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ACHQ

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  1. 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.
  2. 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.
  3. The University/program have their own agenda's, which likely relates to money. From my understanding the University/program gets only 3 years of funding/per resident for the "core" portion of the Internal medicine program (which is 3 years), and then get additional 2 years of funding/per resident in the subspecialty programs. However our CARMS contract guarantees us 4 years of funding if we do the 4 year GIM program. The government however doesn't fund this for whatever reason and so the schools have to find the funding and pay for each resident. That can get pricey if you have 10+ residents doing it (which can equate to 750k- 1million/year). Universities/programs will rarely care about what is best for *you* as an individual. Don't trust them, go with what makes sense to you and your family, because 5-10 years down the line when you're done and struggling to look for work because you became hyperspecialized in x,y,z sub-sub-specialty and there isn't a job in a city where you want to live, the University/program wont even remember your name, and you'll be doing GIM work anyways except that you will have lost all those years of *real* earning potential
  4. hahahah yes. When you get to my stage and start learning this stuff, you get really annoyed with residency. Its literally slave labor. or in the ER, which most people are. I don't know anyone who doesn't bill the SVP when getting called to the ward for any issue (even if it can be resolved over the phone). It does require you to see the patient and document appropriately.
  5. a standard consult is $157, if you admit the patient you add 30%, and since you admit like 90-100% of the patients you see, therefore it turns into $204.10. if you see a patient between 5pm-11:59pm you add $60 per patient seen, therefore a consult+admission is $264.10 if you see a patient between midnight and 7am you add $100 per patient seen, therefore a consult+admission is $304.10 If your call involves covering the hospital ward in any capacity, seeing/assessing an admitted patient can be anywhere from $38 or $79, depending on how extensively you assess the patient. If you do that in the evening (5-11:59pm) or night (midnight to 7 am) you get same premiums as outlined above per patient seen. If you cover code blues in the evenings or overnight, you bill resus codes which are $110.55 for the first 15 min, $55.20 for the next 15 min, and $36.35 for every 15 min thereafter. You can again add the same premium codes as outlined above. Most hospitals also have an on-call stipend as well to supplement billings. These are variable across the hospitals and can range from $300-1000. Those should allow you to crunch some numbers. It does depend on how much you see obviously, which is related to how long your call shift is. Some places have 8 hour call shifts (so therefore you see less and make slightly less), others have 12 hours, and some have 16 hours. Most places with 12 or 16 hour call shifts will make 4-5k in that span. In an 8 hour shift it is much tougher so your looking more at 3-3.5k, unless you are staying late to finish up your work (therefore not really 8 hours).
  6. Common question among Muslim medical students before they start clerkship. I have had no major issues with being allowed to go pray (especially as a medical student). The only issue I've had as a resident is that I've been so busy that I have accidentally missed prayers but you just learn to be hyperaware of the time ahah. Most times people wont even know you slipped away for that time to pray
  7. Depends where you want to practice. I can only speak for the GTA. Most (almost all) Acute care hospitals in the GTA have a GIM hospitalist model now. A few still have some FM hospitalist. This change in the model of care is due to multiple factors, as over time more people end up wanting to do GIM and in turn have taken on more hospitalist roles, I have also heard from division heads that the FM's are moving away from it (due to their own reasons). As mentioned above, some places will have less acute type of patients that FM hospitalists care for. I can't really comment cause I haven't seen the FM hospitalist list before, but GIM lists definitely have several non-acute patients (I think this relates more to having such high volumes that you just do end up with some non-acute patients). If you are flexible in location, are ok with doing low acuity work (rehab hospitals, LTC homes, Complex continuing care, ALC transition hospitals/wards etc...), and like other things FM offers (FM clinics), then do FM + 1 in hospitalist. If you like other aspects of GIM work that is NON-hospitalist, i.e. ER admit service (which imo is the best part of GIM), GIM consult service, GIM clinics, than GIM is the way to go.
  8. I don't know where you heard that, but its not correct. All the community sites I've rotated through and staff I've talked to for job opportunities, routinely are as busy, if not busier than academic sites. The list is variable depending on the time of year and of course the hospital (as some are busier than others, and some have caps on number of patients per team, or ALC floors, or more than just 4-5 GIM MRPs on at a time), but generally between 18-30. I'm not going to dive into whether having a handful of residents do the actual work and staff just supervise is more efficient (its usually not), I guess if you had 2-3 seasoned senior residents (i.e. PGY3+), then it could be... but that's never the case. As a PGY4 at a community site, I can round on 8-12 patients by noon. Things are more efficient and I don't do any scut, there is no teaching or other time sucks which all helps. Also most academic staff aren't good billers and don't bill aggressively enough, as they belong to some communistic style practice plans (all billings and stipends and awards etc... go to a communal pot and it gets distributed to each physician). I would NEVER EVER EVER learn billing from an academic physician. I don't know about other universities, but at UofT department of medicine (as I mentioned above) ALL of the physicians billings go into a "pot". Its a bit complicated but at the end they "give back" a certain amount. Community GIM's are doing it routinely. Once you've been through enough you manage (you'll see once you finish)
  9. The old teaching/wisdom is that doing your residency in an area that you want to end up practicing. This is true to some degree, but the GTA is so large that as long as you choose a field that has lots of job opportunities (FM, Psych, IM etc...) you can still end up doing residency in one spot and end up working in another. You just have to be savvy in terms of networking, doing electives, and reaching out to the places you want to work. If you end up liking something with no jobs (or limited jobs), then thats a different story. I love Toronto. I lived here most of my life and have done medical school and residency here. My comments were geared towards the residency program (as you so rightly pointed out). I think right now you haven't even started your first day of medical school. I wouldn't worry about remaining in the GTA in the long term. If that is your ultimate goal over all else, then you can end up coming back eventually.
  10. Don't get me wrong. The program is strong from the perspective of training good internists, and it happens to be in one of the most posh/bougie cities in all of Canada (which some people like, others hate) But from an admin and political perspective, it's down right obscene. Its not anything that will effect your clinical training or experience (for the most part), but it can make your life less enjoyable. Some of my former UofT classmates would say the same re: medical school, but actually my UofT med school experience was excellent and I have nothing but nice things to say. I speak mostly of the residency experience
  11. As someone who did IM at UofT (and medical school), unless you absolutely cannot live anywhere else (which obviously you can cause according to your quote you're going to Western), stay away.
  12. Again it would depend on the hospital and their needs. At community hospitals the minimum I've seen is 12 weeks/yr (~1 week a month). Others require 16-20 weeks/yr. It also depends on whether you're part time or full time. For example full time 12 weeks is not bad, but for part time that might be a lot. Groups usually are flexible on people doing MORE work (meaning very few people will turn that down, they always need to cover vacations etc...), where as they will be much less flexible on you doing LESS work (cause they have to cover there services). For me personally 16-20 weeks of MRP/inpatient work is a lot. Ideally I want to work between 32-42 weeks a year total (probably more earlier on and then dial back), but definitely not more than 42. Of those 42 I want to minimize inpatient/hospitalist work as much as possible ahahahha. But to each their own. Very few Endo and Rheum will do GIM type work in the community. Mainly cause a) they don't want to/they don't have to so they choose a better lifestyle or b) their too busy with their subspecialty practice. I'm sure people find weeks here and there of GIM (whether its ER or wards) with whatever subspecialty, but for the clinic based ones, they would have to have their clinic closed for the time they are on service for GIM (it would be impossible in the community to do an outpatient busy endo/rheum/whatever clinic and do GIM wards or ER). Yes sorry those above (UHN (TGH, TWH), Mount Sinai, Sunnybrook, St. Mikes and Women's college) are academic sites in Toronto. Anything else is considered community in Toronto (or hybrid). Also be weary of using Academic sites as a model for practice. They are NOT how a community based clinician operates (in terms of number of weeks worked, inpatient vs outpatient mix etc...) or pay
  13. 4 years of GIM can easily find work anywhere NON-academic in the GTA. By non-academic I mean UHN (TGH, TWH), Mount Sinai, Sunnybrook, St. Mikes and Women's college. Outside of those select few hospitals, 4 year GIMs are the ones that get hired in the community (Including Markham, Richmond Hill, Barrie and Newmarket). Weeks on service and the mix of type of work differ between different sites so can't say 100% its always flexible (very few things in medicine are). Are you at UofT? That's the BS they try to sell to everyone on CTU. Most inpatient units across the country will have their share of complex patients, mixed in with the simple patients and the ever so boring ALC patients. As you go through your career your going to want to deal with simpler cases as oppose to the complex ones as they eat away at your soul. But getting back to your question, no a place will only transfer patients to a centre/hospital that is able to do things (of offer things) that the other hospital can't. Most of all the hospitals in the GTA (includoing the ones you listed) have the full spectrum of medicine AND surgical subspecialties. The only thing they don't have (usually) is neuro and cardiac surgery, transplant and trauma, which (if you haven't noticed) IM doesn't normally need on a day to day basis. Even most transplant and cancer patients can be managed at peripheral sites unless they are extremely complex or on experimental Rx. Plus lets be honest, most times on CTU at academic sites, if a patients gets slightly more complicated than a staff would like to admit, they will consult the F out the subspecialists.
  14. Nice! congrats on finding a set up that works for you. I'm looking to outpatient practice myself, but the overhead seems a killer, especially without those chronic disease premium codes. What % of overhead do you pay? How many patients do you see? How many are new consults?? I tried doing the math and it seems it would only be worth it for me if I saw at least 15 patients/day (all new) with 20% overhead, working 5 days a week (for like 42 weeks though).
  15. Its definitely possible anywhere including the GTA. TBH there's enough work that even a GIM (with a focus or not) will get referrals just because sometimes subspecialists referrals can take 2-6 months (whereas GIM you can probably see in like ~ 2 ish weeks at worse), and family doctors maybe too busy to completely be able to work someone up and initiate management. Sometimes they just want an opinion. The issue with most outpatient practice (regardless of specialty) is that you pay a large overhead (as discussed earlier). Sometimes its worth it if you have a better lifestyle. I've been looking into it myself however the overhead is a killer and without those chronic disease premiums it makes it harder to make as much as like an endo, rheum, resp, etc...
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