is it easy for GIM do outpatient full time in ontario?

[lovetoread]

Hi guys, I'm a 4th year Canadian DO student and I am in desperate need of insights on the GIM's scope of practice in Canada. Any information is greatly appreciated as this unusual time has made it impossible to shadow or do an international rotation to have a direct observation.

I am currently torn between IM and FM because I like the GIM outpatient clinic but I heard GIM mostly work in hospitals in Canada. I like GIM outpatient because I enjoy the  continuity of care and the breadth/depth of disease GIM sees. I also don't mind NOT seeing peds or OB/GYN patients (sorry pediatricians and OB/GYNs....). The possibility of specialization after GIM is another attractive factor. As my ultimate goal is to practice in Canada, I'm wondering if it is practical to open a GIM outpatient clinic. I understand anything is achievable if you try but I just want to inquire about the practicality of the idea.

[bearded frog]

1 hour ago, lovetoread said:

I also don't mind NOT seeing peds or OB/GYN patients (sorry pediatricians and OB/GYNs....).

Counterpoint: old people are gross.

[ameltingbanana]

There's lots of GIM outpatient work. The nature of the clinics vary depending on where you are. Bread and butter GIM clinics are things like: longitudinal clinic, some form of rapid referral clinic/IMRAC, periop, community IM clinic. If you're in a community where there aren't many subspecialists, you'll find GIM doing things like: thrombosis, cardiac diagnostics, PFTs. There's certainly IM people doing outpatient only, but if I'm being honest I think a significant portion of us like the inpatient work and if I was interested in outpatient IM only IM residency would have been brutal.

Are you a Canadian doing DO in the US? 

[lovetoread]

11 hours ago, ameltingbanana said:

There's lots of GIM outpatient work. The nature of the clinics vary depending on where you are. Bread and butter GIM clinics are things like: longitudinal clinic, some form of rapid referral clinic/IMRAC, periop, community IM clinic. If you're in a community where there aren't many subspecialists, you'll find GIM doing things like: thrombosis, cardiac diagnostics, PFTs. There's certainly IM people doing outpatient only, but if I'm being honest I think a significant portion of us like the inpatient work and if I was interested in outpatient IM only IM residency would have been brutal.

Are you a Canadian doing DO in the US? 

Yes, I am and this helps a lot! I like the inpatient work but I heard it's not easy to find a hospitalist job with a 3-year GIM training (as I will most likely train in the US) in GTA area. Maybe I'm being naive but I actually prefer a tougher residency over a chill shorter one as it will train me to be a better doctor. 

[ameltingbanana]

Hmm, I think there's issues with the 3 year GIM in the US translating over here, as you need a minimum 4 years of training for internal medicine work here (4 years for an independent license to bill IM codes). I would look into that, I could be mistaken.

Hospitalist sort of has different connotations here - at my centre, hospitalist usually refers to stable patients with more disposition issues and is often staffed by family medicine hospitalists rather than GIM. Acute medicine units/CTUs are usually where IM works here. And residency is VERY inpatient heavy - I think I maybe had like 2-3 months of general medicine clinic total in residency? Have much more now in fellowship.

[JohnGrisham]

On 8/15/2020 at 2:35 PM, ameltingbanana said:

Hmm, I think there's issues with the 3 year GIM in the US translating over here, as you need a minimum 4 years of training for internal medicine work here (4 years for an independent license to bill IM codes). I would look into that, I could be mistaken.

Hospitalist sort of has different connotations here - at my centre, hospitalist usually refers to stable patients with more disposition issues and is often staffed by family medicine hospitalists rather than GIM. Acute medicine units/CTUs are usually where IM works here. And residency is VERY inpatient heavy - I think I maybe had like 2-3 months of general medicine clinic total in residency? Have much more now in fellowship.

You are exactly right. You will need to top up US IM training to match Canadian GIM training. 

And yes Canada, for hospitalist is mostly FM run, sometimes older GIM docs in smaller centres that just bill IM codes. 

[JohnGrisham]

On 8/14/2020 at 6:04 PM, ameltingbanana said:

There's lots of GIM outpatient work. The nature of the clinics vary depending on where you are. Bread and butter GIM clinics are things like: longitudinal clinic, some form of rapid referral clinic/IMRAC, periop, community IM clinic. If you're in a community where there aren't many subspecialists, you'll find GIM doing things like: thrombosis, cardiac diagnostics, PFTs. There's certainly IM people doing outpatient only, but if I'm being honest I think a significant portion of us like the inpatient work and if I was interested in outpatient IM only IM residency would have been brutal.

Are you a Canadian doing DO in the US? 

The GIMs i have worked with in community, make a killing on the monetary front and lifestyle front, and will do 8-14 weeks a year of inpatient GIM consult coverage or Rapid Access IM clinic, to essentially have a guaranteed stream of new patients to follow longitudinally.    Brutal IM residency aside, there is no doubt being a GIM with no end to referrals for outpatient work, is much better than being a FM doc in most provinces. Many FM docs are more than happy to refer mildly "complex" HTN, DM, COPD, Hematological etc patients on to GIM to manage, given the fee structures that make it not worthwhile to spend too much time fiddling around working up patients too extensively when you're being paid 1/5th of what the GIM would bill for a simple consult on the matter. Its a sad state of affairs, but you work with the system you have. 

[lovetoread]

On 8/17/2020 at 9:52 PM, JohnGrisham said:

The GIMs i have worked with in community, make a killing on the monetary front and lifestyle front, and will do 8-14 weeks a year of inpatient GIM consult coverage or Rapid Access IM clinic, to essentially have a guaranteed stream of new patients to follow longitudinally.    Brutal IM residency aside, there is no doubt being a GIM with no end to referrals for outpatient work, is much better than being a FM doc in most provinces. Many FM docs are more than happy to refer mildly "complex" HTN, DM, COPD, Hematological etc patients on to GIM to manage, given the fee structures that make it not worthwhile to spend too much time fiddling around working up patients too extensively when you're being paid 1/5th of what the GIM would bill for a simple consult on the matter. Its a sad state of affairs, but you work with the system you have. 

Thanks for the info! This helps a lot! I always assumed it's harder for GIM getting referrals as FM may just refer them to the specialists who are better trained in managing those patients lol

And correct me if I'm wrong, is it true FM hospitalist jobs may become obsolete in the future because GIM may take over? 

[JohnGrisham]

7 hours ago, lovetoread said:

Thanks for the info! This helps a lot! I always assumed it's harder for GIM getting referrals as FM may just refer them to the specialists who are better trained in managing those patients lol

And correct me if I'm wrong, is it true FM hospitalist jobs may become obsolete in the future because GIM may take over? 

sub-spec waitlists are long, and you often don't need to send to a cardiologist when you can send to GIM who has an interest in cardio for example, who can see them much sooner. 

Hospitalist isn't going anywhere, the types of patients ED sends to hospitalists service v.s. IM service are disticnt. Hospitalist patients are usually more chronically ill and decompanated for longer term stays etc. No sense in IM taking over those patients when they won't have much to offer them. Nor will they want to, after going through 5 years of intense training to waste all that training essentially.

[lovetoread]

13 hours ago, JohnGrisham said:

sub-spec waitlists are long, and you often don't need to send to a cardiologist when you can send to GIM who has an interest in cardio for example, who can see them much sooner. 

Hospitalist isn't going anywhere, the types of patients ED sends to hospitalists service v.s. IM service are disticnt. Hospitalist patients are usually more chronically ill and decompanated for longer term stays etc. No sense in IM taking over those patients when they won't have much to offer them. Nor will they want to, after going through 5 years of intense training to waste all that training essentially.

Wow the patients hospitalists sees sound so different from here in the states. Most of urban and sub-urban hospitalists here are IM and they see everyone admitted from the ED. The hospital where I am at, the turn over rate is around 3-5 days, so I guess there is not much use of having someone like Canadian hosptialists. And if the patients require long term stays, It sounds like it's harder for FM to joggle between clinic and hospital work long-term. 

[frenchpress]

13 hours ago, JohnGrisham said:

sub-spec waitlists are long, and you often don't need to send to a cardiologist when you can send to GIM who has an interest in cardio for example, who can see them much sooner. 

Hospitalist isn't going anywhere, the types of patients ED sends to hospitalists service v.s. IM service are disticnt. Hospitalist patients are usually more chronically ill and decompanated for longer term stays etc. No sense in IM taking over those patients when they won't have much to offer them. Nor will they want to, after going through 5 years of intense training to waste all that training essentially.

Agreed, and GP hospitalist service is growing rapidly in our area. Community GPs or dedicated GP hospitalists are covering the vast majority of the medical inpatient wards at the mid-sized hospitals I am working in regularly,  with general IM and various subspecialty IM acting as a consulting service. I have seen IM docs occasionally covering hospitalist shifts, but this is more because of a shortage of docs / recent reallocations because of COVID, not because its where they want to work or where their skills are most needed. 

[medigeek]

23 hours ago, JohnGrisham said:

sub-spec waitlists are long, and you often don't need to send to a cardiologist when you can send to GIM who has an interest in cardio for example, who can see them much sooner. 

Hospitalist isn't going anywhere, the types of patients ED sends to hospitalists service v.s. IM service are disticnt. Hospitalist patients are usually more chronically ill and decompanated for longer term stays etc. No sense in IM taking over those patients when they won't have much to offer them. Nor will they want to, after going through 5 years of intense training to waste all that training essentially.

Is there a distinction in community hospitals between an FM or IM service? 

[ameltingbanana]

12 hours ago, medigeek said:

Is there a distinction in community hospitals between an FM or IM service? 

In some community hospitals I believe. In my recent community rotation, IM did the admissions, and usually kept the complicated/interesting cases. Simpler stuff was usually admitted under IM, stabilized, and then transferred to the hospitalist service if there were disposition issues, need for rehab, etc. If someone decompensated on the hospitalist side, IM was usually very supportive and offered both a "consult" vs takeover as MRP once more depending on how comfortable the family doc was.

Caveat: smaller community hospital, though probably only about an hour and a half from the nearest community center, and all the IM docs were comfortable with acuity (there was an 8 bed level 2/level 3 ICU and they were also a regional tPA center).

[JohnGrisham]

On 8/20/2020 at 9:56 AM, lovetoread said:

Wow the patients hospitalists sees sound so different from here in the states. Most of urban and sub-urban hospitalists here are IM and they see everyone admitted from the ED. The hospital where I am at, the turn over rate is around 3-5 days, so I guess there is not much use of having someone like Canadian hosptialists. And if the patients require long term stays, It sounds like it's harder for FM to joggle between clinic and hospital work long-term. 

Different terminology. Canadian hospitalists are seeing more chronically ill, less acutely ill patients that don't need to be "worked up" as much compared to proper in-patient IM patients, because the patients are still sick and need to be inhospital.

In the states they also have these lower-acuity wards where patients are not sick enough to be on a higher acuity ward, but not well enough to be discharged home. Definitely still a step up from the ED "observation" units that are typically just manned by ED docs for short 24 hr stays etc. 

Length of stay doesnt really affect that, because you just handover to whoever is on next.  Usually hospitalits do 1 week on at a time, where people who do it more full-time will simply just be "on" consequtively. 

[JohnGrisham]

17 hours ago, medigeek said:

Is there a distinction in community hospitals between an FM or IM service? 

Yes, again, Hospitalits service in most metropolitan areas = FM.  Then GIM docs cover wards with more acutely ill patients - i.e. ones that need more active work-up, mgmt, (i.e. NSTEMI for medical mgmt, ICU/HAU transfers to the ward, severe hyponatremia, DKAs etc).  At most hospitals, both services(hospitalist and IM) do consultation admits from the ED. It is up to ED to triage who they are sending to.  Then if a patient starts to go south while on hospitalist service, they could consult IM, and IM would either take over as MRP, or provide guidance. Or if its severely crashing, you can consult ICU/HAU directly and they would take the patient.  In academic hospitals, the only distinction is often that the IM service is run by residents/med students under an IM attending. 

 

 

[guy30]

On 8/20/2020 at 10:56 AM, lovetoread said:

Most of urban and sub-urban hospitalists here are IM

I'm curious, you said most urban and sub-urban hospitalists in the US are IM, are there not many FM hospitalists there?  I always thought it was common for FM in the states to work in hospitals too? 

 

Also, when there are FM docs working as hospitalists in the US, any difference in scope of practice between FM and IM?  It's an interesting comparison since in the US, IM and FM residency are both 3 years long but in Canada FM is 2 years and IM is minimum 4 years (often 5 nowadays).

[lovetoread]

13 hours ago, guy30 said:

I'm curious, you said most urban and sub-urban hospitalists in the US are IM, are there not many FM hospitalists there?  I always thought it was common for FM in the states to work in hospitals too? 

 

Also, when there are FM docs working as hospitalists in the US, any difference in scope of practice between FM and IM?  It's an interesting comparison since in the US, IM and FM residency are both 3 years long but in Canada FM is 2 years and IM is minimum 4 years (often 5 nowadays).

In my area, FM hospitalists are becoming scarce in the academic or big community hospitals as they are mostly taken over by IMs. When I was talking to the FM docs here, they said they don't have as much flexibility in their practice as before because docs are mostly hired nowadays. The current system is trying to push FMs work mostly in the outpatient setting. FM docs who used to do a lot of OBs are now having to give that up because of that.

[medigeek]

23 hours ago, guy30 said:

I'm curious, you said most urban and sub-urban hospitalists in the US are IM, are there not many FM hospitalists there?  I always thought it was common for FM in the states to work in hospitals too? 

 

Also, when there are FM docs working as hospitalists in the US, any difference in scope of practice between FM and IM?  It's an interesting comparison since in the US, IM and FM residency are both 3 years long but in Canada FM is 2 years and IM is minimum 4 years (often 5 nowadays).

Easy to get a hospitalist job including in open-ICU settings in USA in most settings as FM. Academic centers and large hospitals tend to be IM, aside from FM inpatient teaching services (which is essentially the same as an IM service anyway). 

It's just that most FM docs don't want to be hospitalists. But anyone interested easily finds work, including in 400 bed large hospitals etc. and it's alongside IM docs (zero difference in scope). 

Now there are some settings which are less FM friendly but it's overall not common. 

[medigeek]

On 8/21/2020 at 3:39 PM, JohnGrisham said:

Yes, again, Hospitalits service in most metropolitan areas = FM.  Then GIM docs cover wards with more acutely ill patients - i.e. ones that need more active work-up, mgmt, (i.e. NSTEMI for medical mgmt, ICU/HAU transfers to the ward, severe hyponatremia, DKAs etc).  At most hospitals, both services(hospitalist and IM) do consultation admits from the ED. It is up to ED to triage who they are sending to.  Then if a patient starts to go south while on hospitalist service, they could consult IM, and IM would either take over as MRP, or provide guidance. Or if its severely crashing, you can consult ICU/HAU directly and they would take the patient.  In academic hospitals, the only distinction is often that the IM service is run by residents/med students under an IM attending. 

 

 

I do see quite a few job ads on HFO or hospital physician recruitment jobs for hospitalist positions that essentially state they have a joint team of IM & FM docs and 15-20 acuity medicine patients which does include some post-acuity etc. patients. These are within an hour or so of Toronto (150ish beds). The rehab/post-acuity patient type jobs seem to have completely different types of job ads.

Is it mostly metro areas then that are run by IM when it comes to true acuity inpatients? 

[JohnGrisham]

On 8/22/2020 at 9:11 PM, guy30 said:

I'm curious, you said most urban and sub-urban hospitalists in the US are IM, are there not many FM hospitalists there?  I always thought it was common for FM in the states to work in hospitals too? 

 

Also, when there are FM docs working as hospitalists in the US, any difference in scope of practice between FM and IM?  It's an interesting comparison since in the US, IM and FM residency are both 3 years long but in Canada FM is 2 years and IM is minimum 4 years (often 5 nowadays).

From an inpatient perspective, you can't really compare FM to IM in Canada. IM is significantly more inpatient intensive, regardless of the # of years. 

[ACHQ]

On 8/14/2020 at 7:00 PM, lovetoread said:

Hi guys, I'm a 4th year Canadian DO student and I am in desperate need of insights on the GIM's scope of practice in Canada. Any information is greatly appreciated as this unusual time has made it impossible to shadow or do an international rotation to have a direct observation.

I am currently torn between IM and FM because I like the GIM outpatient clinic but I heard GIM mostly work in hospitals in Canada. I like GIM outpatient because I enjoy the  continuity of care and the breadth/depth of disease GIM sees. I also don't mind NOT seeing peds or OB/GYN patients (sorry pediatricians and OB/GYNs....). The possibility of specialization after GIM is another attractive factor. As my ultimate goal is to practice in Canada, I'm wondering if it is practical to open a GIM outpatient clinic. I understand anything is achievable if you try but I just want to inquire about the practicality of the idea.

GIM staff here,

GIM can do whatever they really want. That being said to do primarily outpatient is not very common due to the high overhead for an outpatient practice which eats into your take home income. The real money in GIM is a hospital based practice, where you do a mix of inpatient hospitalist/MRP work, ER consultations (variety of days, evenings and nights), and outpatient GIM clinics. Not only do you get a nice variety of work, but you also pay 0 overhead.

 

I won't comment any further on GIM hospitalist vs FM hospitalist, as there are lots of regional variability to this. All I will add to that is at my specific site of practice there are FM hospitalists and some of us in the GIM division that do hospitalist work as well (myself included). TBH I don't think they give the GIM'ers the more acute patient's (but I could be wrong), I think they just generally divide the new admits across everyone. I personally find the FM hospitalists will consult more if they have a more acute patient.

[lovetoread]

On 8/25/2020 at 2:34 PM, ACHQ said:

GIM staff here,

GIM can do whatever they really want. That being said to do primarily outpatient is not very common due to the high overhead for an outpatient practice which eats into your take home income. The real money in GIM is a hospital based practice, where you do a mix of inpatient hospitalist/MRP work, ER consultations (variety of days, evenings and nights), and outpatient GIM clinics. Not only do you get a nice variety of work, but you also pay 0 overhead.

 

I won't comment any further on GIM hospitalist vs FM hospitalist, as there are lots of regional variability to this. All I will add to that is at my specific site of practice there are FM hospitalists and some of us in the GIM division that do hospitalist work as well (myself included). TBH I don't think they give the GIM'ers the more acute patient's (but I could be wrong), I think they just generally divide the new admits across everyone. I personally find the FM hospitalists will consult more if they have a more acute patient.

Thank you for the info! the variety of work is definitely an attracting factor. I guess I just need to figure out how I can top up that shorter residency training to be certified in Canada. 

[ACHQ]

On 8/26/2020 at 3:40 PM, lovetoread said:

Thank you for the info! the variety of work is definitely an attracting factor. I guess I just need to figure out how I can top up that shorter residency training to be certified in Canada. 

alot of the american trained IM's do an extra chief year to make up for the shorter residency.