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What’s an Internal Medicine Residency Really Like?

Are you considering going into Internal Medicine? Let’s take a look at what IM is and what you can expect from an IM residency. 

What is Internal Medicine?

Internal Medicine is a broad speciality that encompasses foundational medicine training (often called categorical training) as well as many sub-specialities such as Cardiology, Gastroenterology, and Infectious Disease. It is one of the largest specialities in terms of numbers of residents. About half of residents become general internists and the other half sub-specialize. 

According to the American College of Physicians, Internal Medicine is a science that represents the best of both worlds. The specialty combines the analytical examination of laboratory science with a personalized approach to adult medicine. This combination enables doctors to treat both common illnesses and complex, as well as long-term, medical conditions. They care for only an adult population and can work in the both hospital and outpatient setting.

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Internal Medicine residency programs are three years and sub-specialty fellowships extend training by two or more years. There are also dual training programs available that provide board-certification in IM as well as a second speciality. Med-Peds (Internal Medicine and Pediatrics), EM-IM (Internal Medicine and Emergency Medicine), or Internal Medicine and Psychiatry are examples of dual training programs.

How do you distinguish between different IM residency programs, and if IM is a good fit for you?

There is no one-size-fits all for each doctor or each program. It’s best to begin by exploring what’s important to you and then look for that in the program. 

Do you envision your future as a faculty member at an academic medical center? Then consider seeking a residency at an academic medical center and try to find a research mentor.

Are you planning to sub-specialize? Well-known academic centers tend to have good track records for matching their resident graduates into sub-specialty fellowships. Some academic medical centers reserve a portion of their fellowship positions for residents at their own institutions. If you dream of going into Cardiology, finding a program that hosts a large Cardiology fellowship program could boost your chances of landing that dream job. However, be sure to ask how many of their current fellows in your desired sub-specialty graduated from their internal medicine residency. Sometimes these fellowship programs don’t hire from within.

On the other hand, if you’re not sure if you want to sub-specialize or do a lot of research, or if there is a program close to home or that has a reputation for treating its residents well, don’t shrug these off as sub-par or undesirable. You will be board-certified if you graduate from any accredited program!

How do you decide between Med-Peds and Family Medicine?

One common question that arises is what the difference is between doing an Internal Medicine (IM), Med-Peds, or Family Medicine (FM) residency. 

There are a few key elements that vary between IM/Med-Peds and Family Medicine. Family Medicine requires training in obstetrics, which would not be a part of IM or Pediatrics residencies. The major difference in most programs is the amount of time you spend in the hospital versus the outpatient clinic. Internists (and pediatricians) spend a much larger portion of their core training in the hospital setting compared to FM physicians. 

Hospital training makes it easy for IM residents to go on to do hospitalist work, but if they want to land in an outpatient clinic there may be some additional professional development required. Likewise, FM physicians can go on to do hospitalist work, but it might take some extra effort and/or training to catch up to their IM peers in the hospital (depending on the individual’s residency program of course). If you’d like to work in the hospital setting with adults and children, or want to leave the door open to work with children outside the hospital in addition to adults, you may want to consider Med-Peds.

If you end up doing either general hospitalist work or outpatient work, it may not matter much which path you took in residency. However, your choice of fellowship options will be strongly affected by the residency you choose. Relatively few fellowships accept residents from both FM and IM.

For example, Geriatrics and Palliative Medicine are often accepting of residents from both fields. Any of the IM sub-specialties, such as Cardiology, Gastroenterology, and Hematology/Oncology require an IM residency. Most Sports Medicine fellowships require a FM residency. If you know you want to do general medicine in the outpatient setting for all ages, strongly consider Family Medicine. If you want to leave the door open to a wider number of sub-specialty fellowships, consider Internal Medicine.

Lastly, consider the general mindset that is instilled into people who train in FM versus IM, and how you tend to think about medicine as well. Internal Medicine tends to focus on generating expertise in diagnostic skill and medical knowledge. Family Medicine tends to give more space to developing people skills, communication skills, and a public health or community health perspective. Spend some time around doctors in both of these fields and get the feel for this difference.

How hard is Internal Medicine to match into?

How hard is it to get into IM? If you want to dive into the exact facts and figures, you can see the NRMP’s report here. In general, IM is considered a less competitive speciality, simply because the number of positions available to match into is very large compared to other specialties. Remember, this residency includes everyone who will go on to apply for any IM sub-specialty fellowship, in addition to all the people who decide to practice general IM. However, highly respected and top-rated program are quite competitive to match into.

What’s an Internal Medicine residency schedule REALLY like?

Time working in actual hours spent is very program dependent and rotation/service dependent. When you are working inpatient, your hours worked per day can be quite long. When you’re in clinic seeing patients, it’s possible to follow a more typical 8-10 hour day.

Some programs follow a more traditional schedule which consists of hospital rounds in the morning and clinic in the afternoons. Many programs are shifting now to various block schedules (4+1, 3+1, etc) meaning you get a week or two of clinic every few weeks to break up the long days on the hospital shifts. Many residents say that wards are the most arduous part of their rotation as well as overnight call. 

There may also be periods of study or research, which are much more relaxed in terms of schedule. You likely can divide up your time how you wish. 

How many hours will you REALLY work?

What’s the weekly workload in terms of hours worked during an Internal Medicine residency? According to studies and resident reports, 70-80 hours per week during hospital rotations and 40-50 hours per week on outpatient clinic rotations is normal for this type of residency. However, even with caps on hours worked, it’s not uncommon to go beyond this amount. 

How would that happen if it’s not allowed? Residents want the work experience, and there are often work cultures that encourage residents to under-report their hours so that they don’t “rock the boat.” 

Some programs may try to observe resident duty hour rules more strictly. However, keep in mind that these rules specify a weekly limit that is averaged out over four weeks. So if you go over that limit one week out of four, but you stay well below it the other three weeks, you are still working within that duty hour limit.

How can you take care of yourself during residency?

Residency will challenge you in unexpected ways. In order to handle the long hours, stress, and physical requirements of the profession, work to avoid spending 100% of your time and energy on your residency. You will need some downtime when possible. Your key to success will be having some systems in place. It requires time management and self-regulation. You’ll need a regular exercise routine, time to socialize outside of work, and time to read or enjoy things that are not related to your residency. What are some healthy activities you can do? What are some strategies you can put into place to help you de-stress and relax?

How can you get support?

If you have a spouse/partner, family and friends, or a group you’re part of, you can lean on them for support. You can also talk to your residency director about programs and resources to help residents handle burnout and stress, or deeper issues like depression, substance abuse, or other unhealthy behaviors. 

Where can I learn more about Internal Medicine?

IM also has some great podcasts out there. These podcasts provide not only inside looks into IM and discuss various medical topics, but can also bring some humor and perspective into the daily grind of residency. Check them out:

Best of luck to you as you make your decisions and apply for Match!

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    Tachyon
  • October 15, 2019
You summed it all up very nicely! Good article.
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