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