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INTERNAL MEDICINE
Internists take care of the general medical problems of adults. In a single day, they can act as a diagnostician, an educator, a director, an advocate, a motivator, a healer, and a comforter. In the clinic, they treat their patients’ aches, pains, and sniffles. They also come to their bedsides in the hospital and manage their inpatient care. Some internists spend their time providing acute and chronic primary care, while others become subspecialists in cardiology, gastroenterology, endocrinology, and more. Whether focusing on one organ system or taking care of the whole patient, internists approach everything with great intellectual curiosity. Sick patients with complex medical problems turn to internists for high-quality care.
INTERNAL MEDICINE IS “ADULT MEDICINE”
Two decades ago, the American College of Physicians (ACP) initiated a public relations campaign called “Doctors for Adults” to help patients understand the true role of the internist within the medical community.2 This catchphrase captures the underlying common denominator within internal medicine—physicians who are experts in the nonsurgical health care needs of anyone over the age of 18. In many ways, internists are similar in practice style to pediatricians—but the kids have grown up. There is less asthma and more emphysema, the neonatal intensive care unit has been replaced by the coronary care unit, and instead of worried parents there are concerned adult children.
Internists provide comprehensive medical care over a long period of time. Their primary responsibility is to diagnose and treat acute and chronic medical conditions. A number of illnesses invariably comprise the core of most internal medicine practices. These diseases can range from acute problems such as upper respiratory tract infections, influenza, viral gastroenteritis, and urinary tract infections to more chronic problems like diabetes mellitus, chronic obstructive pulmonary disease, hypercholesterolemia, and hypertension. In fact, a large proportion of medical patients are elderly with complex, chronic comorbidities. Common illnesses treated in the young-adult and middle-aged populations include gastroesophageal reflux disease, peptic ulcer disease, hyper- or hypothyroidism, depression, musculoskeletal injuries, sexually transmitted diseases, and the acute infections listed above. Despite the usual plethora of common complaints and illnesses, internists also have many opportunities to diagnose and treat rare diseases like babesiosis or Still’s disease. This is why a general internist’s daily practice spans a number of medical disciplines. You receive the challenges (as well as the rewards) of treating a broader range of illnesses than in almost any other specialty.
As you can tell, internists are more than just doctors for adults. This specialty is all about diversity: a varied group of patients spanning late adolescence to the end of life, a number of practice settings from the clinic to the hospital, a broad range of illnesses from acute to chronic, and over a dozen subspecialties. For example, a physician trained in general internal medicine will evaluate a 24-year-old woman presenting with weight loss and night sweats while a colleague who specialized in cardiology treats a 70-year-old heart-attack victim in the cardiac catheterization lab. On a given day, a general internist with a special interest in sports medicine will treat a 40-year-old male with a torn rotator cuff, while another colleague gives preventive influenza vaccinations to the residents of a nursing home.
No matter the subspecialty, all internists have a similar set of clinical responsibilities. Most important, they provide complex medical care while diagnosing and treating acute and chronic problems, whether in the office or hospital. Internists were traditionally responsible for taking care of their own patients when they were admitted to the hospital (for problems such as congestive heart failure, pancreatitis, asthma, bacteremia, unstable angina, and pneumonia). Some office-based internists still care for their patients in the hospital, but others rely on general internists who specialize in hospital medicine (hospitalists). Most internists practice preventive medicine, which involves health maintenance and disease screening. Although some internists may have a subset of patients who fall within that physician’s area of expertise, most rely on colleagues in other subspecialties for consultations on advanced problems. General internists must be aware of their own limitations and know when to seek specialized help on a given organ system disease. But do not think that these internists just spend their time consulting others. In fact, they are often asked by surgeons and obstetricians to see patients who have difficult general medical conditions.
Internists and family practitioners both take care of adult patients. So what makes a career in internal medicine unique? Internists have highly detailed knowledge about how to manage the most complicated of medical problems found in the adult population. Family practitioners, on the other hand, care for people of all ages throughout their entire lives. Because they have broader training across other disciplines (obstetrics–gynecology, surgery, psychiatry), family practice doctors have less depth of training in internal medicine. Internists, of course, do not treat young children or deliver babies. Another distinguishing feature of internal medicine is the option to subspecialize in a vast array of fields after residency. Although many internal medicine residents choose to enter a subspecialty fellowship, others remain in the broad field of general internal medicine and become known as general internists.
READY TO EXERCISE YOUR BRAIN?
Internal medicine is perhaps the most cerebral of all specialties. It requires a high level of critical thinking. Many students are drawn to internal medicine for the intellectual stimulation. There are always interesting cases that require a lot of problem solving and interpretation of signs, symptoms, and other pieces of data. Internists are very intellectually curious doctors. They always like to ask questions of themselves and others during the differential diagnosis process. Fascinated by the science of medicine, internists love exploring details—like the mechanisms of drug therapy or the pathophysiology of disease. To stay current with evidence-based medical treatments, internists tend to read quite a bit. Keeping abreast of the latest advances in general medicine requires a career-long commitment to searching the medical literature through traditional journals and reliable online resources that provide summaries and treatment guidelines.
✓ Likes physical diagnosis, pharmacology, and physiology.
✓ Is a thorough, cautious problem solver.
✓ Can interact well with people and maintain long-term relationships.
✓ Likes solving more complex patient conditions.
✓ Is a strong patient advocate and active listener.
Critical thinking is necessary because internists take a scientific approach to being master diagnosticians. They thrive on making a great diagnosis, analyzing a fascinating big case, and solving complex medical problems. Internists love to sit around and discuss disease. They get excited by putting together a patient’s signs, symptoms, and laboratory findings and trying to come up with a long list of possible differential diagnoses. Students who love to solve problems and mental puzzles find internal medicine a fascinating specialty.
Internists are experts at taking patient histories and performing physical examinations. It is with the information derived from the history and physical (H&P) that they make most diagnoses. After talking to the patient, the internist constructs a list of differential diagnoses for each of the patient’s problems. This process allows them to clearly organize in their minds what is going on with the patient and how to address each issue; many patients have multiple medical problems or complaints. To finalize a diagnosis from a list of many, the internist relies on a great deal of critical thinking and deductive reasoning from the data at hand. They take pieces of evidence from the history, physical examination, laboratory data, and imaging studies to rule in or rule out various disease states. It very much resembles detective work. A faculty colleague commented that “figuring out how all the pieces to a patients’ clinical puzzle fit together is extremely rewarding.”
With a confident diagnosis in hand, the internist then moves on to treating the patient. Across the subspecialties of internal medicine, therapeutic interventions take the form of either pharmacologic agents or procedures. General internists, for instance, keep up with the advances in treating high blood pressure with the newest medications and are experts at figuring out the proper antibiotic for a patient with bacterial meningitis. Although this specialty requires thorough, organized thought, internists are more than just thinkers; they are also proficient in many technical skills essential to the diagnosis and treatment of illness. These skills include a number of inpatient procedures, such as thoracentesis, paracentesis, lumbar puncture, and central line placement, and outpatient procedures like flexible sigmoidoscopy, endometrial biopsy, and intra-articular injections. Subspecialists such as cardiologists open blocked arteries through percutaneous transluminal coronary angioplasty, and gastroenterologists excise cancerous colon polyps through colonoscopy or stop upper gastrointestinal bleeding through esophagogastroduodenoscopy.
THE DOCTOR–PATIENT RELATIONSHIP
The ability to listen, understand, explain, advise, and educate are central to the role of an internist. Without strong interpersonal skills, it would be difficult to diagnose an underlying substance abuse problem, help a patient start an exercise program or quit smoking, encourage healthier eating habits, or guide a patient’s decision to sign a do-not-resuscitate order and abandon aggressive treatment. Through comprehensive H&Ps, internists spend a great deal of time with their patients—talking with them and gaining insight into their lives, their values, and their concerns. Physicians with these qualities will establish life-long, trusting relationships with their patients.
Having close relationships with patients and their families is one of the best things about a career in general internal medicine. Unlike the patient of an emergency medicine physician or more procedural specialty, your patient has the potential to stay with you until old age and death. Patients trust internists with their secrets, fears, and insecurities. Internists must respect the privilege of this trust and the enormous responsibility that comes with it. They are the ones, after all, guiding patients through their illness amidst their fears. Internists, also lead patients through the health care system and the myriad of subspecialty care and treatment options. This concept of providing an interface between patients and the health care system has recently been given the term “system-based practice.” At times, they even guide their patients through family stress and turmoil. Internists’ ability to diagnose and treat illness depends on the foundation of a compassionate, insightful, and respectful relationship with their patients.
Although the action of internal medicine practice is not always as tangible as performing a liver transplant, delivering a baby, or intubating a patient before surgery, it is still complex and challenging. Within this specialty, the goal of intervention may not necessarily be to cure disease, but to help the patient understand the disease and cope with its psychosocial ramifications. Beyond thinking and communicating, internal medicine requires exploring patients’ cultural beliefs, recognizing the impact of socioeconomic status, educating patients about diseases and treatments, motivating lifestyle changes, and organizing multidisciplinary care.
As an internist, you will pride yourself on your ability to solve difficult problems under intense pressure and sensitive circumstances. Take the following example. An internist in private practice was evaluating a new patient in the hospital—a Taiwanese man visiting his family in the United States who became acutely and gravely ill but did not have health insurance. The patient’s family members were divided on the decision of whether to continue hospital treatment versus caring for the patient at home due to financial concerns. Although the family was concerned about the patient’s lack of insurance and the cost of continued care, they were also guided by cultural values to pursue every option to preserve the patient’s life. As demonstrated by this case, the internist’s role not only requires challenging medical management but also skills such as cultural competence, family mediation, health care economics, and a holistic view of care.
BEING ON THE FRONT LINE OF MEDICINE
An internist is often the first physician a patient turns to when an illness or symptom arises. By being on the first line of defense, the internist’s initial interaction can influence the likelihood the patient will follow up after this visit. An internist with limited patience, poor communication skills, and skepticism toward the validity of the patient’s complaint may discourage the patient from seeking further medical care. In contrast, the internist who expresses an appropriate level of concern validates the patient’s complaint and offers an understandable follow-up plan that may improve the likelihood that the patient will return for needed medical care. If you enjoy helping others solve problems while providing encouragement, patience, and guidance, then definitely consider a career in internal medicine.
Being on the front line of medicine also offers the intellectual stimulation and challenge of diagnosis. As the first physician to hear and understand the patient’s complaint, your skill as a diagnostician directs the treatment plan. Being an effective diagnostician requires skill as a historian and examiner as well as the ability to synthesize history, physical examination findings, laboratory data, and study results. For example, internists are commonly presented with chief complaints of cough and heartburn. Although many of these cases can be attributed to upper respiratory infections or gastroesophageal reflux, the detail-oriented internist recognizes the necessity of a thorough H&P examination to determine whether further workup is needed. But in today’s health care environment of conservative resource utilization, only good clinical judgment can guide the appropriate decision to explore a patient’s complaint further with laboratory tests and technological studies.
Preventive medicine is another extremely important part of being on the front line of medicine. Some patients may express doubts or hesitation, “I just can’t quit smoking?!” or “Colonoscopy? Let’s talk next year!” The key in these cases and other preventive medicine efforts is aiding the patient in making the necessary and truly life-saving behavioral change that will help them avoid future illness. The prevention of disease has recently achieved an elevated status equal to that of diagnosis and treatment. This change is a result of increasing evidence of the benefits of preventive services.3
The difficulty of addressing chronic, multisystem illnesses in the limited time allotted for patient visits makes preventive health care one of the most challenging (but no less important) areas of internal medicine. If you can envision yourself educating and motivating patients to change their lifestyle, internal medicine certainly provides abundant opportunities to do so. The future of this specialty undoubtedly involves an increase in the number and complexity of screening tests, as well as the opportunity for research on motivating and achieving changes in lifestyle.
THE INTERNIST AS “QUARTERBACK”
Because many patients have multisystem diseases requiring specialized care, the team of physicians and other health care providers can easily become fragmented and disorganized, which in turn may seem confusing and frustrating for patients. An organized internist with leadership skills can prevent or at least minimize this frustration and confusion. By tracking medications prescribed by other physicians, monitoring potential drug interactions, following up on studies or procedures performed by subspecialists, and responding to their recommendations, the internist orchestrates a multidisciplinary care team and helps the patient navigate a complex system of care. In addition, the internist acts as the patient’s advocate within the complex health care environment of resource utilization and restricted access to care.
Internists not only serve as leaders of a multidisciplinary team, but also determine which physicians are on the playing field. As an internist you must provide an appropriate level of specialized care, then recognize your limitations and refer the patient to a subspecialist for optimal care. This can become a fine line for any internist—requiring an impressive breadth of knowledge but a willingness to admit limitations as well. You can imagine a dermatologist being dismayed when an internist could not treat a patient with simple eczema or an infectious disease specialist frustrated by an internist’s insistence on treating HIV even though the internist was not up to date on the standard of HIV care. To provide the best care, internists must learn to turn to subspecialty care when it is appropriate and establish professional, mutually respectful relationships with subspecialists.
LIFESTYLE CONSIDERATIONS AND PRACTICE OPTIONS
The day-to-day life of a practicing internist is quite varied. It really depends on whether the physician is a cardiologist, rheumatologist, critical care specialist, general internist, and so on. Nearly all work long hours. Cardiologists and gastroenterologists are frequently called into the hospital in the middle of the night to perform cardiac catheterizations for heart attack victims and endoscopies for gastrointestinal bleeders. The general internist in private practice is, in a way, on call all the time. When one of their patients is admitted to the hospital, they receive a phone call letting them know.
Residency in internal medicine requires 3 years of postgraduate training. There are currently 467 accredited programs in the United States (excluding combined programs with other specialties). Residency programs are offered by both academic medical centers and community hospitals. The training includes experience in both general internal medicine and subspecialty areas. It is a rigorous program, requiring in-house overnight call every fourth to fifth night while on an inpatient rotation. The first year is the most intense. Rotations in general patient medicine, subspecialties (consults and clinic), intensive care, geriatrics, and emergency medicine are required. Residents must demonstrate technical proficiency in a number of procedures, including abdominal paracentesis, thoracentesis, central venous line placement, and lumbar puncture. Because of the current emphasis on primary care, one-third of the residency must take place in an ambulatory setting. All categorical residents spend one-half day per week in a continuity clinic where they manage their own panel of patients over the course of 3 years. The decision to subspecialize and apply for fellowship typically occurs during the second postgraduate year.
Because of the broad nature of internal medicine, residents often have a tough time responding to the question “Where do you intend to practice?” After all, the answer may change during your training and even over the course of your career. Your initial career plans may be your choice during residency to pursue a subspecialty fellowship or to remain in general internal medicine. For physicians who choose to remain in general medicine, other fellowship opportunities are available in fields such as end-of-life care, medical education, and medical informatics.
Once a general internist is prepared to enter the workforce, the decision between academic medicine and private medicine must be made. Both have many practice opportunities to explore. Some academicians are mainly educators, spending most of their time in the outpatient or inpatient setting seeing their own patients and supervising residents in clinic or on the wards. Others are researchers with few inpatient or outpatient responsibilities who spend most of their time conducting research in areas that are not generally addressed by subspecialty research but broadly applicable to medicine: evidence-based medicine, psychosocial aspects of care, doctor–patient communication, medical ethics, management of medical errors, cost effectiveness, and the impact of socioeconomic status or race on medical care.
General internists who choose private practice also have several options. In the current health care economic environment, solo private practice is becoming much less common. Instead, most internists belong to a group practice such as multispecialty groups or health maintenance organizations. Some private internists have contracts with hospitalists to provide all inpatient care for their patients, and other private internists continue to see patients both in the clinic and in the hospital. Others hold a salaried position at a health maintenance organization.
In both private and academic practice, the generalist initiative of the last decade gave rise to the rapid growth of a new type of internist: the hospitalist. These internists practice only inpatient (hospital-based) medicine. Similar to consultants, they are called on to provide expert management for the care of sick patients admitted to the hospital wards. Typically, hospitalists do not have clinic, practice, or outpatient responsibilities. Instead of following a clinic schedule, hospitalists have a shift-work lifestyle similar to emergency medicine physicians. Patients can benefit from having a hospitalist take care of them instead of their own private doctor since hospitalists work in the hospital on a daily basis. With good communication between the two physicians, hospitalist care has been associated with lower costs, improved patient outcomes, and lower short-term mortality.4 In academic institutions, hospitalists often oversee quality improvement and quality assurance initiatives. They also supervise resident training in patient care, systems-based practice, and procedures.
FELLOWSHIPS AND SUBSPECIALTY TRAINING
Internal medicine comprises many subspecialties. In 2000, roughly half of all graduates from internal medicine residency programs sought fellowship training.5 Currently there are 10 possible areas of subspecialization. Before jumping into one of these disciplines, take a moment for some honest self-evaluation. It is essential that you give some thought to your field of interest and the type of personality most suited to it.
For aspiring physicians who prefer direct primary patient care, general internal medicine is the place to be. Specialists tend to be much more scientifically oriented and enjoy more complex and difficult cases. They serve as consultants to the general internist, directing medical care for a specific organ system and often teaching the general internist about the patients’ disease process. For certain specialties, like cardiology, gastroenterology, and critical care, more time is spent caring for patients in the hospital environment than in the office setting.
No matter whether you choose cardiology or rheumatology, all subspecialists are, at heart, excellent general internists. You will still be required to have high-quality H&P examination skills, as well as the ability to interpret laboratory and radiographic findings, to produce a comprehensive differential diagnosis. In every subspecialty, all internists take care of very sick adult patients who have many medical problems.
Allergy and Immunology
Millions of people suffer from allergies, which ultimately affect their workplace productivity and results in billions of dollars lost each year. These reactions include respiratory diseases (asthma, sinusitis, rhinitis), adverse drug effects, and unusual skin rashes. Because allergies have an underlying immunologic component, these specialists are also experts on antibodies, antigens, and other complex aspects of the immune system. They perform skin tests and drug desensitization protocols.
Allergy and immunology |
$294,245 |
Cardiology |
$483,653 |
Endocrinology |
$242,202 |
Gastroenterology |
$505,194 |
General internal medicine |
$249,588 |
Geriatrics |
$234,181 |
Hematology/oncology |
$416,738 |
Hospitalist |
$275,363 |
Infectious disease |
$261,630 |
Nephrology |
$329,750 |
Pulmonary medicine/critical care |
$385,436 |
Rheumatology |
$251,913 |
Source: American Medical Group Association.
A career in allergy and immunology offers immense intellectual satisfaction, as well as good working hours. Here, there is a strong bond between basic laboratory research and its clinical application. When treating patients (both kids and adults), these specialists witness dramatic improvements in physical functioning. Results are usually fast, positive, and much appreciated. Today, more and more people suffer from asthma and other allergic disorders. As such, there is an extremely high demand for internists with formal training in this discipline. Career options are broad and include private practice, academics, and clinical or basic science research. Some allergist–immunologists also practice general internal medicine in addition to their subspecialty. A fellowship in allergy and immunology lasts 2 years.
Cardiology
Like fighter pilots, cardiologists take calculated risks while exercising skill and precision. As experts in the diagnosis and management of cardiovascular diseases, they take care of life-threatening medical conditions that affect a large majority of the population. These disorders include congestive heart failure, arrhythmias, valvular problems, hypertension, and coronary artery disease. Many of the treatment options, whether pharmacologic or interventional, have immediate life-saving benefits. A procedure-oriented specialty, cardiology requires a great deal of manual dexterity. It is a perfect field for those who love gadgets. You will perform cardiac catheterization, electrocardiograms, nuclear stress tests, and echocardiography. You will place stents within the coronary vasculature, open clogged arteries with balloon angioplasty, and even electrically convert patients into normal sinus rhythms through defibrillation.
• Number of positions available: 7233
• 3851 US seniors and 7959 independent applicants ranked at least one internal medicine program
• 98.2% of all positions were filled in the initial Match
• The successful applicants: 45.7% US seniors, 42.7% foreign-trained physicians, and 9.7% osteopathic graduates
• Mean USMLE Step I score: 233
• Unmatched rate for US seniors applying only to internal medicine: 2.7%
Source: National Resident Matching Program.
Life as a heroic cardiologist, however, can be physically draining. They work extremely long, arduous hours taking care of very sick patients. Due to the large numbers of patients admitted to the hospital with heart attacks, cardiologists frequently come to the hospital in the middle of the night. In the intensive care unit, they help critically ill patients maintain their blood pressure through the administration of vasopressors and other powerful drugs. Despite the rigors of the profession, cardiologists maintain long, intimate relationships with their patients. They also practice preventive medicine by identifying risk factors for early diagnosis of heart disease. If you enjoy studying the anatomy and physiology of the heart and love mastering technical procedures, then cardiology is the subspecialty for you. Fellowships in cardiology last 3 years and are extremely competitive.
Endocrinology
This subspecialty involves the study of hormones, endocrine glands, and their effects on whole-body homeostasis. You will find an intimate connection between the latest basic science research and its application in bedside clinical practice. Endocrinologists are experts in treating disease states in which glands (pituitary, thyroid, adrenal, pancreas, gonadal) are either overproducing or undersecreting hormones. These problems include diabetes, thyroid dysfunction, gonadal disorders, pituitary tumors, adrenal gland dysfunction, and disorders of bone metabolism. Patients often live with chronic endocrine diseases that may not declare themselves for weeks or even years (other than a few subtle symptoms). Many of these diseases are treatable, often even curable.
Like great detectives, endocrinologists make use of an extensive array of diagnostic testing. They study adrenocorticotropic hormone (ACTH) stimulation tests, dexamethasone suppression tests, bone densitometry, and thyroid function panels. Aside from cases of diabetic ketoacidosis, adrenal crisis, and thyroid storm, there are few endocrine emergencies. This allows the clinician ample time to think about and prepare appropriate treatment regimens. Endocrinologists enjoy long-term relationships with their patients, who are typically on the younger side. As part of their patients’ therapy, they often have to address the behavioral and psychosocial aspects of endocrine disease. For instance, patients with poorly controlled diabetes need to be taught (and encouraged) to modify their lifestyle, comply with their medication schedule, and use home glucose monitoring. Although much of their time is spent in the clinic setting, endocrinologists also serve as inpatient consultants for endocrine emergencies and diagnostic or treatment challenges. If you are interested in this highly scientific subspecialty with many positive outcomes, there are 2-year fellowships in endocrinology.
Gastroenterology
Specialists in gastroenterology treat diseases of the entire digestive system—from the esophagus to the anus, as well as the liver, gallbladder, and pancreas. Depending on the disease process, their relationships with patients may range from a single consultation (e.g., a patient presenting with pancreatitis or upper gastrointestinal bleeding) to long-term close relationships (e.g., patients with ulcerative colitis, hemochromatosis, or chronic liver failure due to alcoholic cirrhosis). They often see patients on the surgical wards following liver transplants and in the intensive care unit with massive gastrointestinal bleeding or fulminant hepatic failure. Because of the delicate nature of the subject matter, gastroenterologists often have to pay close attention to psychosocial aspects, particularly when discussing the implications of bowel disease for the patient’s lifestyle.
As in cardiology, exciting technical procedures are an integral part of the management of gastrointestinal disorders. You will become quite adept at inserting tubes into your patients’ mouths and rectums and seeing their diseases right before your very eyes. Colonoscopy, flexible sigmoidoscopy, and esophagogastroduodenoscopy allow the clinician to directly visualize disease, take tissue biopsies for diagnosis, and even provide immediate treatment by excising polyps or cauterizing bleeding vessels. Patients rely on their gastroenterologist to screen for precancerous lesions and to remove them before they become malignant. Whether draining fluid from an abdomen filled with ascites or recording intraesophageal pressures, there are many other diagnostic procedures. With new technology on the horizon, gastroenterologists will soon be able to perform endoluminal surgery with lasers and use built-in ultrasound probes to provide new views of our digestive organs. Gastroenterology is a perfect specialty for students who love this combination of technical interventions and cerebral challenges. Fellowships in gastroenterology require 3 years of training. Special qualifications certificates are available in hepatology (liver disease) and advanced endoscopy.
Geriatrics
Rather than treating a particular disease or organ system, geriatricians care for a specific population—the elderly, the largest growing proportion of the US population. Patients within this age group typically have many complex medical problems, ranging from degenerative neurologic disease such as dementia to systemic diseases like high blood pressure and diabetes. Because older patients take a fair number of medications, geriatricians must be experts on drug interactions, adverse effects, and how drugs are metabolized in an older person. At times, they must be selective about which diagnostic procedures and therapeutic undertakings their patients can tolerate. Using a multidisciplinary approach, they address the physical and psychosocial needs of their patients amidst an extensive constellation of medical issues. After all, the elderly have their own special set of problems, such as delirium, dementia, incontinence, and decline in functional status. Geriatricians are intimately familiar with nursing home settings and dealing with Medicare. The practice options for these highly sought after specialists include traditional outpatient care, consultations at nursing facilities, and academics. Fellowships in geriatric medicine require 1 additional year of training.
Hematology–oncology
Most specialists practice both disciplines as a single field of medicine, usually with an emphasis on oncology more so than hematology. Patients with diseases of the blood, bone marrow, and lymphatic systems require the expertise of a hematologist. These disorders include anemias, clotting abnormalities, leukemias, lymphomas, and bleeding disorders like hemophilia. Medical oncology involves the evaluation and treatment of neoplasms, both benign and malignant, of every organ system, from the brain to the kidneys. Some oncologists develop specific expertise in a particular type of cancer, such as malignant mesothelioma. They are experts on the latest forms of chemotherapy available, particularly those currently used in experimental clinical trials.
Regardless of the area of oncology, you will no doubt acquire both a philosophical and practical approach to life and death. Oncologists recognize that the therapies they prescribe sometimes present both great therapeutic benefit as well as significant risk to the patient. They have to reconcile the benefit of every treatment option with the harm involved, which means exercising courage and faith in their patients’ ability to cope with the burden of disease and its treatment. This specialty, therefore, requires the highest level of sensitivity, compassion, and empathy. While helping patients through a difficult time, oncologists must tell them the truth about their disease in an easily understandable and compassionate manner. They must guide patients and their families through the dying process, easing the process by providing good pain control and maintaining the patient’s dignity. Hematology–oncology is especially rewarding for those who can handle the challenge that despite your best efforts and medical care, many of your patients will not survive. Your efforts will never be in vain, for there are patients whom you will indeed cure or whose lives you will prolong. Despite being specialized, hematologists and oncologists provide a broad base of general internal medicine. Fellowships in hematology–oncology are 3 years in length.
Infectious Disease
If you love studying bacteria, viruses, parasites, and fungi, then the subspecialty of infectious disease is for you. These physicians take the basic science of microbiology and apply it to clinical situations. In their diagnostic workup, they approach the patient’s disease process by taking into consideration recent travel, geographic region, country of origin, and cultural practice. They are experts in the proper collection and analysis of culture specimens, plus a variety of laboratory tests, such as antibiotic sensitivity tests, CD4 counts, and infectious serologies. Their treatment regimens are largely pharmacologic and draw on the latest developments in antibiotic therapy. Through the use of vaccines, they practice a great deal of preventive medicine.
Most patients who require the expertise of these clinicians have diseases that are short-term in nature. Thus, infectious disease specialists typically serve as consultants for other physicians. In the summer of 2002, they were on the front lines of the new West Nile virus outbreak in the United States. They consult on patients in the hospital for diagnostic challenges (e.g., fever of unknown origin) and for treatment regimens of specific infectious diseases (e.g., bacterial endocarditis, meningitis, cellulitis, sepsis). Many infectious disease physicians maintain longer relationships with patients suffering from chronic diseases, such as HIV/AIDS and tuberculosis, who require extensive follow-up. Some practice travel medicine, serving as consultants to patients preparing for international travel and to those who acquired illnesses while overseas. Other areas of expertise include infection control within health care settings, international public health, and the prevention of antibiotic resistance through education and research. They also are involved in the tracking and epidemiology of certain communicable diseases. As the threat of biological attack becomes a growing concern, the prevention, recognition, and treatment of bioterrorism are now focal points of infectious disease. Fellowships require 2 years of training after residency.
Medical Informatics
Internists with a specific expertise in medical informatics continuously optimize the collection, storage, and reporting of health care information. They oversee the integration and interoperability of electronic health records. As a field, medical informatics seeks to improve the safety and efficiency of health care organizations. This specialty was recently established as an ABMS subspecialty with accredited fellowships and board certification. Medical informaticists maintain a focus on systems-based approaches to improve quality, efficiency, and overall delivery of value-based care.
Nephrology
Fascinated by the kidney and complex renal physiology? Nephrologists are masters of fluid, electrolytes, and acid–base homeostasis. After all, the kidneys are responsible for filtering out impurities from the blood. As part of their diagnostic workup, they analyze acid–base studies, electrolyte panels, and urine collections. In this highly intellectual specialty, they treat all types of diseases of the renal system, such as infection, kidney stones, alkalosis/acidosis, autoimmune disorders, renal artery stenosis. The nephrologist must understand how systemic diseases like hypertension and diabetes affect the kidneys, as well as be able to identify renal toxic effects of any medication. Long-term relationships are formed with patients who require chronic dialysis, and life-saving interventions such as acute hemodialysis are often provided within the intensive care setting. Nephrologists also treat postrenal transplant patients and manage the complications of chronic immune suppression secondary to posttransplant medical therapy.
There are several procedural skills to master, particularly the placement of hemodialysis and peritoneal catheters and the ability to biopsy tissue from the kidney. Some nephrologists gain additional interventional training and perform thrombectomies and even angioplasty of renal arteries. Although it requires technical skill, nephrology is also one of the most cognitive subspecialties within internal medicine. You can practice as a consultant, direct a dialysis center, work as an intensivist, or practice both nephrology and general medicine. Although dialysis patients can be demanding at times, solving their complex medical problems is highly gratifying. Nephrology fellowships require 2 years of training.
Pulmonology and Critical Care
Despite taking care of the most critically ill patients, these technically superb specialists never lose their cool under pressure. Although considered two separate subspecialties, most clinicians undergo training in both fields. Pulmonology entails the diagnosis and treatment of diseases of the lungs and upper airways, whether infectious, inflammatory, or cancerous in origin. Every day, they interpret arterial blood gas studies and pulmonary function tests. These specialists often serve as consultants to patients requiring expert management of emergent problems like pulmonary hypertension, hemoptysis, and pulmonary embolism. Continuity of care is also important in pulmonary medicine, particularly for patients with chronic problems such as asthma, emphysema, and occupational lung damage. In the multidisciplinary world of critical care, these physicians deal with more than just disorders of the lung. They take care of very sick patients who have life-threatening multiorgan system problems, from septic shock to heart failure to metabolic abnormalities.
If using high-tech monitors and interventional skills to solve complex clinical problems sounds appealing, then consider a career in pulmonology and critical care. In both areas, you become quite adept at performing many procedures. These specialists are experts at bronchoscopy, thoracentesis, ventilator management, and the placement of central lines and Swan–Ganz catheters. You will witness life-saving interventions as well as prolonged and agonizing death, and you will learn to meet both outcomes with the same level of professionalism. You will also become seasoned in end-of-life decision making. As they try to cope with the imminent death of their loved one, the families of your patients will be grateful for your care and guidance when addressing issues regarding goals of care and resuscitation limitations. Fellowships require an additional 3 years of training. You can also earn certification in only one of the two disciplines through 2 years of fellowship.
Rheumatology
Rheumatologists treat diseases of the musculoskeletal system such as osteoarthritis and gout in addition to complex systemic diseases like lupus and rheumatoid arthritis. They deal mainly with people with chronic diseases that are not curable. Diagnostic challenges are common in rheumatology, as evidenced by the treatment of rare diseases such as scleroderma, amyloidosis, vasculitides, and polymyositis. They interpret complicated rheumatologic blood tests and perform joint aspirations and steroid injections. What are complex presentations of disease for your colleagues, will, in your eyes, appear as routine manifestations of common rheumatologic disorders. Depending on your orientation to laboratory research, you may find yourself working within an overlapping world of rheumatology, immunology, and genetics. The treatment of rheumatologic disease most often consists of immunosuppression as well as adequate pain control. Future advances in gene therapy could potentially revolutionize therapeutic options within the field of rheumatology. Fellowships in rheumatology require 2 years of additional training.
NEW “HORIZONTAL” SUBSPECIALTY AREAS
In recent years, new fellowship opportunities within internal medicine have multiplied. Unlike the organ-based orientation of traditional subspecialties (like cardiology or pulmonary medicine), the focus of these fellowships is specific patient populations and aspects of health care delivery that are applicable across many areas of general medicine. Training opportunities are becoming more abundant and diverse each year. Because the American Board of Medical Specialties does not officially recognize these subspecialties, board certification examinations are not available. Instead, graduates of these fellowships earn a certificate of added qualifications. Programs typically last for 1 to 2 years.
Addiction Medicine
Internists with specific expertise in addiction medicine provide treatment for those addicted to alcohol, tobacco, and illicit drugs on an inpatient and outpatient basis. Because medical professionals have a high rate of substance abuse, some addiction specialists focus on the prevention and treatment of addiction among health care providers.
Adolescent Medicine
In this growing subspecialty, prominent areas of prevention and treatment include substance abuse, eating disorders, acne, sexually transmitted diseases, pregnancy, and depression. In addition, adolescent medicine emphasizes the management of chronic diseases that begin in childhood and continue into adulthood, such as asthma, cystic fibrosis, congenital heart disease, and diabetes. Practice settings include high-school- and university-based student care centers, mobile clinics, and outpatient clinics. Many adolescent medicine specialists work within large academic medical centers or in the public health sector.
Clinical Decision Making
Internists specializing in clinical decision making attempt to optimize health care delivery through analysis of cost effectiveness, health care policy, the development of clinical guidelines, and evaluation of clinical outcomes. Practice settings include academic departments, government policy-making agencies, health insurance companies, and managed care organizations.
Clinical Nutrition
Clinical nutrition focuses on the prevention and treatment of nutritional deficiencies, food allergies, eating disorders, and malnutrition of chronic disease. Some practitioners approach the subspecialty from a public health standpoint, whereas others develop expertise in nutritional aspects of specific diseases such as diabetes mellitus, inflammatory bowel disease, or chronic renal failure.
Palliative Care
A palliative care specialist provides pain control, emotional support, and dignity to dying patients while also addressing the needs of their family members. Practice settings most commonly include inpatient hospice facilities and home hospice care. Patients are not always comfortable discussing death and dying with physicians. As a skilled palliative care specialist, you can help the dying patient accept the passing of his or her life rather than fear and suffer it.
Primary Care Sports Medicine
Sports medicine is the practice of preventing and treating sports-related injuries, as well as promoting exercise as preventive medicine for the general population. Those internists practicing sports medicine often provide acute care of injuries during athletic events. Most work closely with orthopedic surgeons, although most athletic injuries, as many studies have shown, do not require surgery. The treatment of basic medical problems is considered to be sports medicine if the patient is an athlete or the problem is related to exercise.
TELEMEDICINE: LOOKING TO THE FUTURE
In the last 4 years, a great deal of excitement and optimism has revolved around the promise of using technology to connect patients and doctors over distance. Telemedicine is not specific to internal medicine, nor does it have its own specialty, although some physicians feel telemedicine has the potential to evolve into a specialty in the future.6 However, telemedicine and video visits within internal medicine represent a powerful tool to enhance the much-needed access to high-quality medical care through a very cost-effective platform.
As it relates to internal medicine, telemedicine is practiced as face-to-face real-time audio and video visits. Doctors in telemedicine practices often possess multi-state licensure and see patients across state lines. Patients can gain access to these doctors within minutes from the comfort of their own homes which has resulted in much-needed improvements in patient experience.7,8 Telemedicine has clear limitations, but deserves mention as our nation faces worsening primary care shortages.9
WHY CONSIDER A CAREER IN INTERNAL MEDICINE?
There are many misconceptions about internal medicine, probably because it is such a broad field. A study by the American College of Physicians and American Society of Internal Medicine (ACP–ASIM) found that only 18% of patients surveyed thought that general internists could provide primary care, and 56% believed that general internists were subspecialists.10 Some internists, in fact, have a patient base comprised of older children and adolescents, whereas others primarily see elderly patients in their practices. As a result, internists have the flexibility to work in many different settings: the ambulatory clinic, the inpatient ward, the intensive care unit, nursing homes, and hospices. Internal medicine, therefore, is much more than a specialty devoted to chronic illness without possible cures. Instead, this very personally satisfying field of medicine allows a physician to help patients achieve the best quality of life possible.
Internists are knowledgeable in many aspects of medical care. They treat acute and chronic conditions, not to mention common and rare disease entities. Even if you choose another specialty, no physician can avoid the basics of internal medicine. For instance, orthopedic surgeons have to treat hypokalemia, obstetricians–gynecologists need to be well versed in the management of hypertension, and psychiatrists must be able to recognize the signs and symptoms of hypothyroidism. Internal medicine is, in a way, the foundation for all fields of medicine. If you are excited by the prospect of providing care for adults as a diagnostician, healer, motivator, and patient advocate, you would certainly find a career in internal medicine rewarding.
Medical students who are undecided on a specialty should take into account that training in general internal medicine provides the foundation for a long list of career options. Within one career, you could practice general medicine, provide primary preventive care, specialize in one organ system through formal fellowship, or even independently develop a specific expertise. By deciding to enter internal medicine, medical students ensure themselves a career filled with intellectual stimulation, diagnostically challenging patient interactions, and rewarding relationships. The focus on the patient makes practicing the art of internal medicine an extraordinary privilege.
ABOUT THE CONTRIBUTORS
A native of southern Illinois, Dr. Jennifer Tong received her BS from the University of Illinois Urbana–Champaign before entering medical school at the University of Chicago. She completed residency training in internal medicine at Stanford University Hospital. As Chief Medical Information Officer at Contra Costa County Health Services, she leads the Clinical Informatics Division and implementation and optimization of health technology.
After earning a BA in English from the University of California, Berkeley, Dr. Ian Tong also received his medical education from the University of Chicago and completed residency and chief residency at Stanford in Internal Medicine. He is now the Chief Medical Officer at Doctor On Demand, a digital health start-up. Jennifer and Ian live in the Bay Area with their three children. They may be reached by e-mail at jrlambmed@hotmail.com or itong@doctorondemand.com.
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