So You Want to Be an Internal Medicine Doctor

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So you want to be an internal medicine doctor. You like the idea of being a generalist, knowing the interplay of each organ system, and the mental exercise of deeply thinking about your patients for hours on end while rounding. Let’s debunk the public perception myths, and give it to you straight. This is the reality of internal medicine.

Welcome to our next installment in So You Want to Be. In this series, we highlight a specific specialty within medicine, such as internal medicine, and help you decide if it’s a good fit for you. You can find the other specialties on our So You Want to Be playlist.

If you’d like to see what being an IM doc looks like, check out my second channel, Kevin Jubbal, M.D., where we have multiple Day in the Life episodes with internal medicine doctors.

 

What is Internal Medicine?

When you think of a doctor, it’s very likely that the picture you conjure up in your mind is that of an internal medicine physician, or internist. Internal medicine is the specialty that deals with the diagnosis, treatment, and prevention of a broad and extensive number of diseases that affect adult patients. Think real-life Dr. House.

But internal medicine is more difficult than other specialties to categorize and nail down because it’s so broad and expansive in what you can do with it. There are also more fellowship options after internal medicine than just about any other specialty, which we’ll get to shortly.

Those that choose internal medicine are stereotypically the inquisitive and thoughtful ones who love learning, want to be heavily involved with direct patient care, and enjoy the challenge of analyzing broad volumes of information to get their patients back to a healthy baseline. Internal medicine doctors are the generalists of generalists, treating a vast variety of medical conditions, whether common or rare, complex or straightforward, acute or chronic.

The stereotype of internal medicine physicians is that they sit around, hours on end, thinking about how to micromanage each of their patient’s conditions, without ever using their hands. This is partially true. Internal medicine is much more of an intellectual specialty compared to some other specialties, but they do minor procedures occasionally, such as thoracentesis, paracentesis, central line placement, intubation, and others, though it’s rare to do so after residency training. In the outpatient setting, it’s more common to do steroid joint injections, PAP smears, ultrasound, skin tag or wart removals, and the like.

There are a few ways to categorize the specialty.

 

Outpatient vs Inpatient

Outpatient internal medicine doctors work exclusively in the clinic, or outpatient setting, where patients schedule an appointment, have a brief 15-minute visit, and head back home. In this setting, you’ll be dealing with health screenings, vaccinations, addressing chronic and milder conditions, and serving as their healthcare quarterback, referring them to specialists as necessary.

With inpatient, on the other hand, you’ll be treating patients who are admitted, meaning they are staying in the hospital for several days. These are usually sicker patients than those that you’ll see in the outpatient setting, often including acute conditions or exacerbations of chronic conditions. For example, when I was newly diagnosed and in the middle of a severe inflammatory bowel disease flare, I was hospitalized, spending several days recovering until I was feeling well enough to be discharged. My primary care hospitalist doctor in that setting was the one who coordinated and facilitated my care throughout my stay, consulting the GI doctors as necessary for colonoscopy and other recommendations.

 

Academic vs Community vs Private Practice

Physicians who practice in an academic setting are involved not only in patient care, but also in teaching the next generation of physicians, meaning medical students and residents. There are also usually requirements with regards to research, and most faculty are involved in some number of projects at any given time. Academic institutions are also usually better equipped to handle more complex patients, so these doctors are more likely to work with sicker patients.

In community practice, you can work within a smaller or larger organization. At these institutions, your job first and foremost is to be an internal medicine physician, and research or teaching are not principal responsibilities.

The third and least common option is to pursue private practice, where you’ll be your own boss, working primarily in an outpatient clinic setting. Private practice is becoming more of a rarity for many reasons, including the fact that health care organizations and hospitals are buying out private practices.

 

How to Become an Internist?

After medical school, internal medicine residency is 3 years. It’s categorical, meaning you match into one program and complete all three years there, including your intern year. Other specialties can have a transitional or preliminary year prior to the dedicated specialty training, and you can watch our other So You Want to Be specialties for more information about that.

In IM residency, the clinical focus is adult-focused primary care internal medicine and inpatient hospital medicine, which means that you’ll be taking care of patients admitted to the hospital. You’ll be rotating through the wards, ICU, and various subspecialty electives where you will help admit, manage, and discharge patients. Outpatient clinical rotations are also foundational and provide more manageable hours compared to your inpatient rotations. Here you’ll be seeing less acute patients while establishing continuity of care, providing you with a more longitudinal relationship with your patients.

Some residents choose to do an optional fourth year, called a chief year, which helps to hone their clinical acumen, leadership skills, and bolsters their CV, particularly if they’re looking for an academic position. Others may do it to reapply for a fellowship position the following cycle.

In terms of competitiveness, internal medicine is the middle of the pack, ranking 13 out of 22 specialties. The average Step 1 and Step 2CK scores are 235 and 248, respectively, and the match rate is around 97%, which is on the higher end.

Internal medicine is considered the default, largest specialty, and medical students who apply here stereotypically are the ones who couldn’t decide on a specialty. The flexibility of internal medicine is attractive, as you have a variety of options in the practice setting, in addition to the widest variety of specialties to choose from through fellowship. After a couple of years of residency, you are in a position to make another decision – do you want to go out and practice after general IM, or subspecialize into cardiology, gastroenterology, immunology, or something else?

Medical students that choose internal medicine are also generally inquisitive and love the intellectual aspects of medicine. They’re the ones who enjoy complex puzzles, taking in vast quantities of information through history, physical exam, and various labs and imaging, and putting together a diagnosis and management plan for each individual patient.

 

Subspecialties within Internal Medicine

After completing 3 years of internal medicine residency, you can choose to specialize with a fellowship.

Cardiology

Cardiovascular Disease, also called cardiology, is a 3-year fellowship focusing on diseases relating to the heart. Cardiology is a highly competitive fellowship, offering the first or second highest compensation of any internal medicine specialty, duking it out with gastroenterology.

Cardiology is an extremely well-studied field with a robust scientific backing for its treatments, so good outcomes will be routinely faced (which means instant gratification). After a cardiology fellowship, you can specialize further in advanced heart failure, interventional cardiology, electrophysiology, and others.  You can learn more about cardiology and these subspecializations in our So You Want to Be a Cardiologist video.

Gastroenterology

Similar to cardiology, gastroenterology is also a highly competitive fellowship, lasting 3 years, with similarly high compensation. GI doctors do many procedures, with not just endoscopies and colonoscopies, but ERCP and liver biopsies as well.

To be happy as a gastroenterologist, you have to be ok dealing with feces, as colonoscopies are bread and butter. However, you can also subspecialize further, such as with transplant hepatology, which is an additional 1 year of training after GI fellowship.

Pulmonary/Critical Care

Pulmonary and critical care is a 3-year fellowship for those who want to take care of the very sick patients in the ICU. ICU patients, compared to floor patients, are generally more complex, as they’re often receiving multiple interventions, such as respiratory assistance through ventilators or pressors to maintain their blood pressure in states of shock. ICU doctors spend a great deal of time having deep and often very emotional discussions with families of the critically ill, as this is an incredibly trying time for everyone involved.

Pulmonologists on the other hand are lung doctors. They see patients both in the hospital setting on the floors, and in the clinic, and are the specialists for lung pathology including cancers, COPD, asthma, pulmonary hypertension, and many other conditions. Pulmonologists also frequently perform bronchoscopies, where a tube is inserted into the trachea to biopsy a mass or to clear a mucus plug.

Infectious Disease

Infectious disease, or ID doctors, deal with patients who have a variety of bacterial, viral, fungal, and parasitic infections. If you liked microbiology and pharmacology in medical school, this is the specialty for you. You’ll be using labs, imaging, physical exam, and history to figure out what bug is causing the patient’s symptoms. Did they go on a cruise recently? Travel out of the country? Any contact with animals? These all play an important role in narrowing the differential diagnosis. ID is a 2-year fellowship. As a word of caution, you will be dealing with plenty of notable smells and unforgettable infections!

Hematology/Oncology

Heme/Onc is focused on blood disorders and cancers. Hematology specifically deals with diseases related to the blood and its components as they affect the lymphoid and myeloid cells. They often deal with bleeding disorders, such as platelet disorders, leukemia, which is a cancer of the white blood cells, and various anemias involving dysfunctional red blood cells.

Oncology is focused on the diagnosis and treatment of cancer. Oncologists work closely with pathologists, radiologists, surgeons, and other fields to coordinate care for cancer patients. This field can be emotionally draining, and patients often have poor outcomes.

You could do hematology for 2 years or oncology for 2 years as separate specialties, but many opt for a combined heme/onc fellowship over 3 years.

Nephrology

Nephrology, a 2-year fellowship, is the specialty focused on the kidney, dealing with everything from acute kidney failure to end-stage renal disease. You’ll often be managing patients on dialysis, which is a mechanical process whereby machines mimic the function of the kidney to filter the blood. This is a delicate process requiring careful attention to electrolytes, acid/base levels, and mathematics.

We’ve only just scratched the surface of fellowships you can pursue after an internal medicine residency. There’s also endocrinology, rheumatology, sports medicine, sleep medicine, hospice and palliative medicine, geriatric medicine, allergy and immunology, addiction, and adolescent medicine to name a few.

 

What You’ll Love About Internal Medicine

There’s a lot to love about internal medicine. Most prominently, it’s a specialty that offers tremendous flexibility. If you want to work as a hospitalist, taking care of admitted patients, you can do that straight after IM residency. If you want to do primary care in an outpatient clinic, that’s common too. If you’d like to specialize and further your interest with something more focused like cardiology or gastroenterology, there’s a clear path for that as well.

Internists generally have a favorable work-life balance. As a hospitalist, the most common model is 7 on 7 off, but it’s not uncommon to have 2 weeks on and 2 off, meaning you work for 14 days straight, followed by 2 weeks off. During those weeks on, it can sometimes be hectic, but those weeks off are glorious. If you’re admitting on call, you can work 12 hours or more in a day, depending on many variables. You won’t necessarily be admitting every day, and often times you’ll be able to leave for the day after completing daily tasks and rounding on your patients.

Because just about every patient who walks into the hospital needs an internist, there is never a shortage of patients! While some other services rely on consults to see patients, internists will always have patients to see.

In many outpatient gigs these days, you can choose to work 4 or 5 days per week. This is appealing for those who enjoy working regular business hours with holiday vacations.

IM doctors also maintain their level of medical knowledge. Medical students in their later years know what I’m talking about. You spend thousands of hours and incredible effort learning about the various organ systems and their pathologies. Internal medicine is one of the few specialties where you continue to develop that broad knowledge. Many other specialties narrow down and dive deep at the expense of most of the other things you learned in medical school. There’s an inherent satisfaction in knowing you’re able to manage most anything that walks through the door to some extent. You genuinely feel like you are a true doctor, and know a little something about everything!

 

What You Won’t Love About Internal Medicine

While internal medicine is an awesome specialty, it’s not for everyone.

Given the medicolegal ramifications, bureaucratic processes, and social issues in medicine, you’ll often find yourself babysitting patients in a hospital bed that don’t necessarily require your care.

Compared to surgical specialties, there’s much more charting and computer work. You’ll often be consulting other services, such as cardiology or gastroenterology, who will give you recommendations on caring for your patient, but ultimately it’s up to you to assess these recommendations, place the orders, write notes, and monitor the patient despite these other consulting services.

Compensation is in the bottom quartile of specialties, with internal medicine doctors making on average $251,000 per year. But remember that by subspecializing with something like cardiology or gastroenterology, you can greatly increase your earning potential.

IM doctors also find themselves inundated with social tasks including many logistics of patient care and stay. For example, if a patient cannot safely go home and requires discharge from the hospital to a skilled nursing facility or acute rehabilitation center, you’ll often have much back and forth with case management, social workers, PT, OT, and insurance to ensure your patient receives the help they need and the appropriate placement on discharge. Many times, internal medicine can be a “dumping ground” for patients who have received the care they needed from surgery, OBGYN, ICU, and other specialties. The IM docs must facilitate the next step of the patient’s individualized care with medical recommendations, placements, and discussions to ensure good follow up.

The sheer amount of knowledge that is required to be a good internist, especially considering the amount of new research, requires keeping up with the latest even as an attending to provide the most optimal care for your patients; this can be a good or a bad thing, depending on what you are looking for.

 

Should You Become an Internist?

If you love taking your time to know a patient’s story and love mental puzzles as it relates to the human body and disease, internal medicine may be the field for you.

You must love learning, as this is a complex field with many moving parts and a great deal of research continuously updating and improving various therapies and modern medicine’s understanding of disease. While all doctors must be lifelong learners to be at the top of their craft, internal medicine doctors must do so at another level.

Or as my friend says, if you’re a massive nerd and cannot decide on any other specialty to do, you’ll probably just default to internal medicine anyway.

Are you hoping to become an internal medicine doctor? To get into medical school and match into IM residency, you’ll need to score well on your class tests and standardized exams. If you need help acing your MCAT, USMLE, or other exams, our tutors can maximize your test-day performance. If you’re applying to medical school or internal medicine residency, our Insiders can share the ins and outs of what it takes and how to navigate the highly competitive process most effectively. We’ve become the fastest-growing company in the industry, and it’s no surprise. Our customers love us because we’re committed to delivering results, period. Learn more at MedSchoolInsiders.com .

Thank you all so much for watching! Check out our So You Want to Be a Cardiologist article, or another specialty on our So You Want to Be playlist. Much love, and I’ll see you guys there.

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