Like to puzzle over diagnoses? Internal medicine may be for you
This is the eighth in a series of articles profiling medical specialties. The others focused on anesthesiology, physical medicine and rehabilitation, osteopathic manipulative medicine, dermatology, emergency medicine, obstetrics-gynecology and general surgery.
Osteopathic medical students who relish diagnostic challenges and have an intense interest in disease processes and organ system function should consider internal medicine as a specialty. “Internists tend to be highly analytical,” says Natasha N. Bray, DO, the internal medicine program director at Broward General Medical Center in Fort Lauderdale, Fla.
Internal medicine is a cognitive specialty, although some of the subspecialties involve a number of procedures, notes David F. Hitzeman, DO, a general internist in Tulsa, Okla. “Internists like dealing with complex issues in a very intuitive way, coming to a diagnosis and developing a treatment plan,” he says. “Internists also like direct patient care.” While general internists and some internal medicine subspecialists provide longitudinal care to patients, internists in hospital medicine and critical care focus on diagnosing and treating extremely ill inpatients.
“Medicine is forever changing. So to be a good internist, you have to be someone who likes to read and is well-versed in the medical literature—someone who wants to keep up with the latest innovations,” says Judith A. Lightfoot, DO, who serves on the Board of Directors of the American College of Osteopathic Internists (ACOI). But at the same time, internists of all types need the interpersonal skills to motivate patients so that they comply with medication regimens and demonstrate healthful habits, such as giving up smoking, losing weight and exercising regularly, says Dr. Lightfoot, who practices in Vorhees, N.J. Constantly coordinating care with other specialists and health professionals, physicians in this specialty need to have top-notch leadership, organizational and communication skills.
Internists, who complete three years of residency training, constitute 40% of U.S. primary care physicians. Given the ever-growing need for more primary care specialists, “opportunities for internists are wide open,” the ACOI notes on its website.
Osteopathic medical students considering primary care sometimes struggle to decide between internal medicine and family medicine, but the distinctions are many. First, general internists traditionally limit their practices to patients age 17 and older and don’t provide obstetrical services. “When I ask people why they want to do internal medicine, a common answer is, ‘I don’t want to see kids,’ ” says Dr. Bray, who is also Broward General’s director of medical education.
While internists do practice in rural settings, students who envision themselves setting up a solo practice in an underserved rural area might be better off obtaining the broader training of a family physician.
Although some have strictly ambulatory practices, general internists typically manage their patients who become hospitalized with acute illness. Because of their expertise in diagnosing disease and managing critically ill patients, internists sometimes serve as consultants to family physicians, according to the ACOI.
But a growing proportion of medical students today are drawn to internal medicine because of the chance to subspecialize or pursue hospital medicine. The ACOI reports that among DOs completing internal medicine residencies in 2012, 42% entered subspecialty training and 36% became hospitalists.
“Internists like dealing with complex issues in a very intuitive way, coming to a diagnosis and developing a treatment plan.” Dr. Hitzeman
Today, 103 AOA-approved internal medicine residency programs offer more than 1,600 funded positions. The AOA has also approved 11 combined programs in internal medicine-emergency medicine, one program in internal medicine-pediatrics and one in internal medicine-neuromusculoskeletal medicine. In addition, the AOA has approved internal medicine fellowship programs in many subspecialties.
Because of the recent agreement between the AOA and the Accreditation Council for Graduate Medical Education (ACGME) to work toward a single accreditation system, DOs training in AOA-approved internal medicine residencies still also have the option of applying to ACGME-accredited subspecialty fellowship programs.
General internists earn more than family physicians and pediatricians on average, with internal medicine hospitalists making more than internists in primary care. Those entering subspecialties that involve procedures have the highest incomes. In 2011, internists in primary care earned an average of $165,000 a year, according to a survey by Medscape. In contrast, nephrologists made $209,000 on average; pulmonologists, $242,000; oncologists, $295,000; gastroenterologists, $303,000; and cardiologists, $314,000.
But the difference between primary care and specialty care is not always clear-cut. Dr. Lightfoot, whose specialty is infectious diseases, typically becomes the primary care physician for her patients who have HIV infection and AIDS. Many of these patients now live until their 70s and 80s with the virus, which can affect most of the body’s organ systems, from the lungs to the kidneys.
Because pulmonologist Wilfred VanderRoest, DO, has developed 20-year relationships with some of his patients, he often becomes their go-to doctor for all manner of medical advice and referrals. “Sometimes their primary care doctor has retired or they pick a physician they think is wet behind the ears,” says Dr. VanderRoest, who directs the AOA-approved pulmonary and critical care fellowship program at Botsford Hospital in Farmington Hills, Mich.