Less common IM specialties

[Guest physiology]

I know the hotshot specialties are cardio and GI, but what about the lesser known ones like

 

1) rheumatology

2) hematology

3) oncology

4) nephrology

5) respirology

4) infectious diseases

 

And are there others? The latter seems very interesting, what would an infectious disease IM resident do?

 

Oh, and let's say you do IM, and then do a fellowship in cardiology. If you get sick of cardiology, can you fall back and become a PCP as a general internist? (I'm sure you'd encounter cardio stuff anyway...but....for the helluva of it, I want to know )

 

Thanks!

[Guest Kirsteen]

Hi there,

 

A pal of mine is surrounded by IMs who specialized in Infectious Disease. There is a decently-sized department at Mount Sinai for these folks. Apparently many of them went on to complete a PhD as part of their residency. They now do all sorts of research and round on patients who may have incurred SARS, TB, etc.

 

Cheers,

Kirsteen

[Guest physiology]

Hello Kirsteen,

 

Thanks for the info! Could you open up a private clinic as well?

 

What's ur first choice in terms of med schools?

 

Physiology

[Guest marbledust]

Kirsteen might have a better idea about this...but, I think the nature of the speciality (research driven, government work, etc) would mean that many of these specialists would have some sort of academic affiliation. In addition to the conditions Kirsteen mentioned (SARS, TB), there are private practice clinics in Calgary that specialize in things like travel medicine, tropical medicine, or sexually transmitted diseases. I think it would be a fascinating field to specialize in.

 

Of course Kirsteen's first choice for med school is Calgary right? (just kidding)

[Guest Kirsteen]

Hi there,

 

I suppose you could open up a private ID clinic, but its success would be, in part, a function of the size of the patient base that you could attract. I'm not sure about this one, but I'd assume that it could be more difficult to find clinic-worthy patients with IDs than other problems. For example, if a GP were to suspect SARS, yellow fever, or some other sort of exotic ID, then they'd probably send the patient first to the emergency room as opposed to a private clinic, no?

 

From what I've heard of the ID experience in Mt. Sinai, and also UBC, the ID specialty does seem to be tied very closely to hospital and academic medicine. Their practices seem to involve being a bit of a hospital watchdog, that is, these guys will be paged to visit and manage patients on any ward in the hospital who are suspect or probable cases of various IDs.

 

As to my first choice in medical school, that's a toughie. There are many program factors that I'd consider if I was in the luxurious, multi-acceptance position, e.g., geography, length, progressiveness, size, faculty, clinical opportunities, research opportunities. We'll see!

 

Cheers,

Kirsteen

[Guest UWOMED2005]

One of the Infections Disease profs at UWO has a private Travel clinic where he does most of his work. Travel medicine is no longer covered by OHIP, much to his chagrin, so there are less patients seeking this service (but more seeking medical treatment when they return to Canada with malaria or Hep A!) but I think he still does reasonably well.

 

Other than that, infectious disease does tend to be a VERY academic field. Most doctors know how to deal with run of the mill pneumonias, URTIs, GI disturbances, sepsis and the like. . . ID consults are generally reserved for much rarer things such as encephalitis or complicated travel history with symptoms and signs of infection.

 

But on the whole, Infectious Diseases is an area that is chosen for interest and not for the lucre. My impression is that the lucrative IM subspecialties (and by some ?coincidence? most competitive) tend to be Cardiology, Gastroenterology and Nephrology, with Respirology and Oncology following, and ID, Rheumatology and Geriatrics following quite a bit behind. It seems to me that there's enough of a difference in competition, that matching to Internal medicine fellowships is a lot like CaRMS: tons of competition for spots in Cardiology, Gastro and Nephro and conversely tons of competition for applicants in the others.

[Guest physiology]

Thanks so much! Wow, you guys are such a great resource and such nice people too!

 

I really like level 4 haemorraghic fevers like ebola, lassa, and hanta, and I was just thinking that ID would be the way to go to Africa and don a space suit to centrifuge suspect blood samples!

 

What does a nephrologist do other than monitor people while on dialysis?

 

Thanks!

[Guest cheech10]

Here's what I understand (but IANAI - I am not an internist - so take it with a grain of salt).

 

As far as I know, you could go back and do general IM if you decided you didn't like your subspecialty. Basically, you've already completed the first 3 years of an IM residency, and only missed out on the chief year, which is geared more towards administrative and academic training anyways.

 

As for what each specialty does, the best thing to do is go talk to some of the physicians in each of the specialties. Keep in mind as well that there are differences between what is done as a doc in a smaller town vs. a larger city, and a large difference between the work of a community based doc and an academic position. Also, IM as a whole is moving more and more toward outpatient care rather than the inpatient setting, so clinics would give you a better idea about the general practice than following around on the wards. Of note as well is that the degree of (uber)subspecialization is quite high in academic settings that you would be more likely to encounter as a student, and are often very different from the typical work of even other subspecialties in the same field.

 

Other fields include: endocrinology, allergy and immunology, critical/intensive care, and geriatrics.

 

Cards and GI are far ahead of the others in terms of competition. The next tier is nephro, heme, onc, and allergy. The others are less competitive.

 

I know more about hematology than the others, but since you asked about nephro, it's not just dialysis (although much of the income comes from dialysis). Interestingly, in Europe, other specialties are also involved in doing dialysis, it's just here in N America that they do all of it. Much of their practice also deals with the other aspects of renal disease, particularly hypertension, and diabetes managements (although HTN and DM can be managed by general internists or other subspecialists depending on the individual patient and their main problems). Electrolyte abnormalities are quite common in really sick patients, so nephro can be consulted about them too. Hope this helps a bit.

[Guest physiology]

Hello Cheech,

 

So as a geriatrician, you would specifically see older patients? Why do pediatricians not become certified through internal medicine as well then?

 

Hematology sounds interesting as well, is that what you want to specialize in ?

[Guest Ian Wong]

Geriatrics encompasses a lot of Internal Medicine, particularly since the elderly are so vulnerable to many of the chronic diseases that are most prevalent in the elderly; ie: coronary disease, hypertension, diabetes, COPD, etc. The fact that elderly patients also often have complex social situations makes them often more challenging to manage, and manage well.

 

After all, if you are trying to regulate your 45 year old bank manager's poorly controlled diabetes, that's likely pretty straightforward to swing as an general internist. However, if it's your 80 year old patient with poorly controlled diabetes, who may have mobility issues because of a previous heart attack, finds it hard to get into your office regularly because he can no longer drive, might not be able to afford the medications you prescribe, or may not be able to remember to take them on a consistent basis, now things get a bit more difficult.

 

I think finding a great deal of satisfaction in unravelling these social complexities is one of the rewards of a geriatrics practice. The reason that it isn't more popular is probably a combination of the fact that it's very hard work (for the above reasons), and as far as Internal Medicine subspecialties go, the compensation is probably quite far on the low end of the scale.

 

As far as Pediatrics goes, in the US, you can find combined Internal Medicine/Pediatrics residencies (called Med/Peds), where you can become board-certified in both fields. These combo residencies don't exist in Canada. The diseases seen in the Pediatric and Internal Medicine population are pretty different (although obviously there's also a huge amount of overlap), and certainly interacting with a one month old baby is much different than a 65 year old retiree.

 

Mechanistically, both fields are similar in that they can blend work in the clinic along with the management of inpatients in the hospital. As well, the opportunities for subspecializing after an Internal Medicine or Pediatrics residency are abundant (ie. you can get into Cardiology through Internal, or Peds Cardiology through Pediatrics, or Endocrinology through Internal, or Peds Endocrinology through Pediatrics, etc). But, fundamentally the two specialties take a different mindset, and really treat a completely different set of patients, which is why they are distinct specialties, and why you cannot jump from Internal Medicine practice into a Pediatrics practice without going back and doing a Pediatrics residency first.

 

Ian