Careers in Internal Medicine or Whats an Internist Anyway

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Careers in Internal MedicineorWhats an
Internist Anyway?

• Karen McClean MD FRPC

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Topics.

• Review of Internal Medicine and General Internal
  Medicine
• The UofS program structure
• What makes a good internist?
• The UofS program status of program
• Career choices in general
• Getting the most out of clerkship

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Whats so great about IM?

• My journey
• In medical school
• Transient (very, very transient) inclination to
  neurology
• Loved surgery lots of hands on, high level of
  responsibility on my JURSI rotation
• Did NOT enjoy much about Internal Medicine
• Internship
• Straight surgical internship in London, Ontario
• Loved surgery rotations but also had a great
  medicine preceptor with similar interestshmmm
  maybe medicine isnt so bad after all.
• Rotating internship
• Loved surgery rotations and did lots of advanced
  hands on stuff
• Medicine was ok too (1 great preceptor, 1 OK
  preceptor) but I still liked the surgical stuff
  best.

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My journey

• Africa
• Lots of surgery general, ortho, ophtho, gyne,
  plastics, even the odd burr hole
• After 3 ½ years. What could we do better?
• Not much more by way of surgery no ICU, no
  ventilators, no infusion pumps, no monitors,
  limited radiology lab resources etc
• Lots of scope for improvement in our medical
  management of patients with chronic diseases
  (hypertension, asthma, heart failure, diabetes
  etc.)
• For me, the decision to train in Internal
  Medicine was a very pragmatic one
• Eventually, I came full circle back to my
  undergrad / pre medical experience in
  Microbiology (Infectious Diseases)
• Hematology was a close second
• Still dont really have any affinity for some
  areas of Internal Med!
• No regrets!

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General Internal Medicine

• General internists handle the broad and
  comprehensive spectrum of illnesses affecting
  adults. ACP
• Experts in diagnosis
• Experts in management chronic illness, complex
  patients with multiple diagnoses
• General internists are consultants
• See patients on referral from a primary care
  physician or other specialist

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Dr. David Sackett

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

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General Internal Medicine

• Office based / outpatient practice
• Hospital based practice
• Consultations
• Inpatient care for medical problems
• In many centres, patients are admitted under
  family physicians, with consultation to the
  internist very close working relationships
  between the family physician and internist
• For most mixture of inpatient and outpatient
  medicine, acute / short term and chronic / long
  term patients

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Internal Medicine GIM

• United States model
• Primary care
• Primarily office / or pure hospital
• Training
• 3 years
• Board eligible or Board certified
• Mixed Paediatrics / Internal Medicine programs or
  Categorical programs
• US general internists struggle with their
  identity in contrast to family physicians.

• Canadian model
• Consultants
• Office / Hospital
• Training
• 4 years
• No such thing as Royal College exam eligible
  status certified or not certified
• No mixed programs
• Canadian general internists struggle with their
  identity in comparison to IM subspecialists

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Internal Medicine subspecialties

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

• Less common subspecialties
• Allergy and Immunology
• Clinical Pharmacology
• Hospitalist Medicine
• Occupational medicine
• Palliative care
• Sports medicine
• Transfusion medicine
• Bioethics
• Medical informatics
• Clinical epidemiology
• Not all recognized by RCPSC

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Internal Medicine allied programs

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

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Two views of GIM

• Not a subspecialty
• Forms the basis for all the Internal Medicine
  subspecialties
• All subspecialists are also internists though
  some practice little outside their own
  subspecialty field
• Little recognition of a separate skills set /
  body of knowledge
• To date, the dual certification process
  perpetuates this. (All subspecialists are first
  certified as Internists)

• Subspecialty in its own right
• Core IM training is common to all Internists
• Post core training got GIM is unique, just as it
  is with other subspecialties
• Defined and distinct body of knowledge
• Many subspecialists are not functioning as
  general internists (may do limited amount of non
  subspecialty based IM, but not the true spectrum
  of GIM)

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The World of Internal Medicine
Internal Medicine
Subspecialty Internal Medicine

General Internal
Medicine
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Internal Medicine GIM vs. SS

• Distinct body of knowledge
• Peri-operative medical management
• Medical disorders of pregnancy
• Multi-system medical disease
• GIM is not currently recognized as a subspecialty
  but this will likely happen in your practice
  lifetime.
• Does it matter?
• Depends on your perspective.
• Does not have major effect on what general
  internists can do / bill for.
• Not a major income related issue.

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Why make GIM a discrete subspecialty?

• Recognize the discrete body of knowledge and
  skills of the general internist.
• Facilitate development of training programs that
  robustly address this discrete body of knowledge.
• Eliminate the differential status of internist
  and subspecialist.
• Establish an exam system that reflects Core / GIM
  / SS knowledge at appropriate points in time.

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Training in Internal Medicine

• Internal Medicine
• 3 years of core training PLUS
• 1 year of GIM
• 2 years of GIM
• 2 years of other subspecialty
• Core curriculum (first 3 years)
• 12 months of General Internal Medicine (office,
  consults, CTU)
• 24 months of subspecialty rotations and electives
• Rotations through the majority of subspecialty
  areas
• Cardiology and critical care mandatory
• Research
• Ambulatory care

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Training in IM at UofS

• PGY-1
• 5 to 7 months on CTU
• ER and Office based rotations
• Cardiology and neurology
• Selected subspecialty rotations (Geriatrics,
  Endo, Rheum, Derm...)
• PGY-2
• Subspecialty rotations
• Critical care
• Electives
• PGY-3
• CTU Senior
• Remaining subspecialty rotations
• Electives

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Training in IM at UofS

• Schedule is designed with purpose
• CTU Junior quickly gain experience in patient
  assessment, recognition of the sick patient,
  development of differential diagnosis, management
  of common problems in a hierarchical setting with
  backup available at all times.
• Office rotation early exposure to non hospital
  based practice
• ER Promote strong collaboration skills between
  ER and IM.
• 2nd year Subspecialty rotations develop
  consultancy skills, building on the framework of
  first year experience
• CTU senior deferred to third year focus on
  teaching, supervision and organization of the
  team.
• 3rd year subspecialty rotations refine and
  strengthen consultancy skills

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Examinations
Supspec exam
Cardiology exam
Internal medicine exam
everybody
GIM 1 year
GIM 2 years
Other SS 2 years
Cardiology 3 years
Core Internal Medicine (3 Years)
Everyone receives a Specialist Certificate as an
Internist Subspecialists also receive a
Certificate of Special Competence in the area of
their subspecialty.
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Why 1 vs. 2 years of GIM Training?

• Traditionally one additional year of training.
• As the distinct features of GIM have evolved, the
  role for added training has become evident.
• How is training structured?
• First year refines consultancy skills, focus on
  GIM-specific body of knowledge
• Medical problems of pregnancy
• Peri-operative medicine
• Complex, multisystem illness / multi disease
  illness
• Second year planned to meet the needs of the
  trainee
• Skills echo, stress testing, scopes
• Special area of focus Maternal Fetal medicine,
  palliative care, epidemiology..
• Can be focused on skills for academic practice,
  rural practice etc.
• Offers great flexibility

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Why do people chose IM?

• Negative reasons
• They have poor eye-hand coordination
• They faint at the sight of blood
• They dont cope well with sick kids
• They dont look good in greens!

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Why do people chose IM?

• Positive reasons
• Great mentors
• Attracted to a specific subspecialty area
• Enjoy physiology / pathophysiology
• Enjoy breadth and versatility in terms of scope
  of practice
• Potential for long term relationships with some
  patients without the need for long term
  relationships with all!

• Enjoy sorting out complex problems / good
  reasoning skills

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Distinguishing characteristics of the Internist

• The ability to be a diagnostician
• Strong clinical reasoning / critical thinking
  skills
• The ability to provide care of complex acute and
  chronic problems
• Strong knowledge skill base, strong
  organizational skills
• The ability to be a consultant for generalists,
  specialists and subspecialist
• Strong communication and team skills
• Curiosity
• Links between disease and pathophysiology
• Links between therapy and mechanism of action

Dr. Robert L. Wortmann
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Good Internists

• Listen to and understand the patients story
• Understand the context of the disease in the
  individual patient
• Apply science, and evidence based medicine within
  the patients context
• Engage patients in informed decision making /
  collaborative care
• Play well with others

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Questions to ask yourself

• Do I enjoy physical diagnosis, pharmacology,
  physiology, pathogenesis?
• Do I like solving problems and tackling
  challenges? (Deductive reasoning and critical
  thinking)

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Questions to ask yourself

• Can I interact well with all kinds of people and
  maintain effective long term relationships?
• Can I listen attentively to the patients story
  and explore the context of the disease for the
  patient?
• Am I good in team settings? (as leader and member)

Another famous TV doctor.
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Lifestyle

• Internal medicine offers a wide range of
  potential choices that affect the lifestyle you
  can expect to have.
• Income
• Working hours
• On call hours
• Type of work / practice
• Decisions that will affect lifestyle
• Subspecialty
• Practice type (solo, group, community, academic,
  hospital)
• Practice location
• Other activities (teaching, research,
  administration etc.)
• Expectations and systems are changing slowly

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Competitiveness for IM spots

• Huge increase in number of available positions in
  last three years.
• Does not mean you can afford to be complacent!
• Trends in career choices fluctuate significantly
  year by year.
• Number of positions change year by year.
• When matching dont try to play games rank
  your choices according to what you really want.
• Never, never, never rank a program you would not
  be prepared to do!
• Rank your top choice 1 even if you think you
  wont get it.

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Some general comments on choosing a specialty
(nothing specifically to do with IM)
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Career Choices in General

• Discover the field to which you are intangibly
  drawn.
• Try to identify and understand the reasons
• Types of problems
• Types of practice
• Types of patients
• Types of physicians

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Types of problems

• You dont have to love ALL the content area of a
  given specialty to be successful in it, but you
  need to enjoy and find stimulation in more than
  one narrow aspect of it!
• Therefore you need good understanding of the
  breadth and scope of a discipline you are
  considering
• However as a physician you will have some
  ability to focus your practice (within your
  specialty choice) to varying degrees.

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Types of practice

• Procedural specialties
• Surgical specialties (surgery, OG, orthopedics,
  ophthalmology etc)
• Diagnostic specialties (pathology, radiology,
  laboratory medicine)
• Cognitive specialties (no pejorative implication
  on other specialties intended)
• Paediatrics, internal medicine, psychiatry,
  neurology etc.
• Within the cognitive specialties, there is great
  variation in the degree of procedural involvement
• Cardiology, gastroenterology, critical care vs.
• Infectious diseases, endocrinology
• If you are drawn to internal medicine but really
  enjoy doing procedures, there is still plenty of
  scope for you to find a fulfilling career in IM.

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Types of patients

• In every specialty there are certain types of
  patients who try the patience of the physician.
• Once you are in practice you will develop
  strategies to manage these patients in a way that
  enables you to provide good care and maintain
  your equanimity.
• But if there is something you really CANT stand,
  be cautious about getting into a specialty in
  which that makes up a significant portion of the
  practice.

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Types of patients

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

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The influence of mentors

• Mentors are important in our education and
  development as physicians.
• We may find mentors in fields to which we are
  intrinsically drawn.
• We may be drawn to a field because of a mentor or
  role model who works in that field.
• It is important to consider what it is that
  attracts us to a particular field
• personal characteristics of the mentor.
• typical characteristics of physicians who chose
  that field.
• Important to avoid choosing a discipline on the
  basis of a mentor
• who may is actually be an outlier among his or
  her colleagues!
• rather than truly having an affinity to the
  discipline.

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Career Choices

• Discover the field to which you are intangibly
  drawn.
• Try to identify the reasons
• Types of problems
• Types of practice
• Types of patients
• Types of physicians
• Knowing the reasons can help you consider other
  options and assess the validity / strength of
  your inclinations.

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How do I discover what I like?

• What do you most enjoy reading and studying in
  class?
• Caution be aware of
• Reading and doing is not the same
• The influence of good / not so good teachers
• What do you enjoy most in early clinical
  experiences?
• Explore the full spectrum of a discipline
• What you see from one physician or clinic may
  only be a small part of the discipline
• Try to work with several physicians in different
  settings
• Read (lots of online information, be aware of
  differences between US and Canadian systems)
• Ask questions
• Use electives and shadowing opportunities, be
  creative in how you structure electives in key
  areas so that you can get a broad exposure to the
  discipline.
• Be prepared to question initial inclinations (or
  fixed decisions)

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

• Generic tests limited success, poor
  differentiation between specialties
• Strong Vocational Interest blank
• Holland based typology
• Myers Briggs personality types
• Medical aptitude tests limited scrutiny,
  limited validity
• Medical Specialty Preference Inventory
• Medical Specialty Aptitude Test
• Use with caution!
• Differences between disciplines tend to be small
  compared with the variation in personality type
  within disciplines.
• Little scrutiny to link measures with career
  success
• Use might promote or maintain inappropriate /
  undesirable stereotypes.

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What about medical specialty aptitude tests?

• University of Virginia MSATMy results..
• Hematology sure, OK I could do that (some of it
  anyway)
• Rheumatology Hmmm, not so sure
• Occupational med long shot
• Rad oncology no way on earth!
• Med oncology worse yet!
• Nephrology not on your life!
• PMR nope
• Pathology interesting for a year or two
  maybe!
• Infectious diseases number 15!!!! (Same rank as
  endocrinology, nuclear med and GIM, none of which
  I would really be keen to do)
• ER and ortho (two close contenders for me, at
  least at several points in my life) were 29 and
  33 on my list.

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What about medical specialty aptitude tests?

• If the results resonate with you, you may be on
  the right track.
• If your response is Eeewww! or how in the
  heck?, be careful about putting much emphasis
  on the results.
• Probably not much more helpful than

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BMJ
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Some thoughts on being the best you can be and
how it will help you get where you want to go.
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Making the most of clerkship, whatever you want
to do

• Be professional
• Know the expectations and do your utmost to meet
  / even exceed them.
• Be a good team member the educational team and
  the whole care team
• Be patient centered
• Be organized!
• Prioritize
• Keep track of things you need to do.

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Making the most of clerkship

• Use your study time well
• Read, reflect, review and challenge your
  knowledge
• Adopt good study skills and habits that fit will
  with clerkship and they will serve you well into
  residency.
• Actively engage in team learning
• Discuss what you have learned from your reading.
• Ask good questions (but dont grandstand)!
• Speak up share your thoughts, try answering
  questions.
• Prepare to be wrong - nobody expects you to have
  all the answers.
• You learn more by venturing an answer and being
  wrong than by not attempting to answer at all!

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Making the most of clerkship

• Be open to feedback
• Listen to what others tell you about your
  performance, skills, strengths and weaknesses.
• Solicit feedback
• Be honest
• Admit what you dont know, what you did not do

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Making the most of clerkship

• Take ownership of the patient
• Get to know them in depth (as persons, not just
  diseases)
• Take time to talk to them and their family
• Advocate for your patient
• Be prepared to discuss your patientswithout
  notes
• Be the first to know / report changes, new
  results etc.
• Monitor their progress actively even if there is
  also a resident assigned to them
• Identify good and bad role models.
• Learn from both good and bad role models!
• Identify the features that make good role models
  good or bad ones bad so you can take deliberate
  steps to develop good characteristics and avoid
  bad ones.

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Making the most of clerkship

• Basic professional expectations
• Be on time
• Dress professionally
• Treat everyone with respect
• Identify yourself clearly, including your status
  to patients, family and staff.
• Answer pages promptly, if you are going to be
  unavailable, keep the right people informed
• Write legibly
• Communicate clearly
• Respect confidentiality
• Know your limits

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Decisions, decisions, decisions

• Keep in mind
• There is no SINGLE one right specialty for you
  even if you think there is.
• Your choices will determine much of what life
  looks like for you when you are finished and in
  practice.
• Things can be changed over time
• Being clear on your priorities.and making your
  decisions based on those priorities will help you
  reach a best fit.
• Life(style) is a trade-off not a have it all
  situation!

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