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futureGP

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  1. I feel like ICU is so variable depending on the size of your hospital. I figure most of the GTA hospitals are pretty good size and can be considered community-academic if they have >10 vented beds. I can't buy that in >10 vented community ICUs that there is no intensivist overnight. Most of these GTA hospitals are very sizable and would have many emergencies overnight that would demand an in-house intensivist or at least CCRT with ICU attending on-call at home on standby. The ICUs where I've rotated through which are in smaller communities that have at any time 2-3 vented patients with 7-8 telemetry patients tend to be better in terms of lifestyle but definitely doesn't pay as well as the bigger ICUs. The ICU weeks that pay 25-30k are probably larger ICUs with >10 vented patients who need full overnight care in sizable community-academic centres with probably pretty regular CCRT emergencies overnight. OHIP billing code suggests $300 or somewhat per critical care patient per day so you would estimate 10-15 fully-vented/supported patients a day which is certainly not a lifestyle ICU to cover. I've rotated and shadow-billed in communities where you could clear ~15k a week as a royal college IM covering a 18-20 patient ward list and not have to deal with much of an emergency overnight. You'd be done rounding by 2-3 pm everyday and could try to fit in a few private clinic patients to increase the billing a bit.
  2. See some of my other posts for details. Both are clinic-based specialties. Endo/Rheum/Allergy/Geri have better billing codes per pt than FM due to them being specialists (typical consult fee of 157 + special premiums for managing chronic patients. Additional tests or procedures like patch testing, joint injections. The caveat is the consults may take long (~20-30 mins), but it's variable up to each individual on how to make it efficient (i.e. simple seasonal allergy consult may take 15 mins, or new diabetes mgmt may take 15-20 mins vs. complicated diabetic patient with complications or immunodeficiency work-up). Geri will have long consults (1hr or more) but they have a special code for comprehensive geriatric assessment (~$330). So per day you may see 6-7 patients in Geri but make the same as a FM who may see 20-30 a day). Generally speaking, as subspecialists you could see less patients/day ($100-200/pt depending on whether it's a simple follow-up vs. new consult) and bill similar to a family doc who sees more a day ($40/pt). So the psychological stress of having more patients may be different for a similar amount of income.
  3. futureGP

    IM Subspecialties with Best Job Prospects

    Community means different for diff people. in the GTA, good luck finding any job in medicine subspecialties except for Geriatrics and maybe GIM. Private cardiology practice isn't what it used to be in the past where you can open up your office, buy yourself an echo machine and start seeing patients. Now you need to be licensed by the province as an independent health facility to do echos which means you need a level 3 echo license which means an echo fellowship. Plus you need to get a license and who will give out a new license in the GTA where it is already saturated with cardio-diagnostics. So you're looking at essentially 3 GIM + 3 Cardio + 1-2 years of fellowship in imaging, heart failure, EP or interventional to even qualify joining a group that already exists. Same with GI where all scope clinics, inpatient scopes are saturated by older docs who's been there for a while. Hard for a new GI to get into those jobs unless you can bring in new skills in something the older guys want to off-load on. Above mentioned situation seems correct. Same with Nephro where dialysis time is essentially key and most places in GTA are already saturated. Same with Resp where sleep/PFTs are all provincial regulated licenses and GTA is pretty much saturated. So you're left with really Endo/Rheum/Allergy. Sure you can open up your practice, but you may need some time to fill up your practice if you're in a saturated area with 5-6 specialists around. Geri will always have jobs in Toronto/BC cuz nobody wants to do Geri. In further places like Kingston, London, Barrie, Owen Sound, subspecialists will have better luck finding a job. The key is essentially finding a community where there is subspecialty need and breaking ground. Unfortunately nowadays it means working in small-medium sized communities which may not be ideal for some but good for others.
  4. GI was still prty competitive despite the poor job market, must be the combination of simple patient issues and procedural aspects (reflects the huge shift of med students from surgery to medicine that happened a few years ago, they naturally lean towards procedural specialties). Jobs are still pretty tough and almost certainly they need fellowships. A lot of the staff are super young too which reflects the lack of upcoming retirements. Endo/Rheum/GIM/Resp were pretty competitive too due to job aspects (viable pure outpt practice) and lifestyle. Compensation is def rising in clinic subspecialties because of special billing codes for managing chronic patients that some of the procedural specialties don't get. Also, it's a matter of time before GIM's billing increases when special billing code for multiple medical issues gets implemented. Nephro will still have the dialysis but due to the hoarding of dialysis patients, new grads need to work hard to find a job, typically with a fellowship and some sucking up. Cardio is pretty much saturated in major cities and with the government cracking down on cardiac diagnostics, most need a fellowship of 1-2 years (EP, interventional, imaging, heart failure) before finding a job in a non-desirable place. Desirable places all pretty much require fellowship and some research training. So popularity did go down in recent years. Same case for ICU, you need to bring in extra skills, and it's hard for IM->ICU crowd to do that so likely will mean some fellowship in research to grab a job in big centers when you're competing with GSx->ICU, Anes->ICU, CardiacSurg->ICU who have more niche areas like trauma, cardiac surg ICU etc. You can go to the boonies and work in a small ICU, but you're typically overtrained to work in those places so may not be so intellectually satisfying. There is no self-selection of competitive applicants. I'd say anyone who wanted Rheum if they wanted GI they would've been equal or even more competitive than those who went for GI when you compare their clinical skills, research, leadership etc. It's based on my personal experience though. Bottom line is medicine subspecialty match won't ever be as competitive as some of the PGY1 matches because there are pretty even number of applicants/spots and no single specialty has become more desirable than another to a significant degree. People eventually sort themselves out during core 3-year training as to avoid significant competition. Having a perfectly viable back-up of practising community GIM where you can carve your own niche, have a flexible inpatient/outpt practice and making decent coin (400-500k) means people may not necessarily go all-in with their subspecialty matches and only apply to a few places, so that dilutes out the competitiveness a bit too.
  5. lots of nice discussions. I am biased as I am finishing up Internal Medicine but here are my thoughts. To OP's qn, IM residency depends on where you go. Some residencies are more service-based and will have long-hours and busy days whereas others will be more-or-less chill and even comparable to FM in terms of lifestyle and hours. CTU will always be busy because of service-needs but depending on where you do your residency, subspecialty rotations like Nephro, GI, Resp, Endo, Allergy can be quite chill (8:30-4:30) and as a junior you may see 3-4 patients a day if inpatient (means a lot of lounging around, getting teaching etc), or a bit more if outpatient. Even CCU/ICU can be pretty chill during the day when you may have 3-4 patients to look after which as a senior (PGY2-3) is really not that time-consuming. Certain call shifts will be busy, such as CTU junior or Senior Medicine, Cardiology, GI. But others may not be as bad. That said, at other more service-based IM locations, the hours may be different. So to the OP, you really need to ask the residents at each training site to understand what the lifestyle, work-hours are truly like to get a sense of residency lifestyle. Subspecialty life is a totally different topic as you can be busy as a Cardio/GI fellow doing city-wide coverage, or ICU overnight and a few sick patients take up your time. But most other specialties are pretty chill and have relatively low to no call burden. So you're really comparing 3-years IM (with PGY3 being pretty chill) vs 2-years of FM For some insight as to Endo, Allergy, Rheum (i.e. chill outpatient specialties) vs. FM. First, most people who do Endo, Allergy, Rheum do it for the lifestyle and are not working to make bang or full-time busy clinic (some maybe but most aren't). If money, working hard was their deal then during core IM they likely would lean more towards GIM/ICU/Cardio/GI/Nephro etc. So comparing Endo/Allergy/Rheum income to FM is not so easy. That said, if you go to allergy for $$$, there is so much in it - allergy consult + patch tests are easily >$200 per pt, just look at the provincial billing schedules, and if you are an efficient doc you can see a new consult in 15-20mins, very focused hx/px, review of past medical etc (can be 400-600/hr). Plus with the long waitlist of allergists, you will be seeing a lot of new consults as opposed to follow ups. A lot of the consults are also pretty straight forward too (as they should be because you are a subspecialist training in a focused area of medicine). You can do the math for monthly billings etc. Rheum can be interesting too as you can add joint injections to your billings but depending on your working environment (Academic vs community) consults could be either pretty quick (straight-forward RA) or long (vasculitis). Endo is also variable because bread-and-butter T2DM will be a quick consult but unlike Allergy/Rheum you don't have any other billing codes aside from just the usual consult fee (~160 depending on the province). The key benefit of medicine subspecialty is that everything eventually becomes bread-butter to you and things will get very quick and efficiency can sky-rocket if you are smart about it which can translate into higher income at our current fee-for-service environment. As for GIM, you can't compare GIM in GTA hospitals vs GIM in small-town community, the working environment, scope of practice is so much different. GIM in the large community hospitals are typically doing inpatient hospitalist work, medicine consults for surgical wards, GIM rapid assessment clinics, pre-op clinics ($$$), and outpatient Medicine clinics. Income for GIM is largely driven from outside of in-patient work in this setting unless you are running a CTU at a community hospital. GP-hospitalist on the other hand is mostly doing full-time hospitalist work. But even in the near future, with the oversaturation of 4-year GIM physicians in the GTA, I expect that the role for GP-hospitalist will become more limited as more GIM start working at major hospitals in the GTA. All IM residencies in the recent years have been pumping out a lot of 4-year GIMs who have been saturating the job market. But if you are out in small-medium sized communities (~<100k), GP-hospitalists will still mostly be working as MRPs with GIM providing more of a consultant role and filling in the absence of any subspecialists. The scope of practice is broad and includes level 2 ICU, complex medicine consults, diagnostics (PFTs, ECG, stress +/- Echo), procedures (Endoscopy, bone marrows, PICC lines etc). But as you can imagine as population grows in these small centres, more subspecialists will join and slowly take away income-producing procedures from GIM (i.e. scopes to GI, diagnostics to Cardio/Resp etc). Then the practice style gradually approaches the scenario mentioned above. So income for GIM can vary a lot anywhere from ~300-400k at big hospitals to 600-800k at small-medium sized hospitals. GIM really shines in the smaller communities where the needs are high, whereas in the large communities you are mostly seeing the complex/vague patients that don't clearly fit into a subspecialty scope of practice (i.e. complex, multiple medical problems, failure to cope NYD, fatigue NYD, etc).
  6. futureGP

    Being financially independent for med school

    buy bitcoin not now though, wait for it to crash first. high risk, high returns
  7. Many PGY4s that I know took that course during the PGY4 in prep for the Royal College.
  8. I do see your point. In an academic or large community center with access to subspecialty surgeons, then yeah. But if you are in a remote community (it doesnt even have to be that remote), 1-2 hours way from any major center and you are a general surgeon and there is no other surgeons around, then yeah you will have to manage whatever comes through that ER. But as a ENT or Urology, you would never be able to hold those jobs. Likewise, the trend in Medicine could be similar in the sense that In the remote communities, a GIM will have enough reason to cover all subspecialties if nobody else is around but a subspecialty IM like Nephro or Resp may not be able to hold those jobs anymore working as general internists if this new certification becomes the norm. (As opposed to now where you are able to locum or work as general internist with a subspecialty license)
  9. futureGP

    Program Changes

    Any specifics on the high interest savings account? E.g rate, withdrawal limits etc
  10. futureGP

    Avoiding Politicized Answers

    Medical education in Canada is very 'left-wing', so it probably wouldn't hurt if you mention it. It would be more concerning if someone were to suggest we should privatize health care and create discrepancies in health care and argue that health care is a privilege not a right. the fact of the matter is that medical education in Canada is very progressive. Pro-choice, Euthanasia, physician-assisted suicide, women's rights etc. Think of any politically hot topic and it will be lectured in med school in a 'left-wing' manner. So I won't be too worried about it unless you have a tendency to speak in a conservative way, that would hurt your interview.
  11. Unfortunately no affirmative action for black candidates. I certainly do find them severely underrepresented. Probably related to disinterest for academic fields from black individuals in general. I'm not sure if social environments play a role, probably would. East/South Asians, Europeans, Jewish descents typically dominate academic fields most likely due to the entrainment by their parents that academia is king. Whereas I wonder if the emphasis of African-Canadian families is on non-academic fields such as arts, music, sports which they tend to excel in. stereotypes have some truths in them.
  12. i learned to tube, a/c-line, do spinals, etc as a med student. I find that as a med student you can get a lot of procedures if you look confident and eager. Watching NEJM videos is helpful to train your mind but you really need to master the technique manually. The key to procedures is knowing that the principles underlying the techniques are the same. Intubation with direct laryngoscope: Position, position, position. You need to either 1. get down to the patient's head level or 2. bring the patient up (I usually choose the latter). You can elevate them with headrest, or just elevate the bed. -- essentially you want their head to be at your chest level (upper chest if you have good upper arm strength) (This prevents the typical hunching over position of most novice intubators) (This also aligns the orotracheal line the best). ----- Remember that in Germany, anesthesiologists intubate sitting - same principle -- as you insert the direct laryngoscope with your left hand, use your right hand on the back of the patient's head to lift it and position the airway so you can visualize it (essentialy do a head-tilt lift and sniffing position). -- if you do the above, 100% you will see the cords unless patient has anteriorly positioned trachea, retrognathia etc. -- If you still don't see it, take your right hand (while keeping tension on your left hand/laryngoscope to keep the head 'lifted up' and perform a BURP to visualize the cord. Then ask the RT/assistant to keep the BURP in position while you intubate. 2. Central lines: ultrasound-guided is a complex maneuvre. Why? With the left hand, you're moving the probe to visualize the IJ while with your right hand you are 1. holding the syringe/needle 2. holding the plunger with your thumb. -- The actual maneuver is this: Once you visualize the IJ, you keep your left hand steady while with your right hand you insert the needle while at the same time keeping negative pressure on the syringe (i.e. you're using your thumb, finger to pull back on the plunger as you're pushing the syringe/needle through the skin using your forearm/wrist). As you're doing that you're moving the US probe to do the 'creep' technique. -- Essentially, when i was a clerk, I took a central line syringe home and practised doing that maneuver of inserting the needle while pulling on the plunger to get my muscle memory entrained. -- Once you get that maneuver down, inserting a central line is dead simple. It's just poking the black spot. 3. Other procedures (e.g. thora/para/LP/spinal anesthesia, joint injection). Essentially you need to master holding the needle properly. If you know how to hold it properly then you can do any procedure with confidence. -- You must remember that the art is maintaining a specific angle of insertion. This requires dexterity to stabilize the needle -- Whenever I am penetrating the skin space to reach a deep space (unless it is just freezing the skin), I use the following hand technique to stabilize the needle/syringe. -- With my left fingers (usually the index and thumb), I hold near the tip of the needle as much as I can without hurting myself (typically 3-4 cm away from the tip of the needle). This helps stabilize the insertion angle and prevents me from moving as I insert the needle. -- With my right hand, I use the same technique that I use for central line insertion. You are again inserting the needle and aspirating at the same time. -- With these maneuvers, you can stabilize the needle throughout the insertion and be sure of the angulation of the needle. The angulation is particularly important when inserting long needles because even subtle movements at the site of insertion could create significant deviations at the tip if the needle is long (think about the arc created by long needles) I find that the above skills can be applicable in essentially all non-surgical procedures requiring needles (aspiration, injections, insertion using seldinger technique etc).
  13. scrubs 4 lyfe. outpatient, inpatient, clinic, hospital ward. the most intriguing paradox in medicine is, why do we isolate MRSA in inpatients but totally go all over them without gown if they come as an outpatient (in the same hospital). i'm pretty sure i carry MRSA, and so do my 'nice' clothes. hence scrubs 4 lyfe
  14. Sometimes there is a designated rotation director who gets all the evaluations. You could ask that person for a letter.
  15. futureGP

    I Feel Like I Am Super Average...

    dude, i didnt TA, my research sucked (not even a poster), my gpa/mcat just average, didnt do any leadership stuff, and didn't do overseas volunteering etc. still admitted. Honestly man, people just like normal people who are sincere. If you present yourself well in a thoughtful, sincere manner, you will look good during the interview and do well. Be confident and present yourself. Forget all the numbers, scores, relativism nonsense. You are as qualified as the other guy who may have great numbers once you're at the interviews stage. Tons of people with great numbers don't pass the cut, and there is a reason for that. You don't need to be genius to get an MD.
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