Ask questions about family medicine here

[magneto]

I am a recent graduate of family medicine residency and would like to help forum members by answering any questions about family medicine residency or family medicine as a career.

[IMG2015]

I have a question regarding working as a hospitalist as a family physician.

1) Would that require any additional years of training after the core 2 years ? 

2) Would you be able as a Family physician to work as a hospitalist in academic centers or hospitals in large cities or you will be limited mostly to the rural areas ?

[a1b1]

You dont need an R3 as a hospitalist to work on the wards as a family doc. However some (not all but some) tertiary centers will prefer/require you to have an R3 in order to do FM wards in bigger hospitals that have residents for example (i.e JGH).

I did a couple of weeks as a hospitalist without a problem and without an R3 but it was in a rural setting.

hope this helps.

[IMG2015]

Thank you for your reply

[magneto]

On 2/7/2020 at 10:51 PM, IMG2015 said:

I have a question regarding working as a hospitalist as a family physician.

1) Would that require any additional years of training after the core 2 years ?

Most medium and small size hospitals will hire hospitalist without R3.

You don't need a R3 for rural and small towns.

R3 will make you more competitive towards getting a job at a larger hospital/tertiary care hospital.

You should ask yourself - can you work independently as a hospitalist after 2 years of family medicine? If the answer is yes, you don't need a R3 hospitalist. If the answer is no then apply for R3 hospitalist position.

The next thing is to get in touch with the hiring committee at the hospital that you are interested in working and ask about upcoming job opportunities and whether R3 is a requirement or not. If there is only 1 or 2 hospitals that you want to work in and all of them require a R3 then you may not have much choice other than either look for other hospitals OR get a R3 position.

I hope that helps.

[magneto]

On 2/7/2020 at 10:51 PM, IMG2015 said:

2) Would you be able as a Family physician to work as a hospitalist in academic centers or hospitals in large cities or you will be limited mostly to the rural areas ?

There are many hospitalists at larger academic centers and large cities who got the job without R3.

However, as time passes, it is getting difficult to get hire at tertiary care centers in large cities without R3. It is not impossible.

If you can apply broadly to all the community hospitals, you should be able to find a job in a large city without R3. It may only be a small hospital in suburb but if you are happy with that then go for it.

There are not enough R3 graduates from hospitalist programs to fill out all the available new hospitalist positions.

At larger academic centers, they hire their own R3 graduates usually or someone who has had a lot of experience. So that's why it is difficult to get a job at a larger hospital coming straight out of family medicine residency because other applicants will either have R3 or work experience.

[anonymouspls]

What is the typical gross income for a fresh FM grad out of residency? I hear 25-30% overhead is the norm, is this true?

How many patients / hour can you realistically see out of residency without feeling overwhelmed?

How many hours / week are you working, and how many hours per night do you spend charting? Or do you chart during the day? 

Thank you

[HeHeHe]

1. What are the best provinces to work in with regards to billing?

2. What are the best provinces to work in with regards to rural incentives?

3. Is it better to do residency in a particular location if you are planning on practicing there afterwards, or does this not matter as much?

Thank you so much!

[magneto]

14 minutes ago, anonymouspls said:

What is the typical gross income for a fresh FM grad out of residency? I hear 25-30% overhead is the norm, is this true?

The answer from this comes from my co-residents/colleagues/preceptors.

Overhead for most clinics in suburbs/large cities is about 30% but can be up to 40%. Gross income for a fresh FM grad out of residency depends on: (1) fee for service vs rostered patients vs some combination of the two vs salary (2) hours work per day; (3) days per week; (4) weeks per year, (5) province, (6) rural vs suburb (7) clinic practice vs hospital practice (8) call vs no call.

If I had to pick one number, I would say typical gross income would be around $300,000-$350,000 for hard working individuals with lots of variation. And could easily be as much as $500,000 depending on other factors mentioned previously.

14 minutes ago, anonymouspls said:

How many patients / hour can you realistically see out of residency without feeling overwhelmed?

I went into EM after finishing FM.

If I do FM, I can see 4 patients per hour without feeling overwhelmed. If I know all the patients already well enough then maybe 5-6 patients per hour. However, I have found that mental health has become an important part of family medicine and sometimes depending on number of patients coming for mental health conditions, it can be difficult to keep up. But that is not a problem because you are paid for spending extra time with the patients.

 

14 minutes ago, anonymouspls said:

How many hours / week are you working, and how many hours per night do you spend charting? Or do you chart during the day? 

Thank you

I am doing EM residency so I am working a lot.

When I was in FM, I did my charting either right away (if it was short) or at the end of the day (usually 3-5 mins per patient). Sometimes if there were referral letters and other stuff, it would take 10 minutes per patient.

I would recommend to do charting right away rather than at the end of the day.

[magneto]

18 minutes ago, HeHeHe said:

1. What are the best provinces to work in with regards to billing?

I honestly don't know if one is the best.

All provinces fee for service schedule can be found through Google easily.

AB pays one of the best.

Rural areas in all provinces pay well.

I advice to not worry about billing. Choose a place where you will be happy. Money will come, no matter what.

 

18 minutes ago, HeHeHe said:

2. What are the best provinces to work in with regards to rural incentives?

All rural areas pay very well. AB and territories pay well.

If you go to territories for locums (and most remote or rural areas in provinces), they will pay for most (if not all expenses) and you will have zero overhead + rural incentives + on-call stipend.

One of my rural preceptors went into rural practice right after residency. He got a home rent free by the community. He had 0% overhead. This is just one example. Obviously, Canada is such a large country and each province/territory is different.

18 minutes ago, HeHeHe said:

3. Is it better to do residency in a particular location if you are planning on practicing there afterwards, or does this not matter as much?

 

For residency, pick a place where you will be happy and close to family and friends.

It does not matter much where you did your residency and where you end up practicing.

It is easier to always stay in the same province (less paperwork for your practicing license etc.) but many people move provinces without big issues.

 

[ihsh]

Thank you for doing this! I have a few questions:

1) If you have a fee-for-service practice, what kinds of minor procedures (e.g., cryotherapy, biopsies) can you realistically do without running a crazily high overhead?

2) How many years do fresh grads typically spend doing locums before getting a more permanent job?

3) How competitive is it to be part of a family health organization nowadays? 

4) Many rural family docs seem to do FM+ EM. If one doesn't have an interest in EM or the additional training in it, does it significantly limit one's ability to practice in regional/rural setting? I.e., would one be able to practice in, say, Goderich, Ontario by purely doing clinics?

 

 

[MedZZZ]

Thanks for all of your posts. Third year medical student here, seriously undecided between FM and IM (GIM or lifestyle sub specialties like endo and rheum). Do you have any suggestions/insight on the lifestyle and job prospect of these two and how to make this decision considering that CaRMS is getting a lot more competitive and most people choose to do most of their electives in one specialty? Really appreciate it.

[Wachaa]

I'll help answer some questions as well

Graduated 6 years ago.

5 hours ago, ihsh said:

Thank you for doing this! I have a few questions:

1) If you have a fee-for-service practice, what kinds of minor procedures (e.g., cryotherapy, biopsies) can you realistically do without running a crazily high overhead?

2) How many years do fresh grads typically spend doing locums before getting a more permanent job?

3) How competitive is it to be part of a family health organization nowadays? 

4) Many rural family docs seem to do FM+ EM. If one doesn't have an interest in EM or the additional training in it, does it significantly limit one's ability to practice in regional/rural setting? I.e., would one be able to practice in, say, Goderich, Ontario by purely doing clinics?

 

 

 

1) Most offices you join will offer a "split", eg. 30% over head, or something similar. If you enjoying doing these procedures it shouldn't be an issue. You still just give that percentage of your billings to the overhead.

If you run your own office and have to purchase these supplies, you have to consider how many procedures you might realistically do in a given amount of time, and order supplies accordingly. Some clinics, for example, don't do a lot of cryotherapy and thus wouldn't make sense to stock it. However, in a high volume clinic, it makes sense to stock up.

 

2) There seems to be several reasons why people locum. As you mention, fresh grads may want to test the waters and work at different places before settling down. Some people enjoy the locum lifestyle and have been doing it for decades. You have to balance that with certain longitudinal incentives you may not be able to bill (since you're not the GP), and a certain lack of control in how you want to run the office if you're only the locum. For these reasons, a good number of people start a permanent job right away if they happened to find a clinic that is the right fit for them. Maybe just pay attention to the contract details regarding leaving/ switching clinics if it doesn't pan out.

 

3) N/A - Not sure

 

4) You have to check with the specific region. Actually not too hard to find out by asking doctors who work there, or doing a quick search of the locum postings (eg. CMAJ, CFP journals). One point is that in rural communities, often there's an obligation to take on call (if you don't do it, someone else has to). If rural is your interest, there's ample time in rotations/ electives to get the skills.

 

53 minutes ago, MedZZZ said:

Thanks for all of your posts. Third year medical student here, seriously undecided between FM and IM (GIM or lifestyle sub specialties like endo and rheum). Do you have any suggestions/insight on the lifestyle and job prospect of these two and how to make this decision considering that CaRMS is getting a lot more competitive and most people choose to do most of their electives in one specialty? Really appreciate it.

 

To be honest these are very different jobs speaking from a medical point of view. Internal medicine really nails down the nitty gritty of each clinical situation. You're a consultant, whereas a GP's role in primary care won't get into such details. And further, GIM and subspecialty IM are also quite different. If someone came to an endo appointment with 3 issues, they'll likely deal with the relevant one and pass the rest back to the GP/ GIM.

From a "job" perspective, I won't speak too much on FM since most people are already familiar. Outpatient IM can be fairly flexible and depending where you are, you can set up your office together with other subspecialists. You can take on additional hospital work/ calls, etc. The more work you do ends up in higher billings, but cuts into your life/ personal time.

From a "work" point of view, in general, FM can see all ages, and some times you see families together in the same day. You see a wider range of things, eg prenatal care, newborn care, psych, etc. You also see all the weird and wonderful things prior to referring to IM if needed. If deciding between FM/ IM, you decide where on the spectrum you want to see on a daily basis.

[Fortress]

On 2/10/2020 at 10:34 PM, magneto said:

However, I have found that mental health has become an important part of family medicine and sometimes depending on number of patients coming for mental health conditions, it can be difficult to keep up. But that is not a problem because you are paid for spending extra time with the patients.

Can you please elaborate on the fact that billing depends on the amount of time spent with patient? Is that only for mental health or for any type of visit? Can you give us some actual numbers, cuz if thats the case then why do family doctors rush patients.

[bearded frog]

19 hours ago, Fortress said:

Can you please elaborate on the fact that billing depends on the amount of time spent with patient? Is that only for mental health or for any type of visit? Can you give us some actual numbers, cuz if thats the case then why do family doctors rush patients.

Billing varies by province. I checked your history and saw that you would like to stay in Quebec, but the Quebec billing codes are all in French, which is bullshit, so I had to revert to the Ontario ones for an example. I'm pretty sure this is how it works, but someone who actually bills in family medicine can correct me. What you can bill for a standard visit varies depending on patient and reason but on the high end, a "general assessment" is $77.20 billed (A003). A mental health visit is $62.75 per 30 mins, rounded to the closest 30 minute unit (K005) (for example, if the visit is 40 minutes you round down to 30 mins). Even if your standard visits are billed less for periodic health visits etc, if you can see patients in 10-20 minutes clearly it is more profitable to see multiple non-mental health patient then spending extended time on a mental health visit, which doesn't seem equitable imho.

[magneto]

On 2/10/2020 at 11:07 PM, ihsh said:

1) If you have a fee-for-service practice, what kinds of minor procedures (e.g., cryotherapy, biopsies) can you realistically do without running a crazily high overhead?

I think you can do a lot of minor procedures in family medicine clinic.

Now there are commercially available disposable kits for most minor procedures.

That means there is no need to clean and autoclave instruments or pay upfront for expensive medical equipment.

I believe that all family medicine physicians should feel comfortable doing skin biopsies. Other things like simple laceration repairs, simple lumps/bumps etc should be doable without crazy overhead.

 

On 2/10/2020 at 11:07 PM, ihsh said:

2) How many years do fresh grads typically spend doing locums before getting a more permanent job?

Most of my co-residents started with locums. I think most people try to get a permanent job within 6 months - 1 year. There are usually jobs available for fresh grads but in my opinion many fresh grads first try to test out the place by doing a locum. This way fresh grads can move on if they don't like working there as a locum rather than signing on for permanent position and then unable to move on to a better practice.

On 2/10/2020 at 11:07 PM, ihsh said:

3) How competitive is it to be part of a family health organization nowadays?

Are you talking about FHO's in Ontario? It is very competitive to get in but not impossible. As far as I know (I might be wrong) they are not opening new FHOs (I can be totally wrong here). So you need to wait until a position opens up in existing FHOs (someone correct me if I am wrong). Some people like them because they are salaried positions and comes with benefits/pension etc.

On 2/10/2020 at 11:07 PM, ihsh said:

4) Many rural family docs seem to do FM+ EM. If one doesn't have an interest in EM or the additional training in it, does it significantly limit one's ability to practice in regional/rural setting? I.e., would one be able to practice in, say, Goderich, Ontario by purely doing clinics?

No it does not.

In my opinion, after doing 2+1 EM training you are competent to work in any hospital in Canada.

If you want to practice rural and do not want to do EM training, there are bunch of other options. There is a 3 month rural EM program at University of Toronto and I am sure similar programs might exist at other places. Do all of your certifications and read the books - ATLS, ACLS, PALS, NRP, ALARM, cast course etc. It will cost you money but it will teach you basic principles about how to approach most EM presenting complaints. Read around your cases. And try to get some practice and familiarity with airway equipment. Learn how to properly do bag-masked valve and how to insert a supraglottic device. PM me if you have any specific questions.

I am not aware about Goderich policies. However, everytime I have went rural, most docs seem to do clinic + other stuff (like EM, hospitalist). Some rural areas have a policy that expects family physicians to cover something at the hospital if they want to work in the area. However, that is not true for all the communities.

I think if you want to practice in a certain area, you should reach out to physicians who work in the area to get more perspective. Maybe drive down there and get an idea regarding how things are run.

I have done lots of training in rural areas and every location family physicians were doing clinics + something extra (like EM, hospitalist, OB, surgical assist, +1 anesthetia etc). Hope that helps.

 

 

[Fortress]

On 2/6/2020 at 8:46 PM, magneto said:

I am a recent graduate of family medicine residency and would like to help forum members by answering any questions about family medicine residency or family medicine as a career.

Hey! Sometimes people say that family doctors can bill using specialist codes e.g for family doctors working in EM or hospital medicine. Is this true?

[magneto]

On 2/11/2020 at 3:41 AM, MedZZZ said:

Thanks for all of your posts. Third year medical student here, seriously undecided between FM and IM (GIM or lifestyle sub specialties like endo and rheum). Do you have any suggestions/insight on the lifestyle and job prospect of these two and how to make this decision considering that CaRMS is getting a lot more competitive and most people choose to do most of their electives in one specialty? Really appreciate it.

FM and IM share many similarities but also have lots of differences.

Here is my advice. Think about the worst case scenario in FM (lots of work, lots of colds, lots of prescription refills, bad management at the clinic, lack of help) - can you still wake up everyday and be excited about helping others. If not then maybe FM might not be the right choice. FM is a great career but you have to be comfortable with bread and butter FM. This does not mean you will do bread and butter. There are lots of other opportunities like EM, anesthesia, palliative care, geriatrics, sports medicine etc. But sometimes things don't work out for many reasons. And if things don't work out than that means doing family medicine practice that unfortunately most medical students and general public are exposed to - standard clinic, prescription refills, diabetes check ups, coughs/colds, runny noses etc. But everyday I worked as a family doctor, I felt happy. Sometimes I was able to reassure parents that their child has a viral infection and they will be just fine. Sometimes I was able to sit and listen to palliative cancer patients and felt humbled to be part of their life. Sometimes I was able to identify symptoms and signs of MI and properly asked them to go to ED via ambulance. And sometimes I was able to help out the clinic staff by deadling with vasovagal syncopes. Yes, there were times when I felt that I was doing the same work over and over. But I always tried to keep up a positive attitude and always try to teach myself one thing at the end of the day.

IM is a great specialty. There is lots of opportunities to sub-specialize. Or practice as GIM. Lifestyle is tough during residency. Unfortunatley, most places and IM programs put their residents on maximum call and pretty much residents run the IM department. However, once residency is done, you can pick how you want to work. I would again pick the worst case scenario. Lets take GI for example. Would you be willing to wake up at 2AM when I call you from ED because I have a massive UGIB and come over to the hospital without and feel like you are making a difference? Or would you think why did it have to happen at 2AM. Or take endo for example? Would you be okay if I call you at 3AM to get advice regarding how to manage thyroid storm? Or would you say in your head, magneto should know how to manage a thyroid storm? Because that is the practical life. If you feel like you don't want to get a call at 3am then try to go into a specialty that will reduce the probability of getting a calling at 3AM. Do not pick something like cardiology etc. Hope that helps.

Lifestyle is super important. Otherwise you will burn out. So pick something that you will enjoy and be excited about on most days (if not everyday). I don't know if I answer your question but feel free to ask more specific questions.

[magneto]

On 2/19/2020 at 3:51 PM, Fortress said:

Can you please elaborate on the fact that billing depends on the amount of time spent with patient? Is that only for mental health or for any type of visit? Can you give us some actual numbers, cuz if thats the case then why do family doctors rush patients.

Hard to answer this question.

In 100% fee for service, there are different codes for standard visit vs comprehensive visit vs mental health visits. Mental health visits pay a lot more (about 3x) than standard visit (one system problem, for example BP check up and prescription refill.

In rostered patients + part of your fee for service, standard visits pay you only ~ 15% of the full amount because rest of your income comes form yearly stipend for each patient that you take on your roster. However, for mental health visits in most provinces, you get to keep the full 100% of your fee for service.

There are also time-billing codes for palliative care and mental health. So when you spend time, you are properly financially compensated by the government.

For most visits, if you end up taking more time, you can bill extra. For example, there are special codes for general counselling, smoking counselling, addiction counselling, obstetrics counselling etc. They pay more than general visit.

Family doctors rush patients for many reasons. It depends on the family physician. Here are some reasons that I observed:

1. Some doctors take more work that they can handle so they only give a small time to the patient. Otherwise, they will be there all night.

2. Some doctors are experienced and feel like they have done all they can for the patient in short period of time.

3. Financial reasons.

4. Personal reasons.

5. Not caring about the patient.

6. Problems with bed-side manners.

7. Many many more reasons

Some reasons are good. Some reasons are bad.

I don't think patients should be rushed in 95% of the time. But there are definitely some patients who actually benefit from rushed visit vs a prolonged visit.

[magneto]

15 minutes ago, Fortress said:

Hey! Sometimes people say that family doctors can bill using specialist codes e.g for family doctors working in EM or hospital medicine. Is this true?

As far as I know family doctors have their own codes for pretty much everything.

I did my own billing as a resident.

There were family medicine codes for everything from standard visit to procedures to OB to palliative care to hospitalist etc.

The only specialty that have similar codes/pay between family doctors and emergency medicine is 2+1 grads and 5 year FR grads (but only in some provinces not all).

[Oliveoil]

Is it realistically possible to have an exclusive mental health practice as a GP? 

Do you if there is the GP psychotherapy training that allows u to bill for psychotherapy? 

Thank you so much 

[cotecc]

How do you see the impact of nurse practicionners in the future. Will they take a big chunk of work off the GPs?

[medisforme]

Just a word of advice for everyone asking about billing. You should indicate what province you are in/want to practice in so appropriate advice can be given, as billing info is DRASTICALLY different from province to province (ie. 1) there are no time codes for billing in BC,  2) in response to a previous poster who indicated that mental health visits pay more, mental health visits in BC (termed counselling appointments) pay less per 10min then a typical office appointment )

[medigeek]

On 3/6/2020 at 2:55 PM, cotecc said:

How do you see the impact of nurse practicionners in the future. Will they take a big chunk of work off the GPs?

They are the biggest threat (along with PAs) to our profession. 

[magneto]

On 3/5/2020 at 8:51 PM, Oliveoil said:

Is it realistically possible to have an exclusive mental health practice as a GP? 

Do you if there is the GP psychotherapy training that allows u to bill for psychotherapy? 

Thank you so much 

Yes, it is realistically possible to have an exclusive mental health practice as a GP. I believe that mental health is rising and there are not enough psychiatrist/mental health allied care professionals. The more people who are genuinely interested in mental health are needed to help the community. Try to get some extra training. There are some +1 programs out there I believe. If not +1 then do extra electives in psychiatry or try to arrange a 3-6 month informal training with a psychiatrist. If you feel comfortable diagnosing/managing mental health then extra training might not be needed. You need to send out a letter to all the GPs in the area that you are working expressing your interesting in helping diagnose/manage mental health patients etc. Hopefully, you can get referrals that way. And after that do a good job. And word gets around fast in the community and on internet. Just make sure to get psychiatrist/psychologist/social worker/mental health nurse/mental health specialist help when needed. Develop good contacts with other mental health care professionals.

I am not aware about GP psychotherapy pathway. But I know it exists. I am not sure about the billing but my guess is that they have their own codes with ministry. And some also bill privately.