In the Internal Medicine Specialty, Sky Is the Limit!

Session 118

Where will you see the most variety of patients? Internal Medicine, of course! Dr. Hilary Ryder gives us a peek into subspecialties and the IM lifestyle.

Hilary is the Internal Medicine program director at Dartmouth-Hitchcock Medical Center. She shares her internal medicine residency experience, how to pick a program, and how to stand out in your applications and rotations.

If you haven’t yet, please do check out our other resources on Meded Media.

Listen to this podcast episode with the player above, or keep reading for the highlights and takeaway points.

[01:13] Interest in Internal Medicine

Hilary was initially unable to make a decision about what specialty she wanted to go into. Into her fourth year, she thought she wanted to be a dermatologist. What drew her to it was the lifestyle having no nights and weekends. It felt like a lifestyle specialty that she could get into.

During her third year clerkship in medicine, she really loved what she was seeing but she wasn’t sure if she could handle the 30-hour shifts they were doing. Eventually, she did a medicine sub-internship in hospital medicine that didn’t have any overnight shifts.

She ended up falling in love with her team and with how diverse the cases she was managing. She started to take on more ownership of patients. She found it so rewarding that she found the 30-hour shifts to be all worth it.

The’res this idea of spending of 6-12 weeks on Internal Medicine doing some hospital medicine work, ambulatory care work, etc. Then you’re going to figure out this is what you’re going to do.

'A lot of people choose internal medicine like me because they can't make a decision.'Click To Tweet

And so a lot of people choose IM since they haven’t really made their decision. But then when you’re in your residency, you’re stuck making another decision because there are so many different ways to be an internist. You have the breadth of opportunities all over again within internal medicine.

[05:45] Types of Patients

Hilary explains that the types of cases an internist might manage basically depend on your geographic location. She’s from New England and a lot of their primary care doctors are internists.

If you travel more to the midwestern states, you’re going to find that most of the primary care doctors are family medicine doctors. So you go into internal medicine planning to subspecialize.

You can do an internal medicine residency and go into Sports Medicine, Allergy, Interventional Gastroenterology, Interventional Cardiology, Geriatrics, or Critical Care.

'When you look around, the number one place that more doctors than anywhere else start their training is in internal medicine.'Click To Tweet

If you go into Anesthesia or Psychiatry, you’re going to do just a couple of months of medicine. If you’re going into Neurology or Radiology, you’re going to do a year of internal medicine. If you want to be an Endocrinologist, you’re going to do a three-year IM residency. And then spend some more time in a fellowship subspecializing even more in terms of the types of patients you’re going to take care of.

Many of the mentors you’re going to see in your second year are internists. In your preclinical years, a lot of the physiology and the pathophysiology are going to be taught by internists.

In Nephrology, you’re going to learn your acid-base. And you’re going to learn your electrolyte disturbances from internist. They completed their three years of internal medicine and they went on to a Nephrology fellowship.

'Because it's so broad, you could spend your entire third year in internal medicine and still not see the breadth of what we have to offer.'Click To Tweet

[09:30] Typical Day

Their internal medicine residents rotate through a variety of different specialties within internal medicine. A third-year clerkship student rotates through a variety of different departments.

In their program, they have residents in the intensive care unit for a month. They have residents on the interventional cardiology service. They have those taking care of bone marrow transplant patients. They have residents in clinic and residents doing home visits.

In general, students know what the inpatient experience is, the interims of pre-rounding, then the rounding with the residents and seeing patients. What they may not see are some of the other work residents are doing.

Their residents do homecare visits with geriatric populations on their mandatory geriatrics rotation in the second year.

They have dedicated rotations on medical education to try and make their residents better teachers. Because they’re an academic program, they want residents to be able to teach medical students. So they spend some time on medical education.

'One of the things all medical residents are going to do is have a continuity clinic where they act as a primary care doctor for a cohort of patients that they follow longitudinally.'Click To Tweet

In medicine, they work in teams. So residents are going to have to go through a lot of teamwork and leadership. They expect residents to not only provide medical care but also, to teach others and lead teams that provide medical care.

The resident is going to need to learn how to interface with the social worker, the discharge coordinator, the primary care physician, and the student and the nurse. They have to keep those balls in the air and keep the team moving forward. They need to make sure there’s a great plan of care for the patient and the patient’s plan of care is being moved forward.

[Related episode: Resident Duty Hours and the Ripple Effect]

[12:40] Taking Calls

Taking calls is different depending on where you practice. In general, call for people who haven’t done a lot of clinical exposure would be this long-term, multi-day experiences. You live in the hospital and you admit a lot of patients that you cared for longitudinally.

Some programs are have gotten away from the 24-hour calls. This means you’re in the hospital admitting for 24 hours. You can be in the hospital for up to 4-6 hours after that cleaning up before you go home the next day.

Other programs like the night programs have gone to shift-based work where there is no long-term call. Residents will stay in the hospital and admit patients for a certain amount of time. They sign out to an overnight team who comes in to cover the patients and do the admissions overnight.

'One of the things that students should be looking at when thinking about programs is what style of work might work best for them.'Click To Tweet

[15:20] The 3 Kinds of Medical Students

There are medical students who have no idea of what they want to do coming into their IM residency.

There are also those who are pretty sure and they’re right. They end up doing what they think they wanted to do in the first place.

Then there are medical students who are pretty sure and they’re wrong. They try something out and realize it’s not for them. Some of the disease processes you learned about as a medical student may be intriguing. But the most common diseases in a specialty, you might not find all that appealing.

Figure out where you think your career is going. If the residency program you think you want to go to has never sent anyone to an Allergy-Immunology Fellowship and you’re determined to be an allergist, you really need to think if that’s going to be the right place or you.

'The most important is to think of a program where you think is going to get you where you want to go.'Click To Tweet

Consider what your experience is going to be like. Are you going to be with like-minded individuals? Are you going to have the clinical experiences and support you want?

Is it going to get you where you want to go? The best way to determine that is if there’s a track record of other people going there. Look at the schedule and who the leadership is. Look at where people went after residency.

[19:10] The Training Path

After Hilary finished medical school, she went into residency. She was undecided and she was one of the students who loved everything in medical school and thought she wanted to do everything. So she had difficulty choosing.

You spend 36 months in your residency program. You should get exposed to a wide variety of different specialties. If you choose not to go into fellowship, you’re ready to practice.

'Two places you can practice as an internist without further training are primary care and hospital medicine.'Click To Tweet

You can then practice as internist without further training either in primary care or hospital medicine. But even these two are broader than you think. A hospital medicine doctor is going to practice exclusively in the inpatient realm of things.

[21:08] How to Be a Competitive Applicant

Looking at the 2019 match data, 97% of internal medicine spots filled and only 42% are filled by U.S. Seniors from allopathic medical schools. There are a lot of DO students entering IM as well as international medical graduates.

To be most competitive, as with other specialties, they look at the internal medicine grades. Often, there’s an IM clerkship, a primary care clerkship, and at least a sub-I in either medicine or one of the subspecialties. They also look at the surgery grade.

'We look at all of the grades. But the surgery and the medicine clerkships and grades are the ones that we're going to look the most closely at.'Click To Tweet

Hilary believes in the holistic review of the application. They look at the Step scores as a marker of someone’s ability to pass the boards. They’re also looking at experiences. It doesn’t have to be a lot of research.

Some students worry that they’re in an institution that focuses more on clinical excellence or QI than basic science research. But what they’re really looking for is curiosity, leadership, and desire to learn.

They want someone who has done research in GI and inflammatory bowel disease and can talk passionately about that. Or someone who has been involved in medical education, curriculum design, volunteer work.

Other traits to be competitive include enthusiasm, eagerness, and a desire to make the world a better place.

They also look at the letters and they want to see whether the person is a team player. Is the person able to carry a decent patient load? They look at the medical knowledge and clinical decision-making. And the letters or the Dean’s letters are often the best way for them to see this.

You may not match into neurosurgery or orthopedics so you need a backup. However, more than anything else, they want eager residents who want to be at their program.

They can help you with things like if you have less exposure to a certain patient population or certain disease. But if you’d really rather be somewhere else, there’s not a whole lot they can do about that.

They look at any significant evidence that this student actually wants to be in a different specialty. And sometimes, this can be a bit subtle.

[28:20] Common Mistakes Students Are Making in their Sub-I’s and Away Rotations

There are some specialties that you need to do away rotations for you to demonstrate that you’re passionate about it. But you don’t need to do this for internal medicine. In fact, an away rotation can even backfire.

'The biggest mistake that students wanting to go into internal medicine is doing away rotations.'Click To Tweet

That being said, Hilary thinks that an away rotation as an audition rotation makes a lot of sense. You just have to be careful and recognize that you’re signaling to all the programs you’re applying to that you have that interest.

When it comes to sub-internships, the biggest mistake is not bringing in your enthusiastic game with you. It’s a hard month. And if you only the minimum that’s asked of you, the sub-I is the opportunity to do more.

'The sub-internship is the opportunity to do more.'Click To Tweet

Hence, you need to bring your A-game. Bring in your enthusiasm. Do more than what’s expected of you. Be a team player. If an attending asks you a question, make sure you’re researched that and you can answer that the next day.

Be the A-plus version of yourself independent of how tired you are and what else is going on in your life.

[31:50] IM as a Team Sport

Internal Medicine is a team sport. They’re working in teams, not just teams of physicians but also multidisciplinary teams.

When they say bring your A-game, it’s not the student who’s jumping over the other student to answer questions. But it’s someone who is assertive and willing to help out other people in the team.

They want to see that you care about the patients, about your team members, and also, you care about yourself.

'One of the common misconceptions is that doing well on the Shelf is more important than doing well for your patients.'Click To Tweet

They’re going to notice a student trying to get early everyday so they can study for their Shelf. Compared to someone who makes sure the patient is updated and see if there’s anything else they can help with.

[34:54] Common Application Mistakes

One thing Hilary observes that students are doing is panicking. If you’re planning to match in Internal Medicine and you have good mentorship, you’re going to be okay. But students tend to over-apply.

'You need to apply to programs appropriate for you. But you don't need to apply to 40 of them.'Click To Tweet

Personally, Hilary would see applications for people who she really doesn’t think would be happy at their program.

Hence, think about what you want in a residency program. Look and ask your mentor how competitive you are. Think of whether there are geographic restrictions. Or there’s a certain population type that you want to take care of.

Make sure that the residency programs you are applying to and interviewing at are going to give you that.

Get as much information as you can. You don’t want to be applying at programs you wouldn’t actually be happy at. Stick to the ones you think are going to give you the experience that you want.

[38:15] Thoughts on the Pass/Fail System

Hilary doesn’t think medicine is as impacted by the USMLE pass/fail. And that this system will help the people who are extremely dedicated but may not be great test-takers.

What she worries about more is the trend of withholding all information from residency programs.

More and more medical schools are going pass/fail in their clinical years. But if you don’t have grades, it would be hard for them to tell whether you’re going to do well in their program.

[40:45] Final Words of Wisdom

Be your authentic self. Be eager, enthusiastic, engaged, and a hard worker. Find a mentor. Wake up everyday thinking about what you can learn and how you can make the world a better place.

Look for ways to engage and participate. And the path will become clear to you. Surround yourself with like-minded individuals.

Seek your joy. Find out what diseases make you happy and what patients make you happy and what other providers you want to be with. Then you will figure out what the right place is for you.