Internal Medicine Residency: Your Guide

What is Internal Medicine? 

As students start to ponder which medical specialty to choose, the first question many of them have is how Internal Medicine and Family Medicine differ. There’s a fair bit of understandable confusion here: both specialties treat a majority of adult patients over long periods of time, and often orient this care around disease prevention in outpatient clinics. However, Family Medicine, as its name suggests, includes not only adults but the entire family unit, including neonatology and pediatrics, and is in almost all cases strictly confined to standard outpatient clinical settings.  

Internists, on the other hand, deal only with adult patients, and train far more deeply into related subspecialties like endocrinology, rheumatology, and infectious diseases. They work in both inpatient and outpatient settings, and can often be found in hospitals, treatment centers, and hospices unlike family physicians. Overall, they are considered one of the easiest doctors to become, too.

Internal Medicine residency programs therefore focus less on the life cycle and development from birth to death, and rather commit themselves to the diagnosis and treatment of diseases common to adult populations. This includes conditions like cancer, infections, diseases affecting the heart, blood, and kidneys, and even digestive and respiratory health. Most notably though, Internists often pursue careers outside of direct patient care. This may include teaching, administration, research, and even health policy or public health.  

Internal Medicine residency programs therefore feature a significantly different set of training guidelines and goals than those in Family Medicine, and are often longer to include greater pre-fellowship subspecialty work. As the name implies, Internal Medicine specialists focus heavily on multisystem or undifferentiated disease processes, making this additional subspecialty training extremely important. In short, Internists must be master diagnosticians. 

Are you wondering which residencies are most and least competitive?

Internal Medicine Residency: Structure 

Internists must complete an Internal Medicine residency program and related licensure exams like the USMLE Step-3 and COMLEX Level 3 before moving onto independent practice. Residents in their first post-graduate year (PGY1) are usually referred to as Interns, and then simply Residents thereafter in PGY2 and onward. Internal Medicine residency programs in the US and Canada share many training goals and protocols, but differ in a number of important ways. Let’s see how they compare. 

Internal Medicine Residency in the US 

US Internal Medicine residency programs typically last 3 years, and are considered “categorical” or general training programs. This means two things in practice. The first is that Internal Medicine residents who complete only the basic 3-year residency program will usually practice as generalists or General Internists in either primary care or hospital/in-patient care. The second important thing to note about Internal Medicine residency is that it is frequently the springboard not just for further subspecialty work, but can often be a precursor to another secondary specialty that benefits from the foundation that Internal Medicine residency provides. This may include secondary residency in more specialized surgery or organ-specific training like cardiology or nephrology. 

Internal Medicine residencies in the US must meet certain guidelines set by the American College of Physicians (ACP) and Accreditation Council for Graduate Medical Education (ACGME), but there is tremendous variety in how much time residents spend in each subspecialty rotation throughout the program. Internal Medicine residencies are notoriously fast-paced, with interns and residents both switching between rotations on a sometimes weekly basis. While the duration of each rotation varies by program, the overall selection of specialized rotations usually includes time in: 

Of these, the bulk of rotations are usually in General Internal Medicine, with significant time in Cardiology, Neurology, Medical Intensive Care Unit (MICU) care, and Hematology. However, one of the major hallmarks of Internal Medicine residency programs is the shifting setting for these rotations. These different environments may include: 

The ratio of these environments also varies by program, but in general Inpatient and Specialty Wards are the most common settings. Hours worked will vary by setting, but the general rule is that inpatient environments will often be quite long, including some overnight and on-call shifts, while outpatient and clinic rotations will usually stick to an 8-10 hour day. A typical week for an Internal Medicine resident will involve 70-80 hour weeks during inpatient or hospital rotations, and 40-50 hour weeks for outpatient rotations.  

Time for research and elective rotations/projects is usually reserved for PGY2-3, although some programs—especially those that feature academic track residencies—will schedule time for this work throughout PGY1 as well.  

Family Medicine Residency in Canada 

If the anarchic nature of US Internal Medicine residency programs feels hard to conceptualize, Canada’s Royal College of Physicians and Surgeons has thankfully created more specific guidelines for Canadian IM residencies.  

Total Program Length – 4 years, comprised of: 

Throughout all of this, there is a strict limit of 6 blocks per specialty during PGY1-3, and 19 blocks total over PGY1-4. 

This roadmap emphasizes the continuously shifting ground that Internal Medicine residents have to tread, but also that their programs provide tremendous opportunity to explore potential subspecialties. As you might then guess, Internal Medicine residents often follow their core residency program with a subspecialty fellowship or certification program. 

Internal Medicine Fellowships and Certifications 

The nature of Internal Medicine residency programs in both countries makes for a diverse yet somewhat general experience that many residents—roughly half according to the AMA—then follow with additional training in subspecialties. These include: 

1. Adolescent medicine 
2. Adult congenital heart disease 
3. Advanced heart failure and transplant cardiology 
4. Allergy and immunology 
5. Cardiovascular disease 
6. Clinical cardiac electrophysiology 
7. Critical care medicine (usually combined with pulmonary for a combined pulmonary and critical care fellowship) 
8. Endocrinology, diabetes and metabolism 
9. Gastroenterology 
10. Geriatric medicine (one-year fellowship after three years of residency) 
11. Hematology (usually combined with oncology for a combined hematology-oncology fellowship) 
12. Hospice and palliative medicine 
13. Infectious disease 
14. Interventional cardiology 
15. Medical oncology (usually combined with hematology for a combined hematology-oncology fellowship) 
16. Nephrology 
17. Pulmonary disease (usually combined with critical care for a combined pulmonary and critical care fellowship) 
18. Rheumatology 
19. Sleep medicine (one-year fellowship after three years of residency) 
20. Sports medicine 
21. Transplant hepatology 

Most of these fellowship programs last 1-2 years, although combined programs will of course last longer.  

It’s also worth noting again the prevalence of Internal Medicine residency graduates going on to teaching and/or research positions—nearly 17% of Internal Medicine residency graduates. This is far above most other specialties, and speaks to the intellectually diverse and adventurous character of many who choose the specialty. Like Family Medicine, Internal Medicine is a specialty very attractive to those seeking lifelong learning in their career path. 

Matching for Internal Medicine Residency Programs 

Students nearing the end of their time in med school apply to Internal Medicine residency programs using either ERAS in the United States or CaRMS in Canada. Matching—the process by which applicants and programs rank one another and are then “matched” using this data—is then done by the National Resident Matching Program (NRMP) in the US, and CaRMS in Canada. 

Internal Medicine residency programs are not “early match” programs, and so use the standard ERAS timeline. Students seeking to match into Internal Medicine residency programs then begin putting together their application materials during the middle of their third year in medical school and begin the application process in earnest around June of this same year. Interviews for residency programs begin in October and lasts throughout the rest of the year. Following residency interviews, students compile Rank Order Lists in January and February of their 4th year, and main match results are released in mid-March. The overall residency matching process is quite long, but this affords medical students the opportunity to not rush during their busy clinical rotation schedules in this final year of Do or MD school.  

Wondering what you might face in a residency program interview? Check out our tips for answering the 5 hardest residency interview questions:

The CaRMS timeline is similar but utilizes a shorter interview season, which starts in January or February of the 4th year. Match Day still occurs in March. 

As with most things relating to residency programs, specific application requirements—including personal statement length/structure and sources of letters of recommendation—will vary by program. Always check the specific requirements and guidelines of the programs to which you’re applying. 

Tips for Matching in Internal Medicine

Although Internal Medicine residency programs will vary in exact guidelines for application materials, there are some common points of importance that will help you make yours stand out. 

Personal Statement and CV 

Your residency personal statement should capture not only your scientific curiosity but your humanistic side as well. With presenting yourself to Internal Medicine residency programs, the key is always to show your ability to bridge the gap between these two motivations for a career in medicine. In fact, Internal Medicine offers one of the rare specialties that rewards both a deep desire for research and a desire to be personally involved in patients’ care over long periods of time. The complexity of the specialty is such that you will often need to navigate diagnosis and treatment of difficult, multisystem diseases while acting as a kind of counselor. Your patients may range from a total stranger in an emergency ICU to someone you’ve known and treated for decades. The story you tell in your personal statement needs to show your understanding of this need to be both scientist and advisor, lab-geek and confidant.  

As always though, the story in your personal statement needs to be your story. Don’t strain to highlight all the ways in which you’re unique, but rather understand your intrinsic uniqueness and let the details of your life and time in medical school illustrate this on their own. Fortunately, the final two years of most MD programs will include copious rotations in Internal Medicine, so you should have quite a bit of explicitly specialty-relevant experiences to pull from. These stories should highlight your proficiency in dealing with complex problems, and ideally how well you worked alongside your attending physicians and supervisors to solve them. The humanistic dimension of Internal Medicine isn’t just about being a comforting presence to patients, but also your strength as a team player, an adaptable clinician whose humility and listening skills play a huge part in your understanding of your future role in any medical environment.  

Lastly, utilize your residency CV as a starting point for examining your IM-relevant experiences. Take time to go over your rotations, coursework, and electives, and make notes about how these have propelled you toward the specialty. The CV may not be especially narrative on its own, but if you craft your personal statement in concert with it you can strengthen the consistency and coherence of your story, and make sure that residency directors feel confident in your fit for their program. 

Electives 

It’s ideal if you can take elective rotations in Internal Medicine-related subspecialties like gastroenterology, neurology, hematology, and the various age-specific modalities of Internal Medicine. Obviously most medical students won’t have tailored every self-directed hour of their time to a single specialty, but one of the beautiful aspects of Internal Medicine is its truly staggering breadth, and so many subspecialty rotations will be quite relevant to showcasing your suitability for residency. These include outpatient rotations in dermatology, pediatrics, orthopedics, psychiatry, cardiology, rheumatology, and infectious diseases among many others. The best option is a sub-internship in Internal Medicine if available, but if it’s not almost anything else can look good on the elective section of your CV provided you’ve done well and understand its relevance to Internal Medicine residency. 

ERAS Letter of Recommendation  

Although most residency programs won’t explicitly ask for specialty-specific letters of recommendation, having at least one from an attending you worked under for an IM rotation would be helpful. Your letters should remain standardized—that is, should not mention or address specific programs—but if you’re set on Internal Medicine for your career, it makes sense to have at least one voice of authority within the specialty backing you up.  

A key piece of advice we give in most contexts is to start early, and this is especially true of your letters of recommendation. You do not have to “network,” but do put some effort into forming good rapport and relationships with the faculty and attendings you work with throughout medical school. And since many Internists end up in academic or pedagogical roles, it’s entirely likely you won’t have to search very far for someone with experience in the specialty even within your first year of med school. And by all means put every ounce of energy you have into your rotations, whether they’re in Internal Medicine or another specialty. An extremely glowing letter from a pediatrics specialist will be worth far more than a mediocre form letter from a world-renowned IM scholar.  

On that point, diversity is an important factor as well, both in writers and of their understanding of you. If possible, request a letter from a mentor who can attest to your Internal Medicine suitability, as well as your personality and capability with those crucial humanistic dimensions to the practice. Each program will have their own requirements as far as who writes your letters, but working from these guidelines you’ll still often have an array of potential options. And the better you perform throughout medical school the more options you’ll have—start early, try hard, and make sure you act professionally and empathetically with both patients and fellow physicians. 

Medical Student Performance Evaluation (MSPE)  

This last element in your application materials is a blend of self-directed components and things that you’ll have little control over by the time your fourth year is underway. Specifically, the Noteworthy Characteristics section of the MSPE will be something you’ll have at least some input on, and with Internal Medicine residency in your crosshairs you’ll want to highlight many of the skills we’ve discussed so far. Professionalism, academic curiosity, communication skills, adaptability, and especially complex problem-solving are all great general foci for these.  

The ACGME’s Internal Medicine Milestones can help guide these to some extent as well. Although they’re designed to assess residents’ suitability for unsupervised practice at the end of their program, you’ll go a long way to proving your suitability for residency if you can highlight progress in these dimensions. They include your ability to gather and synthesize essential information, develop comprehensive treatment or management plans, and skill in performing procedures among many others. The point is not to somehow seem like you’re functioning at a PGY3 level already, but rather that you understand the responsibilities of the specialty and have made some steps toward proficiency with them. 

Conclusion 

The profound diversity and breadth of Internal Medicine residency may seem dizzying at first, but it has a humble core. Internists seek to provide comprehensive, even creative diagnoses and treatment plans for complex problems that affect a wide variety of adults in many walks of life. And if you find that kind of challenging, big-picture aspect of medicine attractive, you’ll have an easy time motivating yourself throughout the 3, 4, or potentially 6+ years you’ll spend training into the specialty. Internal Medicine is a specialty for people with a strong academic and scholarly streak, but it’s also deeply big-hearted and humanistic in its day-to-day duties. When it comes to applying to Internal Medicine residency programs, this balance and empathy should be your guide, and if you’re drawn to the specialty earnestly you’ll have very little problem creating a strong application package, interviewing well, and ideally matching into your dream program. 

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To your success,

Your friends at BeMo

BeMo Academic Consulting

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