Careers in Internal MedicinePresentation Transcript
Careers in Internal Medicine or What’s an Internist Anyway? Karen McClean MD FRPC
Review of Internal Medicine and General Internal Medicine
The UofS program – structure
What makes a good internist?
The UofS program – status of program
Career choices in general
Getting the most out of clerkship
What’s so great about IM?
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
Straight surgical internship in London, Ontario
Loved surgery rotations but also had a great medicine preceptor with similar interests…hmmm maybe medicine isn’t so bad after all….
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.
Lots of surgery: general, ortho, ophtho, gyne, plastics, even the odd burr hole
After 3 ½ years…. What could we do better?
Not much more by way of surgery – no ICU, no ventilators, no infusion pumps, no monitors, limited radiology & lab resources etc
Lots of scope for improvement in our medical management of patients with chronic diseases (hypertension, asthma, heart failure, diabetes etc.)
For me, the decision to train in Internal Medicine was a very pragmatic one
Eventually, I came full circle back to my undergrad / pre medical experience in Microbiology (Infectious Diseases)
Hematology was a close second
Still don’t really have any affinity for some areas of Internal Med!
General Internal Medicine
“ General internists handle the broad and comprehensive spectrum of illnesses affecting adults.” ACP
Experts in diagnosis
Experts in management chronic illness, complex patients with multiple diagnoses
General internists are consultants
See patients on referral from a primary care physician or other specialist
Dr. David Sackett
When encountering patients with undifferentiated or multi-system disease, general internists excel at “sorting out” their illnesses and balancing the management of multi-system disease. They are particularly skilled in the evaluation and care of such patients when they are acutely and severely ill. This is in contrast to subspecialists who, by focusing on deeper but narrower aspects of single-system disease, are more comfortable practicing in a “rule-out” mode, and often are uncomfortable with sick patients whose illnesses are multi-system or arise from another system (e.g., undifferentiated shock).
General Internal Medicine
Office based / outpatient practice
Hospital based practice
Inpatient care for medical problems
In many centres, patients are admitted under family physicians, with consultation to the internist – very close working relationships between the family physician and internist
For most – mixture of inpatient and outpatient medicine, acute / short term and chronic / long term patients
Internal Medicine: GIM
United States model
Primarily office / or pure hospital
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.
Office / Hospital
No such thing as “Royal College exam eligible status” – certified or not certified
No mixed programs
Canadian general internists struggle with their identity in comparison to IM subspecialists
Internal Medicine: subspecialties
Less common subspecialties*
Allergy and Immunology
* Not all recognized by RCPSC
Internal Medicine allied programs
Dermatology – 2 years of internal medicine
Neurology – 1 to 2 years of internal medicine
Community Medicine – 1 year of internal medicine
Two views of GIM
Not a subspecialty
Forms the basis for all the Internal Medicine subspecialties
All subspecialists are also “internists” – though some practice little outside their own subspecialty field
Little recognition of a separate skills set / body of knowledge
To date, the dual certification process perpetuates this. (All subspecialists are first certified as Internists)
Subspecialty in its own right
Core IM training is common to all Internists
Post core training got GIM is unique, just as it is with other subspecialties
Defined and distinct body of knowledge
Many subspecialists are not functioning as general internists (may do limited amount of non subspecialty based IM, but not the true spectrum of GIM)
The World of Internal Medicine General Internal Medicine Subspecialty Internal Medicine Internal Medicine
Internal Medicine: GIM vs. SS
Distinct body of knowledge
Peri-operative medical management
Medical disorders of pregnancy
Multi-system medical disease
GIM is not currently recognized as a subspecialty but this will likely happen in your practice lifetime.
Does it matter?
Depends on your perspective.
Does not have major effect on what general internists can do / bill for.
Not a major income related issue.
Why make GIM a discrete subspecialty?
Recognize the discrete body of knowledge and skills of the general internist.
Facilitate development of training programs that robustly address this discrete body of knowledge.
Eliminate the differential ‘status’ of internist and subspecialist.
Establish an exam system that reflects Core / GIM / SS knowledge at appropriate points in time.
Training in Internal Medicine
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
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.
2 nd 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.
3 rd year subspecialty rotations – refine and strengthen consultancy skills
Examinations Core Internal Medicine (3 Years) GIM + 2 years Cardiology + 3 years Other SS + 2 years GIM + 1 year Internal medicine exam Supspec exam everybody Cardiology exam Everyone receives a Specialist Certificate as an Internist Subspecialists also receive a Certificate of Special Competence in the area of their subspecialty.
Why 1 vs. 2 years of GIM Training?
Traditionally one additional year of training.
As the distinct features of GIM have evolved, the role for added training has become evident.
How is training structured?
First year: refines consultancy skills, focus on GIM-specific body of knowledge
Medical problems of pregnancy
Complex, multisystem illness / multi disease illness
Second year: planned to meet the needs of the trainee
Skills: echo, stress testing, scopes
Special area of focus: Maternal Fetal medicine, palliative care, epidemiology……..
Can be focused on skills for academic practice, rural practice etc.
Offers great flexibility
Why do people chose IM?
They have poor eye-hand coordination
They faint at the sight of blood
They don’t cope well with sick kids
They don’t look good in greens!
Why do people chose IM?
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