GIM FAQ thread

[ACHQ]

Hello all,

I'm starting this thread for those interested in asking questions about GIM (or even Internal medicine in general... see what I did there )

Who am I? PGY-4 Internal Medicine resident, in the "4-year" GIM program. I will be finishing June 30 2020. Come July, I have a job lined up at a large community hospital in the GTA.

Ask away!

[skyuppercutt]

Hey!

Thank you so much for doing this! I lol'd at the pun 

*After typing this up, I realized it is actually quite long, so I apologize in advance. Feel free to PM me any answers that you think should be private. If instead of typing out an answer you prefer to chat, I could PM you my number and we can talk then I could post a summary of your reply for others to see*

Right now, I'm a PGY2 in internal medicine and I am very much torn between GIM 4 year vs GIM 5 year vs maybe ICU. I feel that I am mostly leaning towards completing the 4-year GIM program and starting an outpatient clinic in the GTA (somewhere between Mississauga to Scarborough, so pretty flexible) with a group of other IM, GPs and peds residents. Ideally, I would also have a hospital appointment somewhere to do some inpatient medicine. 

I'm kind of at a loss of what to do though, especially that by now most of my co-residents have already booked all their electives for PGY2 and 3.

Here are my thoughts and please feel free to correct me if I'm wrong (I've bolded my questions if that helps):

• There really is no big difference between the 4 and 5 year GIM programs other than the fact that the 5 year would allow you to work in an academic centre and maybe allow for more elective time to pursue an AFC like thrombosis. (Would you still be able to persue an AFC with the 4 year program?)
  • Being in an academic centre allows you to have residents that can take call and you have easy access to several subspecialties that you can refer even slightly complicated patients to. This is a great plus, but comes at the cost of the academic centre taking a certain percentage of your billings (I heard this can be anywhere from 20-50%). Is that billing part true? 
  • Does the 5 year program have an exam in addition to the royal college exam that we now write in 3rd year?
  • Billing, finding a community job and starting a clinic is otherwise the same between the 4 year and 5 year program. Is that true?

 

• I enjoy procedures and don't mind call (at least right now), but feel that as I get older I would rather not do overninght call, because it makes me feel that I'm shaving years off of my life. I am interested in ICU partially from the procedures point of view and partly because I've heard they can bill a significant amount
  • From a procedure perspective, right now I'm very comfortable with paras, thoras, central lines and some chest tubes. I'm not sure though if I was in a community hospital doing an overnight shift (or moonlighting), if I would be able to intubate a decompensating patient with an even slightly difficult airway (All my glide scope intubations have been very straightforward) or float a temp wire for someone in heart block. Is this fear out of proportion with reality or is this a skill that I would be able to pick up over the next 2 years of residency? Is this even a skill I would need as an internist working in a community hospital? 
  • Many senior residents that I have spoken to have suggested that if I am consider a 5 year GIM program that I might as well just do ICU, since it opens up further avenues of employment. This doesn't seem like a bad idea, except when I think of why do the extra work as an ICU fellow?
  • I looked up the billings of ICU attendings when the Toronto Star article was released and I was actually underwhelmed with a lot of them compared to what I expected/saw GIM docs make in a busy community hospital. Obviously this doesn't take into account other modes of funding and the fact that many only do a couple of weeks of ICU a year. When I asked similar questions on other forms. I've been quoted things like 300-500/year for GIM docs working in clinics 5 days a week before overhead. Is that inline with what you see/know? 
  • I get the sense that doing an ICU fellowship for the sake of being more comfortable with intubations and dealing with sick patients is overkill, especially if the billings are not as great and the lifestyle isn't as fabulous as that of a 4/5 year GIM doc.

 

• Any ideas or general sense of what the Job market would be like for a 4 year GIM doc at a community hospital in the GTA in 2 years? I know it's hard to predict, but I can't imagine it would go from "You will definitely find a job right now" to "We are 100% saturated as is the case with ortho" in 2 years? How difficult was it to get a job lined up and is that something you only really started to look into during your 4th year?

Thank you so much in advance for offering to do this FAQ. I'm sorry again for asking so many questions. I am kind of at a loss of who to turn to, so seeing this post actually made my day, especially with the timing of it.  

[The Ace of Spades]

3 hours ago, skyuppercutt said:

Being in an academic centre allows you to have residents that can take call and you have easy access to several subspecialties that you can refer even slightly complicated patients to. This is a great plus, but comes at the cost of the academic centre taking a certain percentage of your billings (I heard this can be anywhere from 20-50%). Is that billing part true? 

Not the OP or in GIM, but the billing "tithe" is definitely a thing at academic centres. The academic centre I trained in took 10-20% of all billings (even stuff you did *IN YOUR OWN PRIVATE CLINIC*) to go into the Department of Medicine pot.

[ACHQ]

On 2/20/2020 at 6:47 PM, skyuppercutt said:

Hey!

Thank you so much for doing this! I lol'd at the pun 

*After typing this up, I realized it is actually quite long, so I apologize in advance. Feel free to PM me any answers that you think should be private. If instead of typing out an answer you prefer to chat, I could PM you my number and we can talk then I could post a summary of your reply for others to see*

Right now, I'm a PGY2 in internal medicine and I am very much torn between GIM 4 year vs GIM 5 year vs maybe ICU. I feel that I am mostly leaning towards completing the 4-year GIM program and starting an outpatient clinic in the GTA (somewhere between Mississauga to Scarborough, so pretty flexible) with a group of other IM, GPs and peds residents. Ideally, I would also have a hospital appointment somewhere to do some inpatient medicine. 

I'm kind of at a loss of what to do though, especially that by now most of my co-residents have already booked all their electives for PGY2 and 3.

Here are my thoughts and please feel free to correct me if I'm wrong (I've bolded my questions if that helps):

• There really is no big difference between the 4 and 5 year GIM programs other than the fact that the 5 year would allow you to work in an academic centre and maybe allow for more elective time to pursue an AFC like thrombosis. (Would you still be able to persue an AFC with the 4 year program?)
  • Being in an academic centre allows you to have residents that can take call and you have easy access to several subspecialties that you can refer even slightly complicated patients to. This is a great plus, but comes at the cost of the academic centre taking a certain percentage of your billings (I heard this can be anywhere from 20-50%). Is that billing part true? 
  • Does the 5 year program have an exam in addition to the royal college exam that we now write in 3rd year?
  • Billing, finding a community job and starting a clinic is otherwise the same between the 4 year and 5 year program. Is that true?

 

• I enjoy procedures and don't mind call (at least right now), but feel that as I get older I would rather not do overninght call, because it makes me feel that I'm shaving years off of my life. I am interested in ICU partially from the procedures point of view and partly because I've heard they can bill a significant amount
  • From a procedure perspective, right now I'm very comfortable with paras, thoras, central lines and some chest tubes. I'm not sure though if I was in a community hospital doing an overnight shift (or moonlighting), if I would be able to intubate a decompensating patient with an even slightly difficult airway (All my glide scope intubations have been very straightforward) or float a temp wire for someone in heart block. Is this fear out of proportion with reality or is this a skill that I would be able to pick up over the next 2 years of residency? Is this even a skill I would need as an internist working in a community hospital? 
  • Many senior residents that I have spoken to have suggested that if I am consider a 5 year GIM program that I might as well just do ICU, since it opens up further avenues of employment. This doesn't seem like a bad idea, except when I think of why do the extra work as an ICU fellow?
  • I looked up the billings of ICU attendings when the Toronto Star article was released and I was actually underwhelmed with a lot of them compared to what I expected/saw GIM docs make in a busy community hospital. Obviously this doesn't take into account other modes of funding and the fact that many only do a couple of weeks of ICU a year. When I asked similar questions on other forms. I've been quoted things like 300-500/year for GIM docs working in clinics 5 days a week before overhead. Is that inline with what you see/know? 
  • I get the sense that doing an ICU fellowship for the sake of being more comfortable with intubations and dealing with sick patients is overkill, especially if the billings are not as great and the lifestyle isn't as fabulous as that of a 4/5 year GIM doc.

 

• Any ideas or general sense of what the Job market would be like for a 4 year GIM doc at a community hospital in the GTA in 2 years? I know it's hard to predict, but I can't imagine it would go from "You will definitely find a job right now" to "We are 100% saturated as is the case with ortho" in 2 years? How difficult was it to get a job lined up and is that something you only really started to look into during your 4th year?

Thank you so much in advance for offering to do this FAQ. I'm sorry again for asking so many questions. I am kind of at a loss of who to turn to, so seeing this post actually made my day, especially with the timing of it.  

Hey no worries I will try to answer your questions as best as possible:

1. There really is no big difference between the 4 and 5 year GIM programs other than the fact that the 5 year would allow you to work in an academic centre and maybe allow for more elective time to pursue an AFC like thrombosis. (Would you still be able to persue an AFC with the 4 year program?)

- The 4 year program can allow a lot of elective time (depending on where you are doing your IM residency) that being said, you usually can't do a formal fellowship within that year (at least at UofT). TBH most people who go into the 4 year program don't want to do any fellowships because its not their cup of tea (doesn't add much unless you really want to practice in that niche area). That being said you can definitely do another year in something (thrombosis, OB med etc...) as long as you "get into" (i.e. secure funding) for that fellowship. 

 

2. Being in an academic centre allows you to have residents that can take call and you have easy access to several subspecialties that you can refer even slightly complicated patients to. This is a great plus, but comes at the cost of the academic centre taking a certain percentage of your billings (I heard this can be anywhere from 20-50%). Is that billing part true? 

- This is true for staff who are under the designation "clinical associates". I can't speak to all Universities, but in order to make it "fair" for everyone in the department of medicine (fair meaning more equivalent pay) everyone bills for each patient they see and those billings go into a huge pot. Other sources of income go into the pot as well like research/educational awards $, etc.... A certain percentage (apparently small, like 5% or something but I have no idea exactly how much) of it gets taken by the department to cover some "overhead costs", and the rest then gets redistributed to everyone in the department/division. This allows the people who have a more research focused (or less clinical oriented) career to make more than they would if they just did pure fee for service. That huge percentage you quote above, is for clinical associates (usually betwen 20-30%), who basically get to work as a "staff" and contribute that percentage to the group, without getting any direct benefits of the practice plan (there are some benefits, the details I'm vague on), the "benefit" to the person doing clinical associate year(s ) is that they get a chance to land a permanent job (but no guarantee of one). Generally clinical associates get the worse scheduling and most weeks on service.

 

3. Does the 5 year program have an exam in addition to the royal college exam that we now write in 3rd year?

- Yes, its written after the completion of the 5th year, usually in the fall of the year you completed.

 

4. Billing, finding a community job and starting a clinic is otherwise the same between the 4 year and 5 year program. Is that true?

- 100% true, no one can claim otherwise, and if they are they don't know what they are talking about and/or are lieing. There is no difference in billing codes (yet), and even if they were to make new ones (never think that would happen as there are too few 5 year GIM overall) the billing codes for core internal medicine would have to still exist.

 

5. From a procedure perspective, right now I'm very comfortable with paras, thoras, central lines and some chest tubes. I'm not sure though if I was in a community hospital doing an overnight shift (or moonlighting), if I would be able to intubate a decompensating patient with an even slightly difficult airway (All my glide scope intubations have been very straightforward) or float a temp wire for someone in heart block. Is this fear out of proportion with reality or is this a skill that I would be able to pick up over the next 2 years of residency? Is this even a skill I would need as an internist working in a community hospital? 

- You sound like you have done alot of intubations in just 2 years of residency which is impressive. I don't think any Internal medicine person (other than those that have done ICU fellowships) are ever comfortable with intubating patients. I think it is something healthy to know your limits and respect the airway as much as possible. You could pick up the skill in the next two years but tbh the reason anesthesiologists feel so comfortable with it is because they do it literally ALL THE TIME. There's too much variety in GIM to say you would be doing it very frequently. But let me say this, even in sites where there are no in house ICU physicians (alot of sites are now adopting a model for inhouse ICU as there hospitals and ICU's are too large to be covered completely by one internist all night, for ex the one I will work at does have in house ICU 24/7) there is always in house anesthesia and ER docs and even RT who intubate patients, and if you feel you need help they should be able to help you. The main thing in airway management is being triple prepared, having a plan A, B C and D, having the right tools (direct larygnoscope, glidscope, bougie, LMA, and Bag mask) and making sure you can at least bag mask someone.

TBH other than intubations most other procedures can wait, pressors/inotropes can be given peripherally for a time limited span or if you can learn how to do a quick blind femoral you will save tons of time, you don't really need an art line and/or RT can do it for you. Chest tubes only need to go immediately for large or tension pneumothorax, and if thats the case I would get the in house Gen Sx to do it. So I wouldn't sweat it too much

 

6. Many senior residents that I have spoken to have suggested that if I am consider a 5 year GIM program that I might as well just do ICU, since it opens up further avenues of employment. This doesn't seem like a bad idea, except when I think of why do the extra work as an ICU fellow?

- That line of reasoning only works if you are willing to put yourself through 2 years of ICU training (which can be brutal). BUT there are basically no jobs in ICU, so unless you are completely ok with doing that and ending up working in GIM anyways then sure that would make sense.

 

7. I looked up the billings of ICU attendings when the Toronto Star article was released and I was actually underwhelmed with a lot of them compared to what I expected/saw GIM docs make in a busy community hospital. Obviously this doesn't take into account other modes of funding and the fact that many only do a couple of weeks of ICU a year. When I asked similar questions on other forms. I've been quoted things like 300-500/year for GIM docs working in clinics 5 days a week before overhead. Is that inline with what you see/know?

- You probably checked ICU attending at academic sites. Even in high paying specialties academic physicians don't make nearly as much as their community counterparts, because they have other non-clinical commitments (which pays either $0 or something close to that). If you do GIM work in the community and only do clinics, you would have a huge overhead which would eat into your take home pay, and you make less doing non-hospital affiliated clinics because you can't use the premium codes. The reason GIM community docs make a decent income is because they do hospital based work where they bill premiums (because they are doing evenings/nights/weekends) and have no overhead. The number you quoted is possible if you see about 13-16 patients a day (80-90% of them new consults) and work 46-52 weeks a year. The other good thing about being in the hospital setting in GIM is alot of the time you dont have to work 46 or more weeks.

 

8. Any ideas or general sense of what the Job market would be like for a 4 year GIM doc at a community hospital in the GTA in 2 years? I know it's hard to predict, but I can't imagine it would go from "You will definitely find a job right now" to "We are 100% saturated as is the case with ortho" in 2 years? How difficult was it to get a job lined up and is that something you only really started to look into during your 4th year?

- Things are starting to tighten up a bit, which I noticed with my job search. Not bad but definitely not like a few years ago where you could walk into any hospital and they would basically offer you a job on the spot. Now you have to find the hospitals that are specifically hiring. I agree that in 2 years it shouldn't be as bad as ortho (ahha), but it won't be as good as it is now. That being said GIM will always be better than any other subspecialty job prospects. Also GIM always ALWAYS has locum work (which is usually evenings, nights and weekends/holidays, which unfortunately are the worst times ahaha)

I got lucky in my job search as I set up an elective at a site that knew they were going to hire someone, and we both ended up liking the fit which lead to an interview and eventual offer. You only can start looking in your final year of residency and even then at most 6-8 months prior to your ideal start date, because most departments won't know their personnel needs more advanced then that.

 

Hope this helps

[Fortress]

On 2/19/2020 at 9:30 PM, ACHQ said:

Hello all,

I'm starting this thread for those interested in asking questions about GIM (or even Internal medicine in general... see what I did there )

Who am I? PGY-4 Internal Medicine resident, in the "4-year" GIM program. I will be finishing June 30 2020. Come July, I have a job lined up at a large community hospital in the GTA.

Ask away!

Thanks a lot for doing this.

I am a medical student with an interest in GIM.

1. Could you please elaborate on what the typical schedule looks like for GIM in a community hospital vs. academic hospital? What time do you have to be at the hospital and what time you usually leave? Also what the call schedule is like, and is it an in-house call vs. home call? It would be great if you can as detailed as possible as I want to picture how life looks like as a GIM staff.

2. Income of GIM in community hospital vs. academic hospital vs. outpatient clinic? Just if you could mention what the typical average income is for those 3 as well as respective overhead.

3. How hard is it to get a job at an academic site? Like is the 5-year GIM enough or do you have to be research-oriented and committed to publishing?

[ACHQ]

9 hours ago, Fortress said:

Thanks a lot for doing this.

I am a medical student with an interest in GIM.

1. Could you please elaborate on what the typical schedule looks like for GIM in a community hospital vs. academic hospital? What time do you have to be at the hospital and what time you usually leave? Also what the call schedule is like, and is it an in-house call vs. home call? It would be great if you can as detailed as possible as I want to picture how life looks like as a GIM staff.

2. Income of GIM in community hospital vs. academic hospital vs. outpatient clinic? Just if you could mention what the typical average income is for those 3 as well as respective overhead.

3. How hard is it to get a job at an academic site? Like is the 5-year GIM enough or do you have to be research-oriented and committed to publishing?

1. Could you please elaborate on what the typical schedule looks like for GIM in a community hospital vs. academic hospital? What time do you have to be at the hospital and what time you usually leave? Also what the call schedule is like, and is it an in-house call vs. home call? It would be great if you can as detailed as possible as I want to picture how life looks like as a GIM staff.

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). Note: when I mean community sites I am specifically referring to large non-academic hospitals in the GTA such as Trillium,  Mackenzie Health, North York General, Willam Osler etc.. I can't comment on smaller hospitals outside of the GTA (but I would assume somewhat similar). 

Given that each hospital is slightly different from the way they structure their schedule's it would be impossible for me to give one answer and say that is how it is for ALL of GIM. I can give you what MY layout is like (which is similar to other hospitals, but not exactly the same). At my site they require me to do 9 weeks/yr of MRP/hospitalist (#4), 4 weeks/yr of urgent outpatient GIM clinic (#3), 3 weeks/yr of med consults (#2), and 5 shifts/month of ER consults (#1). These are the minimums, I can fill in my schedule as much or as little as I like as long as I meet these min requirements. A "typical" month will look like: 1 week MRP, 1 week Clinic and 1.5 weeks of ER (depending on how you stack your shifts, and how many extra shifts you take if any). Some months you'll have more space.

Day to day (again this is for community sites, and I am referencing my site more specifically): MRP/ward work typically 8-4/5, depending on how large your census is and how efficient you are, typically the first day is the longest and it gets better afterwards, technically you are responsible for the patients until 6pm (i.e. nurses can page you up until that point), but most issues can be handled over the phone. ER consults days are shifts so set hours,  again different sites have different shifts, the one I'm at has 3 8 hour shifts (0800- 1600, 1600-2400, 0000-0800). Clinic is usually 8-4ish. med consults is usually more chill as well.

When you refer to the "call" schedule, I will assume you mean ER. In the community it is a bit different in that you are technically on "call" for your MRP patients when your on the ward (again until 6 pm at my site), on "call" for med consults (again only until like 5 pm or whenever you leave the hospital), and the ER (which is the shifts I described above). The ER shifts you have to be in house (obviously), and as I mentioned you do 5 shifts a month. I've been told I have to do at least 1 night/month, and 2-3 evenings a month. Again hospitals are slightly different, but this gives you some idea.

Academics is a whole different kettle of fish. I cannot comment with 100% accuracy, but in my experience they have to cover similar services as the above, except they do ALOT more MRP/CTU work, as opposed to it being evenly spread out. Depending on your designation (scientist, quality improvement, educator, teacher) you will do a certain amount of clinical work and the rest of your time is supposed to be devoted to academic endeavors (research, teaching, admin, quality etc...). Typically GIM academic physicians have decent hours (7-5/6) with some weekends, but they are NEVER in house call. They are usually on call with their SMR but they are at home, SMR's try not to call them to wake up (but it does happen, not frequently).

 

2. Income of GIM in community hospital vs. academic hospital vs. outpatient clinic? Just if you could mention what the typical average income is for those 3 as well as respective overhead.

I haven't started practicing yet, but this is from what I've heard and seen first hand from community physicians (and of course the Toronto star data base hahaha). Typically in the community GIM physicians can make 300-500k. That range is huge for a few reason. How much are you willing to work? if you are willing to work 48-50 weeks and take basically very little time off, than you can make close to if not higher than 500k. Also how much "on call" (i.e. evenings, nights and weekends) are you willing to work? Those shifts are much more lucrative and therefore the more you do of those the more you can make. If you only do community hospital work you pay NO overhead.

academic hospitals can be a bit of a black box, but they definitely do not make as much as community physicians. The numbers I hear for academics is between 250-350k. They have a complicated way to pay academic docs (see my first post #2), but for all intensive purposes you will make much much more in the community.

If you do your own outpatient clinic (or join an outpatient practice) and JUST do that then here's a bench mark: work 48 weeks, 5 days a week, see 16 patients a day, 12 new consults, 4 follow ups, you can make roughly 500k before overhead. Overhead at most clinics is 30%, so around 350k after overhead. Note you will have to first build your practice (at first you wont be seeing 16 patients a day).

 

3. How hard is it to get a job at an academic site? Like is the 5-year GIM enough or do you have to be research-oriented and committed to publishing?

I can only comment on the GTA. But getting an academic job is not easy (in any specialty, even GIM). Not only will you have to do the 5 year GIM program, but you will have to show some proficiency in research/education/quality improvement, which not only means great evals or publications, but usually a masters/PhD ontop of that. NOT only do you have do what I mentioned, but they rarely/never hire someone as an active/full time staff with a university appointment right out of residency now. They make the person do something called a clinical associate year(s ), see #2 above. This is supposed to be time limited, but I have seen many people get d$#%ed around for 3-5 years without any full time staff position at the end of it.

To decide if you want to do academics vs community its easy:

Academics= focus on research, teaching, quality improvement, administration etc... Residents/fellows do most of the clinical work under your "supervision"

Community= focus on clinical work, seeing patients, making money. Can still be involved in the above, but to a lesser extent.

[Fortress]

8 hours ago, ACHQ said:

1. Could you please elaborate on what the typical schedule looks like for GIM in a community hospital vs. academic hospital? What time do you have to be at the hospital and what time you usually leave? Also what the call schedule is like, and is it an in-house call vs. home call? It would be great if you can as detailed as possible as I want to picture how life looks like as a GIM staff.

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). Note: when I mean community sites I am specifically referring to large non-academic hospitals in the GTA such as Trillium,  Mackenzie Health, North York General, Willam Osler etc.. I can't comment on smaller hospitals outside of the GTA (but I would assume somewhat similar). 

Given that each hospital is slightly different from the way they structure their schedule's it would be impossible for me to give one answer and say that is how it is for ALL of GIM. I can give you what MY layout is like (which is similar to other hospitals, but not exactly the same). At my site they require me to do 9 weeks/yr of MRP/hospitalist (#4), 4 weeks/yr of urgent outpatient GIM clinic (#3), 3 weeks/yr of med consults (#2), and 5 shifts/month of ER consults (#1). These are the minimums, I can fill in my schedule as much or as little as I like as long as I meet these min requirements. A "typical" month will look like: 1 week MRP, 1 week Clinic and 1.5 weeks of ER (depending on how you stack your shifts, and how many extra shifts you take if any). Some months you'll have more space.

Day to day (again this is for community sites, and I am referencing my site more specifically): MRP/ward work typically 8-4/5, depending on how large your census is and how efficient you are, typically the first day is the longest and it gets better afterwards, technically you are responsible for the patients until 6pm (i.e. nurses can page you up until that point), but most issues can be handled over the phone. ER consults days are shifts so set hours,  again different sites have different shifts, the one I'm at has 3 8 hour shifts (0800- 1600, 1600-2400, 0000-0800). Clinic is usually 8-4ish. med consults is usually more chill as well.

When you refer to the "call" schedule, I will assume you mean ER. In the community it is a bit different in that you are technically on "call" for your MRP patients when your on the ward (again until 6 pm at my site), on "call" for med consults (again only until like 5 pm or whenever you leave the hospital), and the ER (which is the shifts I described above). The ER shifts you have to be in house (obviously), and as I mentioned you do 5 shifts a month. I've been told I have to do at least 1 night/month, and 2-3 evenings a month. Again hospitals are slightly different, but this gives you some idea.

Academics is a whole different kettle of fish. I cannot comment with 100% accuracy, but in my experience they have to cover similar services as the above, except they do ALOT more MRP/CTU work, as opposed to it being evenly spread out. Depending on your designation (scientist, quality improvement, educator, teacher) you will do a certain amount of clinical work and the rest of your time is supposed to be devoted to academic endeavors (research, teaching, admin, quality etc...). Typically GIM academic physicians have decent hours (7-5/6) with some weekends, but they are NEVER in house call. They are usually on call with their SMR but they are at home, SMR's try not to call them to wake up (but it does happen, not frequently).

 

2. Income of GIM in community hospital vs. academic hospital vs. outpatient clinic? Just if you could mention what the typical average income is for those 3 as well as respective overhead.

I haven't started practicing yet, but this is from what I've heard and seen first hand from community physicians (and of course the Toronto star data base hahaha). Typically in the community GIM physicians can make 300-500k. That range is huge for a few reason. How much are you willing to work? if you are willing to work 48-50 weeks and take basically very little time off, than you can make close to if not higher than 500k. Also how much "on call" (i.e. evenings, nights and weekends) are you willing to work? Those shifts are much more lucrative and therefore the more you do of those the more you can make. If you only do community hospital work you pay NO overhead.

academic hospitals can be a bit of a black box, but they definitely do not make as much as community physicians. The numbers I hear for academics is between 250-350k. They have a complicated way to pay academic docs (see my first post #2), but for all intensive purposes you will make much much more in the community.

If you do your own outpatient clinic (or join an outpatient practice) and JUST do that then here's a bench mark: work 48 weeks, 5 days a week, see 16 patients a day, 12 new consults, 4 follow ups, you can make roughly 500k before overhead. Overhead at most clinics is 30%, so around 350k after overhead. Note you will have to first build your practice (at first you wont be seeing 16 patients a day).

 

3. How hard is it to get a job at an academic site? Like is the 5-year GIM enough or do you have to be research-oriented and committed to publishing?

I can only comment on the GTA. But getting an academic job is not easy (in any specialty, even GIM). Not only will you have to do the 5 year GIM program, but you will have to show some proficiency in research/education/quality improvement, which not only means great evals or publications, but usually a masters/PhD ontop of that. NOT only do you have do what I mentioned, but they rarely/never hire someone as an active/full time staff with a university appointment right out of residency now. They make the person do something called a clinical associate year(s ), see #2 above. This is supposed to be time limited, but I have seen many people get d$#%ed around for 3-5 years without any full time staff position at the end of it.

To decide if you want to do academics vs community its easy:

Academics= focus on research, teaching, quality improvement, administration etc... Residents/fellows do most of the clinical work under your "supervision"

Community= focus on clinical work, seeing patients, making money. Can still be involved in the above, but to a lesser extent.

First, thank you so much for your detailed reply. I would like to clarify what I meant by call schedule. You said you are only responsible for patients until 6 pm when doing MRP work. My question is who is responsible for the patient after 6 pm? What happens if a patient deteriorates overnight and needs to be assessed? I was under the assumption that as a GIM staff you have to be physically present in the hospital until 5-6 pm and then go home and on some nights you are on call i.e if the patient deteriorates the hospital would call you and you would have to come to the hospital to assess the patient. And so I assumed there would be like a call schedule where all GIM staff share the burden of being on-call overnight for admitted patients. Same question with regards to med consults. What happens if a patient on the surgical ward develops an IM problem (e.g chest pain, dyspnea) at 11 pm. Who is responsible for that patient? Are there evening, night and weekend MRP and Med consults shifts to take care of patients who need help outside of regular hours? Please correct any misconceptions that I may have.

Another question is: why is an academic job so competitive, even though it isn't as financially rewarding as community medicine? Are there any perks associated with being academic other than the fact that you have residents and fellows doing the work for you? Is it because of presumed "prestige"? Is it simply the ratio between number of people interested in research/teaching and available spots?

 

[ACHQ]

2 hours ago, Fortress said:

First, thank you so much for your detailed reply. I would like to clarify what I meant by call schedule. You said you are only responsible for patients until 6 pm when doing MRP work. My question is who is responsible for the patient after 6 pm? What happens if a patient deteriorates overnight and needs to be assessed? I was under the assumption that as a GIM staff you have to be physically present in the hospital until 5-6 pm and then go home and on some nights you are on call i.e if the patient deteriorates the hospital would call you and you would have to come to the hospital to assess the patient. And so I assumed there would be like a call schedule where all GIM staff share the burden of being on-call overnight for admitted patients. Same question with regards to med consults. What happens if a patient on the surgical ward develops an IM problem (e.g chest pain, dyspnea) at 11 pm. Who is responsible for that patient? Are there evening, night and weekend MRP and Med consults shifts to take care of patients who need help outside of regular hours? Please correct any misconceptions that I may have.

Another question is: why is an academic job so competitive, even though it isn't as financially rewarding as community medicine? Are there any perks associated with being academic other than the fact that you have residents and fellows doing the work for you? Is it because of presumed "prestige"? Is it simply the ratio between number of people interested in research/teaching and available spots?

 

1. Re: who assesses/manages deteriorating patients past 5/6pm. 

- each hospital has a different set-up with regards to this. At my hosptial they actually have someone in house that handles ward pages/assessments from 6pm- 11pm. (At my hosptial there is a large cohort of Family medicine hospitalists, and they rotate through this not the GIM people). Beyond 11pm pages go to the medicine/GIM on call (the guy in the ER). My hospital also has in house CCRT (ICU) which responds to any in hospital emergency that is NOT a code blue (the medicine on call has to run code blues) called by any health care provider (could be a doctor or nurse), therefore if the patient is remotely sick (tachycardia, hypotension, decreases loc, hypoxemia, resp distress etc...) usually CCRT gets involved. I guess what happens if a the medicine on call gets called about a deteriorating patient? I guess if they are not busy in the ER they can see and assess the patient, and see if they truly need icu/CCRT involvement, or just get the nurse to call ccrt directly. 

Most/majority of other sites I have been to in the community have pages past a certain time (usually 6pm) go to the medicine on call (again guy in the ER). The on call guy will have to determine how to triage both floor calls and the Er consults. Again some places have another doc that covers CCRT. 

With regards to medicine consults, I’m not 100% sure but I assume that most calls can be fielded by the actual MRP at home, and assessed the next day. IF they need to involve medicine they would have to call in for a medicine consult to the on call medicine (again guy in the ER). If patients is SICK than they should just call CCRT. Again calling medicine on call for a surgical patient is fairly rare, as either they are stable enough to be assessed in the AM or they are sick enough to be seen by CCRT. 

One thing we should keep in mind is that patients aren’t crashing left, right and center (otherwise I’d be worried about the care being provided Hahahaha) but yeah it can happen.

 

2. Great question and I don’t truly know the answer. I guess people care about the “prestige” which imo is BS. There is also just a feeling of comfort since the academic system is all most of us have known throughout medical school and residency, so people want to stay with something they know. 

[Fortress]

Thanks again for your reply. It is good to know that there is adequate work-life balance as a GIM.

One thing that I would like your insight on is FM hospitalist vs. GIM. From your post, it seems like FM do MRP and also do a bit of consults. Do they do ER consults and clinics as well? Would you happen to know if family docs who work as hospitalists are able to bill using specialist codes? What does their schedule look like (they seem to get the 6 pm-11 pm pages, which are less life-style friendly but more lucrative)? I am basically looking for anything that would justify doing 2 extra years of training as a GIM instead of going through the FM shortcut.

Another topic that I would like your insight on is people doing a fellowship (e.g nephro) and still doing GIM work. Why do people do that?

[ACHQ]

12 hours ago, Fortress said:

Thanks again for your reply. It is good to know that there is adequate work-life balance as a GIM.

One thing that I would like your insight on is FM hospitalist vs. GIM. From your post, it seems like FM do MRP and also do a bit of consults. Do they do ER consults and clinics as well? Would you happen to know if family docs who work as hospitalists are able to bill using specialist codes? What does their schedule look like (they seem to get the 6 pm-11 pm pages, which are less life-style friendly but more lucrative)? I am basically looking for anything that would justify doing 2 extra years of training as a GIM instead of going through the FM shortcut.

Another topic that I would like your insight on is people doing a fellowship (e.g nephro) and still doing GIM work. Why do people do that?

1. I'll refer you to my detailed reply on this thread :

Family medicine hospitalists can ONLY DO MRP work. They cannot do any consultative work because they are not consultants. (there are situations where at smaller hospitals they can do admissions from the ER BUT those aren't billed the same as an internal medicine/specialist consult, and all the large hospitals have GIM's doing this work not GP's). For all intensive purposes in the GTA they can only do MRP work. Family medicine has their own codes to bill for MRP work (which actually amounts to the same as the GIM codes), they cannot bill for consults or use any of the internal medicine specialist codes. I'm not clear on how often they do the 6-11pm shifts and what their schedule is like in general, all I know is that they exist (ahhaha).

With re: 'I am basically looking for anything that would justify doing 2 extra years of training as a GIM instead of going through the FM shortcut.'

If all you want to do is MRP work, and are happy with that (and family medicine clinics), then the FM hospitalist route would make sense for you. Note alot of places are moving away from family medicine hospitalists in general for a couple reasons: there are alot of GIM's/subspecialists being pumped out looking for work, and not all family docs want to do MRP work ever. That being said some large hospitals still have them so not sure if they will go away completely anytime soon.

If you want to do more than just MRP like ER consults/acute medicine, Med consults to non-medical patients, and outpatient consultative work than GIM is definitely the way to go (see my response in the thread posted above).

 

2. Another topic that I would like your insight on is people doing a fellowship (e.g nephro) and still doing GIM work. Why do people do that?

- that’s an easy one: there are NO jobs (or very few/limited work) in many subspecialities, so in order to pay bills people need to work, luckily within internal medicine they can at least do some GIM work. Some unfortunately have to leave their subspecialty training as the job situation is so bad and just do GIM permanently. 

[Fortress]

23 minutes ago, ACHQ said:

Family medicine has their own codes to bill for MRP work (which actually amounts to the same as the GIM codes)

This is the pivotal point for me right here. If a family doc can do the same work as GIM and receive the same pay, then why would anyone go through an IM residency and spend 2 extra years in training? I know you said FM only do MRP and can't do other stuff, but I am comparing here the pay of FM MRP vs. GIM MRP.

Are you sure the FM codes amount to the same as the GIM codes? When I look up the ontario fee schedule, it seems that FM consultation is $77.20 while a GIM consultation is $157.

For me I know I like IM more than FM, but if I am going to go through a more demanding residency and spends more years in training, it has to make financial sense.

[ACHQ]

4 minutes ago, Fortress said:

This is the pivotal point for me right here. If a family doc can do the same work as GIM and receive the same pay, then why would anyone go through an IM residency and spend 2 extra years in training? I know you said FM only do MRP and can't do other stuff, but I am comparing here the pay of FM MRP vs. GIM MRP.

Are you sure the FM codes amount to the same as the GIM codes? When I look up the ontario fee schedule, it seems that FM consultation is $77.20 while a GIM consultation is $157.

For me I know I like IM more than FM, but if I am going to go through a more demanding residency and spends more years in training, it has to make financial sense.

Yes the day to day MRP codes are the same remuneration. The consults and assessments that GIM can bill (depending on the situation) are more. The SOB is very nuanced and even seasoned physicians don't get it. 

Let me to try and clarify: a GIM doing MRP work would still probably make more than a family medicine doing MRP work, but not by that much (and its hard to quantify what is worth the 2 extra years of training, is it 50k? 100k?). Also MRP work does not pay that well overall (unless it is associated with a large stipend, which at most hospitals it is not). The real money is in consults and you do most of that in the ER and clinics (and it adds up with the special visit premiums). As someone in GIM I did NOT go into it for the MRP work. I went into it for the mix.

Let me be clear, a GIM doing the balanced work (as I described above: Consultations to the Emergency department, Consultations to non-medical services (Surgery, Psych), Urgent/rapid referral/post discharge/perio-op/OB medicine clinics and MRP of a medical ward/Hospitalist medicine) will make more than a family physician hospitalist doing only MRP work.

"For me I know I like IM more than FM, but if I am going to go through a more demanding residency and spends more years in training, it has to make financial sense."- It will make financial sense if you are smart about doing a mix of things and not just doing MRP work.

Like I said above, if all you want to do is MRP work than doing a family medicine residency with a +1 in hospitalist medicine would make more sense because you will make comparable (but still probably less) than someone who is GIM and does only MRP work (working the same amount of weeks).

[Fortress]

2 hours ago, ACHQ said:

Yes the day to day MRP codes are the same remuneration. The consults and assessments that GIM can bill (depending on the situation) are more. The SOB is very nuanced and even seasoned physicians don't get it. 

Let me to try and clarify: a GIM doing MRP work would still probably make more than a family medicine doing MRP work, but not by that much (and its hard to quantify what is worth the 2 extra years of training, is it 50k? 100k?). Also MRP work does not pay that well overall (unless it is associated with a large stipend, which at most hospitals it is not). The real money is in consults and you do most of that in the ER and clinics (and it adds up with the special visit premiums). As someone in GIM I did NOT go into it for the MRP work. I went into it for the mix.

Let me be clear, a GIM doing the balanced work (as I described above: Consultations to the Emergency department, Consultations to non-medical services (Surgery, Psych), Urgent/rapid referral/post discharge/perio-op/OB medicine clinics and MRP of a medical ward/Hospitalist medicine) will make more than a family physician hospitalist doing only MRP work.

"For me I know I like IM more than FM, but if I am going to go through a more demanding residency and spends more years in training, it has to make financial sense."- It will make financial sense if you are smart about doing a mix of things and not just doing MRP work.

Like I said above, if all you want to do is MRP work than doing a family medicine residency with a +1 in hospitalist medicine would make more sense because you will make comparable (but still probably less) than someone who is GIM and does only MRP work (working the same amount of weeks).

Gotcha. Makes more sense now.

I would like to know more about how to maximize income in GIM. I guess one thing is to take less time off work for vacation. Another thing I presume is to pick up ER shifts outside regular hours (evenings, nights, weekends). Can you please confirm that ER shifts in those hours pay better than morning weekday ER shifts and if so, what is the mechanism (like are there special premiums for that?). Another thing is to perhaps maximize non-MRP work because as you said MRP work doesn't pay as much. Question here: is it possible to just do the bare minimum of MRP weeks required and fill up your practice with the other stuff e.g clinics? Does the hospital "allow" it?

Apart from all of the above, is there anything else that one can do to maximize income in GIM? What are the people billing more than 500K doing, other than simply working harder? I have heard that opening a cardio-diagnostics clinic can be lucrative. Is that true? What other lucrative opportunities are out there?

[ACHQ]

1 hour ago, Fortress said:

Gotcha. Makes more sense now.

I would like to know more about how to maximize income in GIM. I guess one thing is to take less time off work for vacation. Another thing I presume is to pick up ER shifts outside regular hours (evenings, nights, weekends). Can you please confirm that ER shifts in those hours pay better than morning weekday ER shifts and if so, what is the mechanism (like are there special premiums for that?). Another thing is to perhaps maximize non-MRP work because as you said MRP work doesn't pay as much. Question here: is it possible to just do the bare minimum of MRP weeks required and fill up your practice with the other stuff e.g clinics? Does the hospital "allow" it?

Apart from all of the above, is there anything else that one can do to maximize income in GIM? What are the people billing more than 500K doing, other than simply working harder? I have heard that opening a cardio-diagnostics clinic can be lucrative. Is that true? What other lucrative opportunities are out there?

Check out the link I posted in my previous reply, in that thread I outline the $ for various times of day. In general PER consult this is the ranking (highest pay to lowest): Any night (midnight - 7am) > weekend day/evening > weekday evening (5pm - 11:59pm) > weekday day (7 am - 4:59pm).

Various hospitals have various minimums of how many weeks of MRP, ER consults, clinics that they need you to do. So yes hospitals will "allow" it but some hospitals require only 12 weeks, others require 20 weeks so it depends on the hospitals.

Honestly to make significant amount in GIM is what you outlined, work evenings/nights/weekends and over all lots of weeks. I really doubt you'll be able to do cardio-diagnostics in the GTA given the amount of cardios doing it. Pain is lucrative but the government will almost certainly clamp down on it, plus the GIM person would need additional training to do it.

[Fortress]

1 hour ago, ACHQ said:

Check out the link I posted in my previous reply, in that thread I outline the $ for various times of day. In general PER consult this is the ranking (highest pay to lowest): Any night (midnight - 7am) > weekend day/evening > weekday evening (5pm - 11:59pm) > weekday day (7 am - 4:59pm).

Various hospitals have various minimums of how many weeks of MRP, ER consults, clinics that they need you to do. So yes hospitals will "allow" it but some hospitals require only 12 weeks, others require 20 weeks so it depends on the hospitals.

Honestly to make significant amount in GIM is what you outlined, work evenings/nights/weekends and over all lots of weeks. I really doubt you'll be able to do cardio-diagnostics in the GTA given the amount of cardios doing it. Pain is lucrative but the government will almost certainly clamp down on it, plus the GIM person would need additional training to do it.

Thanks for all the info. What are some of the more high-paying jobs in internal medicine in general? I have heard that interventional cardiologists are some of the highest paid physicians within internal medicine, but of course there is additional years of training and tight job market. Do you know of anything else?

[ACHQ]

4 minutes ago, Fortress said:

Thanks for all the info. What are some of the more high-paying jobs in internal medicine in general? I have heard that interventional cardiologists are some of the highest paid physicians within internal medicine, but of course there is additional years of training and tight job market. Do you know of anything else?

The highest paying jobs in internal medicine are (no particular order): Cardio, GI, Nephro, ICU.

those are also the ones with the worst job prospects

[MedZZZ]

Thanks for your post! Can you also comment about more lifestyle sub specialties of IM like endocrinology and rheumatology? Are these fellowships paid since i have heard some IM fellowships are not paid! Also, can you comment about the job prospect of these sub specialties? Thanks

[ACHQ]

7 hours ago, MedZZZ said:

Thanks for your post! Can you also comment about more lifestyle sub specialties of IM like endocrinology and rheumatology? Are these fellowships paid since i have heard some IM fellowships are not paid! Also, can you comment about the job prospect of these sub specialties? Thanks

I will try to comment as generally (and accurately to my knowledge) as possible, given that I'm not in this field there are obvious specifics I won't know.

Endo and Rheum are primarily outpatient based practices. Due of this their job prospects will generally be "good", because they can just open up/join a clinic and get referrals. Can't comment on how it is in the hospital setting, but with that being said even if you were to have a hospital based practice (all that would really entail would be that you take subspecialty call +/- GIM call and some subspecialty urgent clinics if the hospital has those) I'd be surprised if it was more than 1 week/month, so they still have to have their own outpatient practice (and the vast majority will continue to see patients in clinic, while they are on their subspecialty call at the hospital).

FYI technically speaking these are not actual fellowships, they are royal college subspecialty residency programs. These are always funded, and offered only through CaRMS.

[brady23]

Thanks for doing this. I just finished my internal medicine rotation and surprisingly had a really good time on it. I was wondering if you had any recommendations for Internal Medicine electives and what was your elective split? 

[ACHQ]

4 hours ago, brady23 said:

Thanks for doing this. I just finished my internal medicine rotation and surprisingly had a really good time on it. I was wondering if you had any recommendations for Internal Medicine electives and what was your elective split? 

Surprisingly?? ahahahha no matter how bad residency or work life might seem is the only thing that gets me keeps me in it, is the actual medicine.

 

There's no formula tbh. I did 12 weeks of electives, 10 weeks were in IM with 6 weeks of CTU at two different sites, 2 weeks of Nephro and 2 weeks of ID. I think its good to do a mix of CTU and subspecialty medicine. You also don't want to just do sub-specialty only because you want to be able to feel out the programs core IM and the best way to do that is via CTU. You definitely don't want to just do CTU either, cause a) you'll burn yourself out b) you would necessarily advance your learning/knowledge base and c) who wants to really do that much CTU ahha

I would recommend doing electives at sites you want to go to as a resident. I hear all centres are great places to train, and tbh I don't want to turn this thread into what the "best" IM programs are (secrete: despite what people think/say there is none, surprise!). Good sub-specialty electives to do include: Cardio (ward), Heme, ID, Resp, GI, Geriatrics.

I believe the other sub-specialty are a bit more advanced, and it would be harder to impress (not saying its impossible, just harder), Heme could be on that list to especially if the place you're doing it has a lot of malignant-heme related things.

Also it be wise to consider also doing subspecialty electives in area's you might be interested in pursing because that will help you if when your thinking about sub-specialty during IM.

 

[medaholic]

On 2/21/2020 at 3:05 PM, Fortress said:

 Another question is: why is an academic job so competitive, even though it isn't as financially rewarding as community medicine? Are there any perks associated with being academic other than the fact that you have residents and fellows doing the work for you? Is it because of presumed "prestige"? Is it simply the ratio between number of people interested in research/teaching and available spots?

 

My experience, having gone from community GIM to academic GIM, is that an academic job has a lot more non-clinical variety of work. The pay isn't that bad at all centres, but it is less than a busy community practice. Not all academic centres are set up the way UofT does it, many places are much more equitable to new staff.

Eventually, the money thing becomes less of an issue. What you will really value is time and autonomy, especially if you start a family. You'll be well off in either setting, but a salaried academic job has a lot more flexibility. Not having to do in house call has been great for my well-being and general health. Similarly, I have time to pursue projects and problem solve in non-clinical ways that is rewarding in itself. 

There are parts I miss about community practice, such as the acuity and really testing your clinical abilities when you're on call. But I've found other avenues that are satisfying like teaching, mentorship and innovation. Both are great choices and it really comes down to fit.

[ACHQ]

10 hours ago, medaholic said:

My experience, having gone from community GIM to academic GIM, is that an academic job has a lot more non-clinical variety of work. The pay isn't that bad at all centres, but it is less than a busy community practice. Not all academic centres are set up the way UofT does it, many places are much more equitable to new staff.

 

Yes I should clarify my bias, most of what I speak of applies to UofT and the GTA. That being said I have heard of the practices I describe above at other academic institutions within Ontario...

 

Quote

You'll be well off in either setting, but a salaried academic job has a lot more flexibility. Not having to do in house call has been great for my well-being and general health. Similarly, I have time to pursue projects and problem solve in non-clinical ways that is rewarding in itself.

Just to add another perspective, I find that my upcoming community GIM position pretty flexible. Only requires me to do 34 weeks of total service out of 52. The rest of the time I can do whatever I please. It does require me to do in house call, but they implemented an 8 hour shift model for GIM ER consults, which makes it much more manageable. Also later on if I want to really dial back on evenings/nights there is a system where you can post shifts for others/locums to take.

In terms of non-clinical opportunities, there seems to be a lot at my site especially in the area of quality improvement and other projects. We also get residents (mostly family medicine, some senior internal medicine residents on electives), so there is a bit of teaching opportunity as well. It may not be as abundant as in academic centres but it does exist, if someone truly wants to pursue it.

Again I am speaking specifically for a large hospital in the GTA. I can't comment on other sites with as much confidence.

 

[NLengr]

Just wanted to comment on lines since it got mentioned way up this thread. 

Femoral lines are a great back up for both central venous access and arterial lines. They are relatively easy, can be done blind and unlike subclavian and IJ lines, there isn't a mess of important stuff in the area to hit. And unlike a radial art line, a femoral art line is a nice big pulsing vessel, making it easy to get. 

[medigeek]

2 hours ago, NLengr said:

Just wanted to comment on lines since it got mentioned way up this thread. 

Femoral lines are a great back up for both central venous access and arterial lines. They are relatively easy, can be done blind and unlike subclavian and IJ lines, there isn't a mess of important stuff in the area to hit. And unlike a radial art line, a femoral art line is a nice big pulsing vessel, making it easy to get. 

Except in a crash situation Just do the IO. 

[LittleDaisy]

On 3/3/2020 at 5:15 AM, medaholic said:

My experience, having gone from community GIM to academic GIM, is that an academic job has a lot more non-clinical variety of work. The pay isn't that bad at all centres, but it is less than a busy community practice. Not all academic centres are set up the way UofT does it, many places are much more equitable to new staff.

Eventually, the money thing becomes less of an issue. What you will really value is time and autonomy, especially if you start a family. You'll be well off in either setting, but a salaried academic job has a lot more flexibility. Not having to do in house call has been great for my well-being and general health. Similarly, I have time to pursue projects and problem solve in non-clinical ways that is rewarding in itself. 

There are parts I miss about community practice, such as the acuity and really testing your clinical abilities when you're on call. But I've found other avenues that are satisfying like teaching, mentorship and innovation. Both are great choices and it really comes down to fit.

Thanks ACHQ for posting all the detailed explanation.

Having talked to a few academic GIM staff at University of Toronto, their work-life balance and remuneration is pretty decent! After you passed through the status of clinical associate--> Assistant Professor, or landed a permanent position, you become a part of the group plan. They usually make around 300-400 K with overhead around 5%, I am seriously not kidding! I think that if you have a chance, most people would prefer make 300-400 K per year while having residents doing in-house calls, reviewing consults/teaching during the day; than making 500 K while doing everything yourself, which can easily lead to burnout. 

They are paid around 100 $ per hour per teaching (small group teaching, lectures), it doesn't pay as much as community hospital consults, but I find that it's protective time to take some time away from the crazy ward, and go teach medical students and make an impact. 

Also, if you become an assistant professor, your kids go to UofT for free (doesn't include professional schools like law, MD, pharmacy etc), but that cover a decent 4 years of undergraduate studies. 

Keep in mind, that they also receive some significant money from the Ministry of Health for "teaching stipends" which can result in a few thousands dollars per month depend on how involved you are in teaching.

The caveat is that it's really hard to get in, they do make you work hard for a few years as a "clinical associate" where you have an overhead of 10-20%,.