Transcript INTRODUCTION TO INTERNAL MEDICINE

INTRODUCTION TO INTERNAL
MEDICINE
September 18, 2014
Objectives
1. Prepare for future IMIG Events
2. Identify what an Internist does
3. Appreciate the different subspecialty
options in internal medicine
4. Register for ACP as a student
What is Internal Medicine?
Who are Internists?
 Glen Solomon
 Chair of Internal Medicine
 Karen Kirkham
 Internal Medicine Clerkship Director
 Bruce Scott
 Internal Medicine/Geriatrics/Palliative Care
ICM
Preceptors
Who are Internists?
 William Osler
 Eminent Internist, founder of residencies
 Robert Lefkowitz and Brian Kobilka
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Nobel Prize Winners in Chemistry (G-coupled protein receptors)
 Ken Jeong
 Intern(al)ational Movie Star
Who are Internists?
 One in four US physicians has ABIM board certification1
 Setting:
 Private practice = 80.9%
 Academia = 14.9%
 Both generalists and subspecialists are currently
undersupplied2
 29.3% experienced difficulty in securing first position
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2
ABIM Fast Facts sheet 2014
The Complexities of Physician Supply and Demand: Projections Through 2025, Center for Workforce Studies, AAMC, 2008.
Internal Medicine: Definition
 American College of Physicians:
 “Physicians for Adults” (2009)
 “Physicians who specialize in the prevention, detection and
treatment of illnesses in adults.” (2011)
 “Specialists who apply scientific knowledge and clinical
expertise to the diagnosis, treatment, and compassionate
care of adults across the spectrum from health to complex
illness.” (2013)
 Comes from German for “Interior Doctor,” applied to
someone who uses laboratory results to diagnose diseases
Internal Medicine: Definition
 Focuses on chronic and acute disease processes
 Wide range of practice environments
 Urgent care -> Hospitals -> Clinics -> Work abroad
 Diverse subspecialties
 Cardiology to Complementary Medicine
 Passed the American Board of Internal Medicine Certification
Exam
Internal Medicine Spectrums
Outpatient
Primary Care
Acute
Chronic
Academic
Hospitalist
Intensive Care
Physician
Subspecialist
Inpatient
*Or any combination of the above
Internal Medicine Spectrum
Specialized
General
Rural Primary Care
Geriatrician
Rheumatologist
Electrophysiologist
*General rule: as you get more specialized, have less
individualization of practice
**Family Medicine is that way
Internal Medicine Subspecialties
 To become a subspecialist, must complete a residency
in Internal Medicine first
Years
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2
3 4
Medical School
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3
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3
Residency
Fellowship
(Internal Medicine) (i.e. Gastroenterology)
Internal Medicine: Subspecialties
 American Board of Internal Medicine Certified:
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Adolescent Medicine
Adult Congenital Heart
Disease
Advanced Heart Failure and
Transplant Cardiology
Cardiovascular Disease
Clinical Cardiac
Electrophysiology
Critical Care Medicine
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Medical Oncology
Nephrology
Pulmonary Disease
Rheumatology
Sleep Medicine
Sports Medicine
Transplant Hepatology
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Endocrinology, Diabetes, &
Metabolism
Gastroenterology
Geriatric Medicine
Hematology
Hospice & Palliative
Medicine
Infectious Disease
Interventional Cardiology
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Medical Research
Occupational Health
Medical-Legal Interactions
Tropical Medicine
Complementary Medicine
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Women’s Health
Headache
To be determined
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 Non-ABIM Certified:
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General Internal Medicine
Medical Education
Transplant Infectious
Disease
Transitions of Care
General Internists
AKA Internists
What Do General Internists Do?
• Acute care
– Inpatient setting/ ICU
– MI, stroke, respiratory failure, renal failure, etc.
• Chronic disease care
– Outpatient setting, nursing home, hospice
– DM, HTN, hyperlipidemia, CAD, CHF, COPD, etc.
• Adult wellness/checkups
– Screening for disease
– Counseling on healthy behaviors (smoking, EtOH)
• Subspecialty care (organ-system specific)
• Consultant to other specialties (Surgery, Ob/Gyn)
 Other roles in general
medical care for adults
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Educator
Director
Advocate
Motivator
Healer
Comforter
What Makes a Good General Internist
Enjoys:
 Complex problem-solving/working with mind
 Long term doctor-patient relationships
 A focus on being the front line of medicine
 Acting as head coach/coordinator of care
 Variety of disease entities
Typical Lifestyle
• Highly variable
• mean patient care hours a week is 491
• Outpatient (PCP)
– 10 hour days
weekdays
– 15-30 patients per
day (~15-20 min per
patient)
• Inpatient (Hospitalist)
– Shift work (10-12 hour
shifts)
– One week on, one week off
(26 weeks per year)
– 12-20 patients per day (2030 min per patient)
1Medscape
Physician Survey Data 2010
Salary Data
 General Internal Medicine
 Overall Median = $212,000
 Overall Mean = $195,000
 Primary Care = $192,000
 Academic = $175,000
 Hospitalist = $229,000
MGMA Compensation and Production Survey 2012
Satisfaction Data
University of Davis study in 2009 surveyed 6590 US physicians, had 53% response rate
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Pediatric emergency
Geriatric medicine
Dermatology
Pediatrics
Internal medicine and pediatrics
Other pediatric subspecialty
Neonatal and perinatal medicine
Allergy and immunology
Child and adolescent psychiatry
Radiation oncology
Cardiovascular diseases
Medical oncology
Ophthalmology
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Occupational medicine
Hospitalists
Physical medicine and rehabilitation
Psychiatry
Otolaryngology
Other medical subspecialty
Critical care internal medicine
Endocrinology, diabetes
Urology
Gastroenterology
Infectious diseases
Pulmonary diseases
Satisfaction Data
University of Davis study in 2009 surveyed 6590 US physicians, had 53% response rate
14 Occupational medicine
2 Geriatric medicine
15 Hospitalists
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8
Internal medicine and pediatrics
Allergy and immunology
11 Cardiovascular diseases
12 Medical oncology
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21
General Internal Medicine
Critical care internal medicine
Endocrinology, diabetes
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25
Gastroenterology
Infectious diseases
Pulmonary diseases
Other medical subspecialty
13/25
Main Organizations
 American College of Physicians (ACP)
 Society of General Internal Medicine (SGIM)
 Society of Hospital Medicine (SHM)
 Each subspecialty has its own national organization
 Each organization has its own annual national meeting
Popular Journals
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Journal of the American Medical Association (JAMA)
New England Journal of Medicine (NEJM)
Annals of Internal Medicine
Archives of Internal Medicine
American Journal of Medicine
Journal of General Internal Medicine (JGIM)
Subspecialties
Internal Medicine: Subspecialties
 ABIM Certified:
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Adolescent Medicine
Adult Congenital Heart
Disease
Advanced Heart Failure and
Transplant Cardiology
Cardiovascular Disease
Clinical Cardiac
Electrophysiology
Critical Care Medicine
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Medical Oncology
Nephrology
Pulmonary Disease
Rheumatology
Sleep Medicine
Sports Medicine
Transplant Hepatology
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Endocrinology, Diabetes, &
Metabolism
Gastroenterology
Geriatric Medicine
Hematology
Hospice & Palliative
Medicine
Infectious Disease
Interventional Cardiology
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Transitions of Care
Medical Research
Occupational Health
Medical-Legal Interactions
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Tropical Medicine
Headache
To be determined
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 Non-ABIM Certified:
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General Internal Medicine
Medical Education
Transplant Infectious
Disease
Fellowships
Emerging
Traditional
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Allergy/immunology
Cardiology
Endocrinology
Gastroenterology
General internal medicine
Hematology/oncology
Infectious disease
Nephrology
Pulmonary/critical care
Rheumatology
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Addiction medicine
Adolescent medicine
Geriatrics
Hospice & palliative care
Sleep medicine
Sports medicine
Women’s health
Relative Competitiveness
Less  More
Infectious Disease
Allergy/Immunology
Cardiology
Endocrinology
Nephrology
Gastroenterology
Geriatrics
Rheumatology
Pulmonary/Critical
Care
Hematology/Oncology
Fellowship
Length
Practice Environment
Hours
Salary*
Procedures
Allergy/
Immunology
2 years
Predominately outpatient
Office (Outpt) hours
195K
Allergen skin tests, desensitizations
Cardiology
3-4 years
Inpatient/Outpatient
Long inpt hrs with call balanced with outpt
office hrs
400K
Percutaneous coronary angioplasty,
echocardiograms, stress tests, etc.
Electrophysiology
1 additional
year on Cards
Inpatient/Outpatient
More routine than cardiologist, mostly
outpt procedures
450K
EP studies
Endocrinology
2 years
Predominately outpatient
Outpt hours with minimal inpt consults
200K
Thyroid biopsy
Gastro-enterology
3 years
Inpatient/Outpatient
Long inpt hrs with call balanced with
outpt office hrs
405K
EGDs, Colonoscopys, Liver biopsy,
ERCP, etc.
Geriatrics
1 year
Predominately outpatient
Predominately outpt hrs, with inpt
consults
185K
MOCAs, SLUMS
Heart Failure/Txp
1 year
More outpatient
More routine than cardiologist, mostly
outpt, with inpt consults
?
Echocardiograms
Heme/Onc
3 years
More outpatient
Outpt office hrs, some inpt hrs with call
320K
Chemotherapy administration
Hospice/Palliative
Care
1 year
Mostly outpatient
Outpt hours with call
180K
Paracentesis, thoracentesis
Infectious Disease
2 years
More outpatient
Generally long hours due to combination
of outpt hrs and inpt consults
160K
Anoscopy
Nephrology
3 years
Inpatient/Outpatient
Generally long hours due to combination
of outpt hrs/dialysis management and
inpt consults and call
260K
Dialysis, catheter placement, kidney
biopsies, etc.
Pulmonary/ Critical
Care
3 years
Predominately inpatient
Long inpt hrs, predominately in shifts
(some nights)
275K
Intubation, tPA adminstration,
bronchoscopy, etc.
Rheumatology
2 years
Predominately outpatient
Outpt hours with minimal inpt consults
220K
Joint aspirations,
immunosuppressive therapy
Other Fellowships
 Have fewer trainees due to:
 more esoteric level of interest
 lack of ACGME funding, so can be balanced with some
clinical duties
 vanguard of medical profession
Addiction Medicine
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1 year in length
Board certification available
Can be done after IM, FP, and psychiatry residencies
Main disease entities:
 Alcohol
 Illicit drugs
 Tobacco
Adolescent Medicine
• 1-3 years in length
• Board certification given jointly by ABIM and ABP
• Main disease entities: substance abuse, eating disorders,
acne, STDs, pregnancy, depression, mgmt. of chronic
disease that begins in childhood
• Practice settings:
– High school & university-based clinics
– Mobile clinics
– Outpatient clinics
General Internal Medicine
 2-3 years in length
 Training to become academic internist
 Two tracks:
 Clinician-investigator
 Clinician-educator
 Usually associated with master’s degree (tuition provided)
 Only 20-30% clinical time
Sleep Medicine
 1 year in length
 ABIM certification available
 Can be done after IM residency or Pulm/Critical Care
fellowship
 Most commonly combined with Pulm/CC
 Main disease entities: sleep apnea, narcolepsy,
insomnia
Sports Medicine
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1 year in length
Can be done after IM, FP, or Peds residency
Board certification available
Usually work closely with orthopedic surgeons
Practice settings:
 Outpatient clinic
 Team physician
Women’s Health
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1-2 years in length
Clinical or academic focus
No board certification available
Main disease entities: breast cancer, uterine cancer,
ovarian cancer, menopause, reproductive health
 Generally combined with clinical duties
Other Possibilities
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Clinical nutrition
Clinical decision making
Medical informatics
Quality improvement & patient safety
Applied epidemiology (CDC)
Clinical research (NIH, Robert Wood Johnson)
Complementary & alternative medicine
Advice for Students
 Take care of older adults as  Attend Ohio or National
much as you can
ACP Meeting
 Focus M4 electives in
following areas:
 Cardiology
 Pulmonary/critical care
 Emergency medicine
 Get good evaluations in
your M3 & M4 medicine
clerkships
 Be open to all possibilities
(no rush to decide!)
Resources for Further Exploration
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www.acponline.org
www.sgim.org
http://services.aamc.org/careersinmedicine/
www.hospitalmedicine.org/
Your faculty advisors!
Questions for Our Panel?
Internal Medicine Interest Group
Events:
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ACP Ohio
Subspecialty Panel
EKG Workshop for R2s
Simulation Lab
Match Panel
Internal Medicine Experience
Elective
 Research Projects
October
November
January
February
Late March
Spring
All Year
Watch for emails from your IMIG Officers for more information
Internal Medicine Interest Group
• ACP Ohio – October 16th and 17th
• Poster sessions, didactics, quiz bowl, even political meetings
• $65 for students, 1 hr drive
• Subspeciality Panel - November
• Panel of various subspecialist for Q&A
• Cardiologists, Gastroenterologists, etc.
Watch for emails from your IMIG Officers for more information
Internal Medicine Interest Group
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EKG Workshop - January
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Opportunity to practice EKGs prior to Cardiology Exam
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Likely will offer again in the Spring prior to clinical rotations (after
STEP 1, obviously)
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Target audience is R2s
• Simulation Lab – February
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Opportunity to learn and practice some skills such as central line
placement, IV’s, ultrasound, intubation.
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Very fun and relaxed environment and useful skills that will be used in
3rd year
Watch for emails from your IMIG Officers for more information
Internal Medicine Interest Group
• Match Panel - Late March
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Panel of R4s who have matched explaining process and tips and tricks
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Educational experience to give some guidance on what it takes to
match into Internal Medicine and how students of Boonshoft do it
• Internal Medicine Experience Elective – Spring
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Elective experience in Internal Medicine and IM subspecialties at
Kettering Hospital
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Paid elective ($200)
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2 week elective and counts towards the Boonshoft elective
requirement
Watch for emails from your IMIG Officers for more information
Internal Medicine Interest Group
• Research Projects - All Year
• This year, tapping the Internal Medicine Research Chief to
coordinate research projects
• Jehangir Ansari - [email protected]
• Will identify researchers and tie in students with appropriate
projects
Watch for emails from your IMIG Officers for more information
References
How to Choose a Medical Specialty (3rd edition) by
Anita Taylor.
2. The Ultimate Guide to Choosing a Medical Specialty
(2nd edition) by Brian Freeman.
3. Physician compensation data.
http://www.acponline.org/private/pmc/physcomp_d
ata.htm
1.