IM Burnout - Ambulatory and Better Lifestyle practice models?

[throwaway9876]

Hi all. Bit of a muddled post, bear with me. I’m a PGY2 (almost PGY3) in Internal Medicine in Ontario. I love Medicine but I’ve been increasingly burned out this year and am finding it hard to find any joy in this career any more. I’ve done very well in all my rotations, I know RC coming up will be a grind but I don’t anticipate any problems with it. No specific reasons for burnout, just the typical combination of constant gruelling call, neverending work, no end in sight, and day to day moral injury that’s stamping my light out. Subspecialty wise, I was interested in GI but ultimately don’t love it enough to want to spend the rest of my life doing it. I’m now trying to decide between 4 year and 5 year GIM. I even considered switching to family medicine but at this point it seems foolish to start all over again and more prudent to just power through.

I know everyone goes through burnout at some point and I’ve already made some changes to try to head this off before it sets in too deep. What scares me most is that life doesn’t seem to get all that much better as a staff (correct me if I’m wrong, I haven’t done many community rotations yet but in my limited experience in a mid-size hospital, they are run off their feet and the call is no less busy than residency). I’ve been told anecdotally by many people that the only way to really have a good QOL is to subspecialize in a more ambulatory field (endo, rheum) but it’s a little too late for me to do that. I guess I’m hoping for some wisdom from anyone who does full time GIM and has a reasonable QOL and work/life balance. What do your hours, ambulatory vs. inpatient mix, and call schedules look like? And specifically, does anyone do predominantly ambulatory GIM, and if so, how did you set this up? It seems hard to hang a shingle without a subspecialty focus but this seems like a good fit for me if possible...

[Edict]

1 hour ago, throwaway9876 said:

Hi all. Bit of a muddled post, bear with me. I’m a PGY2 (almost PGY3) in Internal Medicine in Ontario. I love Medicine but I’ve been increasingly burned out this year and am finding it hard to find any joy in this career any more. I’ve done very well in all my rotations, I know RC coming up will be a grind but I don’t anticipate any problems with it. No specific reasons for burnout, just the typical combination of constant gruelling call, neverending work, no end in sight, and day to day moral injury that’s stamping my light out. Subspecialty wise, I was interested in GI but ultimately don’t love it enough to want to spend the rest of my life doing it. I’m now trying to decide between 4 year and 5 year GIM. I even considered switching to family medicine but at this point it seems foolish to start all over again and more prudent to just power through.

I know everyone goes through burnout at some point and I’ve already made some changes to try to head this off before it sets in too deep. What scares me most is that life doesn’t seem to get all that much better as a staff (correct me if I’m wrong, I haven’t done many community rotations yet but in my limited experience in a mid-size hospital, they are run off their feet and the call is no less busy than residency). I’ve been told anecdotally by many people that the only way to really have a good QOL is to subspecialize in a more ambulatory field (endo, rheum) but it’s a little too late for me to do that. I guess I’m hoping for some wisdom from anyone who does full time GIM and has a reasonable QOL and work/life balance. What do your hours, ambulatory vs. inpatient mix, and call schedules look like? And specifically, does anyone do predominantly ambulatory GIM, and if so, how did you set this up? It seems hard to hang a shingle without a subspecialty focus but this seems like a good fit for me if possible...

Not in IM but the IM PGY2 is your worst year and you are at the tail end which is the worst of it. It will definitely get better. Just hang in there. 

[freewheeler]

I mean at the end of the day it's your life so do whatever you are comfortable with.

Being almost a PGY3, it seems to make sense to just keep grinding it out.

As IM staff you will make $$$ in a lot of the subspecialties and even if you do GIM, if you do 1 week of MTU periodically with outpatient clinics in between you should gross way more than a typical FM doc would gross.

If you really just care about having your life back ASAP then you're kind of left with dropping out of medicine, taking a leave, or trying to transfer into FM, but none of those are great options and an FM transfer will only credit you with up to 6 months, meaning you'd still have 1.5 years of residency to do on top of whatever you've done up to this point and until a transfer request could be granted.

You are right though, being a learner on IM sucks.

[JohnGrisham]

6 hours ago, throwaway9876 said:

Hi all. Bit of a muddled post, bear with me. I’m a PGY2 (almost PGY3) in Internal Medicine in Ontario. I love Medicine but I’ve been increasingly burned out this year and am finding it hard to find any joy in this career any more. I’ve done very well in all my rotations, I know RC coming up will be a grind but I don’t anticipate any problems with it. No specific reasons for burnout, just the typical combination of constant gruelling call, neverending work, no end in sight, and day to day moral injury that’s stamping my light out. Subspecialty wise, I was interested in GI but ultimately don’t love it enough to want to spend the rest of my life doing it. I’m now trying to decide between 4 year and 5 year GIM. I even considered switching to family medicine but at this point it seems foolish to start all over again and more prudent to just power through.

I know everyone goes through burnout at some point and I’ve already made some changes to try to head this off before it sets in too deep. What scares me most is that life doesn’t seem to get all that much better as a staff (correct me if I’m wrong, I haven’t done many community rotations yet but in my limited experience in a mid-size hospital, they are run off their feet and the call is no less busy than residency). I’ve been told anecdotally by many people that the only way to really have a good QOL is to subspecialize in a more ambulatory field (endo, rheum) but it’s a little too late for me to do that. I guess I’m hoping for some wisdom from anyone who does full time GIM and has a reasonable QOL and work/life balance. What do your hours, ambulatory vs. inpatient mix, and call schedules look like? And specifically, does anyone do predominantly ambulatory GIM, and if so, how did you set this up? It seems hard to hang a shingle without a subspecialty focus but this seems like a good fit for me if possible...

Outpatient GIM with community referrals for HTN, DM, x y z  seems pretty chill. Not making GI $, but doing better or same as a FM without needing to churn 40 patients a day. Pi

Maybe its just in my centre, but the 3 GIMs i worked with were essentially doing that. Referrals from FM docs and patients who were complex and d/c from emerg, but "Should have IM f/u in the next few weeks just to make sure you're optimized", and it was not complicated stuff at all.  

[brady23]

Endo and Rheum (lifestyle IM subspecialties) are competitive correct?

And if you don't match to those, you're stuck with GIM? Is it possible to do outpatient work with GIM or are you limited to the wards (i.e. being on call, inpatient)?

[Wachaa]

1 hour ago, brady23 said:

Endo and Rheum (lifestyle IM subspecialties) are competitive correct?

And if you don't match to those, you're stuck with GIM? Is it possible to do outpatient work with GIM or are you limited to the wards (i.e. being on call, inpatient)?

Definitely. You can work as pure outpatient GIMs, especially in a large urban city. You need to get your name out there and have GPs refer to you, typically for diagnostic clarification, chronic disease management, medication optimization, etc. In the age of electronic communication, your name would get out there quickly, especially if you have a shorter waiting list.

Most would work together in an office with other GIMs or subspecialists. GIMs are often a very good resource for GPs to refer to. GIMs can then triage to the appropriate subspecialist.

For example, if a GP discovers microalbuminuria, refers to GIM.... who does a workup and suspects likely IgA nephropathy. That patient then gets sent to Nephro.

That specialist clinic can be even more lucrative with ECGs, Holters, stress tests, etc. They'll receive referrals from GP offices for those services, or, GIMs can direct their patients to do tests at their own clinic. There are billings for those services.

[Bluberblubo]

8 minutes ago, Wachaa said:

Definitely. You can work as pure outpatient GIMs, especially in a large urban city. You need to get your name out there and have GPs refer to you, typically for diagnostic clarification, chronic disease management, medication optimization, etc. In the age of electronic communication, your name would get out there quickly, especially if you have a shorter waiting list.

Any idea how much a purely outpatient GIM staff would make if they worked 8am-5pm with 1-hour lunch (8 hour day) assuming they completed all their paperwork so they literally leave at 5pm? Assuming they work 4-5 days per week? I hear people say that you'd average 400k per year for 4 days per week. Is that a realistic estimate?

[ZBL]

2 hours ago, skyuppercutt said:

Any idea how much a purely outpatient GIM staff would make if they worked 8am-5pm with 1-hour lunch (8 hour day) assuming they completed all their paperwork so they literally leave at 5pm? Assuming they work 4-5 days per week? I hear people say that you'd average 400k per year for 4 days per week. Is that a realistic estimate?

I would suspect a little less, but I could be wrong. You basically would have a similar set up to an endocrinologist or rheumatologist at that point so probably similar billing. Could maybe add more doing stress tests or something but not sure how common that is, let alone how common it is to do purely outpatient GIM in the first place.  

[Wachaa]

2 hours ago, skyuppercutt said:

Any idea how much a purely outpatient GIM staff would make if they worked 8am-5pm with 1-hour lunch (8 hour day) assuming they completed all their paperwork so they literally leave at 5pm? Assuming they work 4-5 days per week? I hear people say that you'd average 400k per year for 4 days per week. Is that a realistic estimate?

400k is very reasonable. It varies. You do a bit more or less work and income can fluctuate by +/- 50-100k+

However, the expectation for 8-5PM is not typical. I think most people carry over some work to do at home. You would have to stop seeing patients around ~3:30 in that case.

[Lactic Folly]

Do these numbers include overhead?

To OP: I'd ask whether you have any other interests such as policy, research, education, outreach, etc. These do not necessarily entail fewer hours but can be more flexible than pure clinical work, and enhance your sense of meaningful work / help stave off burnout. These pursuits also often pair better with GIM than with subspecialty IM.

[Wachaa]

2 hours ago, Lactic Folly said:

Do these numbers include overhead?

 To OP: I'd ask whether you have any other interests such as policy, research, education, outreach, etc. These do not necessarily entail fewer hours but can be more flexible than pure clinical work, and enhance your sense of meaningful work / help stave off burnout. These pursuits also often pair better with GIM than with subspecialty IM.

Gross billings, pre-overhead

[LittleDaisy]

On 6/12/2019 at 11:39 PM, Wachaa said:

Definitely. You can work as pure outpatient GIMs, especially in a large urban city. You need to get your name out there and have GPs refer to you, typically for diagnostic clarification, chronic disease management, medication optimization, etc. In the age of electronic communication, your name would get out there quickly, especially if you have a shorter waiting list.

Most would work together in an office with other GIMs or subspecialists. GIMs are often a very good resource for GPs to refer to. GIMs can then triage to the appropriate subspecialist.

For example, if a GP discovers microalbuminuria, refers to GIM.... who does a workup and suspects likely IgA nephropathy. That patient then gets sent to Nephro.

That specialist clinic can be even more lucrative with ECGs, Holters, stress tests, etc. They'll receive referrals from GP offices for those services, or, GIMs can direct their patients to do tests at their own clinic. There are billings for those services.

I find that it's rare that general internists do purely outpatient ambulatory clinic. Unfortunately, there is no centralized referral system in Ontario.

As a young GIM who just graduate and open up a clinic, you really have to get your name out there and have friends in Family Medicine who can recommend you to his or her colleagues.

The overhead of opening up a clinic in downtown Toronto could be quite high - 30%. Most GIM open up clinic with GPs or other IM sub-specialists, but they rarely do 100% outpatient work. 

Otherwise, a lot of GPs are fairly comfortable working up micro-albuminuria if you read up a bit on uptodate and directly refer to nephrology at academic hospital. 

Sometimes, we would refer to academic GIM clinic for complex patients, but I won't say that GPs would refer to outpatient GIM for common work-up that we could do easily, it seems too complicated to refer to general internist for a specialized problem, when we could just directly refer to sub-specialist, cutting the middle man saves time tbh. 

[Wachaa]

5 hours ago, LittleDaisy said:

I find that it's rare that general internists do purely outpatient ambulatory clinic. Unfortunately, there is no centralized referral system in Ontario.

As a young GIM who just graduate and open up a clinic, you really have to get your name out there and have friends in Family Medicine who can recommend you to his or her colleagues.

The overhead of opening up a clinic in downtown Toronto could be quite high - 30%. Most GIM open up clinic with GPs or other IM sub-specialists, but they rarely do 100% outpatient work. 

 Otherwise, a lot of GPs are fairly comfortable working up micro-albuminuria if you read up a bit on uptodate and directly refer to nephrology at academic hospital. 

Sometimes, we would refer to academic GIM clinic for complex patients, but I won't say that GPs would refer to outpatient GIM for common work-up that we could do easily, it seems too complicated to refer to general internist for a specialized problem, when we could just directly refer to sub-specialist, cutting the middle man saves time tbh. 

 

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.

[LittleDaisy]

40 minutes ago, 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.

Hey I didn't know that such thing existed in BC, that's so neat to save referral times.

In Ontario, we don't have a such thing. It's usually a word of mouth regarding who we refer to for specialists, I think that there needs to be changes in the system itself. 
It seems like having a centralized referral system, or having a centralized website showing all the new subspecialists grads taking on new patients, would incredibly reduce the wait time for patients. 

[Wachaa]

6 minutes ago, LittleDaisy said:

Hey I didn't know that such thing existed in BC, that's so neat to save referral times.

In Ontario, we don't have a such thing. It's usually a word of mouth regarding who we refer to for specialists, I think that there needs to be changes in the system itself. 
It seems like having a centralized referral system, or having a centralized website showing all the new subspecialists grads taking on new patients, would incredibly reduce the wait time for patients. 

Yea, so basically a new specialist grad creates their own "profile" to put on the website (called Pathways). They show their waiting times, referral forms, services, etc.

Very easy to navigate, and your secretary can basically do this for you too, if you're a GP and not sure who to refer to.

[futureGP]

If burnout is a concern at that stage I would not be too worried. With all the smr shifts, codes you are going to, and daytime rounding on inpts it can feel like a grind with no end.

 

The difference between 4year GIM vs 5year GIM is just that. An extra year of training in PGY5 where you could do whatever you want. 5th year could mean more preop, ob exposure, ultrasound training, more subspecialty clinics to get your skills down. Nothing you cant do as a skilled 4year GIM.

In the community finding a job won’t be any harder with 4year GIM.

 

outpatient GIM is easy to set up, open up an office and send a few letters to FM groups and consults will come - but will be selected out. E.g. any consult requiring a diagnostic study will go to a subspecialist who can do that (ecg, echo to cardio, pft to resp, scope to GI). But you will still get lots of HTN, DM, vague rheumatoid issue, vague symptoms needing clarifications, complex list of meds, co-management of multi-system problems etc.

 

Billings in Ontario are rather predictable. A pure consult and follow up based practise is easy to estimate. Just follow the billing codes. 157 for consult, 60-80 for follow ups. Working 9-5 with 1 hr lunch break leaves you 7 hours of work. 1 consult / hr with 2 follow ups / hr is probably average. You could definitely speed up and see more people and that is personal. 

Thats roughly 277 an hour (assume 60 bucks for f/u) which is roughly 2000 a day. Do it 4 times a week and work 48 weeks a year (assume 4 weeks vacay). You’re looking at ~380k a year.

now the down side of not subspecializing is you don’t get chronic disease premiums that other specialties in ambulatory care get. E.g. rheumatologist seeing an arthritis patient get 50% bonus to their follow up billings. Endo seeing DM get 50% bonus, resp seeing copd/asthma get 50% bonus to follow up billings.

 

you also miss out on improving efficiency. Eg. Rheum can churn through arthritis consults faster, do more joint blocks a day than a GIM seeing a few joint pts probably could. Similarly, resp can see asthma/copd with spirometry all day long. Setting up a GIM practice with spirometry that is used once a day isn’t very efficient. 

 

Regardless, bottom line is IM is always in demand wherever you go. Nobody stopping you from ditching the hospital and setting up a clinic somewhere. Consults will come.

[Bluberblubo]

Wow, thank you so much for such an informative post. Really did not know about a lot of things you mentioned, especially this:

5 hours ago, futureGP said:

now the down side of not subspecializing is you don’t get chronic disease premiums that other specialties in ambulatory care get. E.g. rheumatologist seeing an arthritis patient get 50% bonus to their follow up billings. Endo seeing DM get 50% bonus, resp seeing copd/asthma get 50% bonus to follow up billings.

One thing that many people have told me is that endo and rheum (even attending rheumatologist) usually bill less than GIM. Is that because on average someone in GIM would still be able to see more patients per hour despite the 50% bonus that the subspecialists can bill for?

Can anyone speak to how easy/difficult it would be for someone in GIM to pick up ER consult shifts at  a community hospital in Ontario e.g. Mississauga, Brampton, Windsor, Scarborough? How would the volume be/expected income be for a shift from midnight to 8am?

I've heard some people say that young attendings can pick up call shifts in places like Sue St Mary where they also run the ICU and end up billing something riduculous like 15k in a weekend (Friday evening, Sat, and Sunday). Is that realistic or an exaggeration?

Thanks! R1 going into R2 internal and leaning towards GIM

[LittleDaisy]

On 6/28/2019 at 6:14 PM, skyuppercutt said:

Wow, thank you so much for such an informative post. Really did not know about a lot of things you mentioned, especially this:

One thing that many people have told me is that endo and rheum (even attending rheumatologist) usually bill less than GIM. Is that because on average someone in GIM would still be able to see more patients per hour despite the 50% bonus that the subspecialists can bill for?

Can anyone speak to how easy/difficult it would be for someone in GIM to pick up ER consult shifts at  a community hospital in Ontario e.g. Mississauga, Brampton, Windsor, Scarborough? How would the volume be/expected income be for a shift from midnight to 8am?

I've heard some people say that young attendings can pick up call shifts in places like Sue St Mary where they also run the ICU and end up billing something riduculous like 15k in a weekend (Friday evening, Sat, and Sunday). Is that realistic or an exaggeration?

Thanks! R1 going into R2 internal and leaning towards GIM

For lower billing of endo and rheumatology, it's not due to the volume. The endocrinologists and rheumatologists usually follow up chronic conditions patients, which means that even they have a higher billing code for follow-up, it is still less lucrative than seeing new consults. It might be that GIM usually see new consults and would then refer them afterwards to subspecialists if needed, or discharge them with clear follow-up instructions to the GP.

I would expect that GIM follow-up to take longer time, as you are dealing with multiple issues instead of one specific issue. 

Also, most GIM do inpatient hospital work -- the billings end up being higher; especially they do overnight calls (higher premiums and higher billing codes for consults, especially for unstable acute care patients). 

[NLengr]

On 6/20/2019 at 10:02 PM, Wachaa said:

 

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.

That seems like a system that a bureaucrat who has never worked in medicine designed. What a waste of family medicine skills, not to mention taxpayer money if anything beyond the very basic work ups are sent to specialists. 

If they really are trying to prevent anything but the most basic work ups by family docs, I expect a push to replace family docs with NPs is coming in the future. 

[Wachaa]

3 hours ago, NLengr said:

That seems like a system that a bureaucrat who has never worked in medicine designed. What a waste of family medicine skills, not to mention taxpayer money if anything beyond the very basic work ups are sent to specialists. 

If they really are trying to prevent anything but the most basic work ups by family docs, I expect a push to replace family docs with NPs is coming in the future. 

Yeah no kidding.

But NPs aren't cheap either. In BC the government created positions where essentially they're paying NPs salary near $160k plus additional $85k for overhead expenses (1680 hours, 220 days per year) . - you can DM me for the reference if you want.

 

 

But getting back to OP. As some people have mentioned, one of the possibilities to not burn out is just to see simpler cases (HTN DM etc). Or at least a higher proportion of these.

[NLengr]

1 hour ago, Wachaa said:

Yeah no kidding.

But NPs aren't cheap either. In BC the government created positions where essentially they're paying NPs salary near $160k plus additional $85k for overhead expenses (1680 hours, 220 days per year)

Christ. What a waste. 

[IMislove]

On 6/20/2019 at 8:32 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.

Does this change when comparing to rural family med, where they may be the majority of docs in a town and very few specialists? Say 1.5 hours away or more to nearest academic center? I know in these cases fam docs do a ton of hospitalist work and very is maybe one GIM in the town. More specifically Ontario if you can speak to that?

[RadCdn]

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. 

[anonymouspls]

28 minutes ago, 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. 

What about 5-6 days a week? Are there any GIM doctors with a narrow focus like yours grossing 400k or more, or is it something only a few superstars are doing? Also whats your overhead?

[VivaColombia]

Based on all this info, is it reasonable to have a take home post-tax income in GIM of 250K provided you gross 400K? And is there paid vacation/pension/etc. included in this or does that have to be accounted for separately?