Internal Medicine!

[ffp]

I know someone posted a thread about IM a while back. Just thought I'd post my own take (especially since the original poster had just matched to IM, and I've been through the guts and glory of the whole 3 years!)

 

Core IM residency is 3 years long. You can enter a fellowship match to subspecialize after your 3rd year, or you can specialize in general internal medicine (GIM). There are 1 and 2-year GIM fellowships available, but most schools are moving to a 2-year requirement, and I suspect the 1-year programs will be phased out in coming years.

 

One of the good things about IM is that it is a jumping point for lots of other specialties. You can practice GIM, or you can do fellowships in:

 

Allergy and Immunology

Cardiology

Endocrine

GI

Nephro

ID

Heme

Medical Oncology

Rheumatology

Geriatrics

Maternal-Fetal medicine

Pulmonary

Intensive Care

Clinical pharmacology

 

and probably a few other fields that I am forgetting now. After your subspecialty fellowship, you can choose to become even more specialized (ie. from cardiology do electrophysiology. From GI do hepatology).

 

Internal med attracts a variety of people. Not only are different specialties available, but if you choose to be a general internist, you can practice in a smaller centre. For any of the subspecialties, you can decide to work in a community or academic setting. You can choose to be primarily a clinician, or to be involved in teaching, research, or administration.

 

If you like procedures, you can choose a specialty like cardio, GI, or pulmonary. If you hate procedures, you can do Allergy, ID, geriatrics...

 

One of the things I liked about IM is its breadth. IM deals with pretty much every organ system, and patients you see will run the spectrum from ordinary/everyday things like pneumonia, to rare tropical diseases and uncommon tumours. When starting a day on call, you never know what you're going to see!

 

If you like solving puzzles, and learning a lot of new information, IM might be for you. This puzzle-solving aspect is one thing I really enjoyed about IM. A 37 year-old male presents with elevated liver enzymes. He mentions that he also has severe arthritis. What could be the common thread between these two complaints? Could he have hemochromatosis? You are called by the ER to see a 55yo female with fevers, drenching sweats, and weight loss. That's all the information you're given, and you have to put your history, physical, and lab findings together to come up with the diagnosis! I found this to be a lot of fun.

 

Internal medicine gets a bad rap for having all elderly patients with chronic conditions who can't be helped. While this certainly is the case sometimes, it isn't always so! Sometimes you do see younger patients, or even older patients with entirely treatable conditions. Sometimes you can make HUGE improvements in a patient's condition despite the fact that their problems are chronic, and will never be 'cured'. Yes, you will always have the elderly patients with no acute medical problems who are just failing to cope at home (the bane of the IM residents' existence), but this is hardly the majority of your patients. Some programs in the country have non-teaching services or hospitalists specifically dedicated to looking after these patients so they don't fall the CTU.

 

IM also gets a bad reputation for its endless rounds - ie) eternal medicine. Many of the patients in IM are quite complicated, with multiple issues, and consults will never be as straightforward as, say, an ortho consult (is it broken? Does it need fixing?) Our progress notes are of necessity more thorough than "AVSS". But it doesn't have to be eternal drudgery. You'll find that different attendings handle things in different ways. Some are very practical and problem-focused, insisting that each patient have a discharge plan in place at the time of admission.

 

"Eternal Medicine" is also a bit of a misnomer. By the end of your 1st year, you get very used to dealing with complex patients. You can walk into the resuscitaton room and see a very sick patient with MULTIPLE issues. You can synthesize these issues and form a management plan QUICKLY, just because you have become so accustomed to dealing with complicated patients with multisystem problems.

 

Another poster alluded to the fact that the IM senior would teach about esoteria in the middle of the night. I tried to avoid this as much as possible. The approach I took as senior was to say, "Let's identify the issues that might kill the patient tonight, or that we can potentially treat tonight. We'll go do some reading/get some sleep, and come to all of these minor problems with a clear head in the morning". My juniors seemed to appreciate that

 

That brings me to another great point about IM - teaching. Much of our time is spent on teams consisting of clerks, juniors, senior, attending. Therefore, you always have backup available. There is always someone more senior to review patients with, or bounce ideas off of. Additionally, we all get to teach. Juniors teach clerks. Seniors teach clerks and juniors. Attendings (ideally) should teach everyone. Teaching was one of my favorite parts of IM residency, and you really do learn the most from your peers!

 

As someone already mentioned, you work with a lot of different specialists in IM. Not only are you closely involved with surgeons, neurologists, radiologists and pathologists, you also work with nurse practitioners, dieticians, PT/OT, pharmacy, etc. In fact, some specialties even have their own multidisciplinary clinics (CV risk-reduction, chronic renal failure, HIV, Hep C, bleeding disorder, heart failure, transplant, to name a few). These clinics are staffed not only by physicians, but by other members of the team. You'd be amazed at how these other health professionals enhance patient care and follow-up. A cardiologist can prescribe all of the evidence-based heart failure therapy (s)he wants to, but it won't work if the patient doesn't adhere to a low-salt diet. NPs and dieticians are very helpful in looking after things like that!

 

Hours in the IM residency are variable. A typical day on CTU is 8-5'ish with call 1 in 4 (will vary depending on where you are, and number of residents on service). On some of the subspecialties, your days will be shorter 9-4 or 5, and your call less frequent. ICU and CCU are BUSY, and your days typically start earlier (7 or 7:30). Call can be as frequent as 1 in 3, but depends on how many residents are on service. I've seen ICU call as low as 1 in 7. Senior call was home-call for us, although I think we were unique in the country.

 

I don't like to make generalizations, but overall I found my IM attendings very approachable and laid back compared to people I worked with in surgery and O&G. Same with the residents (although I'm just a bit biased).

 

When you finish, your hours/lifestyle will be quite variable depending on what you end up doing! If you do a specialty like endocrine or rheum, you will be primarily out-patient focused. If you do a specialty with lots of inpatients (cardio, nephro, etc), you might spend some time attending on the ward. If you practice in an academic centre, you might spend time as an attending on the CTU or inpatient consult service for your subspecialty. You might also work in a community hospital. Some of your days might be devoted to procedures (cath lab, scopes, joint injections).

 

Call will vary depending on specialty and the size of the call group you join. If you are a rheumatologist, your call will be quiet. How many acute rheum emergencies occur at 4am? If you are an interventional cardiologst, expect to be called in stat to the lab in the middle of the night. In that case your lifestyle will depend on whether you are one of 2 interventional cardiologists, or one of 10!

 

Some general internists have extra training to do things like treadmill tests, scopes, read echos, etc. This is great if you're going to practice in a mid-sized community. Beware that you should not expect to do scopes or read echos as a general internist in a major centre. The subspecialty-certified GI and cardio folks will feel that you are stepping on their toes!

 

Remuneration will vary greatly, again depending on type of practice and subspecialty. Generally, the more procedures the more it pays (cardio, GI, nephro). In some centres, academic physicians are salaried. Suffice it to say, you will never starve as a physician!

 

I hope this long ramble helps, and if you think of any questions I haven't addressed, let me know

[Kyleh]

Thanks so much for the post!

 

Just wondering what you mean by inpatients and outpatients.

[ffp]

inpatients = admitted to hospital

outpatients = ambulatory patients. Not admitted to hospita, but come in for tests or to see you in the clinic

[Ève]

Thank you so much! I always thought family medicine was what I would have to do, considering that if I get in this year, I will be 29! But I want to become a doctor because I want to do a useful job that I will love. With your description, it made me think that I just need to keep an open mind, because if I fall in love with IM, well, then I should not let considerations like age get in the way!

 

Thanks again!

[ffp]

Always keep an open mind. You'd be surprised what specialties you might come to love (or hate). You're definitely not too old. I was 27 when I did CTU senior last year, and 90% of my 'juniors' were older than me

 

Good luck

[blinknoodle]

What do internists with MFM do? How similar is it to MFM through O&G?

[tarzi]

Can you comment on any of the subspecialties? What about U of Sask's IM programs?

[ffp]

Blinknoodle,

 

don't know much about MFM through O&G. One of my senior residents did a 4th year of GIM at U of S, then went down to Rhode Island to do a 5th year in MFM. Now she's back working as an attending.

 

Basically, she sees patients with pregnancy-induced hypertension, peripartum cardiomyopathy, gestational diabetes, etc., as well as patients who have underlying chronic diseases and then become pregnant.

 

She sees general internal medicine patients and rotates as one of the attendings on the CTU.

 

I don't know much about it, just because it's not one of the specialties we have here, and I didn't do an MFM rotation in my residency. If you'd like more information, send me your questions and I could certainly find out for you.

[ffp]

Tarzi,

I can comment on quite a few of the subspecialties, but that would take forever! I'll write a separate post about cardiology, because that's the specialty I'm in. If you have questions about any of the other subspecialties, let me know which ones and I'll try to answer your questions.

 

As for the U of S IM program, I really think it's a diamond in the rough! When I did CaRMS, I ranked U of A #1, just because I knew they had a good program, and I didn't want to move. I ended up ranking U of S #2, even though I had never even been to Saskatoon before my interview. I just got very good vibes from my interview there. Oddly, some of the other OOP CaRMS applicants said the same thing. We've had quite a few OOP residents over the past few years who ended up ranking U of S highly - including people from Mac, Dalh, and UBC (not to mention the handful of Albertans that we seem to end up with every year).

 

For me, the main selling point of the U of S program is its small size. By the time you've been there a couple of months, all of the attendings know you, and you know them! You're on a first-name basis with most of them. For the most part, they're very approachable. This makes it easy to get involved in subspecialties... for example, if you're interested in cardio or GI, just make it known! Soon you'll be invited to all of the GI journal clubs and conferences, etc!

 

The small program size also means that you get lots of hands-on early, because there aren't a bunch of other residents or fellows battling each other for procedures. By the end of first year, you are usually comfortable with thoracentesis, paracentesis, LPs, bone-marrow biopsies. By the end of second year, most people have experience with central lines, arterial lines and chest tubes as well. If you show an interest, you might be able to get your hands on the colonoscope, gastroscope or bronchoscope as well. Even though we have lots of hands-on early, we still have appropriate back-up from seniors and attendings at all times.

 

The academic program is also a strong point at U of S. We have daily noon rounds (with lunch paid for by the faculty). We have weekly bedside teaching, and review sessions specially geared toward preparing for the Royal College exams.

 

Call is variable... as a junior resident on the CTU, it's usually about 1 in 4. On the subspecialties, it's usually ~1 in 6 or 1 in 7, but depending on the number of residents, it might be more or less frequent. On CCU, call is 1 in 3, but you go home at 8am the next day. On ICU, call varies from 1 in 3 to 1 in 8 depending on the number of residents, but again - home as soon is morning signover is finished (usually ~7:30). For us, CTU senior and neuro call were home call, but I think we are unique. I think most other programs have in-house senior call.

 

Here is a summary of my 3 years of IM (just to test my memory)

 

PGY-1

Cardio

Neuro

CTU

CTU

Endocrine

Pulmonary

CTU

CTU

CTU

Rheum

CTU

Office

Vacation

Emergency

 

PGY-2

ID

Hematology

Cardio

Vacation

Elective (cardio in Calgary)

Ambulatory

GI

Nephro

GIM

Neuro

GIM

Elective (cardio at Dalh)

ICU

ICU

 

PGY-3

CTU senior

Cardio elective (at U of S)

Cardio

Vacation

Rheumatology

CTU senior

CTU senior

GI

Hematology

Nephro

Pulmonary

ID

Research

GIM

 

I think that most of the programs across the country are pretty standard in terms of the training you get. The key is finding a program where you fit in.

 

Good luck