futureGP

Sounds pretty hard. I don’t think I know of any that was able to do it. Maybe talk to the cardiology PD at your local school to see. Funding may be an issue as well as educational exposure

Periop, palliative, thrombosis, OB medicine, cardiac diagnostics

No. but if you want, I am sure you can no one will stop you.

In Ontario, subspecialists like endo/rheum/allergy/resp will do better in outpatient than GIM even if seeing the same issue due to extra premiums. In busy outpatient clinics in GTA, endo/rheum can easily bill 500+/-100-200k if they work full time. You want to +/- 100-200k because of variables such as efficiency of clinic, efficiency of the physician, # of says worked per week. Their overhead tends to be lower - just pay rent and admin. Resp varies if you have a PFT/sleep lab or not. If you do, then you’re doing pretty well (800-1 mill+), if not then 600-800k GIM outpatient, you’d have to see 30-40 patients a day to reach 600-700k. Its hard, not impossible. Most probably see around 20-30 a day as outpatient and make 400-500k roughly. But your efficiency is limited if you work at hospital clinic - tend to be less efficient than private clinics due to bureaucracy. Cards community - agree probably most bill 800-1mill+. Overhead probably higher. None of the above applies to academia where cases are complex (thus longer consults), and less volume driven. Another way I look at it is Assuming 48 weeks, 5 days work. $480k/yr equals ~$2000/day $960k/yr equals ~$4000/day A medicine consult is roughly $170-185ish depending on subspec. a subspec follow up is roughly $110-135 if there is chronic disease or $75-85 if not. If any subspec is seeing ~30 pts a day which is a very reasonable number. Maybe 1/3 consult, 2/3 follow up. That can be around $3500/day ez. The diff between subspecs then is the extras like diabetes mgmt fees, allergy tssts, joint injections for rheum, pft/sleep study, cardiac diagnostics etc. The complexity of consults also play a role so an allergy consult can be simple vs an autoimmune disease nyd consult for rheum. the other thing is competition. There are many endoscopy clinics in the GTA, many cardiaology clinics in the GTA. So you are competing to fill your volume with each other, which may not be hard given demand is generally high but still there. One thing I would do as a trainee again is to do electives with physicians in whichever subspecialty who have an efficient practice and find out how they do it. This part of medical practice is not rlly taught in academia and something that will have a huge impact in anyone’s clinical practice their whole life.

You dont need plus 1. almost every GTA hospital looming for hospitalist. I would cold call of email medicine chiefs at hospitals. you dont need +1

The only subspex where it’s rlly possible is ICU. you can do anything other than ICU and then subspec in ICU after. But subspec other than ICU will not accept the above, unless you are a special external/self-funded trainee.

Money wise, you will be ahead in any outpatient subspec IM vs FM assuming same degree of work ethic, hours worked etc. Unlike the above post, as outpatient Allergy, Rheum and Endo, it is highly unlikely that you will have to do any general medicine as staff unless you want to. Yeah you may be asked to see inpatients for consults but those are far in between and you will never have to do any MRP GIM work unless you decide to. To comment on ‘breadth’ and ‘complexity’ of cases, these are relative terms. For a family physician, breadth could mean knowing a little bit of peds/adult/ob/surgery. A specialist could also have breadth within their field, eg as a rheumatologist, your breadth of knowledge within rheum is the immunology behind autoimmune diseases and the individual diseases and their managements from RA, lupus, scleroderma to myositis etc. Also a ‘complex’ case to a family physician maybe a simple case to a specialist. So let me tell you that in real practice, an efficient subspecialist practice does not look much different from an efficient FP practice except that a subspec practice will have high volumes of similar issues vs a FP practice will have high volumes of many different issues. so it is easier to scale up a specialist practice vs a family practice and overhead is generally lower. And generally specialist fee codes pay well vs FP so you will be financially ahead. Some good examples of purely office based practice in IM are - allergy clinic -> allergy test/consult is bread and butter. Absolutely no inpatient call reqmt. - endo clinic -> diabetes, thyroid issues, obesity etc. no inpt call reqt. Low overhead. - rheum clinic -> RA, OA, other connective tissue disease, psoriatic arthritis, joint injecfions etc. Again, no inpt call reqmt. Yeah a lot of them are on biologic but most of these are outpt injections and typically handled by the companies that inject them. Low overhead - resp clinic -> cough, asthma, copd, ILD. Can choose not to affiliate with hospital and you have no call requirement. Low overhead. - Medical Oncology -> hospital based clinic practice. 99% oncology practices at least in Ontario do not have inpatient MRP burden. May have to provide inpt consults but never overnight or weekends. No overhead. - pure outpt cardiology clinic -> holter, echo, stress test, chest pain, afib, coronary artery disease. As a cardiologist, you don’t have to affiliate with a hospital if you decide not to -> thus no call burden. - pure outpt GI endoscopist -> can choose not to affiliate with hospital. Work at private endoscopy clinic. Higher overhead but purely bread/butter EGD/colon. - GIM clinic -> can practice pure outpt GIM specializing in areas like periop medicine, OB medicine, Hypertension, low risk cardiac. - sleep clinic -> sleep apnea, insomnia, restless leg syndrome. Low overhead.

i would disagree with this post. having been working in the system for a while, a single payor system does not prevent overtreatment or overdiagnosis. Imagine you own a private endoscopy clinic, cardiology lab, radiology lab where you bill OHIP/MSP etc for services. You still run a business and the untold truth is that there is a shxt ton of unnecessary tests and procedures being done. 30 yo with chest pain from likely anxiety? Gets an echo, stress test and a holter. 45 yo with simple GERD? Gets an EGD and colonoscopy. Because its a single payor system and the payor is the government, the oversight into overbilling practices is very very poorly run. How would you expect a non-medical government official to argue with a ‘cardiologist’ about ordering holter/stress test/echo on a 25 year old coming with atypical chest pain? Frankly speaking, there is no real incentive here either (it’s government workers you’re talking about) Compare that to the private sector with insurance companies. How many times do you hear of people not receiving claims for personal injury. We have a thriving personal injury industry for a reason. There actually is more accountability in private sector because overbilling directly undercuts profit -> upset shareholders. So the incentive is tremendously high to police inappropriate testing/procedures. In addition, in a 2-tier system the private system may actually increase access to health care for the public system. One of the limitations of the public single payor system is that the government pays for all hospital capital equipment / resources. It’s not uncommon for a fairly large community hospital to not have access to what one might consider to be an important medical equipment for population of that size (eg esp. in the surgical world, but it can be as simple as portable US in ED/ICU) By incentivizing the hospitals with revenue from the private patients, those expensive capital equipment purchases that you would have had to rely on rich donors to fund now become available.

Sounds like anesthesia. the thing with overseas mission work is that unless you’re in a surgical field where you can be there for a week, fix a lot of people and come back, it’s hard to commit for long term benefit. so for that, surgical specialties will be better, including anesthesiology. ICU would work too as well as EM. It would be pretty hard to make use of Cards in missions. Most of cardiology is chronic first world problem

I’d do ID. Anyone can do GIM. only ID can do ID After ID, if you miss IM so much, you can easily do both in the community

Outpt cards owning own lab with triple cardiac tests (holter, stress, echo), will clear >1 mill with volume just check out torstar billing data for ontario and look up some local cards that said, you dont need to be cards to do the above. As GIM, you can easily do holter/stress, just not echo.

Hospital work has no overhead, hospital premium but not as efficient. Clinic work has overhead + administrative burden if you’re the owner. But you may make more because you take T fees if you own the clinic. May make less if you work for someone as they may take a cut of your P fees (or not - i think depends on the clinic) in general when you’re young and starting out you’ll do more hospital work. Once you have a stable outpt practice, you may prefer to stop hospital work in your older years.

MRP work will probably never go away even in your 50-60s if you plan to work as full time. In your 50-60s, you may get off night schedule but I would doubt you can negotiate out of weekend schedule. Or you could become the deptchief and run the show and make your own rules

Maybe if you want to spend 5th year for extra skills like OB medicine, thrombosis etc. but do they really need a full year to learn? Probably not.

Do not attempt without them for sanity sake. Don’t be that one person who didn’t use the resources and failed and have to spend another subspecialty year to retake the exam. The fact is every canadian resident will use the resources and review them to the detail in a group setting. IMReview course I thought was alright but more for the social aspect of hanging out with some friends while ‘studying’ for an exam. It alone is def not enough The speakers for the review course are also mostly PGY5s who passed but also studied using the ‘recommended resources’.