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.
Dr. Jubbal, MedSchoolInsiders.com.
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 want to vote in upcoming polls to decide what future specialties we
cover, make sure you’re subscribed.
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.
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 information to figure out the puzzle to help their patients get 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 following 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 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
what 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 docs as necessary for colonoscopy and other recommendations.
Physicians who practice in an academic setting are involved not only in patient care, but
also 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 a 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 that health care organizations and hospitals are
buying out private practices
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, meaning 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, meaning 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 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 practice setting,
in addition to the widest variety of specialties to choose from through fellowship. After a
couple 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.
After completing 3 years of internal medicine residency, you can choose to specialize with
fellowship.
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,
meaning often good outcomes and instant gratification. After cardiology fellowship, you can specialize
further with 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.
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 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, 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!
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
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, 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 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.
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 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,
as an internist you’ll 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 medicine 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 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!
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.
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.
Big thanks to Dr. Harman Singh from the MedBros channel and Dr. Zeeshan Asif from the ZeeMD
channel for helping me in the creation of this video. Links to their social media in
the description.
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
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Thank you all so much for watching! If you enjoyed this video, check out our So You Want
to Be a Cardiologist video, or another specialty on our So You Want to Be playlist. Much love,
and I'll see you guys there.