Careers in Internal Medicine

Careers in Internal Medicineor

What’s an Internist Anyway?

Karen McClean MD FRPC

Topics….

• Review of Internal Medicine and General Internal Medicine

• The UofS program – structure• What makes a good internist?• The UofS program – status of program

• Career choices in general• Getting the most out of clerkship

What’s so great about IM?

• My journey– In medical school

• Transient (very, very transient) inclination to neurology• Loved surgery – lots of hands on, high level of responsibility on my

‘JURSI’ rotation• Did NOT enjoy much about Internal Medicine

– Internship• Straight surgical internship in London, Ontario

– Loved surgery rotations but also had a great medicine preceptor with similar interests…hmmm maybe medicine isn’t so bad after all….

• Rotating internship– Loved surgery rotations and did lots of advanced hands on stuff– Medicine was ok too (1 great preceptor, 1 OK preceptor) – but I

still liked the surgical stuff best.

My journey

• Africa– Lots of surgery: general, ortho, ophtho, gyne, plastics, even the

odd burr hole– After 3 ½ years…. What could we do better?

• Not much more by way of surgery – no ICU, no ventilators, no infusion pumps, no monitors, limited radiology & lab resources etc

• Lots of scope for improvement in our medical management of patients with chronic diseases (hypertension, asthma, heart failure, diabetes etc.)

– For me, the decision to train in Internal Medicine was a very pragmatic one

– Eventually, I came full circle back to my undergrad / pre medical experience in Microbiology (Infectious Diseases)

– Hematology was a close second– Still don’t really have any affinity for some areas of Internal Med!– No regrets!

General Internal Medicine

• “General internists handle the broad and comprehensive spectrum of illnesses affecting adults.” ACP

– Experts in diagnosis– Experts in management chronic illness, complex

patients with multiple diagnoses

• General internists are consultants– See patients on referral from a primary care

physician or other specialist

Dr. David Sackett

• When encountering patients with undifferentiated or multi-system disease, general internists excel at “sorting out” their illnesses and balancing the management of multi-system disease. They are particularly skilled in the evaluation and care of such patients when they are acutely and severely ill. This is in contrast to subspecialists who, by focusing on deeper but narrower aspects of single-system disease, are more comfortable practicing in a “rule-out” mode, and often are uncomfortable with sick patients whose illnesses are multi-system or arise from another system (e.g., undifferentiated shock).


• Office based / outpatient practice• Hospital based practice

– Consultations– Inpatient care for medical problems– In many centres, patients are admitted under

family physicians, with consultation to the internist – very close working relationships between the family physician and internist

• For most – mixture of inpatient and outpatient medicine, acute / short term and chronic / long term patients

Internal Medicine: GIM• United States model

– Primary care– Primarily office / or pure

hospital – Training:

• 3 years

• Board eligible or Board certified

• Mixed Paediatrics / Internal Medicine programs or “Categorical” programs

– US general internists struggle with their identity in contrast to family physicians.

• Canadian model– Consultants– Office / Hospital– Training:

• 4 years

• No such thing as “Royal College exam eligible status” – certified or not certified

• No mixed programs

– Canadian general internists struggle with their identity in comparison to IM subspecialists

Internal Medicine: subspecialties

• Core subspecialties– Cardiology– Critical care– Endocrinology– Gastroenterology– Geriatrics– Hematology– Infectious diseases– Medical Oncology– Nephrology– Respirology– Rheumatology

• Less common subspecialties*– Allergy and Immunology

– Clinical Pharmacology

– Hospitalist Medicine

– Occupational medicine

– Palliative care

– Sports medicine

– Transfusion medicine

– Bioethics

– Medical informatics

– Clinical epidemiology

* Not all recognized by RCPSC

Internal Medicine allied programs

• Dermatology – 2 years of internal medicine• Neurology – 1 to 2 years of internal medicine• Community Medicine – 1 year of internal

medicine

Two views of GIM

• Not a subspecialty– Forms the basis for all the

Internal Medicine subspecialties

– All subspecialists are also “internists” – though some practice little outside their own subspecialty field

– Little recognition of a separate skills set / body of knowledge

– To date, the dual certification process perpetuates this. (All subspecialists are first certified as Internists)

• Subspecialty in its own right– Core IM training is common to

all Internists– Post core training got GIM is

unique, just as it is with other subspecialties

– Defined and distinct body of knowledge

– Many subspecialists are not functioning as general internists (may do limited amount of non subspecialty based IM, but not the true spectrum of GIM)

The World of Internal Medicine


Subspecialty Internal Medicine

Internal Medicine

Internal Medicine: GIM vs. SS

• Distinct body of knowledge– Peri-operative medical management– Medical disorders of pregnancy– Multi-system medical disease

• GIM is not currently recognized as a subspecialty but this will likely happen in your practice lifetime.

• Does it matter? – Depends on your perspective.– Does not have major effect on what general internists can

do / bill for.– Not a major income related issue.

Why make GIM a discrete subspecialty?• Recognize the discrete body of knowledge

and skills of the general internist.• Facilitate development of training programs

that robustly address this discrete body of knowledge.

• Eliminate the differential ‘status’ of internist and subspecialist.

• Establish an exam system that reflects Core / GIM / SS knowledge at appropriate points in time.

Training in Internal Medicine• Internal Medicine

– 3 years of core training PLUS• 1 year of GIM• 2 years of GIM• 2+ years of other subspecialty

– Core curriculum (first 3 years)• 12 months of General Internal Medicine (office, consults,

CTU)• 24 months of subspecialty rotations and electives• Rotations through the majority of subspecialty areas• Cardiology and critical care mandatory• Research• Ambulatory care

Training in IM at UofS

• PGY-1– 5 to 7 months on CTU – ER and Office based rotations– Cardiology and neurology– Selected subspecialty rotations (Geriatrics, Endo, Rheum, Derm...)

• PGY-2 – Subspecialty rotations– Critical care– Electives

• PGY-3– CTU Senior– Remaining subspecialty rotations– Electives

Training in IM at UofS

• Schedule is designed with purpose– CTU Junior – quickly gain experience in patient

assessment, recognition of the ‘sick patient’, development of differential diagnosis, management of common problems in a hierarchical setting with backup available at all times.

– Office rotation: early exposure to non hospital based practice

– ER: Promote strong collaboration skills between ER and IM.– 2nd year Subspecialty rotations – develop consultancy skills,

building on the framework of first year experience– CTU senior deferred to third year – focus on teaching,

supervision and organization of the team.– 3rd year subspecialty rotations – refine and strengthen

consultancy skills

Examinations

Core Internal Medicine (3 Years)

GIM + 2 years

Cardiology + 3 years

Other SS + 2 years

GIM + 1 year

Internal medicine exam

Supspec exam

everybody Cardiology exam

Everyone receives a Specialist Certificate as an Internist

Subspecialists also receive a Certificate of Special Competence in the area of their subspecialty.

Why 1 vs. 2 years of GIM Training? • Traditionally one additional year of training.• As the distinct features of GIM have evolved,

the role for added training has become evident.

• How is training structured?– First year: refines consultancy skills, focus on GIM-specific body of

knowledge• Medical problems of pregnancy• Peri-operative medicine• Complex, multisystem illness / multi disease illness

– Second year: planned to meet the needs of the trainee• Skills: echo, stress testing, scopes• Special area of focus: Maternal Fetal medicine, palliative care,

epidemiology……..• Can be focused on skills for academic practice, rural practice etc.• Offers great flexibility

Why do people chose IM?

Negative reasons:• They have poor eye-hand coordination • They faint at the sight of blood• They don’t cope well with sick kids• They don’t look good in greens!

Why do people chose IM?Positive reasons:• Great mentors• Attracted to a specific

subspecialty area• Enjoy physiology /

pathophysiology• Enjoy breadth and

versatility in terms of scope of practice

• Potential for long term relationships with some patients – without the need for long term relationships with all!

• Enjoy sorting out complex problems / good reasoning skills

Distinguishing characteristics of the Internist1. The ability to be a diagnostician

– Strong clinical reasoning / critical thinking skills

2. The ability to provide care of complex acute and chronic problems

– Strong knowledge & skill base, strong organizational skills

3. The ability to be a consultant for generalists, specialists and subspecialist

– Strong communication and team skills

4. Curiosity– Links between disease and pathophysiology– Links between therapy and mechanism of action

Dr. Robert L. Wortmann

Good Internists

• Listen to and understand the patient’s story• Understand the context of the disease in the

individual patient• Apply science, and evidence based medicine

within the patient’s context• Engage patients in informed decision

making / collaborative care• Play well with others

Questions to ask yourself…

• Do I enjoy physical diagnosis, pharmacology, physiology, pathogenesis?

• Do I like solving problems and tackling challenges? (Deductive reasoning and critical thinking)

Questions to ask yourself…

• Can I interact well with all kinds of people and maintain effective long term relationships?

• Can I listen attentively to the patient’s story and explore the context of the disease for the patient?

• Am I good in team settings? (as leader and member)

Another famous TV doctor….

Lifestyle• Internal medicine offers a wide range of

potential choices that affect the lifestyle you can expect to have.– Income– Working hours– On call hours– Type of work / practice

• Decisions that will affect lifestyle– Subspecialty– Practice type (solo, group, community, academic, hospital)– Practice location– Other activities (teaching, research, administration etc.)

• Expectations and systems are changing slowly

Competitiveness for IM spots• Huge increase in number of available

positions in last three years.• Does not mean you can afford to be

complacent!– Trends in career choices fluctuate significantly year by year.– Number of positions change year by year.

• When matching – don’t try to play games – rank your choices according to what you really want.– Never, never, never rank a program you would not be

prepared to do!– Rank your top choice #1 even if you think you won’t get it.

Some general comments on choosing a specialty (nothing

specifically to do with IM)

Career Choices in General

• Discover the field to which you are intangibly drawn.

• Try to identify and understand the reasons…– Types of problems – Types of practice – Types of patients– Types of physicians

Types of problems

• You don’t have to love ALL the content area of a given specialty to be successful in it, but you need to enjoy and find stimulation in more than one narrow aspect of it!

• Therefore – you need good understanding of the breadth and scope of a discipline you are considering

• However – as a physician you will have some ability to focus your practice (within your specialty choice) to varying degrees.

Types of practice• Procedural specialties

– Surgical specialties (surgery, O&G, orthopedics, ophthalmology etc)– Diagnostic specialties (pathology, radiology, laboratory medicine)

• Cognitive specialties (no pejorative implication on other specialties intended)

– Paediatrics, internal medicine, psychiatry, neurology etc.– Within the cognitive specialties, there is great variation in the degree

of procedural involvement• Cardiology, gastroenterology, critical care vs.• Infectious diseases, endocrinology

• If you are drawn to internal medicine but really enjoy doing procedures, there is still plenty of scope for you to find a fulfilling career in IM.

Types of patients

• In every specialty there are certain types of patients who try the patience of the physician.

• Once you are in practice you will develop strategies to manage these patients in a way that enables you to provide good care and maintain your equanimity.

• But if there is something you really CAN’T stand, be cautious about getting into a specialty in which that makes up a significant portion of the practice.

Types of patients

• Children• Adults• Elderly• Awake patients• Asleep patients• Deceased patients • Short term patients (single visit)• Intermediate term patients (multiple visits)• Long term patients (followed for years)

The influence of mentors• Mentors are important in our education and

development as physicians.– We may find mentors in fields to which we are intrinsically

drawn. – We may be drawn to a field because of a mentor or role model

who works in that field.

• It is important to consider what it is that attracts us to a particular field…– personal characteristics of the mentor. – typical characteristics of physicians who chose that field.

• Important to avoid choosing a discipline on the basis of a mentor …– … who may is actually be an outlier among his or her

colleagues!– … rather than truly having an affinity to the discipline.

Career Choices

• Discover the field to which you are intangibly drawn.

• Try to identify the reasons…– Types of problems– Types of practice – Types of patients– Types of physicians

• Knowing the reasons can help you consider other options and assess the validity / strength of your inclinations.

How do I discover what I like?

• What do you most enjoy reading and studying in class?– Caution: be aware of:

• Reading and doing is not the same• The influence of good / not so good teachers

• What do you enjoy most in early clinical experiences?• Explore the full spectrum of a discipline

– What you see from one physician or clinic may only be a small part of the discipline

– Try to work with several physicians in different settings– Read (lots of online information, be aware of differences between

US and Canadian systems)– Ask questions– Use electives and shadowing opportunities, be creative in how you

structure electives in key areas so that you can get a broad exposure to the discipline.

• Be prepared to question initial inclinations (or fixed decisions)

What about quizzes and tests designed to help you choose a discipline?

• Generic tests – limited success, poor differentiation between specialties

• Strong Vocational Interest blank• Holland based typology• Myers Briggs personality types

• Medical aptitude tests – limited scrutiny, limited validity

• Medical Specialty Preference Inventory• Medical Specialty Aptitude Test

• Use with caution!– Differences between disciplines tend to be small compared with the

variation in personality type within disciplines.– Little scrutiny to link measures with career success– Use might promote or maintain inappropriate / undesirable

stereotypes.

What about medical specialty aptitude tests?• University of Virginia MSAT…My results…..

1. Hematology – sure, OK I could do that (some of it anyway)2. Rheumatology – Hmmm, not so sure3. Occupational med – long shot4. Rad oncology – no way on earth!5. Med oncology – worse yet!6. Nephrology – not on your life!7. PM&R – nope8. Pathology – interesting for a year or two – maybe!

– Infectious diseases = number 15!!!! (Same rank as endocrinology, nuclear med and GIM, none of which I would really be keen to do)

– ER and ortho (two close contenders for me, at least at several points in my life) were 29 and 33 on my list.

What about medical specialty aptitude tests?

• If the results resonate with you, you may be on the right track.

• If your response is “Eeewww! or “how in the heck…?”, be careful about putting much emphasis on the results.

• Probably not much more helpful than…

BMJ

Some thoughts on being the best you can be and how it will help you get where you want to go.

Making the most of clerkship, whatever you want to do…

• Be professional– Know the expectations and do your utmost to

meet / even exceed them.

• Be a good team member – the educational team and the whole care team

• Be patient centered• Be organized!

– Prioritize– Keep track of things you need to do.

Making the most of clerkship

• Use your study time well – Read, reflect, review and challenge your knowledge– Adopt good study skills and habits that fit will with clerkship

and they will serve you well into residency.

• Actively engage in team learning– Discuss what you have learned from your reading.– Ask good questions (but don’t grandstand)!– Speak up – share your thoughts, try answering questions. – Prepare to be wrong - nobody expects you to have all the

answers.• You learn more by venturing an answer and being wrong than

by not attempting to answer at all!


• Be open to feedback – Listen to what others tell you about your

performance, skills, strengths and weaknesses.

• Solicit feedback• Be honest

– Admit what you don’t know, what you did not do


• Take ownership of the patient– Get to know them in depth (as persons, not just ‘diseases’) – Take time to talk to them and their family– Advocate for your patient– Be prepared to discuss your patients…without notes– Be the first to know / report changes, new results etc.– Monitor their progress actively even if there is also a resident

assigned to them

• Identify good and bad role models.– Learn from both good and bad role models!– Identify the features that make good role models good or bad ones

bad so you can take deliberate steps to develop good characteristics and avoid bad ones.

Making the most of clerkship• Basic professional expectations

– Be on time– Dress professionally– Treat everyone with respect– Identify yourself clearly, including your status to patients,

family and staff.– Answer pages promptly, if you are going to be

unavailable, keep the right people informed– Write legibly– Communicate clearly– Respect confidentiality– Know your limits

Decisions, decisions, decisions…

• Keep in mind– There is no SINGLE one right specialty for you –

even if you think there is.– Your choices will determine much of what life

looks like for you when you are finished and in practice.

– Things can be changed over time– Being clear on your priorities….and making your

decisions based on those priorities will help you reach a “best fit”.

– Life(style) is a trade-off – not a “have it all” situation!

http://www.nicholsoncartoons.com.au/cartoons/new/2003-05-08%20media%20epidemic%201.JPG

Health & Medicine

Careers in Internal Medicine