Introduction to internal medicine
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INTRODUCTION TO INTERNAL MEDICINE. September 18, 2014. 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. What is Internal Medicine?. Who are Internists?.

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Introduction to internal medicine

INTRODUCTION TO INTERNAL MEDICINE

September 18, 2014


Objectives

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


What is internal medicine

What is Internal Medicine?


Who are internists

Who are Internists?

ICM Preceptors

  • Glen Solomon

    • Chair of Internal Medicine

  • Karen Kirkham

    • Internal Medicine Clerkship Director

  • Bruce Scott

    • Internal Medicine/Geriatrics/Palliative Care


Who are internists1

Who are Internists?

  • William Osler

    • 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


Who are internists2

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.


Internal medicine definition

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 definition1

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

    Internal Medicine Spectrums

    Outpatient

    Primary Care

    Chronic

    Academic

    Hospitalist

    Intensive Care Physician

    Inpatient

    Acute

    *Or any combination of the above

    Subspecialist


    Internal medicine spectrum

    Internal Medicine Spectrum

    Specialized

    Geriatrician

    Rheumatologist

    Electrophysiologist

    Rural Primary Care

    *General rule: as you get more specialized, have less individualization of practice

    **Family Medicine is that way

    General


    Internal medicine subspecialties

    Internal Medicine Subspecialties

    Years

    1

    4

    1

    1

    3

    3

    2

    2

    3

    2

    Residency

    (Internal Medicine)

    Medical School

    Fellowship

    (i.e. Gastro-

    enterology)

    To become a subspecialist, must complete a residency in Internal Medicine first


    Internal medicine subspecialties1

    Internal Medicine: Subspecialties

    • Adolescent Medicine

    • Adult Congenital Heart Disease

    • Advanced Heart Failure and Transplant Cardiology

    • Cardiovascular Disease

    • Clinical Cardiac Electrophysiology

    • Critical Care Medicine

    • Endocrinology, Diabetes, & Metabolism

    • Gastroenterology

    • Geriatric Medicine

    • Hematology

    • Hospice & Palliative Medicine

    • Infectious Disease

    • Interventional Cardiology

    • Medical Oncology

    • Nephrology

    • Pulmonary Disease

    • Rheumatology

    • Sleep Medicine

    • Sports Medicine

    • Transplant Hepatology

    • Non-ABIM Certified:

    • General Internal Medicine

    • Medical Education

    • Transplant Infectious Disease

    • Transitions of Care

    • Medical Research

    • Occupational Health

    • Medical-Legal Interactions

    • Tropical Medicine

    • Complementary Medicine

    • Women’s Health

    • Headache

    • To be determined

    • American Board of Internal Medicine Certified:


    General internists

    General Internists

    AKA Internists


    What do general internists do

    What Do General Internists Do?

    • Other roles in general medical care for adults

      • Educator

      • Director

      • Advocate

      • Motivator

      • Healer

      • Comforter

    • 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)


    What makes a good general internist

    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

    Typical Lifestyle

    • 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)

    • Highly variable

      • mean patient care hours a week is 491

    1Medscape Physician Survey Data 2010


    Salary data

    Salary Data

    • General Internal Medicine

    MGMA Compensation and Production Survey 2012

    • Overall Median = $212,000

    • Overall Mean = $195,000

    • Primary Care = $192,000

    • Academic = $175,000

    • Hospitalist = $229,000


    Satisfaction data

    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


    Satisfaction data1

    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

    2Geriatric medicine

    5Internal medicine and pediatrics

    Allergy and immunology

    11Cardiovascular diseases

    12Medical oncology

    13/25

    34Other medical subspecialty


    Main organizations

    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

    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)


    Subspecialties

    Subspecialties


    Internal medicine subspecialties2

    Internal Medicine: Subspecialties

    • Adolescent Medicine

    • Adult Congenital Heart Disease

    • Advanced Heart Failure and Transplant Cardiology

    • Cardiovascular Disease

    • Clinical Cardiac Electrophysiology

    • Critical Care Medicine

    • Endocrinology, Diabetes, & Metabolism

    • Gastroenterology

    • Geriatric Medicine

    • Hematology

    • Hospice & Palliative Medicine

    • Infectious Disease

    • Interventional Cardiology

    • Medical Oncology

    • Nephrology

    • Pulmonary Disease

    • Rheumatology

    • Sleep Medicine

    • Sports Medicine

    • Transplant Hepatology

    • Non-ABIM Certified:

    • General Internal Medicine

    • Medical Education

    • Transplant Infectious Disease

    • Transitions of Care

    • Medical Research

    • Occupational Health

    • Medical-Legal Interactions

    • Tropical Medicine

    • Headache

    • To be determined

    • ABIM Certified:


    Fellowships

    Fellowships

    Emerging

    Traditional

    • Addiction medicine

    • Adolescent medicine

    • Geriatrics

    • Hospice & palliative care

    • Sleep medicine

    • Sports medicine

    • Women’s health

    Allergy/immunology

    Cardiology

    Endocrinology

    Gastroenterology

    General internal medicine

    Hematology/oncology

    Infectious disease

    Nephrology

    Pulmonary/critical care

    Rheumatology


    Relative competitiveness

    Relative Competitiveness


    Other fellowships

    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

    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


    Adolescent medicine

    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

    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

    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

    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


    Women s health

    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


    Other possibilities

    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


    Advice for students

    Advice for Students

    • Take care of older adults as much as you can

    • Focus M4 electives in following areas:

      • Cardiology

      • Pulmonary/critical care

      • Emergency medicine

    • Attend Ohio or National ACP Meeting

    • Get good evaluations in your M3 & M4 medicine clerkships

    • Be open to all possibilities (no rush to decide!)


    Resources for further exploration

    Resources for Further Exploration

    www.acponline.org

    www.sgim.org

    http://services.aamc.org/careersinmedicine/

    www.hospitalmedicine.org/

    Your faculty advisors!


    Questions for our panel

    Questions for Our Panel?


    Internal medicine interest group

    Internal Medicine Interest Group

    • Events:

    • ACP OhioOctober

    • Subspecialty PanelNovember

    • EKG Workshop for R2sJanuary

    • Simulation LabFebruary

    • Match PanelLate March

    • Internal Medicine ExperienceSpring

    • Elective

    • Research ProjectsAll Year

    Watch for emails from your IMIG Officers for more information


    Internal medicine interest group1

    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 group2

    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 emails from your IMIG Officers for more information


    Internal medicine interest group3

    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 emails from your IMIG Officers for more information


    Internal medicine interest group4

    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

    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. http://www.acponline.org/private/pmc/physcomp_data.htm


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