IM Burnout - Ambulatory and Better Lifestyle practice models?

[LittleDaisy]

@grapz At beginning when you get hired, they are mostly looking for locums for night shifts. They might have more permanent positions lined up.

People that I know who get hired with 4 year GIM in GTA usually get hired as locums, or pick up a few night shifts here and there, and eventually settling for a part-time position.

Keep in mind that OHIP remunerates anti-social working hours, with 40% more per consult, and re-assessments for overnight hours. 

[medigeek]

On 8/10/2019 at 12:02 AM, Wachaa said:

I'll try to comment a bit here and there

 

Of course. The 400k gross is not by any means "outlier". I wouldn't say it's "average", but it's not unreasonable.

Overhead is difficult to estimate. Even those who do a lot of OUTpatient do some of INpatient too. Or, they don't work in one office but several, each with different splits. I suppose 25-30% is reasonable.

 

 

Totally agree. There'll be a niche that you enjoy working in. You get really efficient and your name gets out there. For example, some IMs do mainly DM, so they will be known for seeing gestational DM too. I don't think it can get "boring" because it's what you like. Some people might find it repetitive.

 

 

Definitely. I was specifically talking about urban, where the large majority of GPs don't even have hospital privileges.

 

On 8/9/2019 at 1:51 PM, RadCdn said:

I work entirely outpatient general IM. I set my own hours, which is a late morning start which is what I prefer. 8 am start?? No way!! I knew early on that I could not work in the hospital. It doesn't suit my introverted personality and the noise in the hospital drives me crazy. In my work, 4 days a week, 300 K net is very reasonable, and I'm a relatively slow paced doctor. Definitely stick it out with IM, as the billings are significantly higher than FM. I do no call whatsoever. Life as an IM Attending is very good. Residency was terrible. 

I did four years of IM. I saw no point in the fifth year. Always keep in mind opportunity cost for the length of your training. The great thing about general IM is that you can easily focus your career on your particular field of interest. I have a colleague who is general IM, but only does Cardiology, stress tests, Echocardiograms every day. Another colleague of mine focuses on diabetes. Your practice will build quickly and you will have no problem receiving consults. It's better to focus on a few diseases as you'll be quicker and of course volume will be higher. I'm still in the phase where I'm focusing on 5-6 different diseases. Eventually I plan to narrow my focus more. 

IM previously had chronic disease premiums, but unfortunately they were removed in Ontario a couple of years ago. 

 

 

Why is FM even referring to IM for type 2 diabetes management? 

[JohnGrisham]

9 minutes ago, medigeek said:

 

 

 

Why is FM even referring to IM for type 2 diabetes management? 

Too complez to figure out Lantus from Glargine

[medigeek]

Just now, JohnGrisham said:

Too complez to figure out Lantus from Glargine

I see FM managing lots of patients on >100 units/day (who also have a dozen other major comorbidities). Not sure why it needs a referral to anyone... 

[Wachaa]

10 hours ago, medigeek said:

 

 

 

Why is FM even referring to IM for type 2 diabetes management? 

I suppose every practice is different. In the same way that many IMs refer to Endo for T2DM, hyperthyroid, ... or refer to cardiology for ischemic heart disease. Can't (or won't) specialize in everything.

[medigeek]

49 minutes ago, Wachaa said:

I suppose every practice is different. In the same way that many IMs refer to Endo for T2DM, hyperthyroid, ... or refer to cardiology for ischemic heart disease. Can't (or won't) specialize in everything.

I guess I meant that T2DM insulin management should be bread and butter for FM.

[Aconitase]

The money is mainly in the night call - most large GTA hospitals you are making 4-6k per night with No overhead. 
 

most GIM jobs (combination of night call/MRP/clinic) is about 350-400k with about 10 weeks off a year 

[Internalmed1234]

wow, 4-6k/night? How many patients do you have to see overnight to bill that much? And what's the bonus that gets added onto consults in the evenings or night? 

[ACHQ]

8 hours ago, Internalmed1234 said:

wow, 4-6k/night? How many patients do you have to see overnight to bill that much? And what's the bonus that gets added onto consults in the evenings or night? 

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).

[Raptors905]

5 hours ago, ACHQ said:

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).

This is very accurate and well laid out. The 8hrs do pay less whereas the 12hours and 16hours more. I would say a range of 3-6k is about right depending on the length of shift 

 

you also have to get out of an academic frame of mind. In an academic centre there is often a lot of push back because residents are overworked and not paid per consult. In the community world often if the ER sees you having a low day they will toss you a few more and there is less pushback because even for an inappropriate consult it’s still remunerated fairly well

[Bluberblubo]

11 hours ago, ACHQ said:

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.

Thank you so much for the write up. This is really informative. One quick question about the above text. Does this mean that if I'm asked to assess a ward patient for something random e.g. they're having abdo pain and are constipated at 2 am I could bill $138? <-- lol that's more than my current 26 hour call stipend 

 

[Raptors905]

26 minutes ago, skyuppercutt said:

Thank you so much for the write up. This is really informative. One quick question about the above text. Does this mean that if I'm asked to assess a ward patient for something random e.g. they're having abdo pain and are constipated at 2 am I could bill $138? <-- lol that's more than my current 26 hour call stipend 

 

Its 38 dollars for a partial assessment. The SVP (time premium) applies if you are called to pay them a visit specifically for this. So if you are on the ward anyway and nurse asks you to see this patient technically it doesn’t apply. 
 

if you are in your call room for instance and come over then it’s a SVP. 
 

[Internalmed1234]

Very informative responses! How do weekends work in terms of pay? 

[Raptors905]

Just now, Internalmed1234 said:

Very informative responses! How do weekends work in terms of pay? 

Weekends have 75 dollar SVP attached premium. Evenings are 60 and overnight 100. You are limited to 20 on weekends and 10 on evenings and unlimited overnight 

 

all of this is available in the schedule of benefits FYI. We are providing you no information that you can’t find yourself by reading a few pages of it in terms of billing codes and premiums 

[Internalmed1234]

Thanks! I looked at the schedule and found it a bit difficult to understand. Are you saying weekends are 75 during the day and then 75+60 evening and 75+100 at night? 

[Raptors905]

4 minutes ago, Internalmed1234 said:

Thanks! I looked at the schedule and found it a bit difficult to understand. Are you saying weekends are 75 during the day and then 75+60 evening and 75+100 at night? 

No. 
 

weekends are 75 during day and evening and 100 at nigjt

 

 weekdays are 20 during day and 60 during evening and 100 at night 

 

[ACHQ]

 

15 hours ago, skyuppercutt said:

Thank you so much for the write up. This is really informative. One quick question about the above text. Does this mean that if I'm asked to assess a ward patient for something random e.g. they're having abdo pain and are constipated at 2 am I could bill $138? <-- lol that's more than my current 26 hour call stipend 

 

hahahah yes. When you get to my stage and start learning this stuff, you get really annoyed with residency. Its literally slave labor.

 

15 hours ago, Raptors905 said:

if you are in your call room for instance and come over then it’s a SVP. 
 

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.

[pcp2md]

On 6/20/2019 at 6:32 PM, Wachaa said:

 

That's all true, depends on the practice and the patient population.

Not too many would open a clinic by themselves. But 7+ would get together and bill more than $3 million combined annually that should cover the overhead and more. Most GIMs would do inpatient work also. But I don't think that's mandatory. In BC there is a centralized referral website that shows waiting times etc. After a few months, the specialists who used to have waitlists of a few weeks goes up by several months, so I know they're getting patients. Some GIMs/ specialists who can see 30+ people a day are able to keep the waitlists short.

In BC we get a report annually, letting us know what labs we order, how we compare to our peers. The general consensus is that most don't order labs beyond the basic labs. If you do, you risk being flagged. So in 5 years I haven't ordered more than a handful of 24 hr urine tests, SPEP, CT/ MRI, etc. 

In general, many GPs here would not investigate further, but would refer to GIM after seeing an ACR of 30+. Stable Hep B or Fatty liver goes to GIM/ subspecialist because we don't order fibroscans. Etc.

Do you get the annual report from MOIS?

[Wachaa]

4 hours ago, pcp2md said:

Do you get the annual report from MOIS?

Doctors of BC - mini profile

https://www.doctorsofbc.ca/news/2019-mini-profiles-now-available

[pcp2md]

19 hours ago, Wachaa said:

Doctors of BC - mini profile

https://www.doctorsofbc.ca/news/2019-mini-profiles-now-available

Thanks! Is DoctorsofBc worth the membership fee?

[Wachaa]

5 hours ago, pcp2md said:

Thanks! Is DoctorsofBc worth the membership fee?

Heh, getting off topic. I think yes. You get more out of it than you put in:

-Free money for continuing medical education

-Reimbursements for CMPA

-Matching TFSA/ RRSP for Doctors of BC

...just to name a few