Final Thoughts: Internal Medicine

My fourth clerkship of third year (Internal Medicine) has come to an end...

• 10 weeks, 54 days, and 399 hours of work in areas ranging from General Internal Medicine Inpatient,  Inpatient and Outpatient Hospice, Hematology Oncology Outpatient Clinic, Cardiology and Autonomic Dysfunction Outpatient Clinic, and Cardiology Inpatient.
• Working at a nearby, larger hospital, I averaged 47.67 hours/week. 
• Working at the Outpatient Clinics, I averaged 25.42 hours/week.
• Working at my medical school's inpatient hospital, I averaged over 41.9 hours/week.
• I enjoyed 16 days off in the last 70 (that's 1.5 days/week). 
• Significantly more days off than usual due to the Christmas Holidays
• Plus 7 days off for Christmas/New Year (my one week off for the entire 52 weeks of third year)
• Every fourth day on Inpatient Medicine, I completed "Long Call", which was a 14 hour day (6a-8p).
• I studied Internal Medicine outside of work a total of around 111 hours.
• My total work in Internal Medicine over the past 10 weeks is: 510 hours in 10 weeks (52.4hrs/week...7.5hrs/day).

What I LOVED about Internal Medicine:

• I use my brain all.of.the.time. This is problem solving at its finest. The sheer amount of knowledge one needs to succeed in Internal is overwhelming at times, but it is definitely achievable.
• There is more than one right way to solve any problem...unless you use mindless algorithms, which suck the intelligence out of medicine and produce a "one-size fits all" workup, diagnosis, and treatment plan for patients. (side note: there is no "one-size fits all" plan that works for everyone, things need to be altered to fit each individual patient if they are to be treated optimally). 
• 3 year residency. Sorry, maybe you didn't catch that clearly enough: THREE YEAR RESIDENCY! 
• The options after internal medicine residency are limitless! There are so many fellowships one may complete after board certification in Internal Medicine.
• This is the pathway to Hematology-Oncology, which is a 2 year fellowship after internal medicine residency. In FIVE years time, I can be a fully licensed and practicing Oncologist, while my peers will still be in their surgery residency. That excites me!
• My other area of interest in Gynecology-Oncology, which involves a 3 year residency in OB-Gyn followed by a 3 year fellowship in Gyn-Onc. SIX years to be fully licensed and practicing Gyn-Onc. 
• BUT I have little to no interest in being an OB-Gyn --- it feels like such a high-risk occupation, with a lot of variables that are out of your control for which you can be held liable. But the babies are so much fun. And the moms are great. And I like to care for women. So I suppose I might actually be a bit up in the air about it...
• There are so many opportunities to teach. I would love to have the time to teach students/residents as an attending some day.
• There is time for research as well, if you're into that, which I am.
• There is a huge flexibility in weekly hours worked once you become an attending. This is really appealing to me, because I know in the future when we start a family, I will likely want to slow down my work and spend time raising our children. 
• But for the time being I would happily work 80 hours a week in the hospital! Let's just get that straight!
• And by slow down, I mean work 40-60 hours as opposed to 60-80 hours per week.
• By going into Internal Medicine, you leave so many options open. There are so many opportunities to specialize, which is very appealing because it allows for time to decide what I want to spend the rest of my life doing without "being stuck" in a less-forgiving pathway like surgery.
• You know a little bit about everything.
• You have more time to interact and educate patients (as compared to surgery or obgyn).

What I DIDN'T love about Internal Medicine:

• The paperwork. Good Lord, the paperwork!!!
• Sick patients will continue to get sicker; Oftentimes, the best we can hope for is to slow the progression of an illness, which can be frustrating.
• But sometimes people get better!
• And sometimes, people will lose weight, quit smoking, eat healthier, and put their health on their priority list, which can mean that some diseases might improve! (ie., diabetes mellitus and hypertension)
• "Frequent Fliers", which is a rude way of categorizing patients who rotate in and out of the hospital on a very regular basis due to chronic and debilitating illnesses.
•  Man, oh man, can rounding take ages!! You might walk around the wards of the hospital for 10 hours, nonstop, just watching the attending write notes and visit patients. This isn't so bad if the attending prefers "table rounds", where we talk about the patients while sitting in a room and discussing treatment options and exploring educational topics that arise before trotting around the hospital in a huge group. I find this approach most educational, and my feet and attention span also appreciate it.
• I would definitely want to specialize. General Internal Medicine is far too broad for me; I want to be the best in one area of medicine.
• Patient compliance is an issue, which is partly due to poor communication with patients regarding treatment and importance of adherence to medication. 
• We sit around. A lot. And I'm not one to sit still...
• I want to work with my hands, at least to a small extent...and I'm not sure how many procedures I would be able to perform as an Internist!
• You see a lot of really sick people, and you see a lot of death. Which is why it is so important to have personable physicians in this field, for the patient's families' sake as well as for the physician's mental health.

I enjoyed Internal Medicine for its intellectual stimulation and problem solving qualities. There is a lot of patient interaction, which I love. I absolutely loved living the outpatient life. Heme-onc just feels like such a perfect fit. And I could do general internal medicine for a few years without going crazy. The residency doesn't seem too horrible, at least from the hours/week standpoint.

I have no idea what it would be like in England. But if I stayed in the states, I would likely go down this route of Internal Medicine residency (3 years) followed by Hem-Onc residency (2 years) and I would be a very happy woman when all is said and done.