1. INTRODUCTION TO INTERNAL MEDICINE
September 18, 2014

2. Objectives Prepare for future IMIG Events
Identify what an Internist does
Appreciate the different subspecialty options in internal medicine
Register for ACP as a student

3. What is Internal Medicine?

4. Who are Internists? Glen Solomon Karen Kirkham Bruce Scott
Chair of Internal Medicine
Karen Kirkham
Internal Medicine Clerkship Director
Bruce Scott
Internal Medicine/Geriatrics/Palliative Care
ICM Preceptors

5. Who are Internists? William Osler Robert Lefkowitz and Brian Kobilka
Eminent Internist, founder of residencies
Robert Lefkowitz and Brian Kobilka
Nobel Prize Winners in Chemistry (G-coupled protein receptors)
Ken Jeong
Intern(al)ational Movie Star

6. 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
1 ABIM Fast Facts sheet 2014
2 The Complexities of Physician Supply and Demand: Projections Through 2025, Center for Workforce Studies, AAMC, 2008.

7. 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

8. 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

9. Internal Medicine Spectrums
Outpatient
Primary Care
Acute
Chronic
Academic
Hospitalist
Intensive Care Physician
Inpatient
*Or any combination of the above
Subspecialist

10. 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

11. Internal Medicine Subspecialties
To become a subspecialist, must complete a residency in Internal Medicine first
Years 1 2 3 4 1 2 3 1 2 3
Medical School
Residency
(Internal Medicine)
Fellowship
(i.e. Gastro-
enterology)

12. Internal Medicine: Subspecialties
American Board of Internal Medicine Certified:
Adolescent Medicine
Endocrinology, Diabetes, & Metabolism
Medical Oncology
Adult Congenital Heart Disease
Nephrology
Gastroenterology
Pulmonary Disease
Advanced Heart Failure and Transplant Cardiology
Geriatric Medicine
Rheumatology
Hematology
Sleep Medicine
Cardiovascular Disease
Hospice & Palliative Medicine
Sports Medicine
Clinical Cardiac Electrophysiology
Transplant Hepatology
Infectious Disease
Critical Care Medicine
Interventional Cardiology
Non-ABIM Certified:
General Internal Medicine
Medical Research
Women’s Health
Medical Education
Occupational Health
Headache
Transplant Infectious Disease
Medical-Legal Interactions
To be determined
Tropical Medicine
Transitions of Care
Complementary Medicine

13. General Internists
AKA Internists

14. 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
Educator
Director
Advocate
Motivator
Healer
Comforter

15. 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

16. Typical Lifestyle Highly variable Outpatient (PCP)
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 (20-30 min per patient)
1Medscape Physician Survey Data 2010

17. Salary Data General Internal Medicine Overall Median = $212,000
Academic = $175,000
Overall Mean = $195,000
Hospitalist = $229,000
Primary Care = $192,000
MGMA Compensation and Production Survey 2012

18. Satisfaction Data
University of Davis study in 2009 surveyed 6590 US physicians, had 53% response rate
1 Pediatric emergency
2 Geriatric medicine
3 Dermatology
4 Pediatrics
5 Internal medicine and pediatrics
6 Other pediatric subspecialty
7 Neonatal and perinatal medicine
8 Allergy and immunology
9 Child and adolescent psychiatry
10 Radiation oncology
11 Cardiovascular diseases
12 Medical oncology
13 Ophthalmology
14 Occupational medicine
15 Hospitalists
16 Physical medicine and rehabilitation
17 Psychiatry
18 Otolaryngology
19 Other medical subspecialty
20 Critical care internal medicine
21 Endocrinology, diabetes
22 Urology
23 Gastroenterology
24 Infectious diseases
25 Pulmonary diseases

19. Satisfaction Data
University of Davis study in 2009 surveyed 6590 US physicians, had 53% response rate
14 Occupational medicine
15 Hospitalists
19 General Internal Medicine
20 Critical care internal medicine
21 Endocrinology, diabetes
23 Gastroenterology
24 Infectious diseases
25 Pulmonary diseases
2 Geriatric medicine
5 Internal medicine and pediatrics
Allergy and immunology
11 Cardiovascular diseases
12 Medical oncology
13/25
34 Other medical subspecialty

20. 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

21. Popular Journals 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)

22. Subspecialties

23. Internal Medicine: Subspecialties
ABIM Certified:
Adolescent Medicine
Endocrinology, Diabetes, & Metabolism
Medical Oncology
Adult Congenital Heart Disease
Nephrology
Gastroenterology
Pulmonary Disease
Advanced Heart Failure and Transplant Cardiology
Geriatric Medicine
Rheumatology
Hematology
Sleep Medicine
Cardiovascular Disease
Hospice & Palliative Medicine
Sports Medicine
Clinical Cardiac Electrophysiology
Transplant Hepatology
Infectious Disease
Critical Care Medicine
Interventional Cardiology
Non-ABIM Certified:
General Internal Medicine
Transitions of Care
Tropical Medicine
Medical Education
Medical Research
Headache
Transplant Infectious Disease
Occupational Health
To be determined
Medical-Legal Interactions

24. Fellowships Traditional Emerging Addiction medicine
Allergy/immunology
Cardiology
Endocrinology
Gastroenterology
General internal medicine
Hematology/oncology
Infectious disease
Nephrology
Pulmonary/critical care
Rheumatology
Addiction medicine
Adolescent medicine
Geriatrics
Hospice & palliative care
Sleep medicine
Sports medicine
Women’s health

25. Relative Competitiveness
Less  More
Infectious Disease
Endocrinology
Geriatrics
Allergy/Immunology
Nephrology
Rheumatology
Cardiology
Gastroenterology
Pulmonary/Critical Care
Hematology/Oncology

26. Hospice/Palliative Care
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
More routine than cardiologist, mostly outpt procedures
450K
EP studies
Endocrinology
Outpt hours with minimal inpt consults
200K
Thyroid biopsy
Gastro-enterology
3 years
405K
EGDs, Colonoscopys, Liver biopsy, ERCP, etc.
Geriatrics
1 year
Predominately outpt hrs, with inpt consults
185K
MOCAs, SLUMS
Heart Failure/Txp
More outpatient
More routine than cardiologist, mostly outpt, with inpt consults ?
Echocardiograms
Heme/Onc
Outpt office hrs, some inpt hrs with call
320K
Chemotherapy administration
Hospice/Palliative Care
Mostly outpatient
Outpt hours with call
180K
Paracentesis, thoracentesis
Infectious Disease
Generally long hours due to combination of outpt hrs and inpt consults
160K
Anoscopy
Nephrology
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
Predominately inpatient
Long inpt hrs, predominately in shifts (some nights)
275K
Intubation, tPA adminstration, bronchoscopy, etc.
Rheumatology
220K
Joint aspirations, immunosuppressive therapy

27. 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

28. Addiction Medicine 1 year in length Board certification available
Can be done after IM, FP, and psychiatry residencies
Main disease entities:
Alcohol
Illicit drugs
Tobacco

29. 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

30. 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

31. 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

32. Sports Medicine 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

33. Women’s Health 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

34. Other Possibilities Clinical nutrition Clinical decision making
Medical informatics
Quality improvement & patient safety
Applied epidemiology (CDC)
Clinical research (NIH, Robert Wood Johnson)
Complementary & alternative medicine

35. Advice for Students Take care of older adults as much as you can
Attend Ohio or National ACP Meeting
Focus M4 electives in following areas:
Get good evaluations in your M3 & M4 medicine clerkships
Cardiology
Be open to all possibilities (no rush to decide!)
Pulmonary/critical care
Emergency medicine

36. Resources for Further Exploration
Your faculty advisors!

37. Questions for Our Panel?

38. Internal Medicine Interest Group
Events:
ACP Ohio October
Subspecialty Panel November
EKG Workshop for R2s January
Simulation Lab February
Match Panel Late March
Internal Medicine Experience Spring
Elective
Research Projects All Year
Watch for s from your IMIG Officers for more information

39. 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 s from your IMIG Officers for more information

40. Internal Medicine Interest Group
EKG Workshop - January
Opportunity to practice EKGs prior to Cardiology Exam
Likely will offer again in the Spring prior to clinical rotations (after STEP 1, obviously)
Target audience is R2s
Simulation Lab – February
Opportunity to learn and practice some skills such as central line placement, IV’s, ultrasound, intubation.
Very fun and relaxed environment and useful skills that will be used in 3rd year
Watch for s from your IMIG Officers for more information

41. Internal Medicine Interest Group
Match Panel - Late March
Panel of R4s who have matched explaining process and tips and tricks
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
Elective experience in Internal Medicine and IM subspecialties at Kettering Hospital
Paid elective ($200)
2 week elective and counts towards the Boonshoft elective requirement
Watch for s from your IMIG Officers for more information

42. Internal Medicine Interest Group
Research Projects - All Year
This year, tapping the Internal Medicine Research Chief to coordinate research projects
Jehangir Ansari -
Will identify researchers and tie in students with appropriate projects
Watch for s from your IMIG Officers for more information

43. References
How to Choose a Medical Specialty (3rd edition) by Anita Taylor.
The Ultimate Guide to Choosing a Medical Specialty (2nd edition) by Brian Freeman.
Physician compensation data.