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Can You Work With Just Royal College Of Im After Exam?

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I know GIM is now 5 years to be RC specialist. But now the exam if after R3, meaning you will be RC certified. Can you choose to work and not pursue fellowship? My understanding is NO. Moonlighting doesn't count as you're considered still a resident. 

 

Any ideas?

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Right now you only need to pass the internal medicine exam (aka the 4th year one) to work as an internist. My friend is an internist in a smaller hospital and she only did 4 years.

 

The 5 year GIM fellowship is only recent. I don't know if it will mean that the 4th year IM exam disappears eventually. I honestly never really understood the point of creating the fellowship in the first place except credentialism, which is a big thing in academia.

 

Any actual IM people want to chime in?

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Good question. Logically, since it is the same exam just written earlier as an R3, you should be able to work as an internist if you've passed it. I can't imagine it becoming a requirement to have a subspecialty fellowship to work (even in GIM). What happens to people who aren't successful in the MSM match, which you can only enter once? So I guess you'll either become certified to work as an internist after passing the RC exam in R3 or they'll make it so that you still have to do an extra year of training even after you've passed the exam.

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Let me explain,

 

5-year GIM is essentially a fellowship to obtain further academic and clinical training in general internal medicine and will be the standard fellowship required to work in academic centers attending academic CTUs (this is the new standard). There are rumors of fee schedule changes in the future to reflect the additional training (e.g. exclusive comprehensive GIM assessment code) but this is probably political in nature.

 You will probably licensed as FRCPC in Internal Medicine with certification in General Internal Medicine

 

4-year GIM is essentially the 'default' Internist and is licensed as FRCPC in Internal Medicine. This is most likely enough if you want to work in community hospitals. In the immediate reality there is probably no difference between this and 5-year GIM in employability in the community (since most general internists in the community are 4-year trained). The fear seems to be that with this designation you may not qualify for additional fee codes in the future should they become reality.

 

 

the new Royal College direction of moving certification examination to the PGY3 year does not change the timing of obtaining your FRCP and hence does not change the fact that you still need 4 years of Internal Medicine training to work as an internist.

The following is the reason why.

If you look at the Specialty Training Requirements at the Royal College website for Internal Medicine it states that you need to complete 3 of the following to obtain certification in the specialty (i.e. FRCPC)

1. Pass royal college exam in internal medicine

2. Complete a scholarly work in internal medicine

3. Complete 4-years of internal medicine training (3 years must be in core internal medicine and 1 year could be in a subspecialty).

 

Therefore even if you pass the exam in PGY3, you will not receive your FRCP therefore you will not obtain your independent CPSO/CPSBC etc, therefore you will not be able to work independently until you finish an additional year of training.

 

Will the Royal College change that 3rd requirement? I am not aware of any talks currently to remove that or change that to 3-years of internal medicine training. My guess is most likely not given that historically academics have lengthened training but rarely shortened one.

 

 

In addition, this whole 5-year process could be very political in nature. One can liken it to the late 80s and early 90s when family medicine received its own specialty training and became the standard of care. Prior to that, residents in specialty training could locum as GPs with their independent licenses obtained using LMCCs. However, since the standardization of FM training, we are no longer able to locum as GPs even after obtaining our LMCCs.

 

A similar situation could arise 10-20 years down the road with the FRCP in Internal Medicine. It may unfortunately end up becoming a throw-away exam that doesn't provide one with any additional practising privileges. Currently subspecialty trainees in PGY5 years and above after obtaining their FRCP in internal medicine (e.g. GI, Endo, CritCare fellows) can locum as 'Internists' to supplement their income until they finish their subspecialty training.

     10-20 years down the road once GIM subspecialty designation becomes widespread and the 'standard' of certification, other subspecialty trainees with FRCP in internal medicine may not be able to get an independent CPSO/BC/A/S/M license to locum just like how we can't practise as GPs with our LMCCs now.

 

Why would anyone do that? Well, you can sugar-coat it with terms like 'better training' 'better education' 'more specialized care' but you can also think it could be related to $$ and jobs. 

e.g. What do you expect the job situation for FMs will be if all the subspecialty trainees could now practise as GPs (locums etc). It won't be better for sure. It may be the same or even worse.

With the same logic, one can argue that currently there may be subspecialty trainees in IM subspecialty who are occupying jobs that could be taken by a general internist, even if it's a locum position. But it's not even the subspecialty trainees but also subspecialists who do a lot of general internal medicine.

 

In the future, there could be even a remote possibility that as a subspecialist in IM (e.g. Resp), you may not be able to work in medicine CTUs, or even general medical wards, or receive any non-Resp referrals. Just like how the surgical specialties are now (ENT will never be able to see an appy, chole, whereas GSx could do thyroids. Urology could never do GI stuff whereas GSx could do nephrectomies).

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Let me explain,

 

5-year GIM is essentially a fellowship to obtain further academic and clinical training in general internal medicine and will be the standard fellowship required to work in academic centers attending academic CTUs (this is the new standard). There are rumors of fee schedule changes in the future to reflect the additional training (e.g. exclusive comprehensive GIM assessment code) but this is probably political in nature.

You will probably licensed as FRCPC in Internal Medicine with certification in General Internal Medicine

 

4-year GIM is essentially the 'default' Internist and is licensed as FRCPC in Internal Medicine. This is most likely enough if you want to work in community hospitals. In the immediate reality there is probably no difference between this and 5-year GIM in employability in the community (since most general internists in the community are 4-year trained). The fear seems to be that with this designation you may not qualify for additional fee codes in the future should they become reality.

 

 

the new Royal College direction of moving certification examination to the PGY3 year does not change the timing of obtaining your FRCP and hence does not change the fact that you still need 4 years of Internal Medicine training to work as an internist.

The following is the reason why.

If you look at the Specialty Training Requirements at the Royal College website for Internal Medicine it states that you need to complete 3 of the following to obtain certification in the specialty (i.e. FRCPC)

1. Pass royal college exam in internal medicine

2. Complete a scholarly work in internal medicine

3. Complete 4-years of internal medicine training (3 years must be in core internal medicine and 1 year could be in a subspecialty).

 

Therefore even if you pass the exam in PGY3, you will not receive your FRCP therefore you will not obtain your independent CPSO/CPSBC etc, therefore you will not be able to work independently until you finish an additional year of training.

 

Will the Royal College change that 3rd requirement? I am not aware of any talks currently to remove that or change that to 3-years of internal medicine training. My guess is most likely not given that historically academics have lengthened training but rarely shortened one.

 

 

In addition, this whole 5-year process could be very political in nature. One can liken it to the late 80s and early 90s when family medicine received its own specialty training and became the standard of care. Prior to that, residents in specialty training could locum as GPs with their independent licenses obtained using LMCCs. However, since the standardization of FM training, we are no longer able to locum as GPs even after obtaining our LMCCs.

 

A similar situation could arise 10-20 years down the road with the FRCP in Internal Medicine. It may unfortunately end up becoming a throw-away exam that doesn't provide one with any additional practising privileges. Currently subspecialty trainees in PGY5 years and above after obtaining their FRCP in internal medicine (e.g. GI, Endo, CritCare fellows) can locum as 'Internists' to supplement their income until they finish their subspecialty training.

10-20 years down the road once GIM subspecialty designation becomes widespread and the 'standard' of certification, other subspecialty trainees with FRCP in internal medicine may not be able to get an independent CPSO/BC/A/S/M license to locum just like how we can't practise as GPs with our LMCCs now.

 

Why would anyone do that? Well, you can sugar-coat it with terms like 'better training' 'better education' 'more specialized care' but you can also think it could be related to $$ and jobs.

e.g. What do you expect the job situation for FMs will be if all the subspecialty trainees could now practise as GPs (locums etc). It won't be better for sure. It may be the same or even worse.

With the same logic, one can argue that currently there may be subspecialty trainees in IM subspecialty who are occupying jobs that could be taken by a general internist, even if it's a locum position. But it's not even the subspecialty trainees but also subspecialists who do a lot of general internal medicine.

 

In the future, there could be even a remote possibility that as a subspecialist in IM (e.g. Resp), you may not be able to work in medicine CTUs, or even general medical wards, or receive any non-Resp referrals. Just like how the surgical specialties are now (ENT will never be able to see an appy, chole, whereas GSx could do thyroids. Urology could never do GI stuff whereas GSx could do nephrectomies).

Surgery isn't really the way you described. The reality of the situation is except for a couple areas of cross over with other specialties (adrenals and thyroids for example), general surgeons have become basically GI/peritoneal cavity surgeons. They have a focused area of practice like all other aurgical specialties. The days of the do it all general surgeon are largely historical (except maybe some people in really remote areas).

 

I don't know a single Gen Surg who will do a Nx outside of the trauma setting (either intra-op trauma or external Trama like an MVA). It's kind of like how some urologists will do spleenectomies or bowel resections for intra-op trauma but you won't see them doing primary Splenectomies or bowel resections. They do use the bowel a lot of conduits or neobadders

 

Adrenalectomy is the classic area of cross over but more and more of them seem to be done by urologists.

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IM still requires 4 years of training. So people passing in their 3rd year need to complete a 4th year of training in something that also gives them adequate credits towards internal medicine certification.

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Surgery isn't really the way you described. The reality of the situation is except for a couple areas of cross over with other specialties (adrenals and thyroids for example), general surgeons have become basically GI/peritoneal cavity surgeons. They have a focused area of practice like all other aurgical specialties. The days of the do it all general surgeon are largely historical (except maybe some people in really remote areas).

I don't know a single Gen Surg who will do a Nx outside of the trauma setting (either intra-op trauma or external Trama like an MVA). It's kind of like how some urologists will do spleenectomies or bowel resections for intra-op trauma but you won't see them doing primary Splenectomies or bowel resections. They do use the bowel a lot of conduits or neobadders

Adrenalectomy is the classic area of cross over but more and more of them seem to be done by urologists.

 

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)

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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)

I am more referring to elective work. There aren't many general surgeons doing Nephrectomies for RCC anymore. They refer them out to the closest urologist and the patient travels. Even in the remote North (my residency center and med school were referal locations for different areas of Canada's north) those people are still sent out for thier surgery. The exception in that case is emergencies where the patient can't travel (stability, weather etc.) or things are minor enough that you can handle it. I agree with you that for Emerg stuff in a rural area as a gen surg you can end up doing all kinds of stuff (usually being helped by the appropriate specialist via phone).

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