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BigM

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BigM last won the day on October 26

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About BigM

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  1. It’s interesting to see the announcement of the Ontario Specialists Association’s board of directors which is “representing a broad range of specialties”. Two radiologists, a gastroenterologist, a cardiologist, a nephrologist, an eye surgeon, a vascular surgeon and an emerg doc. Is this a group that looks like they are going to defend the status quo?
  2. That’s one of the difficulties of the situation. As someone in one of the lower paid specialties (psychiatry, a 0.86 based on CANDI score) why would I want to support a group that I suspect wants to maintain the status quo of having such significant disparities in pay between different medical specialties? I certainly wouldn’t feel that a specialty interest group would see the interests of my specialty as being a priority despite the fact that we are one of the largest based on numbers. The group being formed by a radiologist makes me suspect the intentions of this right from the get-go. This current malignant environment has existed between the MOHLTC and Ontario physicians for at least the past 8 years (I was a pre-clerk when our previous contract ended and things started to escalate in ugliness between the OMA and MOHLTC). It’s been very difficult to have any meaningful decision about rebalancing/realitivity for this exact reason, when the OMA finally started to talk about making concrete changes based on realitivity, it caused splinters within groups of doctors which now weakens our overall bargining power. It’s also an understanding of mine that the grassroots organization Concerned Doctors Ontario was largely funded by and driven by the high paid specialties. Unfortunately at the end of the day money usually talks louder than everything else. We like to consider our physicians at large to be much more altruistic than we are. Especially coming from a speciality which is often treated with hostility and disrespect (at least at academic centres, but I also suspect in the community setting to a lesser degree) from other medical specialties, it makes it a bit harder to find a lot of sympathy for some of these groups being targeted by realitivity changes. I really don’t feel that the current remuneration is reflective of the hours worked and responsibility that some specialties have. One group in particular that I do feel bad for is pediatrics. IMO they are certainly undervalued financially (compared to other physicians at least) for the responsibility that they carry.
  3. I agree with what other people say above. However, I should preface this by saying I'm not in surgery and didn't have much interest in that path. At the end of the day, attitude is more important than achievement. That said, some of the people who are quite accomplished are so because they have great attitudes and strong work ethic. However, A good portion of the people that have graduate degrees in your program likely did so because they were unsure of what they wanted to do next after their undergrad or they didn't feel that they were competitive enough for medical school admissions directly after undergrad. The more difficult part is going to be looking more competitive on paper than these individuals. If you're serious about being more competitive than them, start early and be keen. In person time and electives are going to be your opportunity to shine. Your first couple of years of medical school are a great opportunity to do observerships and to start meeting some people in the field. It's also going to give you some exposure to help answer one of the most important questions, is a surgery career really what you want with your life?
  4. I’m not aware of any hidden agenda. One thing that it’s good to be mindful of is that the end of each residency year will be moved back by the amount of time you take off. I.e if you take 1 month of paternity leave in PGY3 then your PGY4 year won’t start until the end of July (vs July 1st), likewise for PGY5. This matters as you won’t move up on the salary scale every year until a month after your classmates.
  5. PGY5 is a year of electives if you opt not to do a sub specialty. So you can basically make what you want of it. You can do outpatient care and maintain a fairly steady 8-4 with call shifts being in addition to that, or you can opt for a busier service if you want. The thing to keep in mind is that this is generally your last year before independent practice so you need to see enough and do enough that you feel comfortable being the MRP. Personally I have opted to focus more on learning around my cases and reading topics of interest rather than following more traditional routes of exam preparation. What is the most yield info for exam purposes is often not the same high yield info for clinical practice. The pass rates for royal college exams are also very high, I believe in psychiatry it is over 99% for Canadian grads. As I get closer to the exam I will likely get spooked and spend more time practicing old exam questions, etc, but right now I am able to remain fairly confident that I can focused on learning the most clinically useful stuff and still do okay on the exams.
  6. I’m a PGY5 psych resident. My undergrad contained all of one 1st year course in psychology. Psychiatry and psychology are in many ways different. As a psychiatrist you will learn the theoretical backbone of different psychological models, but unless you do work is focused on psychotherapy (which isn’t the case for most psychiatrists), most of your work will include taking a history, reviewing symptoms and discussing medications, I.e. practicing medicine. However, your knowledge of psychology will help you understand/formulate patients, explain things to them and work alongside other health care workers who primarily provide therapy. The requirements for neuro knowledge depend on what you do in your practice. Neuropsych obviously needs a lot of neuro knowledge. Likewise, geriatric psychiatry and consultation-liaison also require you to have a good working knowledge of neurology. In general, child and adolescent involves much less neurology and general medicine.
  7. My understanding is that it doesn't require going through CaRMs but does generally require a space in the program you want to match to being available and an agreement from the program directors of both programs. Having matched to ENT you have 5 years of funding that was allocated to your postgrad training which apparently results in less of a barrier than switching from family medicine to a 5 year program.
  8. I don’t find it clear what happens if you do a fellowship. It says that fellowships are not covered by the program. Does that mean that doing a fellowship means you broke the contract and need to pay out? Does your fellowship count towards time served if it is in Ontario? Does it just delay the start of the ROS by a year?
  9. It wouldn’t necessarily be a Locum as those tend to be time-limited, but a very similar principle. This would be a situation where you are billing X organization Y dollars/hour for your time for Z number of hours. They define this as a contract for services. X could be a provincial government, community health Center or another organization. I suspect this is probably the same thing as a “sessional” but admit I don’t fully know what the term means.
  10. I’m hoping some more knowledgeable individuals can provide me with some info on this. I know that you cannot incorporate as a salaried physician. Can you incorporate if you are being paid an hourly rate for contracted services, I.e $200/hr + a % of shadow billing. I suspect the answer for this is yes but I would appreciate a more educated opinion. thanks!
  11. As others have said, you would need to check with the college of the province you are thinking of practicing in. My gut tells me that you won't be able to do this easily. As a physician you cannot provide a medically necessary service as an out-of-pocket expense. I am going to assume that psychotherapy is a covered medically necessary service in all provinces. If your patient cannot afford to pay $200/hr for psychotherapy sessions anymore, are you going to stop seeing them? You still have the option of billing through the provincial health insurance plan to see them. But then how are you going to do this for some patients and not for others? There are a additional complexities to consider as well. I doubt that you can just take off your family physician hat selectively for some patients and not for others. As a family doctor, most things are considered within your scope of practice. If you identify unaddressed needs in your patients which fall within your scope of practice, there is likely liability in not addressing it, especially if the patient doesn't have someone else readily available to go to (e.g. another primary care provider). Also, while I have no data to back this up, I imagine that your both your liability and responsibility in providing care to your psychotherapy patients would both increase. As a MD the buck stops with you (unless you have an appropriate specialist involved). If there are bad outcomes and people are going to go after you, they are going to go after the physician you, not the psychologist in you. I am nearing the end of my psychiatry training. My per hour billings will generally be less than a psychologist but there are definite benefits to being an MD (in this case psychiatrist) as well. I don't need to work near as hard as a psychologist to drum up business given the massive shortage in psychiatrists. I can send a fax to the GPs in an area and generally have a full practice within weeks if I'm willing to stay general and not be selective about accepting consults. My earnings are predominately limited by the number of hours I want to work (yet still drastically lower than almost all other types of MDs). I can see patients who otherwise would not be able to afford therapy. And lastly, I can use medications alongside therapy which is often very effective. Make sure you give consideration to the possibility of psychiatry if you are interested in becoming an MD. Being a psychiatrist certainly doesn't limit you to being a psychopharmacologist and it provides you with a lot of open doors. Your use of other areas of medicine as a psychiatrist is really limited by your comfort level and practicality. Although you're in your early 30's, you still have a lot of potential years ahead of you. Psychiatrists who do a lot of psychotherapy tend to practice fairly late into life, some will even go well into their 70's. It's fairly easy on the body, an easy lifestyle and there is a passion for it. If you're looking at family medicine vs psychiatry before starting medical school you're looking at 6 vs 9 years, when you factor in the length of medical school its not as drastic of a difference. In many provinces you can also moonlight in your higher years which would probably be very easy to do with a background as a psychotherapist.
  12. My understanding is that the rates are based on the cost of settling/paying out past lawsuits against members of that specialty. This is just an educated guess of why neurology is high, but bad neurological outcomes can have very high morbidity (stroke, etc) without death which can leave patients requiring very expensive care for the rest of their lives. Patients who experience bad outcomes in other medical fields probably on average don't tend to live as long after the outcome occurs.
  13. I enjoy most of the patient interactions that I have. One of the hard parts (depending on your perspective) about medical school and residency is you need to learn in a variety of settings, including the ones that you enjoy and the ones that you don't enjoy. As you advance in your training you usually get more flexibility to spend more time doing the things that you like to do. In many fields (unfortunately not all) there is even more flexibility after you finish training to practice in the areas that you like. I am in psychiatry and really enjoy outpatient care. I recognize that getting adequate training in the emergency department, in the acute inpatient setting and in the chronic inpatient setting are all important as this will give me the experience to handle my more difficult outpatient cases in the future. But by and large, most cases seen in outpatient psychiatry aren't super complex (by psychiatrist standards) and respond well to treatment. Even with the areas that you don't like as a resident, once you realize that as a staff you will bill for every case you seen, instead getting paid the $4-5/hour you get regardless of work load for being on call as a resident, it seems a lot more positive.
  14. BigM

    Forensic Psychiatry

    The lower pay in psych tends to go with the fact that OHIP renumerates procedures better than counselling. Psychiatry is time-based billing which means that you have to log a certain amount of time with each patient. If you're doing procedures, you're getting paid for the number you do regardless of how long it takes. Psychiatrists also tend to spend more time documenting things, sitting in in multi-disciplinary rounds, and doing other things that aren't renumerated or are poorly renumerated (e.g. disability applications on complex patients).. That said, most psychiatrists aren't hurting at all. At some busy academic centers 400K+ is common as there are a lot of on-call consults done by residents and residents can run parallel clinics without a lot of (or pretty much any) extra work by the psychiatrist. In some specialties having residents slows you down and results in lower billings, that definitely isn't the case in psychiatry. It's time based billing and you're billing for the time spent by two MD's. Also, the overhead in psych is lower so that $255K goes further than it would for a specialty like family medicine where you need a lot of equipment and supplies.
  15. BigM

    Forensic Psychiatry

    I'll attempt to give you the best answers I can about this. I am a psych resident but have spent no real time in forensics so hopefully a more knowledgeable answer emerges. 1. Forensics fellowship is not absolutely necessary to get a job in forensics. The fellowship program is only a few years old now and many programs haven't actually established their fellowship program yet. The vast majority of those in the field did not do fellowship training. That said, if there are a few people applying to jobs then the fellowship program is going to make a big difference. The psychiatry residency curriculum is pretty structured during years 1-4 which doesn't leave you a whole lot of time to get experience in something like forensics which can be quite different from the core areas of psychiatry you do in your residency. There is no mandatory forensics time built into the curriculum. Those interested in doing a fellowship would start the 2 year fellowship at the beginning of their 5th residency year and then do an additional 6th year giving them 24 months of forensics experience. Prior to 5th year you may only get 1-4 months of forensics experience and that's if you choose to do your electives there. 2. My understanding is that the job market is very good. The forensic mental health system is desperately lacking man power, especially in jails. Many individuals with mental illness unfortunately end up in the jail system when they would be better served elsewhere. Right now there is no shortage of demand for services, how much funding infrastructure is in place, I don't know. 3. Yes this can be done. From what I have seen most people who do forensics do exclusively forensics. 4. I have only heard about this in passing, but what I understand forensics renumeration is higher than general psychiatry. That said, general psychiatry is relatively low, on average its the second lowest paying specialty just behind pediatrics (depends on where you work of course). Any medico-legal work tends to pay well if you are efficient. 5. Early exposure is a great idea. Forensics is not a popular area and there are many training programs that would love to have more learners come out and see what they are about. I would recommend setting up a couple of observerships with preceptors that have good reputations among learners. It won't take long before you know more about forensics than I do. Hope that helps a bit.
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