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ACHQ

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  1. Thank you for your post. I have my bias's about academic medicine which I will not air here (as I have already made it clear in my other posts). Suffice to say there are differences and pros and cons to each.
  2. When it comes to residency (generally speaking), what I have seen from surgery residents (at my center) is that they definitely have longer hours (on non-call days) and less post call days than my IM colleagues. If you are smart/efficient and aren't a tool your days on IM generally run from 8-5/6 at the worst. Occasional busy days you will finish later but those in my experience were far and few in between (and they are balanced out by the days you can take off early). I can't comment for sure but it seems all surgical residents are in the hospital on non-call days past 6pm (and they start usually before 7). IM will also ALWAYS get a post call day. I will say though IM residents (especially the SMR on call) are routinely busy AF. The volumes are much higher for IM (on avg) than surgery overnight. That being said we also have 3 JMRs on top of the SMR to do split the work, but the SMR has to review everything and see all the patients anyways... (and plus we go into a crap ton of detail when seeing patients) This refers to the core 3 years of IM residency and not subspecialty. Because hands down surgery is busier than any subspecialty IM (with maybe the exception of cardio and ICU) I also agree with all residency's suck big time, don't base your decision on residency lifestyle especially if they are the same length.
  3. Yes I should clarify my bias, most of what I speak of applies to UofT and the GTA. That being said I have heard of the practices I describe above at other academic institutions within Ontario... Just to add another perspective, I find that my upcoming community GIM position pretty flexible. Only requires me to do 34 weeks of total service out of 52. The rest of the time I can do whatever I please. It does require me to do in house call, but they implemented an 8 hour shift model for GIM ER consults, which makes it much more manageable. Also later on if I want to really dial back on evenings/nights there is a system where you can post shifts for others/locums to take. In terms of non-clinical opportunities, there seems to be a lot at my site especially in the area of quality improvement and other projects. We also get residents (mostly family medicine, some senior internal medicine residents on electives), so there is a bit of teaching opportunity as well. It may not be as abundant as in academic centres but it does exist, if someone truly wants to pursue it. Again I am speaking specifically for a large hospital in the GTA. I can't comment on other sites with as much confidence.
  4. Surprisingly?? ahahahha no matter how bad residency or work life might seem is the only thing that gets me keeps me in it, is the actual medicine. There's no formula tbh. I did 12 weeks of electives, 10 weeks were in IM with 6 weeks of CTU at two different sites, 2 weeks of Nephro and 2 weeks of ID. I think its good to do a mix of CTU and subspecialty medicine. You also don't want to just do sub-specialty only because you want to be able to feel out the programs core IM and the best way to do that is via CTU. You definitely don't want to just do CTU either, cause a) you'll burn yourself out b) you would necessarily advance your learning/knowledge base and c) who wants to really do that much CTU ahha I would recommend doing electives at sites you want to go to as a resident. I hear all centres are great places to train, and tbh I don't want to turn this thread into what the "best" IM programs are (secrete: despite what people think/say there is none, surprise!). Good sub-specialty electives to do include: Cardio (ward), Heme, ID, Resp, GI, Geriatrics. I believe the other sub-specialty are a bit more advanced, and it would be harder to impress (not saying its impossible, just harder), Heme could be on that list to especially if the place you're doing it has a lot of malignant-heme related things. Also it be wise to consider also doing subspecialty electives in area's you might be interested in pursing because that will help you if when your thinking about sub-specialty during IM.
  5. I will try to comment as generally (and accurately to my knowledge) as possible, given that I'm not in this field there are obvious specifics I won't know. Endo and Rheum are primarily outpatient based practices. Due of this their job prospects will generally be "good", because they can just open up/join a clinic and get referrals. Can't comment on how it is in the hospital setting, but with that being said even if you were to have a hospital based practice (all that would really entail would be that you take subspecialty call +/- GIM call and some subspecialty urgent clinics if the hospital has those) I'd be surprised if it was more than 1 week/month, so they still have to have their own outpatient practice (and the vast majority will continue to see patients in clinic, while they are on their subspecialty call at the hospital). FYI technically speaking these are not actual fellowships, they are royal college subspecialty residency programs. These are always funded, and offered only through CaRMS.
  6. The highest paying jobs in internal medicine are (no particular order): Cardio, GI, Nephro, ICU. those are also the ones with the worst job prospects
  7. Check out the link I posted in my previous reply, in that thread I outline the $ for various times of day. In general PER consult this is the ranking (highest pay to lowest): Any night (midnight - 7am) > weekend day/evening > weekday evening (5pm - 11:59pm) > weekday day (7 am - 4:59pm). Various hospitals have various minimums of how many weeks of MRP, ER consults, clinics that they need you to do. So yes hospitals will "allow" it but some hospitals require only 12 weeks, others require 20 weeks so it depends on the hospitals. Honestly to make significant amount in GIM is what you outlined, work evenings/nights/weekends and over all lots of weeks. I really doubt you'll be able to do cardio-diagnostics in the GTA given the amount of cardios doing it. Pain is lucrative but the government will almost certainly clamp down on it, plus the GIM person would need additional training to do it.
  8. Yes the day to day MRP codes are the same remuneration. The consults and assessments that GIM can bill (depending on the situation) are more. The SOB is very nuanced and even seasoned physicians don't get it. Let me to try and clarify: a GIM doing MRP work would still probably make more than a family medicine doing MRP work, but not by that much (and its hard to quantify what is worth the 2 extra years of training, is it 50k? 100k?). Also MRP work does not pay that well overall (unless it is associated with a large stipend, which at most hospitals it is not). The real money is in consults and you do most of that in the ER and clinics (and it adds up with the special visit premiums). As someone in GIM I did NOT go into it for the MRP work. I went into it for the mix. Let me be clear, a GIM doing the balanced work (as I described above: Consultations to the Emergency department, Consultations to non-medical services (Surgery, Psych), Urgent/rapid referral/post discharge/perio-op/OB medicine clinics and MRP of a medical ward/Hospitalist medicine) will make more than a family physician hospitalist doing only MRP work. "For me I know I like IM more than FM, but if I am going to go through a more demanding residency and spends more years in training, it has to make financial sense."- It will make financial sense if you are smart about doing a mix of things and not just doing MRP work. Like I said above, if all you want to do is MRP work than doing a family medicine residency with a +1 in hospitalist medicine would make more sense because you will make comparable (but still probably less) than someone who is GIM and does only MRP work (working the same amount of weeks).
  9. 1. I'll refer you to my detailed reply on this thread : Family medicine hospitalists can ONLY DO MRP work. They cannot do any consultative work because they are not consultants. (there are situations where at smaller hospitals they can do admissions from the ER BUT those aren't billed the same as an internal medicine/specialist consult, and all the large hospitals have GIM's doing this work not GP's). For all intensive purposes in the GTA they can only do MRP work. Family medicine has their own codes to bill for MRP work (which actually amounts to the same as the GIM codes), they cannot bill for consults or use any of the internal medicine specialist codes. I'm not clear on how often they do the 6-11pm shifts and what their schedule is like in general, all I know is that they exist (ahhaha). With re: 'I am basically looking for anything that would justify doing 2 extra years of training as a GIM instead of going through the FM shortcut.' If all you want to do is MRP work, and are happy with that (and family medicine clinics), then the FM hospitalist route would make sense for you. Note alot of places are moving away from family medicine hospitalists in general for a couple reasons: there are alot of GIM's/subspecialists being pumped out looking for work, and not all family docs want to do MRP work ever. That being said some large hospitals still have them so not sure if they will go away completely anytime soon. If you want to do more than just MRP like ER consults/acute medicine, Med consults to non-medical patients, and outpatient consultative work than GIM is definitely the way to go (see my response in the thread posted above). 2. Another topic that I would like your insight on is people doing a fellowship (e.g nephro) and still doing GIM work. Why do people do that? - that’s an easy one: there are NO jobs (or very few/limited work) in many subspecialities, so in order to pay bills people need to work, luckily within internal medicine they can at least do some GIM work. Some unfortunately have to leave their subspecialty training as the job situation is so bad and just do GIM permanently.
  10. 1. Re: who assesses/manages deteriorating patients past 5/6pm. - each hospital has a different set-up with regards to this. At my hosptial they actually have someone in house that handles ward pages/assessments from 6pm- 11pm. (At my hosptial there is a large cohort of Family medicine hospitalists, and they rotate through this not the GIM people). Beyond 11pm pages go to the medicine/GIM on call (the guy in the ER). My hospital also has in house CCRT (ICU) which responds to any in hospital emergency that is NOT a code blue (the medicine on call has to run code blues) called by any health care provider (could be a doctor or nurse), therefore if the patient is remotely sick (tachycardia, hypotension, decreases loc, hypoxemia, resp distress etc...) usually CCRT gets involved. I guess what happens if a the medicine on call gets called about a deteriorating patient? I guess if they are not busy in the ER they can see and assess the patient, and see if they truly need icu/CCRT involvement, or just get the nurse to call ccrt directly. Most/majority of other sites I have been to in the community have pages past a certain time (usually 6pm) go to the medicine on call (again guy in the ER). The on call guy will have to determine how to triage both floor calls and the Er consults. Again some places have another doc that covers CCRT. With regards to medicine consults, I’m not 100% sure but I assume that most calls can be fielded by the actual MRP at home, and assessed the next day. IF they need to involve medicine they would have to call in for a medicine consult to the on call medicine (again guy in the ER). If patients is SICK than they should just call CCRT. Again calling medicine on call for a surgical patient is fairly rare, as either they are stable enough to be assessed in the AM or they are sick enough to be seen by CCRT. One thing we should keep in mind is that patients aren’t crashing left, right and center (otherwise I’d be worried about the care being provided Hahahaha) but yeah it can happen. 2. Great question and I don’t truly know the answer. I guess people care about the “prestige” which imo is BS. There is also just a feeling of comfort since the academic system is all most of us have known throughout medical school and residency, so people want to stay with something they know.
  11. 1. Could you please elaborate on what the typical schedule looks like for GIM in a community hospital vs. academic hospital? What time do you have to be at the hospital and what time you usually leave? Also what the call schedule is like, and is it an in-house call vs. home call? It would be great if you can as detailed as possible as I want to picture how life looks like as a GIM staff. For a large community hospital in the GTA the "GIM division" has to (generally) have physicians provide coverage for the following areas: 1. Consultations to the Emergency department 2. Consultations to non-medical services (Surgery, Psych) 3. Urgent/rapid referral/post discharge/perio-op/OB medicine clinics 4. MRP of a medical ward (Hospitalist medicine) Each hospital will have a different way of how it structures the coverage (most of these will be separate distinct physicians covering each "service", however some hospitals do have some cross coverage where a physician will cover a ward and sometimes do ER consults or clinic, however this is becoming less and less common). Note: when I mean community sites I am specifically referring to large non-academic hospitals in the GTA such as Trillium, Mackenzie Health, North York General, Willam Osler etc.. I can't comment on smaller hospitals outside of the GTA (but I would assume somewhat similar). Given that each hospital is slightly different from the way they structure their schedule's it would be impossible for me to give one answer and say that is how it is for ALL of GIM. I can give you what MY layout is like (which is similar to other hospitals, but not exactly the same). At my site they require me to do 9 weeks/yr of MRP/hospitalist (#4), 4 weeks/yr of urgent outpatient GIM clinic (#3), 3 weeks/yr of med consults (#2), and 5 shifts/month of ER consults (#1). These are the minimums, I can fill in my schedule as much or as little as I like as long as I meet these min requirements. A "typical" month will look like: 1 week MRP, 1 week Clinic and 1.5 weeks of ER (depending on how you stack your shifts, and how many extra shifts you take if any). Some months you'll have more space. Day to day (again this is for community sites, and I am referencing my site more specifically): MRP/ward work typically 8-4/5, depending on how large your census is and how efficient you are, typically the first day is the longest and it gets better afterwards, technically you are responsible for the patients until 6pm (i.e. nurses can page you up until that point), but most issues can be handled over the phone. ER consults days are shifts so set hours, again different sites have different shifts, the one I'm at has 3 8 hour shifts (0800- 1600, 1600-2400, 0000-0800). Clinic is usually 8-4ish. med consults is usually more chill as well. When you refer to the "call" schedule, I will assume you mean ER. In the community it is a bit different in that you are technically on "call" for your MRP patients when your on the ward (again until 6 pm at my site), on "call" for med consults (again only until like 5 pm or whenever you leave the hospital), and the ER (which is the shifts I described above). The ER shifts you have to be in house (obviously), and as I mentioned you do 5 shifts a month. I've been told I have to do at least 1 night/month, and 2-3 evenings a month. Again hospitals are slightly different, but this gives you some idea. Academics is a whole different kettle of fish. I cannot comment with 100% accuracy, but in my experience they have to cover similar services as the above, except they do ALOT more MRP/CTU work, as opposed to it being evenly spread out. Depending on your designation (scientist, quality improvement, educator, teacher) you will do a certain amount of clinical work and the rest of your time is supposed to be devoted to academic endeavors (research, teaching, admin, quality etc...). Typically GIM academic physicians have decent hours (7-5/6) with some weekends, but they are NEVER in house call. They are usually on call with their SMR but they are at home, SMR's try not to call them to wake up (but it does happen, not frequently). 2. Income of GIM in community hospital vs. academic hospital vs. outpatient clinic? Just if you could mention what the typical average income is for those 3 as well as respective overhead. I haven't started practicing yet, but this is from what I've heard and seen first hand from community physicians (and of course the Toronto star data base hahaha). Typically in the community GIM physicians can make 300-500k. That range is huge for a few reason. How much are you willing to work? if you are willing to work 48-50 weeks and take basically very little time off, than you can make close to if not higher than 500k. Also how much "on call" (i.e. evenings, nights and weekends) are you willing to work? Those shifts are much more lucrative and therefore the more you do of those the more you can make. If you only do community hospital work you pay NO overhead. academic hospitals can be a bit of a black box, but they definitely do not make as much as community physicians. The numbers I hear for academics is between 250-350k. They have a complicated way to pay academic docs (see my first post #2), but for all intensive purposes you will make much much more in the community. If you do your own outpatient clinic (or join an outpatient practice) and JUST do that then here's a bench mark: work 48 weeks, 5 days a week, see 16 patients a day, 12 new consults, 4 follow ups, you can make roughly 500k before overhead. Overhead at most clinics is 30%, so around 350k after overhead. Note you will have to first build your practice (at first you wont be seeing 16 patients a day). 3. How hard is it to get a job at an academic site? Like is the 5-year GIM enough or do you have to be research-oriented and committed to publishing? I can only comment on the GTA. But getting an academic job is not easy (in any specialty, even GIM). Not only will you have to do the 5 year GIM program, but you will have to show some proficiency in research/education/quality improvement, which not only means great evals or publications, but usually a masters/PhD ontop of that. NOT only do you have do what I mentioned, but they rarely/never hire someone as an active/full time staff with a university appointment right out of residency now. They make the person do something called a clinical associate year(s ), see #2 above. This is supposed to be time limited, but I have seen many people get d$#%ed around for 3-5 years without any full time staff position at the end of it. To decide if you want to do academics vs community its easy: Academics= focus on research, teaching, quality improvement, administration etc... Residents/fellows do most of the clinical work under your "supervision" Community= focus on clinical work, seeing patients, making money. Can still be involved in the above, but to a lesser extent.
  12. Hey no worries I will try to answer your questions as best as possible: 1. There really is no big difference between the 4 and 5 year GIM programs other than the fact that the 5 year would allow you to work in an academic centre and maybe allow for more elective time to pursue an AFC like thrombosis. (Would you still be able to persue an AFC with the 4 year program?) - The 4 year program can allow a lot of elective time (depending on where you are doing your IM residency) that being said, you usually can't do a formal fellowship within that year (at least at UofT). TBH most people who go into the 4 year program don't want to do any fellowships because its not their cup of tea (doesn't add much unless you really want to practice in that niche area). That being said you can definitely do another year in something (thrombosis, OB med etc...) as long as you "get into" (i.e. secure funding) for that fellowship. 2. Being in an academic centre allows you to have residents that can take call and you have easy access to several subspecialties that you can refer even slightly complicated patients to. This is a great plus, but comes at the cost of the academic centre taking a certain percentage of your billings (I heard this can be anywhere from 20-50%). Is that billing part true? - This is true for staff who are under the designation "clinical associates". I can't speak to all Universities, but in order to make it "fair" for everyone in the department of medicine (fair meaning more equivalent pay) everyone bills for each patient they see and those billings go into a huge pot. Other sources of income go into the pot as well like research/educational awards $, etc.... A certain percentage (apparently small, like 5% or something but I have no idea exactly how much) of it gets taken by the department to cover some "overhead costs", and the rest then gets redistributed to everyone in the department/division. This allows the people who have a more research focused (or less clinical oriented) career to make more than they would if they just did pure fee for service. That huge percentage you quote above, is for clinical associates (usually betwen 20-30%), who basically get to work as a "staff" and contribute that percentage to the group, without getting any direct benefits of the practice plan (there are some benefits, the details I'm vague on), the "benefit" to the person doing clinical associate year(s ) is that they get a chance to land a permanent job (but no guarantee of one). Generally clinical associates get the worse scheduling and most weeks on service. 3. Does the 5 year program have an exam in addition to the royal college exam that we now write in 3rd year? - Yes, its written after the completion of the 5th year, usually in the fall of the year you completed. 4. Billing, finding a community job and starting a clinic is otherwise the same between the 4 year and 5 year program. Is that true? - 100% true, no one can claim otherwise, and if they are they don't know what they are talking about and/or are lieing. There is no difference in billing codes (yet), and even if they were to make new ones (never think that would happen as there are too few 5 year GIM overall) the billing codes for core internal medicine would have to still exist. 5. From a procedure perspective, right now I'm very comfortable with paras, thoras, central lines and some chest tubes. I'm not sure though if I was in a community hospital doing an overnight shift (or moonlighting), if I would be able to intubate a decompensating patient with an even slightly difficult airway (All my glide scope intubations have been very straightforward) or float a temp wire for someone in heart block. Is this fear out of proportion with reality or is this a skill that I would be able to pick up over the next 2 years of residency? Is this even a skill I would need as an internist working in a community hospital? - You sound like you have done alot of intubations in just 2 years of residency which is impressive. I don't think any Internal medicine person (other than those that have done ICU fellowships) are ever comfortable with intubating patients. I think it is something healthy to know your limits and respect the airway as much as possible. You could pick up the skill in the next two years but tbh the reason anesthesiologists feel so comfortable with it is because they do it literally ALL THE TIME. There's too much variety in GIM to say you would be doing it very frequently. But let me say this, even in sites where there are no in house ICU physicians (alot of sites are now adopting a model for inhouse ICU as there hospitals and ICU's are too large to be covered completely by one internist all night, for ex the one I will work at does have in house ICU 24/7) there is always in house anesthesia and ER docs and even RT who intubate patients, and if you feel you need help they should be able to help you. The main thing in airway management is being triple prepared, having a plan A, B C and D, having the right tools (direct larygnoscope, glidscope, bougie, LMA, and Bag mask) and making sure you can at least bag mask someone. TBH other than intubations most other procedures can wait, pressors/inotropes can be given peripherally for a time limited span or if you can learn how to do a quick blind femoral you will save tons of time, you don't really need an art line and/or RT can do it for you. Chest tubes only need to go immediately for large or tension pneumothorax, and if thats the case I would get the in house Gen Sx to do it. So I wouldn't sweat it too much 6. Many senior residents that I have spoken to have suggested that if I am consider a 5 year GIM program that I might as well just do ICU, since it opens up further avenues of employment. This doesn't seem like a bad idea, except when I think of why do the extra work as an ICU fellow? - That line of reasoning only works if you are willing to put yourself through 2 years of ICU training (which can be brutal). BUT there are basically no jobs in ICU, so unless you are completely ok with doing that and ending up working in GIM anyways then sure that would make sense. 7. I looked up the billings of ICU attendings when the Toronto Star article was released and I was actually underwhelmed with a lot of them compared to what I expected/saw GIM docs make in a busy community hospital. Obviously this doesn't take into account other modes of funding and the fact that many only do a couple of weeks of ICU a year. When I asked similar questions on other forms. I've been quoted things like 300-500/year for GIM docs working in clinics 5 days a week before overhead. Is that inline with what you see/know? - You probably checked ICU attending at academic sites. Even in high paying specialties academic physicians don't make nearly as much as their community counterparts, because they have other non-clinical commitments (which pays either $0 or something close to that). If you do GIM work in the community and only do clinics, you would have a huge overhead which would eat into your take home pay, and you make less doing non-hospital affiliated clinics because you can't use the premium codes. The reason GIM community docs make a decent income is because they do hospital based work where they bill premiums (because they are doing evenings/nights/weekends) and have no overhead. The number you quoted is possible if you see about 13-16 patients a day (80-90% of them new consults) and work 46-52 weeks a year. The other good thing about being in the hospital setting in GIM is alot of the time you dont have to work 46 or more weeks. 8. Any ideas or general sense of what the Job market would be like for a 4 year GIM doc at a community hospital in the GTA in 2 years? I know it's hard to predict, but I can't imagine it would go from "You will definitely find a job right now" to "We are 100% saturated as is the case with ortho" in 2 years? How difficult was it to get a job lined up and is that something you only really started to look into during your 4th year? - Things are starting to tighten up a bit, which I noticed with my job search. Not bad but definitely not like a few years ago where you could walk into any hospital and they would basically offer you a job on the spot. Now you have to find the hospitals that are specifically hiring. I agree that in 2 years it shouldn't be as bad as ortho (ahha), but it won't be as good as it is now. That being said GIM will always be better than any other subspecialty job prospects. Also GIM always ALWAYS has locum work (which is usually evenings, nights and weekends/holidays, which unfortunately are the worst times ahaha) I got lucky in my job search as I set up an elective at a site that knew they were going to hire someone, and we both ended up liking the fit which lead to an interview and eventual offer. You only can start looking in your final year of residency and even then at most 6-8 months prior to your ideal start date, because most departments won't know their personnel needs more advanced then that. Hope this helps
  13. Hello all, I'm starting this thread for those interested in asking questions about GIM (or even Internal medicine in general... see what I did there ) Who am I? PGY-4 Internal Medicine resident, in the "4-year" GIM program. I will be finishing June 30 2020. Come July, I have a job lined up at a large community hospital in the GTA. Ask away!
  14. There is a special fee code called: "Special Visit Premium", which according to the SOB in Ontario states: "Special visit means a visit initiated by a patient or an individual on behalf of the patient for the purpose of rendering a non-elective service" There are separate codes for seeing a patient in the ER (K99_), hospital clinic (U99_) and the hospital ward (C99_). The amount will also differ depending on the time of day (0700-1659, 1700-2359, 2359-0659) and whether its a stat holiday Below are the payment rules, copied and pasted from the SOB. From my crude understanding these are codes specifically for non-elective visits, I've mostly seen them used for the ER (all day) and urgent calls from the ward (off hours 5pm-8am). I've also seen them used in urgent outpatient clinics by some. AFAIK you cannot use them for your regularly scheduled (elective) clinic even if it occurs in the evening or weekends. I guess you can use it if you were to schedule a patient in to be seen urgently... but I'm not too well versed with its use in clinics tbh Payment rules: 1. Special visit premiums are only eligible for payment when rendered with certain services listed under "Consultations and Visits" and "Diagnostic and Therapeutic Procedures" sections of this Schedule. 2. Regardless of the time of day at which the service is rendered, special visit premiums are not eligible for payment in the following circumstances: a. or patients seen during rounds at a hospital or long-term care institution (including a nursing home or home for the aged); b. in conjunction with admission assessments of patients who have been admitted to hospital on an elective basis; c. for non-referred or transferred obstetrical patients except, in the case of transferred obstetrical patients for a special visit for obstetrical delivery with sacrifice of office hours for the first patient seen (C989); d. for services rendered in a place, other than a hospital or long-term care facility, that is scheduled to be open for the purpose of diagnosing or treating patients; e. for a visit for which critical care team fees are payable under this Schedule; f. in conjunction with any sleep study service listed in the sleep studies section of this Schedule; or g. for services rendered to patients who present to an office without an appointment while the physician is there, or for patients seen immediately before, during or immediately after routine or ordinary office hours even if held at night or on weekends or holidays. 3. Special visit premiums are not eligible for payment with services described by emergency department "H" prefix fee codes.
  15. For a large community hospital in the GTA the "GIM division" has to (generally) have physicians provide coverage for the following areas: 1. Consultations to the Emergency department 2. Consultations to non-medical services (Surgery, Psych) 3. Urgent/rapid referral/post discharge/perio-op/OB medicine clinics 4. MRP of a medical ward (Hospitalist medicine) Each hospital will have a different way of how it structures the coverage (most of these will be separate distinct physicians covering each "service", however some hospitals do have some cross coverage where a physician will cover a ward and sometimes do ER consults or clinic, however this is becoming less and less common). Some community sites will have Family doctors who can do #4 (this is also becoming less common because the # of GIM's being pumped out, but AFAIK it still exists, and places are still hiring). There's one site I know of that has Family doctors that also cover ER admissions, but this is not common place anywhere else. 99% of the time the ER consultations are done by a GIM or sub-specialist. Family doctors do not do #2 or #3 anywhere in the GTA. *Generally* sub-specialists can cover any of those services above (from a billing and legal standpoint). However all/most will only be required to do #1. #1 is usually a requirement from the hospital department of medicine so as to spread the ER call coverage amoungst a larger number of people. Many subspecialists will try to give away their required ER calls. Some will do them (either because they want to or because its good $$). Some will take more because they can't find a permanent job. The main point I'm trying to make is, if you want to do GIM work (all the above I listed), then do GIM. If you like a certain sub-specialty then do that. But to do a subspecialty and try to both (in terms of full breadth and scope) is difficult.
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