INTRODUCTION TO INTERNAL MEDICINE

September 18, 2014

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

What is Internal Medicine?

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

General InternistsAKA Internists

• 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)

Subspecialties

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

Questions for Our Panel?

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 - dr.jehangir.ansari@gmail.com• Will identify researchers and tie in students with

appropriate projects

Watch for emails from your IMIG Officers for more information

1. How to Choose a Medical Specialty (3rd edition) by Anita Taylor.

2. The Ultimate Guide to Choosing a Medical Specialty (2nd edition) by Brian Freeman.

3. Physician compensation data. http://www.acponline.org/private/pmc/physcomp_data.htm

References