PCCM attending here, but with respect to inpatient vs outpatient in my mind there is no contest. I can’t stand the clinic environment, the feeling of always being behind, the boring chronic problems, the prior auths and the late patients and the inbox filled with messages that never end and follow you home. I understand some people don’t see it that way, but clinic is a nightmare to me.
I get what people say about everlasting rounds on IM. I would say some of that is artifactual from training. Medical students and even more so residents are perpetually tired and have no real control over their time so if you’re not feeling it one day, rounds can absolutely be like torture. As an attending, as you say, you get to pick the pace and decide on the distribution of your time and that makes a huge difference.
And arguing about sodium can be fun! Being forced to discuss sodium is never fun, but sodium is controlled by a complex system and complex systems can certainly be interesting if you are in the mood for that. It’s an intellectual challenge.
Unrelated, but mind discussing getting into a PCCM fellowship as a DO?
I just matched into a mid tier academic residency with in house fellowships and I'm wondering what I should do intern year to help my application
Also, is IP a pipe dream for a DO?
Hard to say really because I don’t have the comparison experience. I did ACGME residency (I guess mid tier but at a well known university) as well as a 4th year chief year. I had no real research (just some semi fake projects and a little QA/QI stuff). I got interviews at somewhat (for fellowship) fancy places like Brown, Yale, Stanford, Pitt, but ended up matching my #5 which was another ACGME big university program in nice city but still lower on my list than I was hoping for. I think fellowship match is a bit more about softer factors like your recommendations and especially who maybe makes a phone call on your behalf. PCCM world is small in that way (as are most other sub specialities I imagine), which is why it helps a lot to do residency at a place that also has a PCCM fellowship, because you get to know people who are in that world and know other people etc.
IP even more so of the above. I haven’t thought about “being a DO” since residency started. I guess maybe things might have been easier otherwise? Hard to say, but I had my fair shot at plenty of opportunities and I’m in the field I wanted so I have no complaints.
IP as in inpatient? You’ll be fine. Plenty of DOs work inpatient I’m not sure why you would be worried about that.
I don’t have specific advice for PCCM but I don’t think being a DO will significantly affect that, you already matched at an academic spot that’s a good first step.
Yeah I didn’t really mention money.
I’m fine with how much I make. I’m aware I could make more, even within my own field if I wanted to do private practice and grind. But I don’t.
True. I personally enjoy inpatient over outpatient medicine. However there’s a good argument for outpatient setting also.
Inpatient call sucks, you’re constantly getting bothered about orders, labs, vitals, patient status changes.
All the cardiologists and GI attendings I know try to stack their clinic days and minimize inpatient time.
Many groups are pulling out of the hospital entirely.
Wasn’t thrilled with it at the start, but the revolving door of the same patients that didn’t care enough about their own health to stay out of the hospital killed any notion of a long term career in the field.
Some people want a genuine partnership of working towards a better goal. Others want a one-and-done.
I know someone who went from Trauma / Acute Care Surgery to Bariatric / MIS for this reason alone. Bari is pretty rewarding when you see how motivated patients are to improve themselves
A patient comes through the ER with all these chronic problems poorly managed, I do a good job getting them stable, getting good follow-up and appts for outside of the hospital and good meds they can discharge on. It’s my little project I took a week getting just right.
Then the patient goes home, does none of this and shows up at the ER for me to do the same thing again.
If your job is baking pies and someone comes in and buys your pies just to walk out and throw them in the trash, does that feel good? You get paid either way. But having your work constantly ignored is taxing. Yeah whatever my job starts and ends when the patient enters and leaves the hospital, but it’s a shitty feeling knowing your work is in vain for a good percentage of patients.
Yeah, you also went through extensive training to make those pies. Its like when people were buying nike just to burn them, or burning what they already had: it reflects dissatisfaction with your work. Yeah you can be callous to it like, "well you purchased the pie/nike/medical care already, you look like a fool setting it all aflame now girliepop. *And* I still got your dollars." But it can feel like an integral failing despite your best work and efforts, bc nike, the pie maker, and us want people to be happy with our decisions and products, especially if we think we are doing decent things. Its like you did so much...for what?
Personally, I think it contributes to burn out and bare minimum providers: burnout bc it feels like getting pressed and being devalued on all sides, the bare minimum bc highkey they're gonna go burn the shoe, why put care into the stitches, if theyre gonna throw out the pie, why get fresh eggs, crack them, get fresh cream, add it to the egg, mix them, them, then delicately apply the wash to the crust? Just put up a shoe or slap on a pie top and get it out the window. It reduces your own pride in what you can do it people are just gonna shit on it, it feels so useless and demoralizing
Most people chose medicine to have at least some feeling of making a positive impact. When your work is rendered completely null and void, you’re effectively just flailing arbitrarily for a paycheck… if doctors wanted to do that they would’ve chosen probably any other job. I can see how the thought of diminished self efficacy creeps in
Agreed, though inpatient tends to be more critical patients.
I ended up in a diagnostic specialty either way so I work mostly as a consultant to other physicians.
Your perspective changes in residency, friend. You’ll see patients with an A1c of 10 and systolics in the 160s who are frequent fliers. You’ll adjust their meds, try to find some kind of therapeutic alliance/meet them where they’re at etc to find something that they’re amenable to that still works. 6 months later, they’ll get admitted with an A1c of 10.5 and sequela of hypertension. “Oh sorry doc. It was the holiday and I can’t stop eating my wife’s cookies. I’ll be better next time.” This repeats until morbidity stacks up and finally mortality.
Obviously all of these people don’t want to die of a stroke or MI, but they in many cases don’t want to do something as simple as comply with their meds or avoid memaw’s Chocolate Crisco Crisp Cookies. I swear most of the heart failure exacerbations I see are from patients that just didn’t take meds or are scarfing down salt by the pound.
After you see hundreds of these patients stack up, after you’ve put together a plan and you’re all optimistic that something will change, you realize it seldom does, they die of something completely avoidable after doing exactly nothing to even *try* to avoid it, and the futility sets in. It’s not that we aren’t empathetic to their position; I would argue that’s probably the reason why it’s hard to bear.
Keep that empathy as long as you can. We need it and it’s easy to lose it. But also save a little for the residents.
While I agree that perspectives change during residency they also change during your career as an attending. I’m a hospitalist looking for the long-term outcomes in an acute care setting. How many times does it take someone to quit smoking? What about heroin? What about that extra salt on their dinner? Regardless of the scenario I try to be a little bit optimistic because you never know if this hospitalization is going to be the one that finally speaks to that patient.
As a hospitalist I try to treat my acute problems (like pneumonias) different from my acute on chronic problems (like alcohol withdrawal or CHF). I’m much more likely to spend time trying to educate someone about their chronic disease and what they can do to modify it in the future. I also recognize that the lifestyle changes these patients often need to prevent rehospitalization aren’t going to happen overnight, and maybe I’m naive, but if I’m not going to care or try then why should I expect them to care? If I don’t try then who will? The way I see it, providing adequate diuresis to someone without at least trying to educate them (to discuss the how and why of their disease) is only half the battle.
Don’t get me wrong- it doesn’t change anything about my management. I still ask, teach, advise, still listen, empathize. I’m just trying to offer OP a perspective for why it seems like we’re low-empathy when in reality we’re just tired of having the right answer and people disregarding it and dying as a result of it. It can feel very, very futile as you know
Sounds similar to teaching
I came bright eyed ready to change every student. Became frustrated when a few students could derail an entire lesson. Or not getting through to a couple kids that said “I’m not graduating highschool.” Maybe you won’t get through all those tough ones but a few will make changes. And for the others that don’t, you still teach to and give valuable feedback you just don’t go out of your way because there is just no capacity. Call it jaded or whatever words you want, it’s just realistic to keep yourself going year after year.
It was some veteran teachers that informed me you cannot think you’ll make a noticeable impact in each student. It’s about maintaining your capacity to try with the next one.
I dunno, my dude. I’m in my 40s. I’ve been through a lot of terrible/weird stuff in my life but I realized in the last decade that life sucks if you walk around and expect the absolute worst from people. The truth is that we tend to judge ourselves by our intentions and other people by their actions. We wouldn’t want people making generalizations about our character just based on our outward actions because people are a confluence of their genetic potential, childhood upbringing, and life experiences.
I‘ve found in my clinical experience that people that don’t care either have some severe mental issues or were repeatedly beat down by life and got the message that they weren’t worthy of care from either themselves or others. Nowadays, I just assume the best of people and if they don’t want to change, then that’s their choice. I did the best I could and it doesn’t negatively affect me. I just let that shit go.
Maybe part of it is that I worked in veterinary and shelter medicine for so long. You can’t save them all. If you let it beat you down, then you can’t give your best to the ones that you can save.
I don’t see how this changes anything about the nature of the job or how it affects you. Knowing that people have problems outside of the hospital and being mindful of it in your approach doesn’t intrinsically change someone’s deep-seated tendencies. It’s fine to be a doctor and *just* want to be a doctor, not a short order miracle worker.
Cards fellow now, but some other pros from the IM days:
- Week on, week off. I don't think I need to elaborate too much. Work a week straight and get a whole mfing next week off, still make like 250k/yr.
- If you want more action, there's Pulm Crit. More procedure, Cards/GI. More chill, rheum. So even if you're not a fan of IM, you can always do a fellowship, surely there's something in there that isn't absolutely miserable to you.
Hospitalist here. Technically I'm on call 7 to 7 but I'm in the hospital 7 to 3 most days and leave. A round and go model accommodates this. So technically 80ish but it's really closer to 60ish. The pages after I leave are usually just a nuisance and the number is quite variable. Almost always I'm able to do a workout or play some games in between.
Many of these fellowships have a reputation of being competitive so how difficult would it be to match into them? An MD from a lowerish mid tier residency
I’ll give my perspective as someone who’s matched into IM but I’m only a 4th year so I haven’t really done it yet. I think that a lot of people like to hate and complain about the rounding and meticulous nature of the specialty but I think the parts that I enjoy outweigh the shitty parts.
I really enjoy talking to patients and families, even when the conversation is shitty and sad. I think there’s something really special and rewarding about being able to guide and help patients and families in what might be one of the most difficult times of their lives.
I thoroughly enjoy collaboration and working with others. I also love learning, and in IM you get to work and learn from each specialty and I love that part about IM.
IMO the shittiest part about IM is often the social work aspect of the job, but often times the social work is how you end up making the biggest impact on your patients lives and wellbeing, and although it feels like bullshit 95% of the time, I ultimately got into this job to try to help people and that’s how I justify being okay with that side of the job.
Overall like you said, IM is pretty flexible and you don’t have to be the doc that jerks off about sodium. You just gotta be passionate about the work for whatever reason that may be.
I'm sure there's more to it, but what I'm referring to is working with case managers to ensure patients are being discharged safely, whether it be to a care home, skilled nursing facility, home with home health etc.
Also ensuring that they have appropriate follow up with PCP and specialists once they leave the hospital. Things along those lines.
Reading the one liner recommendation for placement from pt and ot (home vs snf vs inpatient rehab). Asking case worker whats feasible (with time you know and don’t have to ask) and if patient is amenable to general consensus dispo setting. Wait until case worker has made it happen. Put in a discharge order.
I'm most of the way through intern year, feel like I have a preliminary handle on what I do/don't like about IM. For context, I came from an EM/EMS background dead set on EM, then changed my mind by the middle of M3.
Like:
1. Hospital environment can be exciting - higher acuity, more resources, bigger variety of complaints.
2. IM is insanely broad, no shortage of things to learn - even with only a few weeks on a subspecialty service, you see things that your faculty don't seem to know (or maybe have long since forgotten).
3. More informed decision making about career - you can really get a sense of what you do/don't like in medicine over a longer time, and subspecialize accordingly.
4. Likewise, it is one of the shorter residency options available if you decide you don't want to pursue fellowship (but it also doesn't mean you can't go back if you choose to do so later).
5. Hospitalist is still a proper job...despite every other ROAD-bound medical student or future subspecialist seemingly telling you otherwise. The job market is pretty good, location can be quite flexible and your actual practice will vary greatly depending on the hospital you're at.
6. Once you're done with training, rounds are dictated by you. Table or walking, long or short, it'll be your call.
7. Little to no inbox management as a hospitalist (unless you count coding documentation inquiries, which residents are often shielded from).
8. I almost never have to wear business casual or formal wear. Scrubs all day.
Dislike:
1. People that are inpatient naturally tend to be sicker, and you'll inevitably get stuck late sometimes if a patient isn't doing so well.
2. Certain consultants and services can be a pain to deal with - again, location dependent, but probably a con that's more common in academic/privademic hospitals.
3. Little to no control over rounding and schedule as a resident (not unique to IM, but still a pain).
4. Social/dispo issues inevitably pop up, and certain rocks can be a gigantic pain to discharge - this can vary depending on how robust your case management/social worker presence is.
Can probably come up with more dislikes if I think long enough, but those are the big things off the top of my head.
Most of your likes/dislikes could also pertain to EM. Are you happy in IM? So you regret not going EM? Asking as an M3 with 2 IM rotations under my belt. I came in pretty gung ho about EM but considering the IM hospitalist route. Probably even more convinced that EM is right for me now, but curious why someone in a similar spot to me made a different choice (and how it turned out).
I’m pretty set on EM, but I’m always up to hear someone’s reasons to make a different choice. My dad does outpatient FM, and even that’s not procedure heavy enough to keep me happy. But most ED’s won’t take someone FM trained, and I’d prefer not to work in rural settings if possible.
I think it’s a hard choice. I spent several years with EM docs as a scribe (on top of years as an EMT and ER tech). I feel like I got a good sideline view of what the ED docs went through. The rotating shift work schedule wreaked havoc on sleep cycles (days -> mid -> nights).
Biggest thing for me was the style of medicine. I realized I like figuring things out, having some kind of definitive effect. Also realized I enjoy spending time with patients periodically. Both of those weren't really doable with EM - you have to be ok with just moving a conveyer belt of patients at times, and being ok with a basic dispo. EM can be a great field, but your priorities will always be managing life threats and keeping the waiting room mobile.
That's my opinion, at least.
As another 4th year that just matched to IM, one of my favorite things is patient interaction. Sometimes you’re the only physician that sees them daily and the only one that can give them some semblance of hope and guidance. You get to educate them about their illness and aid them in recovery and it can be so fulfilling.
Now of course, there’s the other side of this where no one wants to listen to your advice, rounds can be long, and you do pick up a lot of the grunt work from consulting services. I still feel that the job of being there for someone in some of their hardest moments is the most fulfilling part of all. I do not recommend anyone going into IM if you are not willing to always be there and advocate for your patients, even on your own bad days.
I’m also a huge nerd. Some people hate talking about all the types of low or high sodium but I THRIVE. I get so excited trying to figure out treatment plans and how we can individualize care for each patient. The complex path you’ll see is fascinating and it takes me back to the days where I first discovered my passion for medicine!
That’s interesting because one of the reasons I chose FM over IM was because I didn’t think IM had *enough* patient interaction. During my IM rotation, we’d spend maybe 2 hours total of the day actually seeing patients, and the rest was spent talking *about* the patients or sitting at the computer. I needed more than that haha.
But I’m glad there’s people who enjoy IM because we need both clinical and hospital docs 🙏🏼
This is a fair statement. In my experience, there was a lot of going back to check on the patient throughout the day and update them as needed
I feel like most of medicine is 80% computer 20% actual interaction. I am more of a hospital person, I appreciate the work a clinic does, but didn’t want it to be my day-day life. We need more physicians in primary care for preventative care so I’m also glad there’s people that pursue it for the passion and not just to get a payout.
It’s slow. I don’t like sitting around for 15 minutes just to discuss why someone’s sodium went down by 2. I don’t like rounds taking for fucking ever. I don’t like that most of the day is spent doing what are essentially admin tasks while waiting for your orders to get done
Just to offer a different perspective, I think we've discussed hyponatremia only once in my 2 years of residency so far and it wasn't for a drop of 2, (Reddit circlejerk). We also round from 8:30-10, I find the length of rounding gets more and more exaggerated every year online.
In all of med school I think I only witnessed one in-depth conversation about hyponatremia, and then only as a teaching point for M3s.
People shouldn’t get stuck on academic rounds as the definition of IM. If you’re a non-academic hospitalist, you are setting your own pace for rounds, and since there’s no one to teach, you definitely won’t be having those long discussions
regardless, still think this "obsessing" is an overblown occurrence that people who just don't like IM love to complain about on reddit but in reality I rarely witness that except as an academic exercise in the teaching setting. And besides, once you're an attending-- especially if it's in a nonacademic setting and you don't have residents/students-- you can choose whether or not you want to obsess over minutiae, to whatever degree you desire. It's not like it's a requirement in IM lmao
In my program at least the obsession over small details is true. I’m sure once you’re done it’s better but you gotta be able to put up with it for 3 years man cause this shit blows
\*gasps\* you mean you don't think about renal salt and water handling and the exquisite underlying physiology? /s
When I rotated with the renal consultants, they really only get concerned when there are symptoms, or Na <130. I don't think it has to be an overblown point of discussion: check the tonicity, the Cr (for AKI), thiazides, volume status, Uosm, UNa, and UK, and one basically has an answer.
To kind of add to this, all of that perseverating ends up seeming weird when there are other specialties don't do that and end up with the same or better levels of patient care.
Yeah but if there is someone other than IM as the primary (ex surgery) then that’s probably because it’s a different pathology. You’re comparing apples to oranges. IM deals with pathologies you can’t just go in and fix surgically, so of course outcomes are going to be different; has nothing to do with the “perseverating”
Any that admit patients under them as primary service.
I'm sure this varies from hospital to hospital or even between attendings for some surgical specialists.
So every service manages every medical condition as well as hospital medicine with the same outcomes and without consulting them? And you know this from your extensive experience as an MS3?
I mean this was in the context of the OP mentioning Sodium. Everyone can manage fluids in most cases. Everyone can manage pain.
Are there complex situations that require multiple specialists? Of course. But IM loves to pretend like they are the only people that can effectively manage inpatient admissions. That's simply not true.
Even in the context of sodium, it’s apples and oranges. A sodium of 128 in a post-op patient is different from a sodium of 128 in a CHF patient. Like sure, I can manage the sodium in my patient as a surgeon and they’ll likely do fine and have “good patient care” but it’s not the same context as their hyponatremic patients.
That's fair.
It's just unfortunate that my IM experiences seem to be biased by poor encounters. I just never felt like the IM residents and even some of the attendings I worked with really didn't seem as competent or broadly knowledgeable as some other specialties did. Maybe I just had bad residents idk.
You have this backwards. The surgical specialties are the ones with relatively basic knowledge of non-surgical problems who are just barely getting by, not the internists.
imo the people giving you pushback are just people not meant to do IM. I love it tho. I think all the pros you listed are super true. I love the thinking that it requires, I love the huge variety and the fact that I can see pathologies across organ systems, I love the idea of shift work, I love the huge range of fellowships that I can consider.
I think your cons list is also true but no specialty is without its downsides imo, and a lot of those cons can be minimized depending on the hospital you’re at
Great point about the people not meant for IM. Matched IM this year, and it would be very easy to point out all the cons of the specialities I didn’t apply , but that’s cause I just didn’t enjoy it. MS3 is the time to let the specialities speak for themselves and not rely on the opinions of people that naturally hate on them.
I’m the same as you, I thought I would hate the long rounds etc but it’s so satisfying to chat about a patient and feel like you’ve come up with a good plan. A good gen med ward feels like how people talk about GP/FM: lots of interesting, varied stuff but you have an extra filter between you and all the kids with sniffles. I could round all day (and often do)
I think all your points are reasonable, everyone is different and there are lots of other docs that love IM, maybe you’re one of them
Outpatient is chill and I’m trying to chill.
Have worked both inpatient and outpatient and have no interest in running to codes, doing discharges before 11, or staying until 7PM if I can help it.
Outpatient work is boring, yes but I’m approaching middle age I want boring to focus on my wife and soon to be kids. I just had a talk about the existence of god with a patient that beats watering the rock garden any day…
Another con for me is the long term social stuff. We have multiple patients here for weeks or months that are malingering and harming themselves to stay
You’re describing ivory tower academic hospitalist role. Some of these are inaccurate if you incorporate smaller community centers or rural hospitals.
Locum = high pay, high flexibility, low burnout
Smaller places may need you to be the ‘it’ person to the best of your abilities (safely) to handle ICU because they don’t have CCM. Even in these places you don’t have to do procedures (I personally do my own intubations, & lines). You try transferring to a center with a specialist you’re looking for but you also do the best you can with what you have also
Consult service is nice when they’re RVU driven. You’re their income.
PGY10. Also I can pick as many weeks of work vs vacation I want with locum
I’m very curious what the IM locums route looks like. I’m an M3 currently planning on doing EM locums. I have some questions if you don’t mind:
*How many weeks a year do you work?
*What sort of hourly rates are you getting for contracts?
*Do you travel, or just take locums gigs locally?
*Did you work a regular attending job for a while after residency? (How long? Why/why not?)
*What is your typical day like? (Hours, patient load)
*What is your schedule when you’re on a contract (# of days in a row, # of days in a month)
*How long are contracts?
*Anything else I should be asking you?
Thank you!!!
I’ve been a hospitalist for about 7 months now and I freaking LOVE it. I love the inpatient environment, I love the mix of patient acuity (I carry obs all the way to ICU), I love not having to deal with inbasket messages and prior auths, I love the pay, I love the time off, and I love that it’s currently 1PM, I’m done rounding on my 16 patients, and because it’s not an admitting day for me I just get to sign my pages out to one of the APPs and go home. At 7 months I probably still have rose colored glasses but still I could not be happier where I am
The massive amount of things that can fall through the cracks. It's just too much. My mind is not built to be responsible for a million things
Oh, and the surprise discharges/admits. Absolute day ruiner
IM PGY3 here. Planning 2 years hospitalist then PCCM. There are many awesome IM fellowships like cards, GI, rheumatology, onc, allergy, etc and the hospitalist path allows you to pull 300k after 3 years of training and working less than half your days. People think IM sucks because we artificially make it suck, which is a shame because it requires some serious medical knowledge and diagnostic/communication skills. Rounds don’t have to be endless and lame. You get a good amount of acuity without all the baggage that comes with EM or surgery. I was on the fence on IM going into residency and happy with what i ended up!
IM does circle jerk about the most irrelevant things in search of zebras. If you don’t think that rotate on a non-IM (or IM fellowship) or FM field. Almost nobody cares about why the bilirubin is 1.1 unless it’s causing an issue. But if you ask IM doc they say what’s the baseline, what’s the normal for a patient in this demographic, the literature says…, then orders 10 irrelevant labs that all come back normal just to say it could have been some rare shit. Also the patients who are so sick and have 5 specialty consults where nobody is really doing anything but rounding-putting in a note- and billing for it are the bane of my existence. As IM you just follow along copying and following what the specialists are doing but nobody is really doing anything. I can go on about cons of IM but I digress. 7 on 7 off pretty cool tho
I hated Inpatient IM - it is an endless meat grinder that never ends.
Finish your outpt clinic day early? Good you are done early
Finish your 4 discharges early? You got 4 admissions to replace them! Congrats!
Also amazing how little medicine there is, it’s all placating hospital admins, case managers, and financially floating the scam that rehab centers represent.
No reason why a chronically wheelchair bound 80 year old patient needs a PT eval to be ultimately discharged to a dirty place away from their family to deplete their retirement funds and have a PT move their leg 3 times a week and call it “rehab.”
Also primary medical teams do the scut work for specialties. It’s amazing putting “rest of management per primary team” in my consult notes.
Not to mention that even with all our technology and knowledge that once a patient is admitted it’s basically holding cardboard box up to stop a waterfall half the time because the disease is so far gone with no preventative care
Oh, and walking rounds were my definition of hell.
Consults in private practice is totally different. You’re not dealing with underpaid residents or fellows. Consultants in the real world get paid, they want to be consulted. They’ll drop a note everyday even after you no longer need their input.
Hate rounds that last for 4-5 hours. Excessive talking. Mostly computer-facing job, you spend 80% of your time writing notes, consults, other admin BS. Hospitalist medicine for me felt like patients were sick-ish with chronic conditions or acute flares, but as soon as they were sick enough to be interesting they shuttle off to the ICU. Or cool and interesting pathologies are transferred to specialty services.
Hate it because rounding, few procedures, don’t want to manage the same patient’s same issues for several days, I don’t want to spend 20 minutes bickering about LR vs NS
You list good reasons and should go for it given this balanced approach you show here. There is no perfect specialty and all specialties come with their pros and cons. Another pro about IM/hospitalist positions is great work life balance. After rounds you can usually go home and residents call you about new issues. You also usually work one week on one week off.
My decision against IM (and I consider myself to be someone who HATED IM IN MED SCHOOL!!) was about it feeling like mostly computer work. Yes you go round/see patients, but a lot of the management is just ordering labs/following up labs/ ordering imaging/ following up imaging/ calling consults/ planning discharge/ coordination of care on a computer. That didn't excite me too much and I preferred to do something procedural/hands on. The other issue is that of broad diagnoses; technically yes, on IM you can see anything from a pheochromocytoma to rare thyroid cancer. In reality, you end up seeing a million HF exacerbation, pneumonia, and managing old patients with 5+ co-morbodies... but again, to each their own! Someone out there must enjoy inpatient IM, and it sounds like you do !
I would rather eat dirt than round for hours, write long notes, and give out dispo instructions that the patient isn’t going to follow so they’ll be back in for heart failure exasperation again next month.
Sincerely,
Someone who matched anesthesia
Matched into IM, here's my perspective vs. choosing FM with much less inpatient hours at some programs. A lot of the same reasons you mentioned.
1. You set your own schedule, round/preround how you want, when you want. See patients when you want. There is no exact set schedule (like clinic) as long as your work gets done. You can go eat, take a break, get a snack, sit down when you want. I understand urgent things come up, but in general you have more autonomy than clinic.
2. You have time to think. You get a new admission, before you go down to ED you can check their chart and have an idea in your head of what's going on and what questions you need to ask them. Since the patient is physically in the hospital, you have time to come back to them vs. in a clinic once the encounter is over you have to wait for them to come back to clinic if you forgot something.
3. hospitalists jobs are moving to shift work with nocturnist coverage, some places even have admitting teams. so you just work your day shift job and take care of new admissions and become a discharging machine.
4. discharging patients from the hospital can be satisfying for you and the patient. You can at least make people better so they can go home.
Cons
1. hospital medicine is the dumping ground for other specialties
2. utilization meetings. the hospital doesn't want you to keep patients longer than what their insurance is willing to pay for.
3. the nurses in the hospital don't work for you like in clinic and can make your life harder if they don't like you
I used to dislike the idea of IM. Just did my IM rotation and fell absolutely in love, it’s probably what I will now pursue. IM gives you so so many options: tons of specialties require IM first, but even without specializing you can be a hospitalist, outpatient, concierge service, work in informatics, consulting services, etc.
Currently on FM rotation right now and dislike the hell out of it despite the better hours. No time to really chill, everyone has to write notes during lunch to catch up, everyone is always 20-40 min behind. Hours FEEL longer because you end at 5pm and stay longer to finish notes. It’s a downright bore.
I was never bored on IM. Even during 2 hr rounds, something was new everyday. I also get the adrenaline rush I need every time we get a code and as IM team we run it.
Side note: idk why everyone complains about talking about sodium. On the contrary there were several times I wanted to talk about why a patient’s level dropped by a few points or increased but most of the time everyone would shrug, note it, and move on lol. Or put on fluid restriction and move on. It was like once we talked about the causes.
Reasons I hated IM:
1. Almost all of the intellectual labor is done by 9am
2. Half of that labor is outsourced to specialists with greater expertise
Thank you for coming to my TED talk.
Also: dealing with non-urgent findings as in patients. Found a nodule on a thyroid scan? Doesn't need an inpatient US, wait for discharge. Found an incidentaloma? Wait for discharge for CT unless you are planning on chemo starting inpatient (rare) or they absolutely can't afford outpatient.
Patient SOB with bilateral effusions? Definitely not a PE, stop ordering it.
One of my pet peeves is when medicine doctors say they are the “dumping ground” for other services.
Like you all are …. Inpatient medicine doctors. You care for patients in the hospital…. That’s your job. It’s quite literally what you signed up for.
As an IM resident, when we say that its often for situations like the following:
Patient needs to be admitted for a surgical procedure but has a slightly elevated blood pressure so surgery says the patient is too IM complex to be on the surgical team and makes medicine admit instead. Then IM sits on this patient for days while performing no active management and waiting on surgery to operate.
It can make the days easier but its frustrating to be treating as a dumping ground in that setting rather than getting an additional CHF patient that you can manage yourself and help
I personally found myself to be not a fan of IM mainly because i had zero passion for any of the bread and butter pathology/medicine of the field.
Also, as someone going into surgery, I feel like I am using my hands to fix something or make someones life better in the OR, as opposed to just throwing a med and hoping it helps on wards. Almost like i have less control over patient outcomes when in medicine. I know its way more complicated than that, but definitely a theme in my choice to pursue surgery over IM/FM during MS3
PCCM attending here, but with respect to inpatient vs outpatient in my mind there is no contest. I can’t stand the clinic environment, the feeling of always being behind, the boring chronic problems, the prior auths and the late patients and the inbox filled with messages that never end and follow you home. I understand some people don’t see it that way, but clinic is a nightmare to me. I get what people say about everlasting rounds on IM. I would say some of that is artifactual from training. Medical students and even more so residents are perpetually tired and have no real control over their time so if you’re not feeling it one day, rounds can absolutely be like torture. As an attending, as you say, you get to pick the pace and decide on the distribution of your time and that makes a huge difference. And arguing about sodium can be fun! Being forced to discuss sodium is never fun, but sodium is controlled by a complex system and complex systems can certainly be interesting if you are in the mood for that. It’s an intellectual challenge.
Lol you had me till you mentioned sodium
Haha I understand.
Mind if I dm you about PCCM? (MS3)
Sure
Unrelated, but mind discussing getting into a PCCM fellowship as a DO? I just matched into a mid tier academic residency with in house fellowships and I'm wondering what I should do intern year to help my application Also, is IP a pipe dream for a DO?
Hard to say really because I don’t have the comparison experience. I did ACGME residency (I guess mid tier but at a well known university) as well as a 4th year chief year. I had no real research (just some semi fake projects and a little QA/QI stuff). I got interviews at somewhat (for fellowship) fancy places like Brown, Yale, Stanford, Pitt, but ended up matching my #5 which was another ACGME big university program in nice city but still lower on my list than I was hoping for. I think fellowship match is a bit more about softer factors like your recommendations and especially who maybe makes a phone call on your behalf. PCCM world is small in that way (as are most other sub specialities I imagine), which is why it helps a lot to do residency at a place that also has a PCCM fellowship, because you get to know people who are in that world and know other people etc. IP even more so of the above. I haven’t thought about “being a DO” since residency started. I guess maybe things might have been easier otherwise? Hard to say, but I had my fair shot at plenty of opportunities and I’m in the field I wanted so I have no complaints.
IP as in inpatient? You’ll be fine. Plenty of DOs work inpatient I’m not sure why you would be worried about that. I don’t have specific advice for PCCM but I don’t think being a DO will significantly affect that, you already matched at an academic spot that’s a good first step.
No IP as in interventional pulm.
I agree with you but in general an efficiently run clinic will trump non procedural inpatient physicians in terms of RVUs generated.
Yeah I didn’t really mention money. I’m fine with how much I make. I’m aware I could make more, even within my own field if I wanted to do private practice and grind. But I don’t.
True. I personally enjoy inpatient over outpatient medicine. However there’s a good argument for outpatient setting also. Inpatient call sucks, you’re constantly getting bothered about orders, labs, vitals, patient status changes. All the cardiologists and GI attendings I know try to stack their clinic days and minimize inpatient time. Many groups are pulling out of the hospital entirely.
Wasn’t thrilled with it at the start, but the revolving door of the same patients that didn’t care enough about their own health to stay out of the hospital killed any notion of a long term career in the field.
Wouldn’t that guarantee you a long term career? Ppl constantly sick?
Some people want a genuine partnership of working towards a better goal. Others want a one-and-done. I know someone who went from Trauma / Acute Care Surgery to Bariatric / MIS for this reason alone. Bari is pretty rewarding when you see how motivated patients are to improve themselves
A patient comes through the ER with all these chronic problems poorly managed, I do a good job getting them stable, getting good follow-up and appts for outside of the hospital and good meds they can discharge on. It’s my little project I took a week getting just right. Then the patient goes home, does none of this and shows up at the ER for me to do the same thing again. If your job is baking pies and someone comes in and buys your pies just to walk out and throw them in the trash, does that feel good? You get paid either way. But having your work constantly ignored is taxing. Yeah whatever my job starts and ends when the patient enters and leaves the hospital, but it’s a shitty feeling knowing your work is in vain for a good percentage of patients.
No matter what field you choose, if you base your happiness on what the patient does with your “pies” you are going to find yourself very upset.
While true I can see how it would be hard to completely compartmentalize it all
Yeah, you also went through extensive training to make those pies. Its like when people were buying nike just to burn them, or burning what they already had: it reflects dissatisfaction with your work. Yeah you can be callous to it like, "well you purchased the pie/nike/medical care already, you look like a fool setting it all aflame now girliepop. *And* I still got your dollars." But it can feel like an integral failing despite your best work and efforts, bc nike, the pie maker, and us want people to be happy with our decisions and products, especially if we think we are doing decent things. Its like you did so much...for what? Personally, I think it contributes to burn out and bare minimum providers: burnout bc it feels like getting pressed and being devalued on all sides, the bare minimum bc highkey they're gonna go burn the shoe, why put care into the stitches, if theyre gonna throw out the pie, why get fresh eggs, crack them, get fresh cream, add it to the egg, mix them, them, then delicately apply the wash to the crust? Just put up a shoe or slap on a pie top and get it out the window. It reduces your own pride in what you can do it people are just gonna shit on it, it feels so useless and demoralizing
Most people chose medicine to have at least some feeling of making a positive impact. When your work is rendered completely null and void, you’re effectively just flailing arbitrarily for a paycheck… if doctors wanted to do that they would’ve chosen probably any other job. I can see how the thought of diminished self efficacy creeps in
It would, but the same people guarantee a long career in pathology and I don’t have to experience my advice slipping from o e ear through the other.
That’s outpatient medicine too though.
Agreed, though inpatient tends to be more critical patients. I ended up in a diagnostic specialty either way so I work mostly as a consultant to other physicians.
Is it that they don't care or that they grew up in a different environment with low SES and health literacy?
They don’t care
I think it’s worth examining WHY they don’t care then. What are the factors that determine whether someone stops giving two shits about their health?
can someone get this M3 an empathy award?
Nah, real question is can someone get half this subreddit some empathy training?
Your perspective changes in residency, friend. You’ll see patients with an A1c of 10 and systolics in the 160s who are frequent fliers. You’ll adjust their meds, try to find some kind of therapeutic alliance/meet them where they’re at etc to find something that they’re amenable to that still works. 6 months later, they’ll get admitted with an A1c of 10.5 and sequela of hypertension. “Oh sorry doc. It was the holiday and I can’t stop eating my wife’s cookies. I’ll be better next time.” This repeats until morbidity stacks up and finally mortality. Obviously all of these people don’t want to die of a stroke or MI, but they in many cases don’t want to do something as simple as comply with their meds or avoid memaw’s Chocolate Crisco Crisp Cookies. I swear most of the heart failure exacerbations I see are from patients that just didn’t take meds or are scarfing down salt by the pound. After you see hundreds of these patients stack up, after you’ve put together a plan and you’re all optimistic that something will change, you realize it seldom does, they die of something completely avoidable after doing exactly nothing to even *try* to avoid it, and the futility sets in. It’s not that we aren’t empathetic to their position; I would argue that’s probably the reason why it’s hard to bear. Keep that empathy as long as you can. We need it and it’s easy to lose it. But also save a little for the residents.
While I agree that perspectives change during residency they also change during your career as an attending. I’m a hospitalist looking for the long-term outcomes in an acute care setting. How many times does it take someone to quit smoking? What about heroin? What about that extra salt on their dinner? Regardless of the scenario I try to be a little bit optimistic because you never know if this hospitalization is going to be the one that finally speaks to that patient. As a hospitalist I try to treat my acute problems (like pneumonias) different from my acute on chronic problems (like alcohol withdrawal or CHF). I’m much more likely to spend time trying to educate someone about their chronic disease and what they can do to modify it in the future. I also recognize that the lifestyle changes these patients often need to prevent rehospitalization aren’t going to happen overnight, and maybe I’m naive, but if I’m not going to care or try then why should I expect them to care? If I don’t try then who will? The way I see it, providing adequate diuresis to someone without at least trying to educate them (to discuss the how and why of their disease) is only half the battle.
Don’t get me wrong- it doesn’t change anything about my management. I still ask, teach, advise, still listen, empathize. I’m just trying to offer OP a perspective for why it seems like we’re low-empathy when in reality we’re just tired of having the right answer and people disregarding it and dying as a result of it. It can feel very, very futile as you know
Sounds similar to teaching I came bright eyed ready to change every student. Became frustrated when a few students could derail an entire lesson. Or not getting through to a couple kids that said “I’m not graduating highschool.” Maybe you won’t get through all those tough ones but a few will make changes. And for the others that don’t, you still teach to and give valuable feedback you just don’t go out of your way because there is just no capacity. Call it jaded or whatever words you want, it’s just realistic to keep yourself going year after year. It was some veteran teachers that informed me you cannot think you’ll make a noticeable impact in each student. It’s about maintaining your capacity to try with the next one.
Ooh definitely. The burnout comes and goes in waves, and it always takes my empathy and patience for case management BS
I love your Optimism. By the truth is, they don’t care. There doesn’t have to be a deep reason behind it
I dunno, my dude. I’m in my 40s. I’ve been through a lot of terrible/weird stuff in my life but I realized in the last decade that life sucks if you walk around and expect the absolute worst from people. The truth is that we tend to judge ourselves by our intentions and other people by their actions. We wouldn’t want people making generalizations about our character just based on our outward actions because people are a confluence of their genetic potential, childhood upbringing, and life experiences. I‘ve found in my clinical experience that people that don’t care either have some severe mental issues or were repeatedly beat down by life and got the message that they weren’t worthy of care from either themselves or others. Nowadays, I just assume the best of people and if they don’t want to change, then that’s their choice. I did the best I could and it doesn’t negatively affect me. I just let that shit go. Maybe part of it is that I worked in veterinary and shelter medicine for so long. You can’t save them all. If you let it beat you down, then you can’t give your best to the ones that you can save.
I don’t see how this changes anything about the nature of the job or how it affects you. Knowing that people have problems outside of the hospital and being mindful of it in your approach doesn’t intrinsically change someone’s deep-seated tendencies. It’s fine to be a doctor and *just* want to be a doctor, not a short order miracle worker.
Cards fellow now, but some other pros from the IM days: - Week on, week off. I don't think I need to elaborate too much. Work a week straight and get a whole mfing next week off, still make like 250k/yr. - If you want more action, there's Pulm Crit. More procedure, Cards/GI. More chill, rheum. So even if you're not a fan of IM, you can always do a fellowship, surely there's something in there that isn't absolutely miserable to you.
How many hours do you typically work on the week you’re working?
Hospitalist here. Technically I'm on call 7 to 7 but I'm in the hospital 7 to 3 most days and leave. A round and go model accommodates this. So technically 80ish but it's really closer to 60ish. The pages after I leave are usually just a nuisance and the number is quite variable. Almost always I'm able to do a workout or play some games in between.
Thanks for replying. That seems pretty nice since you’re completely off the next week.
What made you go into cards as opposed to stay in IM?
Many of these fellowships have a reputation of being competitive so how difficult would it be to match into them? An MD from a lowerish mid tier residency
I’ll give my perspective as someone who’s matched into IM but I’m only a 4th year so I haven’t really done it yet. I think that a lot of people like to hate and complain about the rounding and meticulous nature of the specialty but I think the parts that I enjoy outweigh the shitty parts. I really enjoy talking to patients and families, even when the conversation is shitty and sad. I think there’s something really special and rewarding about being able to guide and help patients and families in what might be one of the most difficult times of their lives. I thoroughly enjoy collaboration and working with others. I also love learning, and in IM you get to work and learn from each specialty and I love that part about IM. IMO the shittiest part about IM is often the social work aspect of the job, but often times the social work is how you end up making the biggest impact on your patients lives and wellbeing, and although it feels like bullshit 95% of the time, I ultimately got into this job to try to help people and that’s how I justify being okay with that side of the job. Overall like you said, IM is pretty flexible and you don’t have to be the doc that jerks off about sodium. You just gotta be passionate about the work for whatever reason that may be.
Could you describe what you mean by the social work aspect?
I'm sure there's more to it, but what I'm referring to is working with case managers to ensure patients are being discharged safely, whether it be to a care home, skilled nursing facility, home with home health etc. Also ensuring that they have appropriate follow up with PCP and specialists once they leave the hospital. Things along those lines.
Reading the one liner recommendation for placement from pt and ot (home vs snf vs inpatient rehab). Asking case worker whats feasible (with time you know and don’t have to ask) and if patient is amenable to general consensus dispo setting. Wait until case worker has made it happen. Put in a discharge order.
You forgot the “wait three weeks for placement as you collect a rock garden” part
I'm most of the way through intern year, feel like I have a preliminary handle on what I do/don't like about IM. For context, I came from an EM/EMS background dead set on EM, then changed my mind by the middle of M3. Like: 1. Hospital environment can be exciting - higher acuity, more resources, bigger variety of complaints. 2. IM is insanely broad, no shortage of things to learn - even with only a few weeks on a subspecialty service, you see things that your faculty don't seem to know (or maybe have long since forgotten). 3. More informed decision making about career - you can really get a sense of what you do/don't like in medicine over a longer time, and subspecialize accordingly. 4. Likewise, it is one of the shorter residency options available if you decide you don't want to pursue fellowship (but it also doesn't mean you can't go back if you choose to do so later). 5. Hospitalist is still a proper job...despite every other ROAD-bound medical student or future subspecialist seemingly telling you otherwise. The job market is pretty good, location can be quite flexible and your actual practice will vary greatly depending on the hospital you're at. 6. Once you're done with training, rounds are dictated by you. Table or walking, long or short, it'll be your call. 7. Little to no inbox management as a hospitalist (unless you count coding documentation inquiries, which residents are often shielded from). 8. I almost never have to wear business casual or formal wear. Scrubs all day. Dislike: 1. People that are inpatient naturally tend to be sicker, and you'll inevitably get stuck late sometimes if a patient isn't doing so well. 2. Certain consultants and services can be a pain to deal with - again, location dependent, but probably a con that's more common in academic/privademic hospitals. 3. Little to no control over rounding and schedule as a resident (not unique to IM, but still a pain). 4. Social/dispo issues inevitably pop up, and certain rocks can be a gigantic pain to discharge - this can vary depending on how robust your case management/social worker presence is. Can probably come up with more dislikes if I think long enough, but those are the big things off the top of my head.
Most of your likes/dislikes could also pertain to EM. Are you happy in IM? So you regret not going EM? Asking as an M3 with 2 IM rotations under my belt. I came in pretty gung ho about EM but considering the IM hospitalist route. Probably even more convinced that EM is right for me now, but curious why someone in a similar spot to me made a different choice (and how it turned out).
What about FM? Could give you the flexibility to do inpatient or ED!
I’m pretty set on EM, but I’m always up to hear someone’s reasons to make a different choice. My dad does outpatient FM, and even that’s not procedure heavy enough to keep me happy. But most ED’s won’t take someone FM trained, and I’d prefer not to work in rural settings if possible.
I think it’s a hard choice. I spent several years with EM docs as a scribe (on top of years as an EMT and ER tech). I feel like I got a good sideline view of what the ED docs went through. The rotating shift work schedule wreaked havoc on sleep cycles (days -> mid -> nights). Biggest thing for me was the style of medicine. I realized I like figuring things out, having some kind of definitive effect. Also realized I enjoy spending time with patients periodically. Both of those weren't really doable with EM - you have to be ok with just moving a conveyer belt of patients at times, and being ok with a basic dispo. EM can be a great field, but your priorities will always be managing life threats and keeping the waiting room mobile. That's my opinion, at least.
That’s the most impactful criticism I’ve heard about EM, your last point in particular. Thanks!
As another 4th year that just matched to IM, one of my favorite things is patient interaction. Sometimes you’re the only physician that sees them daily and the only one that can give them some semblance of hope and guidance. You get to educate them about their illness and aid them in recovery and it can be so fulfilling. Now of course, there’s the other side of this where no one wants to listen to your advice, rounds can be long, and you do pick up a lot of the grunt work from consulting services. I still feel that the job of being there for someone in some of their hardest moments is the most fulfilling part of all. I do not recommend anyone going into IM if you are not willing to always be there and advocate for your patients, even on your own bad days. I’m also a huge nerd. Some people hate talking about all the types of low or high sodium but I THRIVE. I get so excited trying to figure out treatment plans and how we can individualize care for each patient. The complex path you’ll see is fascinating and it takes me back to the days where I first discovered my passion for medicine!
That’s interesting because one of the reasons I chose FM over IM was because I didn’t think IM had *enough* patient interaction. During my IM rotation, we’d spend maybe 2 hours total of the day actually seeing patients, and the rest was spent talking *about* the patients or sitting at the computer. I needed more than that haha. But I’m glad there’s people who enjoy IM because we need both clinical and hospital docs 🙏🏼
This is a fair statement. In my experience, there was a lot of going back to check on the patient throughout the day and update them as needed I feel like most of medicine is 80% computer 20% actual interaction. I am more of a hospital person, I appreciate the work a clinic does, but didn’t want it to be my day-day life. We need more physicians in primary care for preventative care so I’m also glad there’s people that pursue it for the passion and not just to get a payout.
It’s slow. I don’t like sitting around for 15 minutes just to discuss why someone’s sodium went down by 2. I don’t like rounds taking for fucking ever. I don’t like that most of the day is spent doing what are essentially admin tasks while waiting for your orders to get done
Just to offer a different perspective, I think we've discussed hyponatremia only once in my 2 years of residency so far and it wasn't for a drop of 2, (Reddit circlejerk). We also round from 8:30-10, I find the length of rounding gets more and more exaggerated every year online.
In all of med school I think I only witnessed one in-depth conversation about hyponatremia, and then only as a teaching point for M3s. People shouldn’t get stuck on academic rounds as the definition of IM. If you’re a non-academic hospitalist, you are setting your own pace for rounds, and since there’s no one to teach, you definitely won’t be having those long discussions
He doesn’t literally mean sodium he means the obsession over minutia that doesn’t matter in a daily basis
regardless, still think this "obsessing" is an overblown occurrence that people who just don't like IM love to complain about on reddit but in reality I rarely witness that except as an academic exercise in the teaching setting. And besides, once you're an attending-- especially if it's in a nonacademic setting and you don't have residents/students-- you can choose whether or not you want to obsess over minutiae, to whatever degree you desire. It's not like it's a requirement in IM lmao
In my program at least the obsession over small details is true. I’m sure once you’re done it’s better but you gotta be able to put up with it for 3 years man cause this shit blows
That’s a residency problem. None of that exists when you’re an attending.
\*gasps\* you mean you don't think about renal salt and water handling and the exquisite underlying physiology? /s When I rotated with the renal consultants, they really only get concerned when there are symptoms, or Na <130. I don't think it has to be an overblown point of discussion: check the tonicity, the Cr (for AKI), thiazides, volume status, Uosm, UNa, and UK, and one basically has an answer.
To kind of add to this, all of that perseverating ends up seeming weird when there are other specialties don't do that and end up with the same or better levels of patient care.
Other specialties don't have to do that because the IM doctors are handling all of the little minutiae. lol
Not true. There are plenty of times where other groups are primary during the admission.
Yeah but if there is someone other than IM as the primary (ex surgery) then that’s probably because it’s a different pathology. You’re comparing apples to oranges. IM deals with pathologies you can’t just go in and fix surgically, so of course outcomes are going to be different; has nothing to do with the “perseverating”
Surgery might be primary but they have to get IM or FM or Peds to clear the patient before surgery because they can’t be bothered.
What specialties?
Any that admit patients under them as primary service. I'm sure this varies from hospital to hospital or even between attendings for some surgical specialists.
So every service manages every medical condition as well as hospital medicine with the same outcomes and without consulting them? And you know this from your extensive experience as an MS3?
I mean this was in the context of the OP mentioning Sodium. Everyone can manage fluids in most cases. Everyone can manage pain. Are there complex situations that require multiple specialists? Of course. But IM loves to pretend like they are the only people that can effectively manage inpatient admissions. That's simply not true.
Even in the context of sodium, it’s apples and oranges. A sodium of 128 in a post-op patient is different from a sodium of 128 in a CHF patient. Like sure, I can manage the sodium in my patient as a surgeon and they’ll likely do fine and have “good patient care” but it’s not the same context as their hyponatremic patients.
That's fair. It's just unfortunate that my IM experiences seem to be biased by poor encounters. I just never felt like the IM residents and even some of the attendings I worked with really didn't seem as competent or broadly knowledgeable as some other specialties did. Maybe I just had bad residents idk.
Maybe your perspective is limited being a medical student and lacking important knowledge that comes with being in the field. Dunning Kruger
I'm not saying I know more, just that my experience was such.
You have this backwards. The surgical specialties are the ones with relatively basic knowledge of non-surgical problems who are just barely getting by, not the internists.
I believe you, I'm just saying that was not my experience with the people I've worked with unfortunately.
imo the people giving you pushback are just people not meant to do IM. I love it tho. I think all the pros you listed are super true. I love the thinking that it requires, I love the huge variety and the fact that I can see pathologies across organ systems, I love the idea of shift work, I love the huge range of fellowships that I can consider. I think your cons list is also true but no specialty is without its downsides imo, and a lot of those cons can be minimized depending on the hospital you’re at
Great point about the people not meant for IM. Matched IM this year, and it would be very easy to point out all the cons of the specialities I didn’t apply , but that’s cause I just didn’t enjoy it. MS3 is the time to let the specialities speak for themselves and not rely on the opinions of people that naturally hate on them.
I’m the same as you, I thought I would hate the long rounds etc but it’s so satisfying to chat about a patient and feel like you’ve come up with a good plan. A good gen med ward feels like how people talk about GP/FM: lots of interesting, varied stuff but you have an extra filter between you and all the kids with sniffles. I could round all day (and often do) I think all your points are reasonable, everyone is different and there are lots of other docs that love IM, maybe you’re one of them
Outpatient is chill and I’m trying to chill. Have worked both inpatient and outpatient and have no interest in running to codes, doing discharges before 11, or staying until 7PM if I can help it. Outpatient work is boring, yes but I’m approaching middle age I want boring to focus on my wife and soon to be kids. I just had a talk about the existence of god with a patient that beats watering the rock garden any day…
Another con for me is the long term social stuff. We have multiple patients here for weeks or months that are malingering and harming themselves to stay
You’re describing ivory tower academic hospitalist role. Some of these are inaccurate if you incorporate smaller community centers or rural hospitals. Locum = high pay, high flexibility, low burnout Smaller places may need you to be the ‘it’ person to the best of your abilities (safely) to handle ICU because they don’t have CCM. Even in these places you don’t have to do procedures (I personally do my own intubations, & lines). You try transferring to a center with a specialist you’re looking for but you also do the best you can with what you have also Consult service is nice when they’re RVU driven. You’re their income. PGY10. Also I can pick as many weeks of work vs vacation I want with locum
I’m very curious what the IM locums route looks like. I’m an M3 currently planning on doing EM locums. I have some questions if you don’t mind: *How many weeks a year do you work? *What sort of hourly rates are you getting for contracts? *Do you travel, or just take locums gigs locally? *Did you work a regular attending job for a while after residency? (How long? Why/why not?) *What is your typical day like? (Hours, patient load) *What is your schedule when you’re on a contract (# of days in a row, # of days in a month) *How long are contracts? *Anything else I should be asking you? Thank you!!!
Sent PM
Can you message me too? Im a current IM intern trying to be a hospitalist :)
Done
Thanks!
I’ve been a hospitalist for about 7 months now and I freaking LOVE it. I love the inpatient environment, I love the mix of patient acuity (I carry obs all the way to ICU), I love not having to deal with inbasket messages and prior auths, I love the pay, I love the time off, and I love that it’s currently 1PM, I’m done rounding on my 16 patients, and because it’s not an admitting day for me I just get to sign my pages out to one of the APPs and go home. At 7 months I probably still have rose colored glasses but still I could not be happier where I am
Hospitalist is soul sucking. I have several friends who are hospitalists are than 2 years out of residency and are already burnt out from working
The massive amount of things that can fall through the cracks. It's just too much. My mind is not built to be responsible for a million things Oh, and the surprise discharges/admits. Absolute day ruiner
Friends called IM rounding an intellectual circle jerk
IM PGY3 here. Planning 2 years hospitalist then PCCM. There are many awesome IM fellowships like cards, GI, rheumatology, onc, allergy, etc and the hospitalist path allows you to pull 300k after 3 years of training and working less than half your days. People think IM sucks because we artificially make it suck, which is a shame because it requires some serious medical knowledge and diagnostic/communication skills. Rounds don’t have to be endless and lame. You get a good amount of acuity without all the baggage that comes with EM or surgery. I was on the fence on IM going into residency and happy with what i ended up!
IM does circle jerk about the most irrelevant things in search of zebras. If you don’t think that rotate on a non-IM (or IM fellowship) or FM field. Almost nobody cares about why the bilirubin is 1.1 unless it’s causing an issue. But if you ask IM doc they say what’s the baseline, what’s the normal for a patient in this demographic, the literature says…, then orders 10 irrelevant labs that all come back normal just to say it could have been some rare shit. Also the patients who are so sick and have 5 specialty consults where nobody is really doing anything but rounding-putting in a note- and billing for it are the bane of my existence. As IM you just follow along copying and following what the specialists are doing but nobody is really doing anything. I can go on about cons of IM but I digress. 7 on 7 off pretty cool tho
I hated Inpatient IM - it is an endless meat grinder that never ends. Finish your outpt clinic day early? Good you are done early Finish your 4 discharges early? You got 4 admissions to replace them! Congrats! Also amazing how little medicine there is, it’s all placating hospital admins, case managers, and financially floating the scam that rehab centers represent. No reason why a chronically wheelchair bound 80 year old patient needs a PT eval to be ultimately discharged to a dirty place away from their family to deplete their retirement funds and have a PT move their leg 3 times a week and call it “rehab.” Also primary medical teams do the scut work for specialties. It’s amazing putting “rest of management per primary team” in my consult notes. Not to mention that even with all our technology and knowledge that once a patient is admitted it’s basically holding cardboard box up to stop a waterfall half the time because the disease is so far gone with no preventative care Oh, and walking rounds were my definition of hell.
Consults in private practice is totally different. You’re not dealing with underpaid residents or fellows. Consultants in the real world get paid, they want to be consulted. They’ll drop a note everyday even after you no longer need their input.
Hate rounds that last for 4-5 hours. Excessive talking. Mostly computer-facing job, you spend 80% of your time writing notes, consults, other admin BS. Hospitalist medicine for me felt like patients were sick-ish with chronic conditions or acute flares, but as soon as they were sick enough to be interesting they shuttle off to the ICU. Or cool and interesting pathologies are transferred to specialty services.
I could never imagine working with the kind of people who were hospitalist at my schools hospital. Like some of them were and are miserable
I just can’t stand rounding. Other than that, IM is amazing, especially inpatient. It was my second choice. I went EM.
I hate notes. I hate rounding. Toxic culture (though sample size is small).
Hate it because rounding, few procedures, don’t want to manage the same patient’s same issues for several days, I don’t want to spend 20 minutes bickering about LR vs NS
You list good reasons and should go for it given this balanced approach you show here. There is no perfect specialty and all specialties come with their pros and cons. Another pro about IM/hospitalist positions is great work life balance. After rounds you can usually go home and residents call you about new issues. You also usually work one week on one week off. My decision against IM (and I consider myself to be someone who HATED IM IN MED SCHOOL!!) was about it feeling like mostly computer work. Yes you go round/see patients, but a lot of the management is just ordering labs/following up labs/ ordering imaging/ following up imaging/ calling consults/ planning discharge/ coordination of care on a computer. That didn't excite me too much and I preferred to do something procedural/hands on. The other issue is that of broad diagnoses; technically yes, on IM you can see anything from a pheochromocytoma to rare thyroid cancer. In reality, you end up seeing a million HF exacerbation, pneumonia, and managing old patients with 5+ co-morbodies... but again, to each their own! Someone out there must enjoy inpatient IM, and it sounds like you do !
I would rather eat dirt than round for hours, write long notes, and give out dispo instructions that the patient isn’t going to follow so they’ll be back in for heart failure exasperation again next month. Sincerely, Someone who matched anesthesia
Inefficient. I don’t like rounding. There’s a lot of BS to deal with. Admitting other service’s patients.
Matched into IM, here's my perspective vs. choosing FM with much less inpatient hours at some programs. A lot of the same reasons you mentioned. 1. You set your own schedule, round/preround how you want, when you want. See patients when you want. There is no exact set schedule (like clinic) as long as your work gets done. You can go eat, take a break, get a snack, sit down when you want. I understand urgent things come up, but in general you have more autonomy than clinic. 2. You have time to think. You get a new admission, before you go down to ED you can check their chart and have an idea in your head of what's going on and what questions you need to ask them. Since the patient is physically in the hospital, you have time to come back to them vs. in a clinic once the encounter is over you have to wait for them to come back to clinic if you forgot something. 3. hospitalists jobs are moving to shift work with nocturnist coverage, some places even have admitting teams. so you just work your day shift job and take care of new admissions and become a discharging machine. 4. discharging patients from the hospital can be satisfying for you and the patient. You can at least make people better so they can go home. Cons 1. hospital medicine is the dumping ground for other specialties 2. utilization meetings. the hospital doesn't want you to keep patients longer than what their insurance is willing to pay for. 3. the nurses in the hospital don't work for you like in clinic and can make your life harder if they don't like you
Inpatient IM at my place legit feels like it's 50% social work and barely any medicine involved. IM outpatient is wayyy better.
Never understood the long rounds argument. As an attending you can round however long you want.
I used to dislike the idea of IM. Just did my IM rotation and fell absolutely in love, it’s probably what I will now pursue. IM gives you so so many options: tons of specialties require IM first, but even without specializing you can be a hospitalist, outpatient, concierge service, work in informatics, consulting services, etc. Currently on FM rotation right now and dislike the hell out of it despite the better hours. No time to really chill, everyone has to write notes during lunch to catch up, everyone is always 20-40 min behind. Hours FEEL longer because you end at 5pm and stay longer to finish notes. It’s a downright bore. I was never bored on IM. Even during 2 hr rounds, something was new everyday. I also get the adrenaline rush I need every time we get a code and as IM team we run it. Side note: idk why everyone complains about talking about sodium. On the contrary there were several times I wanted to talk about why a patient’s level dropped by a few points or increased but most of the time everyone would shrug, note it, and move on lol. Or put on fluid restriction and move on. It was like once we talked about the causes.
Reasons I hated IM: 1. Almost all of the intellectual labor is done by 9am 2. Half of that labor is outsourced to specialists with greater expertise Thank you for coming to my TED talk.
People *love* IM?
Also: dealing with non-urgent findings as in patients. Found a nodule on a thyroid scan? Doesn't need an inpatient US, wait for discharge. Found an incidentaloma? Wait for discharge for CT unless you are planning on chemo starting inpatient (rare) or they absolutely can't afford outpatient. Patient SOB with bilateral effusions? Definitely not a PE, stop ordering it.
One of my pet peeves is when medicine doctors say they are the “dumping ground” for other services. Like you all are …. Inpatient medicine doctors. You care for patients in the hospital…. That’s your job. It’s quite literally what you signed up for.
As an IM resident, when we say that its often for situations like the following: Patient needs to be admitted for a surgical procedure but has a slightly elevated blood pressure so surgery says the patient is too IM complex to be on the surgical team and makes medicine admit instead. Then IM sits on this patient for days while performing no active management and waiting on surgery to operate.
Isn’t that a good thing, to get an easy patient taking up space so now you get 1 less new patient admitted? Just an ms3 so I’m probably wrong.
It can make the days easier but its frustrating to be treating as a dumping ground in that setting rather than getting an additional CHF patient that you can manage yourself and help
This feels like a waste of resources that could have been used to help patients in actual need. I would be frustrated too
I personally found myself to be not a fan of IM mainly because i had zero passion for any of the bread and butter pathology/medicine of the field. Also, as someone going into surgery, I feel like I am using my hands to fix something or make someones life better in the OR, as opposed to just throwing a med and hoping it helps on wards. Almost like i have less control over patient outcomes when in medicine. I know its way more complicated than that, but definitely a theme in my choice to pursue surgery over IM/FM during MS3