Internal Medicine: The "Classic" Physician

By Brent Schnipke

If the average reader is asked to imagine a typical medical student, he or she might picture the following scene: a group of frazzled young people in short white coats, scurrying around the wards of a large academic medical center. They travel in hordes, flocking to the nearest attending, who calmly asks them asinine questions and then chides them for their lack of knowledge. This scene is stereotypical of an often-stereotyped field, and might be something one would see in a caricature of the hospital – on a show such as Grey’s Anatomy or Scrubs. Although this is only one example of what medical education can look like, it is helpful for giving a simplified look at the life of a third-year medical student in the throes of clinical rotations.

This “typical” scene would probably occur during the internal medicine (or simply medicine) clerkship; ironically, this is my last rotation of third year. Thus the typical picture of a third-year medical student is something I’ve not even done up till now, the end of my third year. It is a strange experience: many of the other disciplines and rotations I have completed have assumed I’ve already had my internal medicine clerkship, because it forms the foundation for much of medicine and is at least a component of most other specialties. I have pieced together information about how the wards operate, how hospital medicine is delivered and how to manage patients who are admitted to the hospital from my other rotations. These are all the core components of internal medicine, but I didn’t have the opportunity to learn them directly until after completing everything else.

Although this is somewhat backwards, I believe that it has allowed me to grow as a student in ways that wouldn’t have been possible otherwise.

Because I began this clerkship with the collective knowledge of the other rotations I had done (OB/GYN, pediatrics, surgery, psychiatry, and family medicine), I was already primed to think clinically about a wide variety of problems. This rotation has been an excellent opportunity to hone skills I learned previously and to synthesize the complex knowledge and tasks that comprise being a physician. I am not yet ready to be a doctor, but I am excited at how much I’ve learned – and this rotation has really put that into perspective, as I was pushed to start thinking about problems like a resident, and found that I was able to do so (with plenty of help along the way).

Internal medicine is perhaps the broadest yet least understood branch of medicine by the general public. It is the specialty which focuses on the medical care of adult patients. The classic picture of an internal medicine doctor (or internist) is the hospital-based physician, making rounds and managing patients admitted to the hospital. This is a large portion of internists, but it is an incomplete picture. Internists can and often do practice in the outpatient setting as well, serving as primary care physicians for adult patients. Further, medicine is the route by which most medical specialists are initially trained, so physicians such as cardiologists, nephrologists, and pulmonologists all began their training in internal medicine.

Internal medicine is often confused with family medicine, because both are considered primary care and many of the skills and training overlap. Internists who practice in the outpatient setting may be indistinguishable from family doctors on the surface. The primary difference is in the components of residency rotations, which creates a different scope of practice. Internists focus on the medical care of adults, which allows more time during training to delve into the various subspecialties. They do not necessarily manage more complex patients than family doctors, but the more focused training does often give them more experience with a depth of problems. By contrast, family doctors spend a portion of their training in obstetrics, in pediatrics, and even in general surgery, creating a broader scope of practice. Despite these differences in training, many family doctors are functionally similar to internists, seeing mainly adult patients in the clinic setting.

Internal medicine as a specialty tends be very academic; the inpatient service at most large hospitals in the United States is tied to a residency program and/or medical school. This connection is appropriate, because what struck me about this rotation was the opportunity to constantly learn.

In addition to structured didactics each week, we had mini-lectures at morning report and a topic lecture during noon conference every single day. The attendings and residents with whom I worked were generally very interested in teaching; each patient we saw was a new opportunity to review a common topic or explore a new disease process. Further, the focus on evidenced-based medicine (EBM) was quite clear; internal medicine was the specialty that piloted the EBM movement, and as such there are treatment guidelines and protocols and new studies that create a system of effective, evidence-guided clinical practice. As a medical student, I found it to be a valuable approach to medicine, because it allowed me to constantly learn something new, and I finished the rotation feeling sharp on a wide variety of topics.

Internal medicine can be a difficult specialty from an emotional side as well, especially inpatient medicine. Any time a person is hospitalized, there are inherent social and personal challenges – dependent on the person – beyond the pathophysiology and management complexities that may also be present. For the internists who work in the hospital, there may be the unfortunate reality of continuity – patients who get admitted regularly and are well-known, but not because they are following up in clinic. Patients with chronic diseases who are in and out of the hospital often comprise a large portion of the patients admitted on any given day, and this too requires skill to navigate the social situations of people who spend much of their time as a hospitalized patient.

As I have already alluded to, there are plenty of practice opportunities and specializations available within internal medicine. Categorical internal medicine residency is three years long and offers training in both inpatient and outpatient general medicine as well as the subspecialties that form a cohesive educational experience with a broad knowledge base. Specialties that are found under the umbrella of medicine include Allergy & Immunology, Adolescent Medicine, Cardiology, Endocrinology, Gastroenterology, Geriatric Medicine, Hematology & Oncology, Hospice and Palliative Care, Infectious Diseases, Nephrology, Pulmonology & Critical Care, and Rheumatology. Additionally, medicine is often combined with other specialties to form combined training programs; these include Internal Medicine/Pediatrics (Med/Peds), IM/Preventive Medicine, IM/FM, and IM/Psychiatry.

This rotation concludes my third year of medical school, which is particularly hard to believe as I look back over the past year of learning and life changes. As I head into fourth year, I am going to continue this column; I will continue to write about clinical experiences and the process of choosing a medical specialty. I plan to highlight a few more specialties which I haven’t yet been able to, as well write about the final stages of choosing a specialty and applying, since that what I’m about to do! If you have specific questions you’d like answered or topics you would like covered, please send an email to [email protected] Thanks for following along.

Central to the skillset of every physician is the differential diagnosis; this is the process by which new patients are evaluated to establish the most likely diagnosis. Similarly, the first clinical year of medical school is like a differential for each student, except instead of a medical diagnosis, students are seeking to determine which specialty they will choose. This column explores this differential: experiences from each rotation by a current third year student.

About the Author
Brent Schnipke is a third year medical student at Wright State University Boonshoft School of Medicine in Beavercreek, OH. He is a graduate of Mount Vernon Nazarene University with a degree in Biology. His interests include medical education, writing, medical humanities, and bioethics. Brent is also active on social media and can be reached on Twitter @brentschnipke.
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