and pathologist usually don't have to do that depth of analysis for the vast majority of what we do. We cannot - we have literally 100s of patients to see a day (I read at times well over a 120 studies a day, with say up to 40 of them cross sectional. I am not learning all the subtle points about a patient except in are but of course the most rare and interesting cases. If you have hundreds of slides to review a day it is similar.). Sure there is a ton of reading to learn the field and keep up with it but it isn't about a particular patient, case, or pathology - it is just the background knowledge so I know what something is when I see it so I am not slowed down by something weird when it shows up (it is the 5% of the cases that are "what the hell is that?" that consume all your time. Getting that 5% to a lower number where you are accurate is the goal.). Radiologists can see patients a lot of the time in some branches (not just interventional!) but most of us along with pathologists don't. 

Also you have to be careful with a few things as your career will be long. There will come a point rapidly where you will now all the important things on most of the patients you see. You will treat your 1000 case of whatever, and you know everything about that. That will change a bit how and what you learn. You will still have odd things to figure out of course - medicine is always a challenge with that - and have to update your skills and learn new approaches and treatments and internal will always have more reading than many other fields.

But if you find yourself reading around your case and it is something somewhat relatively common, 5 years from now you won't be doing that ha, just like I am not looking up things on every CT scan I read (its X, I know its X, I don't have to read around X, I write papers that other people read when they want to read around X). Your field has to allow you satisfaction in the end state. If you are a surgeon it is important you still like surgery after you have removed your 1000th gallbladder. If you are going into internal medicine you have to be happy treating your 1000th case of COPD flare etc. etc.

 

 

 

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One's experience as MS3 is often diluted, for example seeing less acute patients. I'd say keep IM in your mind, but keep an eye out in the next 2-3 months for something else that might catch your eye. As MS3 it's rare to be good at something, unless you've had extensive exposure to the field. 

What I would more consider is how does the field match your general skill set. For example, if you are a visual pattern recognition person, pathology, radiology and dermatology will be good choices. If you like verbal communication, then FM, psych might be good. etc etc. If you like physiology and thinking about organ systems, anesthesia, IM and pediatrics may be good. If you prefer to think at the cellular level, then pathology, genetics may be better. If you really like pharmacology, anesthesia, IM might be good.

The other question is how does your work style fit into the specialty. Do you like to sit in a chair and work things out on a computer? Do you prefer solving problems by hand? Do you prefer a quick smattering of short cases, or fewer cases but more complex problems and solutions? Do you like to follow a person longitudinally over time, or you prefer to finish a case, forget about it and move onto the next case? These will not only play into how you select your residency, but also your fellowship and job etc.

And lastly, beware of academic bias. For example the kind of patient you see at a subspecialty clinic in an academic center is not representative of what you might see in the community. Also sometimes people in academic centers are worse off, or sometimes better off, than people in the community. For example, if you are 1 of only 2 surgeons in a small city, then you'll be on call 1 in 2, but your call likely will not be that busy and will likely not be of the same complexity as those in a large center. 

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21 hours ago, pyridoxal-phosphate said:

Hello, 

I'm in the first half of Clerkship nearing the end of CTU, and previously had 3 months of Surgery. CTU has been my favourite rotation by far, and surgery wasn't really my jam but I get the feeling that my CTU experience wasn't very typical. Ours was run a bit more on the informal side, I was never carrying close to as many patients/tasks as the MSI4s and residents and the patients I were assigned tended to be quite stable and had prolonged hospital stays for other reasons so I didn't get much variety and was sort of just rounding on these patients over and over again for weeks. Similarly, the consults I had overnight tended to be more worked up and less acute than the MSI4 and resident ones. I did express that I would be like to try having more patients and more variety but I don't think that will happen by the end of the rotation. Again, this was still my favourite rotation by far (really enjoyed it in fact) so I don't want to sound ungrateful as I understand that the team/patients come first. I'm just unsure if I can see myself liking/being good enough at CTU to actually do electives in it (since I never performed close to the level of an MSI4 in my opinion). 

Part of what I loved about CTU was the reading before/after seeing patients/consults. So I was wondering if a more diagnostic specialty like pathology would be good, but I don't know if I would like the microscopic/histological side of things (i'm very unfamiliar with pathology though so I could have it all wrong). 

Would be open to hearing thoughts! I won't have family medicine before elective selection which is something else I am considering (i'm basically open to most non surgical fields at this point). 

Thanks!

 

GIM staff here,

if you really enjoyed CTU as a CC3 and are describing yourself getting the more "boring" cases then IMO that is a good sign that you would be overall interested in IM. 

I often say if you can put up with/stand the worst of a specialty than thats a good sign that you will enjoy the specialty overall.

 

Good luck

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On 10/9/2021 at 9:21 AM, ACHQ said:

GIM staff here,

if you really enjoyed CTU as a CC3 and are describing yourself getting the more "boring" cases then IMO that is a good sign that you would be overall interested in IM. 

I often say if you can put up with/stand the worst of a specialty than thats a good sign that you will enjoy the specialty overall.

 

Good luck

Thanks a bunch! I think you're right about putting up with the more "boring" cases. I guess my concern was that since I haven't been exposed to higher workloads or more complicated cases i'm just worried about doing electives in it and then getting a more complicated consult overnight and then feeling overwhelmed or that i'm not cut out for it haha. 

On 10/9/2021 at 6:00 AM, shikimate said:

One's experience as MS3 is often diluted, for example seeing less acute patients. I'd say keep IM in your mind, but keep an eye out in the next 2-3 months for something else that might catch your eye. As MS3 it's rare to be good at something, unless you've had extensive exposure to the field. 

What I would more consider is how does the field match your general skill set. For example, if you are a visual pattern recognition person, pathology, radiology and dermatology will be good choices. If you like verbal communication, then FM, psych might be good. etc etc. If you like physiology and thinking about organ systems, anesthesia, IM and pediatrics may be good. If you prefer to think at the cellular level, then pathology, genetics may be better. If you really like pharmacology, anesthesia, IM might be good.

The other question is how does your work style fit into the specialty. Do you like to sit in a chair and work things out on a computer? Do you prefer solving problems by hand? Do you prefer a quick smattering of short cases, or fewer cases but more complex problems and solutions? Do you like to follow a person longitudinally over time, or you prefer to finish a case, forget about it and move onto the next case? These will not only play into how you select your residency, but also your fellowship and job etc.

And lastly, beware of academic bias. For example the kind of patient you see at a subspecialty clinic in an academic center is not representative of what you might see in the community. Also sometimes people in academic centers are worse off, or sometimes better off, than people in the community. For example, if you are 1 of only 2 surgeons in a small city, then you'll be on call 1 in 2, but your call likely will not be that busy and will likely not be of the same complexity as those in a large center. 

Thank you! Your advice is always super helpful here. I'll keep an open mind over these next few months to see if I like anything else as well! 

On 10/8/2021 at 3:36 PM, rmorelan said:

I mean........you would be good enough for the field. That probably shouldn't be a consideration in your thought process (that way madness lies....ha). You passed your premed classes? Your staff you are working with don't think you are an idiot? Then you have the capacity. They vowed to train you, and you have been trained.

I am a diagnostician - a radiologist - and that has overlap in some ways with pathology. If you like reading around the complexities of each case and deep diving into the pathology of things about a patient you may be disappointed in my side of the fence. If it is isn't obvious I really really like what I do - I solve problems all day, and often am the first person that knows what is "wrong" but I solve them quickly. I don't, and pathologist usually don't have to do that depth of analysis for the vast majority of what we do. We cannot - we have literally 100s of patients to see a day (I read at times well over a 120 studies a day, with say up to 40 of them cross sectional. I am not learning all the subtle points about a patient except in are but of course the most rare and interesting cases. If you have hundreds of slides to review a day it is similar.). Sure there is a ton of reading to learn the field and keep up with it but it isn't about a particular patient, case, or pathology - it is just the background knowledge so I know what something is when I see it so I am not slowed down by something weird when it shows up (it is the 5% of the cases that are "what the hell is that?" that consume all your time. Getting that 5% to a lower number where you are accurate is the goal.). Radiologists can see patients a lot of the time in some branches (not just interventional!) but most of us along with pathologists don't. 

Also you have to be careful with a few things as your career will be long. There will come a point rapidly where you will now all the important things on most of the patients you see. You will treat your 1000 case of whatever, and you know everything about that. That will change a bit how and what you learn. You will still have odd things to figure out of course - medicine is always a challenge with that - and have to update your skills and learn new approaches and treatments and internal will always have more reading than many other fields.

But if you find yourself reading around your case and it is something somewhat relatively common, 5 years from now you won't be doing that ha, just like I am not looking up things on every CT scan I read (its X, I know its X, I don't have to read around X, I write papers that other people read when they want to read around X). Your field has to allow you satisfaction in the end state. If you are a surgeon it is important you still like surgery after you have removed your 1000th gallbladder. If you are going into internal medicine you have to be happy treating your 1000th case of COPD flare etc. etc.

 

 

 

Thanks Rrmorelan! I guess I have a tendency to sell myself short I was just worried that my more diluted CTU experience might affect my ability to gauge if I can perform on electives in the future and beyond. 

Regardless, I'll keep an open mind (i'm not set on anything) while keeping your others points in mind :)

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I wouldn't worry about workload, you'll be able to handle the workload if you are enjoying what you are doing at your current workload. Besides, the workload is probably worst in PGY-1 and 2 but it gets better after that because you develop pattern recognition skills and get better and way more efficient. So, I don't think workload should really factor in at this point for you. I'd seriously consider IM because its very flexible and if you like the idea of being a traditional doctor and you don't mind or don't want to see kids, IM is for you. 

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On 10/14/2021 at 8:16 AM, Edict said:

I wouldn't worry about workload, you'll be able to handle the workload if you are enjoying what you are doing at your current workload. Besides, the workload is probably worst in PGY-1 and 2 but it gets better after that because you develop pattern recognition skills and get better and way more efficient. So, I don't think workload should really factor in at this point for you. I'd seriously consider IM because its very flexible and if you like the idea of being a traditional doctor and you don't mind or don't want to see kids, IM is for you. 

Thanks a bunch! I'll definitely keep IM on my mind while also keeping an open mind as I rotate through more non-surgical specialties this year. 

I imagine that as a resident you probably show rapid growth and become much more efficient. I suppose I was more so worried about hypothetically picking electives  and then arriving in 4th year feeling like a fish out of water after my diluted 3rd year experience (since I was rounding in the same patients who weren't acute, so saw less variety in pathologies, maybe not used to carrying the amount of patients that elective students do etc). Unfortunately I won't have any more core CTU experience in 3rd year, so I'm not sure if there are any other indications/gauges I could use to see if IM is for me. Perhaps if my rural family rotation has some inpatient rounding, and if my pediatrics is an a CTU that could help me gauge while also honing some of the skills I didn't get in my core CTU?

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1 hour ago, pyridoxal-phosphate said:

Thanks a bunch! I'll definitely keep IM on my mind while also keeping an open mind as I rotate through more non-surgical specialties this year. 

I imagine that as a resident you probably show rapid growth and become much more efficient. I suppose I was more so worried about hypothetically picking electives  and then arriving in 4th year feeling like a fish out of water after my diluted 3rd year experience (since I was rounding in the same patients who weren't acute, so saw less variety in pathologies, maybe not used to carrying the amount of patients that elective students do etc). Unfortunately I won't have any more core CTU experience in 3rd year, so I'm not sure if there are any other indications/gauges I could use to see if IM is for me. Perhaps if my rural family rotation has some inpatient rounding, and if my pediatrics is an a CTU that could help me gauge while also honing some of the skills I didn't get in my core CTU?

Many students coming into 4th year, even pre-covid, often have similar experiences to you - your experience does not sound particularly diluted. As a 3rd year, you have less experience, so of course you’re carrying fewer patients, less acute patients, etc. No one arrives in 4th year, let alone residency, totally ready to handle every challenge - going through those challenges is part of how you’ll learn. You’re right that people generally become more efficient over time, often one case and one day at a time. Other general Medicine rotations like peds and family will definitely help you improve your skills, and will probably also give you some useful data points in deciding about applying to IM. Just remember you’re still really early in training, you can’t expect to have it all figured out after one rotation.

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2 hours ago, pyridoxal-phosphate said:

Thanks a bunch! I'll definitely keep IM on my mind while also keeping an open mind as I rotate through more non-surgical specialties this year. 

I imagine that as a resident you probably show rapid growth and become much more efficient. I suppose I was more so worried about hypothetically picking electives  and then arriving in 4th year feeling like a fish out of water after my diluted 3rd year experience (since I was rounding in the same patients who weren't acute, so saw less variety in pathologies, maybe not used to carrying the amount of patients that elective students do etc). Unfortunately I won't have any more core CTU experience in 3rd year, so I'm not sure if there are any other indications/gauges I could use to see if IM is for me. Perhaps if my rural family rotation has some inpatient rounding, and if my pediatrics is an a CTU that could help me gauge while also honing some of the skills I didn't get in my core CTU?

Just keep working hard throughout clerkship and studying around your cases. You'll be surprised how quickly your growth is in 4th year as well. I felt totally lost on my CTU rotation, but I did an ICU block in my 4th year where the patients are much sicker and I surprised myself with how much I could keep up with the content and the management of the patients (and received relatively good feedback as well from preceptors). Things start to click once you rotate through all the core rotations and see medicine from all the different perspectives.

Just remember if you haven't seen stuff clinically you should still read up on it, especially core things like CHF exacerbation, COPD exacerbation, GI Bleed, etc. You're not gonna see everything in your 3rd year core but if you at least know the basics of management, when you see it you can at least take a stab at it and get some teaching as you go

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On 10/17/2021 at 10:17 AM, frenchpress said:

Many students coming into 4th year, even pre-covid, often have similar experiences to you - your experience does not sound particularly diluted. As a 3rd year, you have less experience, so of course you’re carrying fewer patients, less acute patients, etc. No one arrives in 4th year, let alone residency, totally ready to handle every challenge - going through those challenges is part of how you’ll learn. You’re right that people generally become more efficient over time, often one case and one day at a time. Other general Medicine rotations like peds and family will definitely help you improve your skills, and will probably also give you some useful data points in deciding about applying to IM. Just remember you’re still really early in training, you can’t expect to have it all figured out after one rotation.

 

On 10/17/2021 at 11:02 AM, Redpill said:

Just keep working hard throughout clerkship and studying around your cases. You'll be surprised how quickly your growth is in 4th year as well. I felt totally lost on my CTU rotation, but I did an ICU block in my 4th year where the patients are much sicker and I surprised myself with how much I could keep up with the content and the management of the patients (and received relatively good feedback as well from preceptors). Things start to click once you rotate through all the core rotations and see medicine from all the different perspectives.

Just remember if you haven't seen stuff clinically you should still read up on it, especially core things like CHF exacerbation, COPD exacerbation, GI Bleed, etc. You're not gonna see everything in your 3rd year core but if you at least know the basics of management, when you see it you can at least take a stab at it and get some teaching as you go

Thanks both of you! I think I have a tendency to overthink things so your posts really helped calm me down haha 

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