Is pulmonary medicine rewarding?

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NewMDontheblock

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Hi!

I'm a first year resident in internal medicine in Canada.
I'm considering pulm for many reasons : I like the physiology, I like the imagery and I like vents/NIV.

My only worry is how poor the treatment options and patient outcomes are. I'm worried I will become jaded. I'm not going to lie, sometimes I envy surgery for that : unlike them, we can't ''fix'' things...

How do you experienced doctors feel about it? Thanks for your time :)

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Just realised I used an old account I had back when I was a medical student! Honest mistake, sorry about it!
I shall answer with this one from now on.

PS: I wanted to delete this thread and start over, but couldn't!
 
Just realised I used an old account I had back when I was a medical student! Honest mistake, sorry about it!
I shall answer with this one from now on.

PS: I wanted to delete this thread and start over, but couldn't!

You still have the same question?
 
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You still have the same question?

I think you misunderstood, I've had this question only since I've been a resident (not when I was a med student)! I just logged in with the wrong account using facebook.

Either way, I would appreciate any answer !
 
I think you misunderstood, I've had this question only since I've been a resident (not when I was a med student)! I just logged in with the wrong account using facebook.

Either way, I would appreciate any answer !

I like pulmonary medicine for the most part, but it is kind of a thankless job. The patients are pretty sick by the time they get to you or they have a cough (which you probably won't be able to ultimate help with either). If it looks like only prednisone and inhalers, it's because it is. So yeah it can be a bit of a toil at time, but I get kick out of helping smokers quit - I'm good at it. And every once in awhile you'll get someone's asthma or COPD dialed in and patients are very very thankful to be breathing better. Also, for some of the worse stuff cancers and ILD - at least you can give patients an answer even if you often can't offer too much sometimes (remember with rheum ILD you treat the rheumatologic condition to treat the lungs!) and sometime just giving people an answer is helpful to them.
 
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Good to know! Do you think treatment for ILD will get better in the future? Is the research in pulm active?
Also, do you feel pulm is on par with the other medical specialities as far as patient outcome is concerned, or are there other specialities that seem better at it compared to the others?
Lastly, what attracted you to the field if it is ''kind of a thankless job''?
I really appreciate your output jdh71, I've stumbled on your posts on theses forums and they are quite insightful :)
 
Ok , I'll bite. As a third yr fellow at a large academic centre, I could not be happier with my career choice. Our ability to multi task in several different settings : from the ICU to bronchoscopy suite to inpt consults to clinic is unmatched which not only keeps things interesting but also gives you plenty of options once you graduate. You can tailor your job based on what you like more. You will see sick pts, people will die on you but you will have your " saves" . A good intensivist makes a huge difference in pt outcomes and I see it every day. I think it is not only exciting but also very rewarding. And it pays really well.
Yes, there is some very path breaking research going on in ILD/ IP and pulm in general. Which is true for pretty much every sub speciality.
Every speciality has its own pros and cons but from my own personal experience (n=1) , trauma surgery ( "I envy surgery for that : unlike them, we can't ''fix'' things" ) is the most thankless job in the hospital.
We do fix things, it just takes longer .
 
Good to know! Do you think treatment for ILD will get better in the future? Is the research in pulm active?
Also, do you feel pulm is on par with the other medical specialities as far as patient outcome is concerned, or are there other specialities that seem better at it compared to the others?
Lastly, what attracted you to the field if it is ''kind of a thankless job''?
I really appreciate your output jdh71, I've stumbled on your posts on theses forums and they are quite insightful :)

There's always research into ILD. Though the future will be figuring out how to treat things that can't be studied in a big RCT. Also the future of asthma looks theoretically good. For every 10 to 15 asthma patients younger dialed in on conventuals therapy you'll have one that just doesn't seem to respond to anything predictably. Asthma is a syndrome not a discrete and specific disease entity - the future is bio marker/ gene directed therapy.

Almost all of medical sub-specialties is managing chronic specific medical illness. It's going to be the same for all of them really. Many gastros have done their best to move away from anything but scope work, so there is that. And if you're an interventional cards guy who can find a group that won't make you do anything other than that . . . But most people will be dealing with chronic stuff most of the time. Nothing you can fix really. Things you can manage - help with symptoms and hopefully prevent progression.

I just like pulm. It's complicated and requires you to be a "doctor". There is a lot of nuance. Plus having a a certain procedural component is nice. It's nice that almost none of it is emergent so you can schedule when it works for you and the patient. EBUS has revolutionized lung cancer screening and diagnosis. And Navigational bronch will only get more and more advanced - in 10 years you'll be able to get to any lesion anywhere in the lungs without too much difficulty. The technology currently has some kinks to it, but with the right case selection is great. I've even been using it to get get diagnostic samples for ILD prior to sending patients to the surgeons for lung VATS lung biopsies with good results (part of the issue with yield in studies of transbronchial biopsies is youre doing it sort of blindly).
 
Ok , I'll bite. As a third yr fellow at a large academic centre, I could not be happier with my career choice. Our ability to multi task in several different settings : from the ICU to bronchoscopy suite to inpt consults to clinic is unmatched which not only keeps things interesting but also gives you plenty of options once you graduate. You can tailor your job based on what you like more. You will see sick pts, people will die on you but you will have your " saves" . A good intensivist makes a huge difference in pt outcomes and I see it every day. I think it is not only exciting but also very rewarding. And it pays really well.
Yes, there is some very path breaking research going on in ILD/ IP and pulm in general. Which is true for pretty much every sub speciality.
Every speciality has its own pros and cons but from my own personal experience (n=1) , trauma surgery ( "I envy surgery for that : unlike them, we can't ''fix'' things" ) is the most thankless job in the hospital.
We do fix things, it just takes longer .

He wasn't talking about the ICU.
 
Ok , I'll bite. As a third yr fellow at a large academic centre, I could not be happier with my career choice. Our ability to multi task in several different settings : from the ICU to bronchoscopy suite to inpt consults to clinic is unmatched which not only keeps things interesting but also gives you plenty of options once you graduate. You can tailor your job based on what you like more. You will see sick pts, people will die on you but you will have your " saves" . A good intensivist makes a huge difference in pt outcomes and I see it every day. I think it is not only exciting but also very rewarding. And it pays really well.
Yes, there is some very path breaking research going on in ILD/ IP and pulm in general. Which is true for pretty much every sub speciality.
Every speciality has its own pros and cons but from my own personal experience (n=1) , trauma surgery ( "I envy surgery for that : unlike them, we can't ''fix'' things" ) is the most thankless job in the hospital.
We do fix things, it just takes longer .

As jdh71 mentionned, here in Canada, pulmonology and ICU are two different specialities. Although some pulm do a ICU fellowship and work both. Would you feel the same about your job if you did only pulm? :)

I just like pulm. It's complicated and requires you to be a "doctor". There is a lot of nuance. Plus having a a certain procedural component is nice. It's nice that almost none of it is emergent so you can schedule when it works for you and the patient. EBUS has revolutionized lung cancer screening and diagnosis. And Navigational bronch will only get more and more advanced - in 10 years you'll be able to get to any lesion anywhere in the lungs without too much difficulty. The technology currently has some kinks to it, but with the right case selection is great. I've even been using it to get get diagnostic samples for ILD prior to sending patients to the surgeons for lung VATS lung biopsies with good results (part of the issue with yield in studies of transbronchial biopsies is youre doing it sort of blindly).

You are absolutely right about the chronic disease that's the same for all specialities. At least in pulm, there seems to be less functionnal diseases. I think I'd shoot myself in GI.

Would you mind elaborating on the ''requiring you to be a doctor'' part? Did you mean you have to be a good diagnostician? Or something else?
I'm also glad you find your job nuanced, because on the surface one might find the bread and butter (COPD exacerbations, sleep apnea...) kind of reduntant...
 
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You are absolutely right about the chronic disease that's the same for all specialities. At least in pulm, there seems to be less functionnal diseases. I think I'd shoot myself in GI.

Would you mind elaborating on the ''requiring you to be a doctor'' part? Did you mean you have to be a good diagnostician? Or something else?
I'm also glad you find your job nuanced, because on the surface one might find the bread and butter (COPD exacerbations, sleep apnea...) kind of reduntant...

Yes. You need to be a good diagnostician. Something is odd on the chest imaging. What is it? Well . . . could be lots of things!

Anyway, I don't find bread and butter as redundant as I do a bit of a an easy breather in a long clinic day. If you can walk in and know what to do before you even see the patient, that is nice too. If every case was a hard or interesting case you'd get bogged down.
 
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Anyway, I don't find bread and butter as redundant as I do a bit of a an easy breather in a long clinic day. If you can walk in and know what to do before you even see the patient, that is nice too. If every case was a hard or interesting case you'd get bogged down.
So much this (and not just in Pulm). As a resident/fellow, I hated the bread and butter, simple consults/follow-up stuff. So boring. Now as an attending, it's how I gain back both the 2 hours I lost on a single new consult, and my sanity
 
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So much this (and not just in Pulm). As a resident/fellow, I hated the bread and butter, simple consults/follow-up stuff. So boring. Now as an attending, it's how I gain back both the 2 hours I lost on a single new consult, and my sanity

Point taken. What matters for me is that all my work end up making a difference for the patient. Sometimes in internal medicine, you do these huge work-ups and none of it really changes the patient outcome...
 
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Point taken. What matters for me is that all my work end up making a difference for the patient. Sometimes in internal medicine, you do these huge work-ups and none of it really changes the patient outcome...

All your work won't in anything in internal medicine.
 
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Again, it's good for me to have that kind of talk with attendings...! I guess my point was that I'd want my speciality to make a difference most of the time, or at least more than the average!
 
Again, it's good for me to have that kind of talk with attendings...! I guess my point was that I'd want my speciality to make a difference most of the time, or at least more than the average!
10% of the time is a pretty good target.

If that's not enough for you, consider derm or plastics.
 
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10% of the time is a pretty good target.

If that's not enough for you, consider derm or plastics.

10%?! That's depressing.
I don't know about plastics, I heard something like 30% of patients getting reconstructive surgery has personnality disorders :O
 
The bar you set is awfully high. Considering musculoskeletal deconsitioning contributes greatly to symptoms of days ones and your mess can't fix that, and the high incidence of co-existing depression that exists, and that at least in the US, COPd has a higher 5 year mortality than most cancers, yeah 10% is about right. There are a few you can make a real impact on, the cancers get depressing since ~15% can be "cured" most are already metastatic by the time you find them and yeah most Pulm fibrosis can't and won't respond to a damn thing you do or they get the ****s from the new mess for IPF and then the other are too old too fat or too sick for transplant. I ignore CF as this takes a special personality to manage these patients and I do not posses this. Transplant Pulm takes a personality whom hasn't had their optimism sucked out along with the soul from doing years worth of critical care.

I can't imagine myself in another specialty.
 
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Point taken. What matters for me is that all my work end up making a difference for the patient. Sometimes in internal medicine, you do these huge work-ups and none of it really changes the patient outcome...
You should really focus more on quality of life than on "fixing" things. Some of my favorite patients back in my RT days weren't the ones that we fixed. They were the CFers that lived long enough to get a college degree, or the COPDers I got to quit smoking before they were tied to a tank. You can't save most people, but you can do your best to help them have a better life. Gotta enjoy the little victories, because a lot of the time you're just breaking even with a patient that you know is just treading water. Medicine isn't like the TV shows, but you know that already. Rare are the House-like moments where you not only get to figure out what is wrong with someone, but get to actually cure them, and that's not something that changes much regardless of medical specialty.
 
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10%?! That's depressing.
I don't know about plastics, I heard something like 30% of patients getting reconstructive surgery has personnality disorders :O
Welcome to medicine. Your status says that you're a resident. If that's true, and you're truly "fixing" more than 10% of your patients at this point, you're either lying or uncertain about the meaning of the word "fixed".

And 30% of patients with personality disorders sound like...well, it sounds like the general population.
 
The bar you set is awfully high. Considering musculoskeletal deconsitioning contributes greatly to symptoms of days ones and your mess can't fix that, and the high incidence of co-existing depression that exists, and that at least in the US, COPd has a higher 5 year mortality than most cancers, yeah 10% is about right. There are a few you can make a real impact on, the cancers get depressing since ~15% can be "cured" most are already metastatic by the time you find them and yeah most Pulm fibrosis can't and won't respond to a damn thing you do or they get the ****s from the new mess for IPF and then the other are too old too fat or too sick for transplant. I ignore CF as this takes a special personality to manage these patients and I do not posses this. Transplant Pulm takes a personality whom hasn't had their optimism sucked out along with the soul from doing years worth of critical care.

I can't imagine myself in another specialty.

I understand. You have a very mature assessment !

Just curious, if you can't make a real impact on the majority of patients, why can't you see in any other speciality?

I suspected pulmonary medicine was like that, so I guess what drives pulm docs every day is my real question!

You should really focus more on quality of life than on "fixing" things. Some of my favorite patients back in my RT days weren't the ones that we fixed. They were the CFers that lived long enough to get a college degree, or the COPDers I got to quit smoking before they were tied to a tank. You can't save most people, but you can do your best to help them have a better life. Gotta enjoy the little victories, because a lot of the time you're just breaking even with a patient that you know is just treading water. Medicine isn't like the TV shows, but you know that already. Rare are the House-like moments where you not only get to figure out what is wrong with someone, but get to actually cure them, and that's not something that changes much regardless of medical specialty.

You know, it might sound naive, but House is what got me first interested by medicine. After medical school and a year of residence under the belt, I can tell you I was really wrong!

I'm a young guy, I guess I still gotta work on my maturity. Part of me wants to go for the home run, the KO. But I'm sure that with time I will, like you put it, put to rest the notion of really curing patients, and move to palliation.

Welcome to medicine. Your status says that you're a resident. If that's true, and you're truly "fixing" more than 10% of your patients at this point, you're either lying or uncertain about the meaning of the word "fixed".

And 30% of patients with personality disorders sound like...well, it sounds like the general population.

I'm indeed a resident. You're right, I don't fix more than 10% of my patients. I just wished the percentage was more.
 
You always have the option to use it to get the ICU component later
 
my friend who did not match into Pul CC this year took a spot in a pulmonary only program. He's kind of depressed about it, but I told him he should just apply regular CC in 2 years or something.
 
my friend who did not match into Pul CC this year took a spot in a pulmonary only program. He's kind of depressed about it, but I told him he should just apply regular CC in 2 years or something.

Why is he depressed about it?
 
That's sad, he probably thinks that pulmonary is only COPD and Asthma. Traditional fellowship programs are pulm and crit together so you only receive 6 months of Pulmonary experience. This is the reason why IP was invented. On the other hand, pulmonary only fellowships give you more pulmonary experience and you may enjoy doing work outside the micu. CPET, Pulmonary Rehab, ILD, Right heart caths, bronchoscopy +/-EBUS. There's more to pulm only than people realize and it requires thinking outside of the "ICU Box". There's a reason why Mayo opened up a pulm only fellowship this year. Soon you'll see a resurgence in it.
 
I went into pccm for the CCM and I'm very damn good at it. But the thing I realized my last year is I'd get rather cranky doing pure CCM. The pulm is more challenging in the long term and I now personally find more rewarding.

CCM only will likely be easier to roll into after pulm.
 
I really enjoy this thread.

For me CC is what I want to do. As for the route and what to do when not managing patient in the unit... This is the real question.

Anesthesia / CC seems viable in my head. However this has been discussed at length in the CC and Anesthesia board. Seems the job prospects are improving slightly.

Pulm / CC is the obvious powerhouse here. Most grups I know of are pure pulm / cc ran.

the EM / CC sees like a distant 3rd.
 
I went into pccm for the CCM and I'm very damn good at it. But the thing I realized my last year is I'd get rather cranky doing pure CCM. The pulm is more challenging in the long term and I now personally find more rewarding.

CCM only will likely be easier to roll into after pulm.

I love Ccm and got into Pulm/Ccm( from ID) for it.... But it grew on me in a good way... So much that not being able to do it in a practice is a deal breaker... I'll retire doing Pulm/id...
 
I love Ccm and got into Pulm/Ccm( from ID) for it.... But it grew on me in a good way... So much that not being able to do it in a practice is a deal breaker... I'll retire doing Pulm/id...

How do you not argue with yourself all day every day about whether it's an infection or not.
 
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That's sad, he probably thinks that pulmonary is only COPD and Asthma. Traditional fellowship programs are pulm and crit together so you only receive 6 months of Pulmonary experience. This is the reason why IP was invented. On the other hand, pulmonary only fellowships give you more pulmonary experience and you may enjoy doing work outside the micu. CPET, Pulmonary Rehab, ILD, Right heart caths, bronchoscopy +/-EBUS. There's more to pulm only than people realize and it requires thinking outside of the "ICU Box". There's a reason why Mayo opened up a pulm only fellowship this year. Soon you'll see a resurgence in it.

If I may, what do you enjoy most about pulm only?

I went into pccm for the CCM and I'm very damn good at it. But the thing I realized my last year is I'd get rather cranky doing pure CCM. The pulm is more challenging in the long term and I now personally find more rewarding.

CCM only will likely be easier to roll into after pulm.

CCM is cool but I agree, too much of a good thing is bad.
What do you find challenging and rewarding about pulm? Alleviate dyspnea for the terminal COPDers ? Staging a lung nodule?
 
I really enjoy this thread.

For me CC is what I want to do. As for the route and what to do when not managing patient in the unit... This is the real question.

Anesthesia / CC seems viable in my head. However this has been discussed at length in the CC and Anesthesia board. Seems the job prospects are improving slightly.

Pulm / CC is the obvious powerhouse here. Most grups I know of are pure pulm / cc ran.

the EM / CC sees like a distant 3rd.

Anes/CCM using the OR as a "break" from the unit never made sense to me--the OR can be easily as stressful/high intensity as the ICU (if not more-so). If anything the ICU would be a break from the OR...
 
That's sad, he probably thinks that pulmonary is only COPD and Asthma. Traditional fellowship programs are pulm and crit together so you only receive 6 months of Pulmonary experience. This is the reason why IP was invented. On the other hand, pulmonary only fellowships give you more pulmonary experience and you may enjoy doing work outside the micu. CPET, Pulmonary Rehab, ILD, Right heart caths, bronchoscopy +/-EBUS. There's more to pulm only than people realize and it requires thinking outside of the "ICU Box". There's a reason why Mayo opened up a pulm only fellowship this year. Soon you'll see a resurgence in it.


@PurplePepper, I find it gratifying in many ways. The pathology is complex, almost most diseases require some visceral reasoning/physiology. The lifestyle is more predictable and there's a shortage of outpatient/inpatient pulmonary only physicians. From a procedural aspect, it's rewarding because whether you're doing a regular airway exam or a biopsy, you're likely helping a primary service that has consulted you in some shape or form. Bronchoscopy and advanced bronchoscopy has a bright future for research too (ie A. Mehta's stem cell implantation via bronch research @ CCF).
 
How do you not argue with yourself all day every day about whether it's an infection or not.

It's a lifelong ordeal... In my case less antibiotics are better!
I'm all up for stopping all of them as soon as cultures are back( or at least descalating) and see what happens( some of my colleague are not as eager).
I hope they accept my poster for ATS 16....
 
Yeah I went into it because I want CC not for the pulm at all. My residency program never introduced me to things like EBUS or right heart caths, so I dont really feel like I miss anything.
 
my friend who did not match into Pul CC this year took a spot in a pulmonary only program. He's kind of depressed about it, but I told him he should just apply regular CC in 2 years or something.

It will take the same time. Pull two years plus for for CCM. Tell him not to pout. Just get it done.
 
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I wonder why dont more people just apply CCM and Pulm separately, or apply both CCM and Pul CC together. It seems to be easier that way. It looks like the CCM piece of the harder one to get into.
 
my friend who did not match into Pul CC this year took a spot in a pulmonary only program. He's kind of depressed about it, but I told him he should just apply regular CC in 2 years or something.
There's some 1 year CCM fellowships out there for people who have completed a fellowship in pulm or other subspecialties of IM. He can still do it in 3 years if he plays his cards right and has a strong application.
 
There's some 1 year CCM fellowships out there for people who have completed a fellowship in pulm or other subspecialties of IM. He can still do it in 3 years if he plays his cards right and has a strong application.

You don't need a strong application. Send a application to Mayo after two years of palm. Be willing to take fellow critical care call for a year. Done.
 
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You don't need a strong application. Send a application to Mayo after two years of palm. Be willing to take fellow critical care call for a year. Done.
What I'm really curious about is how difficult these one year fellowships are to get into out of the other paths (ID, nephro, endo, etc). I really want to do CCM, but am curious how hard it'd be to break into if I don't land a pulm spot. Question for another thread, I guess.
 
What I'm really curious about is how difficult these one year fellowships are to get into out of the other paths (ID, nephro, endo, etc). I really want to do CCM, but am curious how hard it'd be to break into if I don't land a pulm spot. Question for another thread, I guess.

right now critical care is easy to get into, two year programs, or one year programs out of the other fellowships

since people are getting more and more folks are getting interested in critical care, because of the shiftwork model and the relatively high compensation (outside of the NE and southern california) so hard to say in a few years

though I suggest landing a solid IM residency and then stop worrying about it too much
 
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right now critical care is easy to get into, two year programs, or one year programs out of the other fellowships

since people are getting more and more folks are getting interested in critical care, because of the shiftwork model and the relatively high compensation (outside of the NE and southern california) so hard to say in a few years

though I suggest landing a solid IM residency and then stop worrying about it too much
Guess I should stop worrying so much about it. Maybe I'll be able to chill when I get my Step scores back ;)
 
What I'm really curious about is how difficult these one year fellowships are to get into out of the other paths (ID, nephro, endo, etc). I really want to do CCM, but am curious how hard it'd be to break into if I don't land a pulm spot. Question for another thread, I guess.


It's not hard to get into A Pulm/Ccm or Ccm program. The top programs are always competitive but you will find a spot to train somewhere, rest assured.

As corny as it sounds, Just aim for the stars and rest assured you will land In a spot if you miss on your way down.
 
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