My third year of medical school cemented the passion for primary care I developed as a volunteer in a clinic for undocumented immigrants in San Francisco. Relationship building, continuity of care, and seeing the impact a primary care physician can have on a patient’s health all ignited my passion more than any angioplasty or neurosurgery ever could. But one question continued to nag me as I filled in the bubbles of my electronic residency application form and formulated my personal statement: family medicine or internal medicine?
I loved both rotations during third year. Family medicine because it was broad, all-inclusive, and promoted an ethos of family — and community-centered care that aligned with my ideological predispositions. Internal medicine because it was cerebral, stretching the limits of my medical knowledge and pushing me to think creatively about a patient’s symptoms to get to the bottom of what her body was telling us.
Between my third and fourth years of medical school, I pursued a master’s in public health and a policy fellowship. For nine months, my mind was opened to entirely new health concepts I hadn’t entertained before. The social determinants of health were drilled into me, while the concept of community organizing for health ignited my desire for change in the health care system. I was sure at the end of this degree that I would apply in family medicine and treat the community as my patient, one family at a time.
But here I am, one year later, coming to the end of my intern year in an internal medicine primary care program. Why the switch? Did I lose the values that initially drew me to family medicine? No. The simple answer is I see medicine as a tool for two distinct purposes that I want to fulfill — and I found a residency program that fulfills both.
The first purpose is social change. Many diseases, especially chronic ones like diabetes and heart disease, afflict the poor more than any other group. Chronic diseases are the embodiment of the extreme inequality present in this society. They can be improved with conscientious and thorough care on the part of health professionals dedicated to the underserved and prepared to advocate on their behalf. This ethos is promoted by many family medicine programs, which emphasize the physician’s responsibility to the community and the family as well as the individual patient. Many family medicine residencies are located in areas of need and specifically aim to produce primary care physicians to improve health care outcomes in these areas.
In contrast, internal medicine programs are known for emphasizing preparation for fellowship and sub-specialization. Less than 30 percent of internal medicine residents choose primary care as a field. In some programs, this generates a culture that is unfriendly to primary care generally and a lack of mentors in primary care. There is also a very strong emphasis on hospital work in many internal medicine programs, to the detriment of the primary care experience. Thankfully, I was able to find an internal medicine program that values primary care preparation and social disparities in health more than the sub-specialties, which is a perfect fit for my worldview.
The second distinct purpose of medicine that fascinates me is the diagnosis and treatment of difficult symptoms that don’t have an easy explanation. Internal medicine has an ethos of dealing with these sorts of issues that I found compelling. Moreover, required rotations through the medical subspecialties bolster knowledge about rarer diseases and complications I may confront, and improve my facility with physical exam and history-taking skills in specialist areas. In this sense, I appreciate the focus on adults only, which allows me the breathing room to delve deep into these biomedical topics and to think carefully before I have to refer. I can also devote more time to pressing problems that affect adults only, like addiction medicine and geriatrics, both of which figure prominently in my residency curriculum.
I still occasionally think about family medicine, and the trade-offs I made in choosing internal medicine. I do not get as much variety as a family physician does, and I can feel the atrophy of the pediatrics and obstetrics parts of my brain. I’m also subjected to more hospital work than I would like. My love is the clinic. But I don’t regret my choice and still feel both fulfilled and challenged on a daily basis by the social and biological diseases that confront my health system.
Hugo Torres is an internal medicine resident who blogs at Primary Care Progress.