Why become an internist?

8

Category : Medical Rants

A reader asks an interesting question:

I’m a pre-med student and, although it’s way early, I am trying to figure out my “end game” as far as medical education is concerned.

What I was wondering is, if you were so inclined, could you write a little about why a med student (or pre-med that is getting ahead of themselves) would want to be an internist? Personally, even if internists made more money than any other specialty I still wouldn’t do it because my perception of the work is that it is very low acuity run-of-the-mill stuff day in and day out. (It should come as no surprise after that comment that I am looking at Emergency Medicine or Pulmonology/Critical Care).

I don’t say that to denigrate primary care, but only to express my nescience about it. If there are any other pre-med/med students out there perhaps this would be handy for others as well.

Several commenters have already addressed this issue nicely, but I cannot easily resist an opportunity to pontificate (here db rolls his eyes and smirks).

So how should one choose a specialty in medicine? This question has worried medical students for many years. Some students know what they want to do prior to starting medical school, and some of them do not change their mind. Others have not a clue, and do not decide into midway through their 4th year.

What advice to I give medical students? First, some students listen, and others do not. That should not surprise anyone. Second, we know that students consider multiple factors in their decision making. These are the factors that I believe are the most important.

Each student must decide on their goals. I was looking for a field that was both intellectually and emotionally satisfying. Some students get to the 3rd year, and only look at making money and working predictable hours (so called lifestyle specialties). Some students look for excitement; others look for dramatic intervention.

I do not believe any pre-med student has enough information to pick a specialty. He/she needs the experience of learning about different medical careers.

Why should one become an internist? This is a very difficult question, because I cannot imagine myself doing any other specialty. So I should explain what attracts me to internal medicine.

I am driven by both the intellectual challenge and the interpersonal relationships in medicine. I enjoy puzzle solving and relating to individual patients.

When I was a 3rd year student, I had no idea what I wanted to do. When I started internal medicine I found my intellectual home.

So why become an internist? Internal medicine deals with the most complex patients and most complex situations. Internists handle complex comprehensive care. The understanding of internal medicine by the writer – “it is very low acuity run-of-the-mill stuff day in and day out” – is inaccurate. Internal medicine is rarely “run-of-the-mill”.

Internal medicine contains all the medical subspecialties. As an internist I must keep up to date on cardiology, pulmonary, nephrology, etc. Internal medicine encompasses both inpatient and outpatient medicine. Most important (to me) internal medicine is about the patient. We develop strong relationships with our patients – often long term, but sometimes in the hospital we bond quickly.

I would choose internal medicine again, because I love the content and emotional satisfaction. I could make more money doing something which I would consider more boring (others would disagree – that is the beauty of medicine).

So why become an internist? Become an internist if the content will give you many years of an intellectually and emotionally satisfying profession.

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Comments (8)

Interestingly, I hear the same question within my own specialty of gynecology. Regrettably, in a number of surveys, many of my colleagues (understandably) urge medical students to avoid ob/gyn. Of course, a lot of this has to do with malpractice issues, but it’s not the entire reason.

I also think that one’s personality has a lot to do with his or her choice of medical specialty. So in some ways, your personality pretty much dooms you to one specialty or another 😎

Dear medical student,

Here is some bad news–you don’t really know what each specialty is like until you have a few months (years?) under your belt. Additoinally, some of the exposure you get in medical school and residency is in the wrong location. Most of the GI stuff you see is in the hospital, but a large part of their day is spent in the clinic. If you haven’t spent a month in GI clinic, how can you tell if you’d like it. (or hate it?)

You then ask, well why would I buy a car with a 30 year loan if I can’t even test drive it. Exactly.

I few ways to feel out your strengths: If you are a coddler (and you know if you are), office based specialties, especially primary care is your calling. Run to it. If you find you hate listening to people, you should avoid psych and primary care. If you get a sense of accomplishment from fixing a discrete problem, think procedural or surgical specialty.

If you have a huge amount of debt, that matters as well. Pscyh, peds, IM and family practice do not pay alot of money. The powers that be have decided that the longer you train, the higher your pay should be. I don’t know if that is right or wrong, but it is generally true. (except for geriatrics, endocrine and rheum)

My advice to you–if you have a week off between sessions, holidays, etc. ask one of the attendings in both an academic setting and a private pracitce setting if you can follow them an entire week. If you completely hate it, follow another type of doctor the next week you have off. That week may save you several YEARS of pain.

You should do general internal medicine if you don’t have alot of debt, if you like seeing people over time, if you like looking at the big picture and can tolerate not knowing everything and if you are prepared to make a decision between “officist” and hospitalist (because it is happening).
b

Thanks to the commentors in the previous thread, and to DB for addressing my question!

I’ve found this to be somewhat persuasive. I’m still trying to figure out what it is that really made me decide to pursue med school (short answer is PALS). In my case I am quite familiar with medicine. I’ve been in healthcare in one form or another for 6 years, the last two as a vascular sonographer.

Today I had a patient that got me thinking about how much internists do though… I was doing a hemodialysis access creation exam on a patient (Diabetic, renal failure Cr= 6, back & flank pain) that was ordered by the consulting vascular surgeon. As I reviewed her chart I noticed that she had also been seen by Infectious Disease, Gastroenterlogy, and Nephrology. I started picturing the internist as something more like an air traffic controller in this scenario with the nephrologist DC’ing orders that the internist had written and so on.

I think over the next year or two (I’m only half way to my B.S.) that I’m just going to talk more specifically with various docs about their jobs and see what I come up with. I know two really sharp hospitalists that would probably talk to me about IM and so on. These comments have certainly at least turned me on to it, one think that I struggle with when I consider EM is that in some ways it still feels like being an EMT (I’m also an EMT-II), as far as one’s role being to stabilize and hand-off to definitive treatment (obviously with a much larger scope of practice and the latitude to discharge patients etc.). So the idea of seeing a patient through an illness is certainly the appeal of IM/Critical care for me….

Also if there are any other students reading this thread, I really liked the ACP’s page about internists at http://www.doctorsforadults.com/about.htm

Thanks again! I’ll keep reading 😉

-Dan

I find your comment about “run of the mill” to be quite telling…. as mentioned earlier, my career as a Family Physician is never considered run of the mill. Instead, I am on the frontlines of ANYTHING that walks in the door- whether it be related to Cardiology, GI, Neurology, OB, Peds, Sports Medicine, etc. As such, I have to remain on the top of my game at all times- no one has narrowed my problems down into one system or (sometimes in the case of subspecialists) already made my diagnosis for me.

Also, the “air traffic controller” comment… I think you greatly underestimate the role of ATC. Also, if you notice, I would bet that, in most cases, it is the same as it is in mine- the subspecialists clear their orders through you as their attending physician.

Above all else, go into med school with an open mind- you may be surprised what you find!

Another bit of advice I would offer is to make sure you get some of your expereince when choosing your career outside of an academic medical center. The Ivory Tower just doesn’t work the same as it does in the rest of the real world.

From what I have seen, the variations of practice within a specialty are as great as the variations across specialties, so you can probably find satisfaction no matter what specialty you choose. It is true, though, that each specialty has a typical cluster of practice types, and since it can be hard to go against the grain, it may be easier to pick the ‘right’ specialty first.

Be aware that time can also change the nature of a specialty. Twenty years ago GI was a cognitive specialty, and cardiology was just starting to pioneer some procedures. In the next 20 years, many surgical specialties are going to be affected by surgical robots. Who knows, by 2025 perhaps surgery will be a ‘cognitive’ specialty where the surgeon is the leader of a team that writes software to control the robots, and spends most of his/her clinical time talking with patients and families!

Internal medicine simply is one of the worst field. As an internest, you are the first person who have fill all of their forms (i.e. work form, insurance, disability, even requesting drugs which more insurance co. are refusing, and referrals). all of the above done without a single penny paid out to you. You are guaranteed to make less money in the future (the way medicare is going), and guaranteed to be sued within 5 yrs even if you are not at fault, your malpractice premium will skyrocket. You will see patients complaining for not getting paid for their overtime, during the time which you are post call. yes, you have to be on call for the rest of your life (and not get paid for it again.) medicare does not pay you unless you see the patient. If a patient comes in at 9pm and you happen to be home, you still have to give orders, and care for the patient until you see him. If he is complicated, you’ll spend about 1hr on the phone with the nurses giving orders and following up on it (again not getting a penny for it). Good luck with your internal medicine residency.

I’m a practicing hospitalist of 4 years. While I enjoy my work, I don’t know if I’ll want to do this at age 50.

My wife is in PM&R and both of us would advise our kids NOT to practice medicine unless you love it. If you pick a field for the money and hate it, you’ll regret it for life. Find something you love and do it. Whether you make $200K or 1mil, just make sure it’s something you look forward to every day.

If my son wants to make money, I’d steer him to something where you get a commission or paid what you’re worth. If he really has a passion for medicine, I’d still steer him to something without night call and more longevity than a hospitalist.

As for office docs, with overhead going up and reimbursement going down they’re going to end up having to be employed by HMO’s or hospitals just like hospitalists will be.

We’re headed for a socialist medical system.

-Tom

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