Current Internal Medicine Staff Prospects

[Internalmed1234]

Hi guys,

I'm an internal medicine resident currently. I am probably going into either GIM or endo and was hoping to more specifically get information about the current job prospects of GIM in the Toronto and GTA area (including as north as Barrie). I am interested in both the inpatient and outpatient opportunities that perhaps final year GIM fellows or other internists would know about and/or are applying to currently. 

Thank you!  

[The Ace of Spades]

Disclaimer: Not in Toronto, but am qualified internist.

It is my understanding that there are quite a lot of jobs for 5-year GIM people throughout the GTA. I've even heard of the 4-year IM people getting jobs in community hospitals in the GTA, but I would definitely go the 5-year route if you are intested in the GTA and/or academia. I am not too sure what the Endo job market is like there. I know the GI market is saturated unless you want to work in an outpatient endoscopy clinic only.

See: https://csim.ca/careers/

[LittleDaisy]

2 hours ago, The Ace of Spades said:

Disclaimer: Not in Toronto, but am qualified internist.

It is my understanding that there are quite a lot of jobs for 5-year GIM people throughout the GTA. I've even heard of the 4-year IM people getting jobs in community hospitals in the GTA, but I would definitely go the 5-year route if you are intested in the GTA and/or academia. I am not too sure what the Endo job market is like there. I know the GI market is saturated unless you want to work in an outpatient endoscopy clinic only.

See: https://csim.ca/careers/

Definitely 4 year GIM people are getting community jobs in GTA. I don't think that the community hospitals care about 4 year vs 5 year. It's mostly about knowing the right people at the right time. 

[Internalmed1234]

Thanks for the responses! Can anyone also comment on the types of outpatient opportunities available? Are there clinics hiring GIMs or would it mostly be set up your own practice? Are rapid referrals quite saturated I'd imagine? 

[Raptors905]

On 12/7/2019 at 1:11 PM, Internalmed1234 said:

Thanks for the responses! Can anyone also comment on the types of outpatient opportunities available? Are there clinics hiring GIMs or would it mostly be set up your own practice? Are rapid referrals quite saturated I'd imagine? 

there are lots of GTA hospitals that hire GIMS. The work is a combination of inpatient MRP/ER/clinics. 
 

typical workload is about 12 weeks of MRP a year and 3-5ER shifts and 6 weeks of clinic. Most docs can get a week off a month or so if they stack up work. 
 

it’s got no overhead and billings are about 350-500 depending mainly on ER shifts done and days vs nights vs weekends. 
 

as for a job with absolutely full on outpatient work a lot of it is the walk-in A133 stuff and referrals from GP. A lot of variability here - some guys Bill a million doing the walk ins and those with more referral based true GIM work are making more if they bill cardiology procedures. It’s a bit harder in the heart of GTA bc the cardios are so hungry for work. However you can make a decent go of it but need to pay overhead and will likely not have tons of time off

[Internalmed1234]

7 hours ago, Raptors905 said:

there are lots of GTA hospitals that hire GIMS. The work is a combination of inpatient MRP/ER/clinics. 
 

typical workload is about 12 weeks of MRP a year and 3-5ER shifts and 6 weeks of clinic. Most docs can get a week off a month or so if they stack up work. 
 

it’s got no overhead and billings are about 350-500 depending mainly on ER shifts done and days vs nights vs weekends. 
 

as for a job with absolutely full on outpatient work a lot of it is the walk-in A133 stuff and referrals from GP. A lot of variability here - some guys Bill a million doing the walk ins and those with more referral based true GIM work are making more if they bill cardiology procedures. It’s a bit harder in the heart of GTA bc the cardios are so hungry for work. However you can make a decent go of it but need to pay overhead and will likely not have tons of time off

Thanks for the response! Can you elaborate a little bit more about the walk in? Are these patients who see GIMs without GP referrals? 

Also 12 + 5 + 6 weeks = 23 weeks. What else are GIMs doing as the math doesn't add up that you can only get 1 week off a month. I probably am missing something. 

Also, if you choose to work weekends or evening clinics (not even sure if that's available for GIMs), but are there bonus codes as there are for GPs working outside of regular hours as an outpatient? And I assume from what you are saying that inpatient weekends/evenings/nights pay more than days too as would be expected 

[Raptors905]

5 hours ago, Internalmed1234 said:

Thanks for the response! Can you elaborate a little bit more about the walk in? Are these patients who see GIMs without GP referrals? 

Also 12 + 5 + 6 weeks = 23 weeks. What else are GIMs doing as the math doesn't add up that you can only get 1 week off a month. I probably am missing something. 

Also, if you choose to work weekends or evening clinics (not even sure if that's available for GIMs), but are there bonus codes as there are for GPs working outside of regular hours as an outpatient? And I assume from what you are saying that inpatient weekends/evenings/nights pay more than days too as would be expected 

So 12 weeks of MRP is one week a month 

Clinic weeks are probably 6 -8 a year. 
 

5 ER shifts usually takes two weeks to do since they are a combination of days/evenings/nights. 
 

the majority of GIM income is tied to the ER work. 
 

most GIM don’t do clinics on weekends or evenings. However they usually work evenings and weekends in the ER and yes there are special visit codes that do apply for this 

the walk in would be just that - walk ins without a referral. They can bill a a133 on all of them. It’s crappy work but it pays well

[futureGP]

Gim job exist in gta. You dont need 5-year GIM unless you want academic.

 

if you have frcp in IM you can essentially open a clinic and accept referrals.

i guess you could advertise as walk-in IM and do A133, but why do that when you can A135 from GP. The OHIP req. is essentially the same for double the pay.
 

Also, scheduled clinic appts aren’t eligible for SVPs even if it is a weekend or night time clinics. 

 

Daytime IM work isn’t so lucrative, maybe 1-2k depending on how fast you are. Plus private clinic means overhead unless you’re doing hospital-based clinics. Overnight ER shift is where the $$ is with SVPs and can average 3-5k depending on how busy it is.

 

Sure if you’re shady and that kinda guy, you can try and set up ‘cardiac investigations’ clinic where you do holter/GXT for anyone asymp over age 50, but get rdy to be audited hard (++ shady ‘cardiac investigation’ clinics in GTA)

[Bluberblubo]

36 minutes ago, futureGP said:

Gim job exist in gta. You dont need 5-year GIM unless you want academic.

I'm not sure if it's just the program I'm in, but often times it feels like our internal medicine department and PD are pushing people to apply to GIM and shunning those interested in doing a 4 year program. Is that a legitimate concern or is there an agenda that I'm not aware of i.e. it looks bad for the program if many residents are doing a 4 year program?

[Raptors905]

40 minutes ago, skyuppercutt said:

I'm not sure if it's just the program I'm in, but often times it feels like our internal medicine department and PD are pushing people to apply to GIM and shunning those interested in doing a 4 year program. Is that a legitimate concern or is there an agenda that I'm not aware of i.e. it looks bad for the program if many residents are doing a 4 year program?

There is zero concern. The 5 year is designed for academic types who want an academic job. The PD and GIM have their own agenda there 

 

if you want to work in the community 4 years is adequate. If you do 5 year GIM it’s almost better to have done 5 years as an ICU or nephro and apply to a GIM job since you will have additional skills. The 5th year doesn’t really do anything to make you a better community internist versus a 4 year 

[LittleDaisy]

15 hours ago, Raptors905 said:

So 12 weeks of MRP is one week a month 

Clinic weeks are probably 6 -8 a year. 
 

5 ER shifts usually takes two weeks to do since they are a combination of days/evenings/nights. 
 

the majority of GIM income is tied to the ER work. 
 

most GIM don’t do clinics on weekends or evenings. However they usually work evenings and weekends in the ER and yes there are special visit codes that do apply for this 

the walk in would be just that - walk ins without a referral. They can bill a a133 on all of them. It’s crappy work but it pays well

I wasn't aware of walk-in? I thought you would need a referral MD to bill? Nice to know that those codes exist? Where would you find a GIM clinic without referral?

All the academic hospitals GIM rapid referral clinics require well-detailed referrals with PMhx and HPI.

Also, outpatient work not attached to a hospital --> you have to consider no-shows, late arrivals as well; as they tend to affect your day and make it less efficient. 

[Raptors905]

28 minutes ago, LittleDaisy said:

I wasn't aware of walk-in? I thought you would need a referral MD to bill? Nice to know that those codes exist? Where would you find a GIM clinic without referral?

All the academic hospitals GIM rapid referral clinics require well-detailed referrals with PMhx and HPI.

Also, outpatient work not attached to a hospital --> you have to consider no-shows, late arrivals as well; as they tend to affect your day and make it less efficient. 

You need a referral to bill a consult not an A133. 
 

outpatient work in the hospital sucks - like they rapid referral clinic the cases can take long and the nurses are unionized and work at a not super fast pace and it’s got a lot of no shows and patients who are admitted. Only positive is no overhead. Cases can also be sick and take a lot of time. 
 

you own practice usually you book cases tighter than the staff will call to confirm appointments better and patients are not as sick. 
 

walk ins are not common for internists because most don’t like doing them although at some clinics around the city they do like the famous Mississauga one. The internist there is billing over a million seeing walk ins all da. 

[ACHQ]

16 hours ago, skyuppercutt said:

I'm not sure if it's just the program I'm in, but often times it feels like our internal medicine department and PD are pushing people to apply to GIM and shunning those interested in doing a 4 year program. Is that a legitimate concern or is there an agenda that I'm not aware of i.e. it looks bad for the program if many residents are doing a 4 year program?

The University/program have their own agenda's, which likely relates to money.

From my understanding the University/program gets only 3 years of funding/per resident for the "core" portion of the Internal medicine program (which is 3 years), and then get additional 2 years of funding/per resident in the subspecialty programs. However our CARMS contract guarantees us 4 years of funding if we do the 4 year GIM program. The government however doesn't fund this for whatever reason and so the schools have to find the funding and pay for each resident. That can get pricey if you have 10+ residents doing it (which can equate to 750k- 1million/year).

Universities/programs will rarely care about what is best for *you* as an individual. Don't trust them, go with what makes sense to you and your family, because 5-10 years down the line when you're done and struggling to look for work because you became hyperspecialized in x,y,z sub-sub-specialty and there isn't a job in a city where you want to live, the University/program wont even remember your name, and you'll be doing GIM work anyways except that you will have lost all those years of *real* earning potential

[Internalmed1234]

Thanks for the responses thus far. Anyone know of anyone doing GIM work who isn't a GIM in these community hospitals in the GTA such as covering some service weeks or working ED night shifts? Or do community hospitals tend to select only GIMs for the most part as there are enough GIMs? 

[Raptors905]

6 hours ago, Internalmed1234 said:

Thanks for the responses thus far. Anyone know of anyone doing GIM work who isn't a GIM in these community hospitals in the GTA such as covering some service weeks or working ED night shifts? Or do community hospitals tend to select only GIMs for the most part as there are enough GIMs? 

What do you mean by “isn’t a GIM”?

 

if you mean a post GIM sub specialist (ie nephrologist) then yes there are lots doing both as sub specialist jobs are scarce. 
 

if you mean a GP/hospitalist then yes they do cover in patient MRP weeks but they do not provide ER coverage 

[Internalmed1234]

Deleted 

[Internalmed1234]

4 hours ago, Raptors905 said:

What do you mean by “isn’t a GIM”?

 

if you mean a post GIM sub specialist (ie nephrologist) then yes there are lots doing both as sub specialist jobs are scarce. 
 

if you mean a GP/hospitalist then yes they do cover in patient MRP weeks but they do not provide ER coverage 

I should've been more clear, I meant sub-specialists. Oh so GPs can also cover GIM service weeks or do you mean that they cover hospitalist service? And does your type of subspecialty matter or all are essentially equal when it comes to GIM work. Thanks for your helpful responses! 

[ACHQ]

2 hours ago, Internalmed1234 said:

I should've been more clear, I meant sub-specialists. Oh so GPs can also cover GIM service weeks or do you mean that they cover hospitalist service? And does your type of subspecialty matter or all are essentially equal when it comes to GIM work. Thanks for your helpful responses! 

For a large community hospital in the GTA the "GIM division" has to (generally) have physicians provide coverage for the following areas:

1. Consultations to the Emergency department

2. Consultations to non-medical services (Surgery, Psych)

3. Urgent/rapid referral/post discharge/perio-op/OB medicine clinics

4. MRP of a medical ward (Hospitalist medicine)

Each hospital will have a different way of how it structures the coverage (most of these will be separate distinct physicians covering each "service", however some hospitals do have some cross coverage where a physician will cover a ward and sometimes do ER consults or clinic, however this is becoming less and less common).

Some community sites will have Family doctors who can do #4 (this is also becoming less common because the # of GIM's being pumped out, but AFAIK it still exists, and places are still hiring). There's one site I know of that has Family doctors that also cover ER admissions, but this is not common place anywhere else. 99% of the time the ER consultations are done by a GIM or sub-specialist. Family doctors do not do #2 or #3 anywhere in the GTA.

*Generally* sub-specialists can cover any of those services above (from a billing and legal standpoint). However all/most will only be required to do #1. #1 is usually a requirement from the hospital department of medicine so as to spread the ER call coverage amoungst a larger number of people. Many subspecialists will try to give away their required ER calls. Some will do them (either because they want to or because its good $$). Some will take more because they can't find a permanent job.

The main point I'm trying to make is, if you want to do GIM work (all the above I listed), then do GIM. If you like a certain sub-specialty then do that. But to do a subspecialty and try to both (in terms of full breadth and scope) is difficult.

[Raptors905]

2 hours ago, ACHQ said:

For a large community hospital in the GTA the "GIM division" has to (generally) have physicians provide coverage for the following areas:

1. Consultations to the Emergency department

2. Consultations to non-medical services (Surgery, Psych)

3. Urgent/rapid referral/post discharge/perio-op/OB medicine clinics

4. MRP of a medical ward (Hospitalist medicine)

Each hospital will have a different way of how it structures the coverage (most of these will be separate distinct physicians covering each "service", however some hospitals do have some cross coverage where a physician will cover a ward and sometimes do ER consults or clinic, however this is becoming less and less common).

Some community sites will have Family doctors who can do #4 (this is also becoming less common because the # of GIM's being pumped out, but AFAIK it still exists, and places are still hiring). There's one site I know of that has Family doctors that also cover ER admissions, but this is not common place anywhere else. 99% of the time the ER consultations are done by a GIM or sub-specialist. Family doctors do not do #2 or #3 anywhere in the GTA.

*Generally* sub-specialists can cover any of those services above (from a billing and legal standpoint). However all/most will only be required to do #1. #1 is usually a requirement from the hospital department of medicine so as to spread the ER call coverage amoungst a larger number of people. Many subspecialists will try to give away their required ER calls. Some will do them (either because they want to or because its good $$). Some will take more because they can't find a permanent job.

The main point I'm trying to make is, if you want to do GIM work (all the above I listed), then do GIM. If you like a certain sub-specialty then do that. But to do a subspecialty and try to both (in terms of full breadth and scope) is difficult.

Yeha this sums it up well. GP hospitalists do MRP work but rarely do ER or ward consults or rapid clinics. 
 

In terms of sub specialists a lot just can’t get jobs in their sub speciality so they do GIM until a job comes along. Common in GI and cardio and  Neprho especially. 
 

I would mention ICU as an outlier - often most of them do both ICU and GIM for a while given the nature of ICU work

[NeuroD]

On 12/19/2019 at 8:06 AM, Raptors905 said:

So 12 weeks of MRP is one week a month 

Clinic weeks are probably 6 -8 a year. 
 

5 ER shifts usually takes two weeks to do since they are a combination of days/evenings/nights. 
 

the majority of GIM income is tied to the ER work. 
 

most GIM don’t do clinics on weekends or evenings. However they usually work evenings and weekends in the ER and yes there are special visit codes that do apply for this 

the walk in would be just that - walk ins without a referral. They can bill a a133 on all of them. It’s crappy work but it pays well

Are the special fee codes only for ER? Do GIM or subspec clinics done in evenings/weekends get bonuses?

[ACHQ]

1 hour ago, PhD2MD said:

Are the special fee codes only for ER? Do GIM or subspec clinics done in evenings/weekends get bonuses?

There is a special fee code called: "Special Visit Premium", which according to the SOB in Ontario states: "Special visit means a visit initiated by a patient or an individual on behalf of the patient for the purpose of rendering a non-elective service"

There are separate codes for seeing a patient in the ER (K99_), hospital clinic (U99_) and the hospital ward (C99_). The amount will also differ depending on the time of day (0700-1659, 1700-2359, 2359-0659) and whether its a stat holiday

Below are the payment rules, copied and pasted from the SOB. From my crude understanding these are codes specifically for non-elective visits, I've mostly seen them used for the ER (all day) and urgent calls from the ward (off hours 5pm-8am). I've also seen them used in urgent outpatient clinics by some. AFAIK you cannot use them for your regularly scheduled (elective) clinic even if it occurs in the evening or weekends. I guess you can use it if you were to schedule a patient in to be seen urgently... but I'm not too well versed with its use in clinics tbh

Payment rules:
1. Special visit premiums are only eligible for payment when rendered with certain services listed under "Consultations and Visits" and "Diagnostic and Therapeutic Procedures" sections of this Schedule.
2. Regardless of the time of day at which the service is rendered, special visit premiums are not eligible for payment in the following circumstances:
a. or patients seen during rounds at a hospital or long-term care institution (including a nursing home or home for the aged);
b. in conjunction with admission assessments of patients who have been admitted to hospital on an elective basis;
c. for non-referred or transferred obstetrical patients except, in the case of transferred obstetrical patients for a special visit for obstetrical delivery with sacrifice of office hours for the first patient seen (C989);
d. for services rendered in a place, other than a hospital or long-term care facility, that is scheduled to be open for the purpose of diagnosing or treating patients;
e. for a visit for which critical care team fees are payable under this Schedule;
f. in conjunction with any sleep study service listed in the sleep studies section of this Schedule; or
g. for services rendered to patients who present to an office without an appointment while the physician is there, or for patients seen immediately before, during or immediately after routine or ordinary office hours even if held at night or on weekends or holidays.
3. Special visit premiums are not eligible for payment with services described by emergency department "H" prefix fee codes.

 

 

[Raptors905]

1 hour ago, PhD2MD said:

Are the special fee codes only for ER? Do GIM or subspec clinics done in evenings/weekends get bonuses?

It’s quotes above well. Clinics run in the hospital would get premiums (ie urgent med clinic). Your own clinic is not getting squat 

[TheTank]

Hello.  Thanks to everyone for great responses giving us an idea about life and career in GIM. I understand that GTA has fairly decent prospects for 4 year GIM. However, what about other provinces? How is the 4vs5 yr GIM job prospects in BC, Alberta, Saskatchewan, Manitoba, NS? Is it any different? I'm thinking of 4 yr GIM vs the 5yrs and working in the community but I  would like to keep options open in terms of different provinces. 

[NLengr]

On 12/20/2019 at 3:49 PM, ACHQ said:

 

Universities/programs will rarely care about what is best for *you* as an individual. Don't trust them, go with what makes sense to you and your family, because 5-10 years down the line when you're done and struggling to look for work because you became hyperspecialized in x,y,z sub-sub-specialty and there isn't a job in a city where you want to live, the University/program wont even remember your name, and you'll be doing GIM work anyways except that you will have lost all those years of *real* earning potential

So much of this (in all programs, I'm a surgeon and I saw the same behaviour from universities and academia).

You are a cog in a machine that, as far as most universities and many academic staff are concerned, exists to advance their career, secure extra money (earning or grants) or lessen their workload.

The quicker you learn to trust nobody in medicine, the better off you will be in the long run.

[blah1234]

12 hours ago, NLengr said:

So much of this (in all programs, I'm a surgeon and I saw the same behaviour from universities and academia).

You are a cog in a machine that, as far as most universities and many academic staff are concerned, exists to advance their career, secure extra money (earning or grants) or lessen their workload.

The quicker you learn to trust nobody in medicine, the better off you will be in the long run.

Even if you take the viewpoint that they aren't being malicious, I find that many academic staff are so far removed from the realities of the job market that they have a very incomplete and skewed viewpoint of what it takes to get a job. For the vast majority of medical students and residents, that's what we care about as we'll be out in the community instead of on the academic treadmill.