1. Prepare for future IMIG Events2. Identify what an Internist does3. Appreciate the different
subspecialty options in internal medicine
4. Register for ACP as a student
Objectives
Glen Solomon Chair of Internal Medicine
Karen Kirkham Internal Medicine Clerkship Director
Bruce Scott Internal
Medicine/Geriatrics/Palliative Care
Who are Internists?
ICM Preceptors
William Osler Eminent Internist, founder of
residencies
Robert Lefkowitz and Brian Kobilka Nobel Prize Winners in Chemistry (G-coupled protein
receptors)
Ken Jeong Intern(al)ational Movie Star
Who are Internists?
Who are Internists?
One in four US physicians has ABIM board certification1
Setting: Private practice = 80.9% Academia = 14.9%
Both generalists and subspecialists are currently undersupplied2
29.3% experienced difficulty in securing first position1 ABIM Fast Facts sheet 20142 The Complexities of Physician Supply and Demand: Projections Through 2025, Center for Workforce Studies, AAMC, 2008.
American College of Physicians: “Physicians for Adults” (2009) “Physicians who specialize in the prevention, detection and
treatment of illnesses in adults.” (2011) “Specialists who apply scientific knowledge and clinical
expertise to the diagnosis, treatment, and compassionate care of adults across the spectrum from health to complex illness.” (2013)
Comes from German for “Interior Doctor,” applied to someone who uses laboratory results to diagnose diseases
Internal Medicine: Definition
Focuses on chronic and acute disease processes
Wide range of practice environments Urgent care -> Hospitals -> Clinics -> Work abroad
Diverse subspecialties Cardiology to Complementary Medicine
Passed the American Board of Internal Medicine Certification Exam
Internal Medicine: Definition
Acute
Internal Medicine Spectrums
Chronic
Intensive Care Physician
Inpatient
Outpatient
Hospitalist
Primary Care
Academic
*Or any combination of the aboveSubspecialist
General
Internal Medicine Spectrum
Specialized
Geriatrician Electrophysiologist
RheumatologistRural Primary Care
*General rule: as you get more specialized, have less individualization of practice
**Family Medicine is that way
To become a subspecialist, must complete a residency in Internal Medicine first
Internal Medicine Subspecialties
1 3 42 1 32 1 32
Medical School Residency(Internal Medicine)
Fellowship(i.e. Gastro-enterology)
Years
American Board of Internal Medicine Certified:
Internal Medicine: Subspecialties
• Adolescent Medicine• Adult Congenital Heart
Disease• Advanced Heart Failure
and Transplant Cardiology
• Cardiovascular Disease• Clinical Cardiac
Electrophysiology• Critical Care Medicine
• Endocrinology, Diabetes, & Metabolism
• Gastroenterology• Geriatric Medicine• Hematology• Hospice & Palliative
Medicine• Infectious Disease• Interventional
Cardiology
• Medical Oncology• Nephrology• Pulmonary Disease• Rheumatology• Sleep Medicine• Sports Medicine• Transplant Hepatology
Non-ABIM Certified:• General Internal
Medicine• Medical Education• Transplant Infectious
Disease• Transitions of Care
• Medical Research• Occupational Health• Medical-Legal
Interactions• Tropical Medicine• Complementary
Medicine• Women’s Health• Headache• To be determined
• Acute care– Inpatient setting/ ICU– MI, stroke, respiratory failure, renal failure, etc.
• Chronic disease care– Outpatient setting, nursing home, hospice– DM, HTN, hyperlipidemia, CAD, CHF, COPD, etc.
• Adult wellness/checkups– Screening for disease– Counseling on healthy behaviors (smoking, EtOH)
• Subspecialty care (organ-system specific)• Consultant to other specialties (Surgery, Ob/Gyn)
What Do General Internists Do?
Other roles in general medical care for adults Educator Director Advocate Motivator Healer Comforter
What Makes a Good General Internist
Enjoys: Complex problem-solving/working with
mind Long term doctor-patient relationships A focus on being the front line of
medicine Acting as head coach/coordinator of
care Variety of disease entities
• Highly variable • mean patient care hours a week is 491
Typical Lifestyle
• Inpatient (Hospitalist)– Shift work (10-12 hour
shifts)– One week on, one
week off (26 weeks per year)
– 12-20 patients per day (20-30 min per patient)
• Outpatient (PCP)– 10 hour days
weekdays– 15-30 patients
per day (~15-20 min per patient)
1Medscape Physician Survey Data 2010
Salary Data
Overall Median = $212,000
Overall Mean = $195,000
Primary Care =
$192,000 Academic = $175,000 Hospitalist = $229,000
MGMA Compensation and Production Survey 2012
General Internal Medicine
Satisfaction Data
University of Davis study in 2009 surveyed 6590 US physicians, had 53% response rate1 Pediatric emergency
2 Geriatric medicine3 Dermatology4 Pediatrics5 Internal medicine and pediatrics6 Other pediatric subspecialty7 Neonatal and perinatal medicine8 Allergy and immunology9 Child and adolescent psychiatry10 Radiation oncology11 Cardiovascular diseases12 Medical oncology13 Ophthalmology
14 Occupational medicine15 Hospitalists16 Physical medicine and rehabilitation17 Psychiatry18 Otolaryngology19 Other medical subspecialty20 Critical care internal medicine21 Endocrinology, diabetes22 Urology23 Gastroenterology24 Infectious diseases25 Pulmonary diseases
Satisfaction Data
2 Geriatric medicine
5 Internal medicine and pediatrics
8 Allergy and immunology
11 Cardiovascular diseases12 Medical oncology
14 Occupational medicine15 Hospitalists
19 General Internal Medicine20 Critical care internal medicine21 Endocrinology, diabetes
23 Gastroenterology24 Infectious diseases25 Pulmonary diseases
34 Other medical subspecialty
University of Davis study in 2009 surveyed 6590 US physicians, had 53% response rate
13/25
Main Organizations
American College of Physicians (ACP) Society of General Internal Medicine (SGIM) Society of Hospital Medicine (SHM)
Each subspecialty has its own national organization
Each organization has its own annual national meeting
Popular Journals
Journal of the American Medical Association (JAMA)
New England Journal of Medicine (NEJM) Annals of Internal Medicine Archives of Internal Medicine American Journal of Medicine Journal of General Internal Medicine (JGIM)
ABIM Certified:
Internal Medicine: Subspecialties
• Adolescent Medicine• Adult Congenital Heart
Disease• Advanced Heart Failure
and Transplant Cardiology
• Cardiovascular Disease• Clinical Cardiac
Electrophysiology• Critical Care Medicine
• Endocrinology, Diabetes, & Metabolism
• Gastroenterology• Geriatric Medicine• Hematology• Hospice & Palliative
Medicine• Infectious Disease• Interventional
Cardiology
• Medical Oncology• Nephrology• Pulmonary Disease• Rheumatology• Sleep Medicine• Sports Medicine• Transplant Hepatology
Non-ABIM Certified:• General Internal
Medicine• Medical Education• Transplant Infectious
Disease
• Transitions of Care• Medical Research• Occupational Health• Medical-Legal
Interactions
• Tropical Medicine• Headache• To be determined
Allergy/immunology Cardiology Endocrinology Gastroenterology General internal medicine Hematology/oncology Infectious disease Nephrology Pulmonary/critical care Rheumatology
Fellowships
Addiction medicine Adolescent medicine Geriatrics Hospice & palliative care Sleep medicine Sports medicine Women’s health
Traditional Emerging
Less MoreInfectious Disease
Endocrinology
Geriatrics
Allergy/Immunology
Nephrology
Rheumatology
CardiologyGastroenterologyPulmonary/Critical CareHematology/Oncology
Relative Competitiveness
Fellowship LengthPractice
EnvironmentHours
Salary*
Procedures
Allergy/ Immunology
2 years Predominately outpatient
Office (Outpt) hours 195KAllergen skin tests,
desensitizations
Cardiology 3-4 years Inpatient/Outpatient Long inpt hrs with call balanced with outpt office hrs 400K
Percutaneous coronary angioplasty, echocardiograms,
stress tests, etc.
Electrophysiology
1 additional year on Cards
Inpatient/Outpatient More routine than cardiologist, mostly outpt procedures 450K EP studies
Endocrinology 2 years Predominately outpatient
Outpt hours with minimal inpt consults 200K Thyroid biopsy
Gastro-enterology
3 years Inpatient/Outpatient Long inpt hrs with call balanced with outpt office hrs 405K
EGDs, Colonoscopys, Liver biopsy, ERCP, etc.
Geriatrics 1 year Predominately outpatient
Predominately outpt hrs, with inpt consults 185K MOCAs, SLUMS
Heart Failure/Txp
1 year More outpatient More routine than cardiologist, mostly outpt, with inpt consults ? Echocardiograms
Heme/Onc 3 years More outpatient Outpt office hrs, some inpt hrs with call 320K Chemotherapy administration
Hospice/Palliative Care
1 year Mostly outpatient Outpt hours with call 180K Paracentesis, thoracentesis
Infectious Disease
2 years More outpatientGenerally long hours due to
combination of outpt hrs and inpt consults
160K Anoscopy
Nephrology 3 years Inpatient/Outpatient
Generally long hours due to combination of outpt hrs/dialysis management and inpt consults
and call
260KDialysis, catheter placement,
kidney biopsies, etc.
Pulmonary/ Critical Care
3 years Predominately inpatient
Long inpt hrs, predominately in shifts (some nights) 275K
Intubation, tPA adminstration, bronchoscopy, etc.
Rheumatology 2 years Predominately outpatient
Outpt hours with minimal inpt consults 220K
Joint aspirations, immunosuppressive therapy
Have fewer trainees due to: more esoteric level of interest lack of ACGME funding, so can be balanced
with some clinical duties vanguard of medical profession
Other Fellowships
1 year in length Board certification available Can be done after IM, FP, and psychiatry
residencies Main disease entities:
Alcohol Illicit drugs Tobacco
Addiction Medicine
• 1-3 years in length• Board certification given jointly by ABIM and ABP• Main disease entities: substance abuse, eating
disorders, acne, STDs, pregnancy, depression, mgmt. of chronic disease that begins in childhood
• Practice settings:– High school & university-based clinics– Mobile clinics– Outpatient clinics
Adolescent Medicine
2-3 years in length Training to become academic internist Two tracks:
Clinician-investigator Clinician-educator
Usually associated with master’s degree (tuition provided)
Only 20-30% clinical time
General Internal Medicine
1 year in length ABIM certification available Can be done after IM residency or
Pulm/Critical Care fellowship Most commonly combined with Pulm/CC Main disease entities: sleep apnea,
narcolepsy, insomnia
Sleep Medicine
1 year in length Can be done after IM, FP, or Peds residency Board certification available Usually work closely with orthopedic surgeons Practice settings:
Outpatient clinic Team physician
Sports Medicine
1-2 years in length Clinical or academic focus No board certification available Main disease entities: breast cancer, uterine
cancer, ovarian cancer, menopause, reproductive health
Generally combined with clinical duties
Women’s Health
Clinical nutrition Clinical decision making Medical informatics Quality improvement & patient safety Applied epidemiology (CDC) Clinical research (NIH, Robert Wood Johnson) Complementary & alternative medicine
Other Possibilities
Take care of older adults as much as you can
Focus M4 electives in following areas:
Cardiology
Pulmonary/critical care
Emergency medicine
Attend Ohio or National ACP Meeting
Get good evaluations in your M3 & M4 medicine clerkships
Be open to all possibilities (no rush to decide!)
Advice for Students
www.acponline.org www.sgim.org http://services.aamc.org/careersinmedicine/ www.hospitalmedicine.org/ Your faculty advisors!
Resources for Further Exploration
Internal Medicine Interest Group
Events: ACP Ohio
October Subspecialty Panel
November EKG Workshop for R2s
January Simulation Lab
February Match Panel
Late March Internal Medicine Experience
Spring
Elective Research Projects
All Year
Watch for emails from your IMIG Officers for more information
Internal Medicine Interest Group
• ACP Ohio – October 16th and 17th
• Poster sessions, didactics, quiz bowl, even political meetings
• $65 for students, 1 hr drive
• Subspeciality Panel - November• Panel of various subspecialist for Q&A• Cardiologists, Gastroenterologists, etc.
Watch for emails from your IMIG Officers for more information
Internal Medicine Interest Group
• EKG Workshop - January• Opportunity to practice EKGs prior to Cardiology Exam
• Likely will offer again in the Spring prior to clinical rotations (after STEP 1, obviously)
• Target audience is R2s
• Simulation Lab – February• Opportunity to learn and practice some skills such as
central line placement, IV’s, ultrasound, intubation.
• Very fun and relaxed environment and useful skills that will be used in 3rd year
Watch for emails from your IMIG Officers for more information
Internal Medicine Interest Group
• Match Panel - Late March• Panel of R4s who have matched explaining process and
tips and tricks
• Educational experience to give some guidance on what it takes to match into Internal Medicine and how students of Boonshoft do it
• Internal Medicine Experience Elective – Spring• Elective experience in Internal Medicine and IM
subspecialties at Kettering Hospital
• Paid elective ($200)
• 2 week elective and counts towards the Boonshoft elective requirementWatch for emails from your IMIG Officers for more
information
Internal Medicine Interest Group
• Research Projects - All Year• This year, tapping the Internal Medicine Research
Chief to coordinate research projects• Jehangir Ansari - [email protected]• Will identify researchers and tie in students with
appropriate projects
Watch for emails from your IMIG Officers for more information