The choice between family medicine and internal medicine

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.

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  • Suzi Q 38

    Where is BuzzkillerSmith?
    This is usually the time he lets you know that you made an error because you did not specialize.

    Congratulations. I am sure you will do well.

  • buzzkillerjsmith

    Thanks for the intro, Suzy:

    Hugo, you are not as stupid as you seem to be at first glance. Why? Because you went into IM. Now, if you stay in IM, young man, you are a complete dumb-@34, because general IM is even worse than family medicine and that’s sayin’ a lot. Can you say HTN, DM, obesity, COPD, hyperlipidemia, a little renal failure, tobacco abuse, and depression —all in 15 minutes?

    But you won’t. In time, you will see the light and subspecialize. Sure, you blundered by not going into radiation oncology right off the bat, but not to worry—heme/onc, nephro, gi, cards–they’re calling your name. Hugo, Huuugooo. This is one siren song you ought to heed.

    Don’t do endo (pace Dr. Drake) or ID because talkin’ to people don’t feed the bulldog.

    Cannulate visci or die! This will be your motto.

    If you had gone into fam med, your escape routes would be closed. Sure, you could do sports med or sleep, but how much call is there for that? Or you could do geriatrics, just about as enjoyable as undergoing a couple of LPs and a bone marrow biopsy on a daily basis. Otherwise you’d be chained to the treadmill. Don’t end up like me.

    Keep a’postin’. Keep us up to date on your angst, your inner turmoil. Let us see your human side.

    And when you finally do come to the epiphany that gastroenterolozing is what you were put on earth to do, please share with us the fact that it is not because you loved listening to weeping 47 year-old women with alcoholic husbands and messed-up kids less, but rather because you simply loved tubing intestines more.

    • Dr. Drake Ramoray

      Buzz is correct. Don’t do Endo. Then it will be complicated DM, HTN, Hyperlipidemia, CAD, ESRD on hemodialysis, s/p BKA and non-compliance in 15 minutes. All the non-prior authorization meds will have been already provided to the patient (long ago by the patient example and with the really smart primary care guys this is often the determining factor in making any DM referral).

      The only way I would do Endo is if you have some sort of love affair with the thyroid (like me. In fellowship it was my favorite disease state and thyroid cancer was my area of research) or want to do academics because the former looks to be highly marketable (ultrasound, Nuc med, and biopsies will pay the bills and the red tape for non-diabetes is acceptable).

      More and more Endos are going general endocrine and no diabetes which generally drastically improves the quality of life (less hassles, depending on your location almost exclusively outpatient) but you can’t really sub specialize in adrenal or pituitary without doing academics. Thyroid only is basically one of my outs from the current medical system (one of the others indeed being academics) as opposed to my career plan at your stage (or even a few years ago).

      I’ll be very happy doing thyroid only, my lifestyle will be great, and I won’t have many practice hassles (other than the expected from a small business which will be worth it but I STILL will make half to as third as much as my GI colleagues and it will take me way longer to get there (most fellowships don’t provide the training to practice the way I’m going to the practice.)

      With no little irony I’m with buzz. Right now GI would be the way to go (although that might not be the superstar specialty in ten years). You can alway volunteer at the free clinic to get your (no insurance, salt of the earth, really making a difference, general internal medicine experience) especially if you pick a specialty that pays the bills.

      • buzzkillerjsmith

        Yeah, you’re in a crappy field, but not as crappy as mine (although DM makes it very close). So there.

        • Dr. Drake Ramoray

          Congratulations? You have the worst job in all of Western Medicine.

      • querywoman

        Dr. Drake, you weren’t in Texas when I needed you.
        I saw my first endocrinologist in my early 30s because I had disastrous menstrual disturbance after dosage adjustments. He was not very interested in me at all, when he found out I was not diabetic.
        I think I had started going into diabetes, but back then the fasting standard was 140. I think I was getting fasting sugars of maybe 127 to 138.
        All Endo No. 1 really cared about in me was the blood pressure cuff, something any GP can do well. SO I fired him.
        I was just discussing this with my current endo and I asked him if he thought, in the 1980s, that he was one of the endos who wanted the fasting sugar definition dropped.
        He said, “Oh yes, my mentor was very strict.”
        Where I live, most of the endocrinologists specialize in diabetes.
        I could never get an endocrinologist who cared anything about my complex female hormone problems. However, they all disappeared when I went on insulin in my early 40s.

    • NewMexicoRam

      I agree. I enjoyed being an FP for the first 10 years of practice. Now I’m essentially a geriatric doc. Long hours, heavy demands. And maybe 14 years to retirement, if I’m lucky.

  • FEDUP MD

    Addiction medicine is not adult-only. Most addicted adults start as adolescents, sadly which I see plenty of.

    • NPPCP

      As a complete aside to anything else; thank you so much for doing this. Filling this need Dr. Fedup. I am very grateful for you and your work. Thank you.

  • buzzkillerjsmith

    Hospitalist. Strong work. Outpatient family medicine is for lunkheads like me.

    The only fly in the ointment is that the NPs and PAs might refuse the hand-off, those little stinkers.