IM Subspecialty Fellowship

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Allergy and Immunology
Generally considered one of the most competitive IM subspecialties because of the very small number of fellowship positions available as well as the nice lifestyle it offers. Allergists tend to focus in, well, allergy, and it is a 2-year fellowship. It is typically an office-based practice, in which they see patients with severe allergies of all varieties: foods, pollens, beestings, and medications. They can do a few "procedures", including skin testing of allergens (of which the billing rates are quite high), and allergy shots. A growing area in allergy is in the use of desensitization protocols. These are typically done at academic centers where patients need to get a specific chemotherapy regimen or antibiotic, but they have had an anaphylactic reaction to those medications. The allergist will admit these patients to the hospital for short stays to undergo desensitization regimens to the specific medications.

The American Academy of Allergy, Asthma, and Immunology

Cardiology
This is another popular and competitive IM subspecialty. It also is considered one of the three most procedural subspecialties in IM (sharing the honor with GI and Pulmonary/critical care). Cardiology is a 3 year fellowship, with at least 2 years of required clinical training time. The rest of the fellowship can be spent in research or additional clinical time. The clinical practice of cardiology is highly varied, and it allows for a large number of areas of subspecialization. Cardiologists can do angiograms, angioplasties (with interventional training), right heart catheterization, echocardiograms, manage heart failure, coronary artery disease, hypertension, treat arrhythmias, treat pre- and post- heart transplant patients, and manage adult patients with congenital heart disease, just to name a few. Some cardiologists will choose to do further subspecialty training. After cardiology fellowship, graduates can do a 1-year fellowship in interventional cardiology, where they get trained in such things as angioplasties, coronary artery stenting, valvuloplasty, and even things like pulmonary artery stenting. Another certified fellowship that cardiology grads can do is a 1-year fellowship in cardiac electrophysiology, where fellows are trained in pacemaker placement and interrogation, intracardiac defibrillator placements, cardiac resynchronization therapy, and VT/VF and afib/flutter ablation techniques, among other procedures.

The American College of Cardiology

Endocrinology
Endocrine is a 2-year fellowship, with a minimum of 1 year of clinical training during the fellowship. The rest of the time can be spent either doing research or in additional clinical training. Endocrine is one of the least procedural of the IM specialties. Endocrinologists typically spend their time in outpatient clinics and mostly treat patients with diabetes, and hypo- and hyperthyroidism. They also will deal with the more rare endocrine disorders, such as pan-hypopituitarism, Addison's, and diabetes insipidus.

The American Association of Clinical Endocrinologists

 

Gastroenterology
Gastroenterology is another of the fellowships considered to be very competitive. GI is also a very procedural specialty. It is a 3 year fellowship, with a minimum of 18 months of clinical training. The remainder of the time can be spent in research or in additional clinical work. Gastroenterologists deal with disorders of the stomach and intestinal tract, as well as diseases of the liver, pancreas, and biliary tree. They do a number of procedures, including colonoscopy, EGD, enteroscopy, ERCP, endoscopic ultrasound, PEG tube placements, and liver biopsies. Some GI graduates will do further subspecialty training in the field. Hepatology, for example, is a 1 year fellowship that graduates can do, where they can further train in the management of liver disease, such as cirrhosis, and in the treatment of patients pre- and post-liver transplant.

The American College of Gastroenterology

Hematology/Oncology
Heme/onc is a combined fellowship program that is 3 years long, with a minimum of 18 months of clinical training time during the fellowship. At the end of the fellowship, graduates can be double-boarded in hematology and oncology. A less common path for fellows to pursue is to do a separate heme or onc fellowship. The separate heme and onc fellowships are 2 years each, with 1 year minimum of clinical training time during the fellowship. Heme/onc physicians mostly manage patients with cancer, and will decide on treatment options and chemotherapy regimens for their patients. They will also manage any complications that arise from the chemotherapy and the cancer itself, and pretty much become the oncology patient's primary care doctor while they are undergoing active treatment. In addition, oncologists do bone marrow biopsies, and bone marrow transplants. They also treat benign hematologic conditions, such as sickle cell anemia, the thalassemias, and TTP. The setting that they practice in is mostly outpatient, although physicians who specialize in hematologic malignancies or BMT often spend a significant amount of time in the inpatient setting.

American Society of Clinical Oncology
American Society of Hematology

 

Infectious Diseases
ID is another non-procedural IM subspecialty. It is a 2-year fellowship, where fellows must do a minimum of 1 year of clinical training. ID is primarily an inpatient consultation specialty, and typically see consults involving confusing infectious issues, rare contagious diseases, highly resistant bacteria, fever of unknown origin. They are often considered some of the best diagnosticians in internal medicine. With the development and growth of HIV antiretroviral therapy, many ID specialists have decided to focus on HIV treatment, and have moved from the inpatient setting to outpatient clinics. Even with the prevalence of HIV, most ID physicians choose not to specialize in that area, and so have stayed in the inpatient arena.

Infectious Diseases Society of America

Nephrology
Nephrology, or renal medicine, is a 2-year fellowship, where fellows are required to do at least one year of clinical training during the fellowship. The rest of the time is spent either doing research or additional clinical work. Nephrologists treat diseases of the kidney. A large part of their practice is spent managing patients on hemodialysis and peritoneal dialysis. They also work up patients with new onset renal failure, electrolyte abnormalities, and will do some procedures, including renal biopsies and hemodialysis catheter placements. Nephrologists also manage pre- and post-renal transplant patients.

American Society of Nephrology

 

Pulmonary/Critical Care
Pulmonary/Critical care is a 3-year combined fellowship, where fellows are required to do a minimum of 18 months of clinical training (1 year in pulmonary and 6 months in critical care). At the end of the training, graduates can be double-boarded in pulmonary medicine and critical care medicine. As an alternative, fellows can do straight pulmonary medicine without the critical care portion. This fellowship is 2 years long, with a minimum of 1 year of clinical time. Straight critical care without the pulmonary portion can be done as a 2 year fellowship, with a minimum of 1 year of clinical time. I am discussing the two specialties together because the combined program is the most common route that IM graduates take to pursue both pulmonary and critical care medicine. Pulmonary/critical care is a very procedural field, although not as procedure-heavy as GI. Pulmonologists have a wide variety of clinical practice. Many focus primarily on the inpatient setting, others work mostly in the clinic, while others will focus on the ICU.
Pulmonologists treat patients with lung diseases such as asthma/COPD, interstitial lung disease, TB, MAC, pleural effusions, diaphragmatic dysfunction, pulmonary hypertension, and pre- and post- lung and heart-lung transplant patients. They also do a large amount of diagnostic work, and will see patients with new lung masses, pulmonary infiltrates, and endobronchial lesions. The main procedures pulmonologists do are bronchoscopy with transbronchial biopsy, endobronchial stenting, thoracenteses/chest tubes, and trach placements. A growing field in pulmonary is sleep medicine, which is a one-year fellowship that can be done after completion of a pulmonary fellowship. Sleep is an outpatient practice, and sleep physicians are involved in the diagnosis and management of various sleep disorders such as sleep apnea, PLM, narcolepsy, and sleepwalking.
With training in critical care medicine , pulmologists will often run both medical and surgical ICUs, and do all the procedures needed in the ICU, including intubations, central lines, arterial lines, and Swan-Ganz catheters. Critical care can also be done as a separate fellowship, or can be added onto another IM subspecialty fellowship for one additional year of training. For information on the different tracks to certification in critical care, check out http://www.abim.org/cert/policies_aqccm.shtm

American Thoracic Society
Society of Critical Care Medicine
American College of Chest Physicians

Rheumatology
Rheumatology is a 2-year fellowship, with a required minimum of 1 year of clinical training, and is another of the less-procedural medical specialties. Rheumatologists deal mostly with autoimmune diseases such as lupus, rheumatoid arthritis, dermatomyositis, and ankylosing spondylitis. They also treat other medical diseases of the joints, such as gout and pseudogout. The main procedure that they do is tapping joints - they will tap pretty much any joint in the body. Rheumatology, while not as competitive as the other medical specialties, is an attractive field for many because of the easier hours. It is primarily an outpatient specialty, and there are very few rheumatologic emergencies.

American College of Rheumatology

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