GIM FAQ thread

[UBCmedclass2022]

9 hours ago, ACHQ said:

The medicine wards can sometimes be dumping grounds, and unfortunately we (internal medicine) are too nice to fight too much about it. That being said the majority of stuff you see on the wards is bread and butter medicine.

 

I do mostly urgent GIM clinics linked to a hospital, so I see alot more acuity than say a private GIM practice in the community. Generally speaking most of the stuff we see in clinic are patients that go to the ER and need a work up/diagnosis but don't need to be admitted for it vs post hospital discharge follow up. Examples include (but not limited to): New onset CHF, dyspnea, Anemia/thromobocytopenia, elevated LFTs, malignancy work up, New/uncontrolled diabetes, new cirrhosis, worsening chronic condition that doesn't need admission but titration of meds (stable but decompensated CHF or Cirrhosis or COPD etc...) Random incidental lab findings that need work up.

Wow that sounds like really great variety even in the clinic setting. Sounds like you have a great set up! Thanks for this response

[Jj16]

Hi! I'm a PGY3 internal med in Quebec. I'm having difficulty choosing between PGY4 GIM vs GIM PGY5. 

I'm an older applicant and tired of residency. To me the PGY5 is a money grab to force residents to get paid for nothing for an extra year. My goal is to work in a community hospital within the limits of a big city eg. Toronto GTA or Vancouver. 

The issue is that Quebec is the only province where in order to work here you need to go a GIM PGY5. 

I was wondering if someone who did PGY4 have a community hospital job and how they found the job finding process? Did they feel that many jobs asked for the PGY5 GIM? Did you have to go more rural? 

I'm also interested in pall care aand was wondering if there are any GIM who  have incorporated this into their practice? There is a pall care fellowship that's two years but to me that's way too long. I don't get why fam med get certified after one year but IM is forced to do 2? 

[Jj16]

Hi! I'm a PGY3 internal med in Quebec. I'm having difficulty choosing between PGY4 GIM vs GIM PGY5. 

I'm an older applicant and tired of residency. To me the PGY5 is a money grab to force residents to get paid for nothing for an extra year. My goal is to work in a community hospital within the limits of a big city eg. Toronto GTA or Vancouver. 

The issue is that Quebec is the only province where in order to work here you need to go a GIM PGY5 so there's this mindset that you have to do a PGY5. I'm told by the gim pgy5 in Quebec that it's future proofing and will result in higher paid billing codes. 

I was wondering if someone who did PGY4 have a community hospital job and how they found the job finding process? Did they feel that many jobs asked for the PGY5 GIM? Did you have to go more rural? 

I'm also interested in pall care aand was wondering if there are any GIM who  have incorporated this into their practice? There is a pall care fellowship that's two years but to me that's way too long. I don't get why fam med get certified after one year but IM is forced to do 2? 

[JohnGrisham]

3 hours ago, Jj16 said:

Hi! I'm a PGY3 internal med in Quebec. I'm having difficulty choosing between PGY4 GIM vs GIM PGY5. 

I'm an older applicant and tired of residency. To me the PGY5 is a money grab to force residents to get paid for nothing for an extra year. My goal is to work in a community hospital within the limits of a big city eg. Toronto GTA or Vancouver. 

The issue is that Quebec is the only province where in order to work here you need to go a GIM PGY5 so there's this mindset that you have to do a PGY5. I'm told by the gim pgy5 in Quebec that it's future proofing and will result in higher paid billing codes. 

I was wondering if someone who did PGY4 have a community hospital job and how they found the job finding process? Did they feel that many jobs asked for the PGY5 GIM? Did you have to go more rural? 

I'm also interested in pall care aand was wondering if there are any GIM who  have incorporated this into their practice? There is a pall care fellowship that's two years but to me that's way too long. I don't get why fam med get certified after one year but IM is forced to do 2? 

For sure its a money grab, but if you want to work in many centres, the 5 year GIM is becoming much more common and you will be boxed out if you don't just get the extra year. Most people use the extra year to get a "niche" area of interest, i.e. HTN, DM, IM-OB, Palliative without doing full 2 year fellowship for community related work etc. 

 

[JohnGrisham]

The sentiment from colleagues in some big centres is "I better just suck it up and get PGY5, so i dont have to go work in smaller semi-urban or semi-rural centres with only a 4 year GIM"

[sterntaler]

Does 4 vs 5 years matter if you are mainly interested in doing GIM clinics? 

[who_knows]

Can someone comment please, what is the point of doing 5 years of GIM if one can complete 3 years of IM and 2 years of specialty and then be qualified to do either specialty (if there is a job) or just GIM?

[JohnGrisham]

20 minutes ago, who_knows said:

Can someone comment please, what is the point of doing 5 years of GIM if one can complete 3 years of IM and 2 years of specialty and then be qualified to do either specialty (if there is a job) or just GIM?

I don't think most centres would allow the individual in that situation to work in GIM without having the 4th or 5th year GIM. 

I had seen in the past Cardios and Nephros doing CTU type internal medicine work in hospital, but even that seems to be slowly phasing out. Very centre dependent. 

I think the 3 year base internal medicine doesn't allow for much anymore, as there are now more than enough people with the 4 year GIM, and now 5 year GIM. 

This is the perspective from major centres of course. Smaller centres the world is your oyster.

[JohnGrisham]

1 hour ago, sterntaler said:

Does 4 vs 5 years matter if you are mainly interested in doing GIM clinics? 

Centre dependent, my understanding is no - not a big difference for outpatient. The main thing is, most people tend to do a mix of inpatient and outpatient, and its the inpatient piece that may be affected. Its much easier to do post-ER GIM clinics via hospital for example, and then build up a roster of patients this way for a constant referral stream...then rely solely on family docs to refer to you. Again, very province dependent.

[who_knows]

52 minutes ago, JohnGrisham said:

I think the 3 year base internal medicine doesn't allow for much anymore, as there are now more than enough people with the 4 year GIM, and now 5 year GIM. 

Thanks. That sucks. Agree with the previous speakers, It looks like a clear money grab.

[ACHQ]

13 hours ago, JohnGrisham said:

For sure its a money grab, but if you want to work in many centres, the 5 year GIM is becoming much more common and you will be boxed out if you don't just get the extra year. Most people use the extra year to get a "niche" area of interest, i.e. HTN, DM, IM-OB, Palliative without doing full 2 year fellowship for community related work etc. 

 

ummm not sure this is accurate for the GTA (or even Ontario)

 

I, myself, did the 4 year GIM program. I work at a large tertiary centre (non-academic) in the GTA. Outside of the *true* academic centres (UHN, Mount Sinai, St. Michaels, Sunnybrook, Womens College), as of right now, it makes no difference if you do the 4 vs 5 year program. The 5 year program only pumps out like 5-7 grads a year at UofT and they are the largest program. All the places I interviewed at (large centres non-academic) did not once care or mention that they preferred the 5 year GIM. Even if you have a niche, most 4 years can build that niche in afterwards if need be (but at larger centres there are always subspecialist to take those patients anyways). I don't see this changing anytime soon. Most places don't care about the academic BS associated with doing the 5 year program and just want clinicians that are good at their job and good to work with.

 

As per doing the 5 year vs 4 year program if you are just interested in GIM clinics, there is even less incentive to do the 5 year program, as most clinic work is done outside of a hospital, meaning you can just join a clinic and start seeing patients. Even at hospitals the GIM group at non-academic centres in the GTA would not care. That being said no hospital would let you just do clinics and get out of doing call etc...

 

11 hours ago, who_knows said:

Can someone comment please, what is the point of doing 5 years of GIM if one can complete 3 years of IM and 2 years of specialty and then be qualified to do either specialty (if there is a job) or just GIM?

The 5 year GIM program is geared towards a more academic career. That is the only reason to really do it. Now there are some GIM's that do the 5 year program and end up in the community (not all of them can do academics).

There are some sub-specialists in some places that do some GIM work. Its not as common as before as volumes in all sub-specialties are quiet high. Full time GIM work commands alot of time, so doing another sub-specialty can be tough, but some people do it, but yes its not as common anymore. At my centre its mostly GIM/ICU, but there are some that do GIM/Resp, GIM/Nephro, GIM/ID. The vast majority of these people are doing GIM call only though, but some do hospitalist as well. So if you wanted to really do that then you could you just have to crave out your schedule carefully and have buy in from the various departments.

[who_knows]

Thanks, ACHQ, it makes sense. 

[IM_student_111]

Hi @ACHQ, thank you for this wonderful informative thread. I'm a med student considering going into IM, specifically GIM. I have a few questions as well as thoughts I'd like to hear your opinion on. I apologize in advance for the long post, but I really appreciate your help and look forward to your reply.

1. One of the things that attracts me the most about GIM is the career flexibility. I'm planning on dedicating all my time to medicine for the next decade to train well and to make a good amount of money in my first few years of practice. After that however, I do plan on focusing on building a family. I also have various hobbies that are important to me, and throughout life I think I will go through fluctuating phases of wanting to spend more time on medicine VS more time on my personal projects. GIM, it seems to me, allows for this kind of flexibility: the job market for GIM is generally better than for subspecialized physicians, so there should be a decent chance of finding a hospital practice in which, on a year-to-year basis, we have some degree of control over how little or how much we want to work (e.g., working 15 VS 25 days a month), something we can continually adjust throughout our career to align with our life priorities at any given point in our lives. Is this a rosy misconception, or does GIM sound like a good fit for me given that flexibility is very important to me? Please correct me on where I'm misinformed!

2. When I was considering IM VS FM, one of the biggest things for me was that I can't imagine myself doing 30 consults a day in a FM clinic to make a decent income. Spending 10-15 minutes per patient sounds not only unsafe to me to a degree I'm not comfortable with, but also prevents me from enjoying a connection with my patients, which I value. I hate feeling like I have to rush through everything. I know we have more time per patient in IM, but these patients are also more complex, so do you end up feeling rushed anyway?

3. I've considered IM and FM for a long time because I enjoy the appeal of being a generalist and knowing a lot about medicine and health in general and being able to care for all sorts of problems. However, lately, I've been put off by the sheer degree of uncertainty and frustration my friends in FM struggle with daily because of their lack of expertise, and I don't feel like being a "referologist" would be very meaningful to me. I find that GIM seems to stand in a nice middle ground between generalist and subspecialist; they know enough about everything and can be confident in both the breadth and depth of their knowledge base. I read in one of your earlier posts that you had initially wanted to match into a medicine subspecialty. Now that you are in GIM, how satisfied do you feel about the degree of expertise you exercise in your daily practice? Do you find yourself frequently feeling frustration at lacking more expertise? Do GIMs often end up in a "consultologist" position, to mirror what is often said about FMs being "referologists"?

4. My final question pertains to income. You've said that GIMs in your center generally make 300-500k per year depending on how much they work. If I do the minimum your center requires (which it would seem gives you around 15 days off a month on average, going off another one of your previous posts?), is it realistic to expect 300k? Just sounds a little too good to be true so I wanted to ask. And has the pandemic affected GIM income for physicians in community centers like yours at all?

Again, sorry for the long post, but your insight is super super appreciated

[Jj16]

As someone who was in fam med for a year before transferring into IM I would suggest not doing fam med. Yes its shorter, yes the hours are more flexible and the job prospects are great. But these are not the only reasons why you should pick a residency. I went into family for those reasons and I can tell you that the training is almost never enough to feel comfortable with anything and you do become a referologist. That is the nature of a two year program as a family doctor. 

I've worked with fam med who did hospitalist and GIM staff and I can tell you the knowledge base is simply not the same. Nor should anyone expect it to be. My FM hospitalist counterparts refer way more and do not follow as evidence based practice. But this is to be expected from someone who trained for four years in GIM vs. +1 hospitalist and maybe two CTU rotations in fam med residency. 

[JohnGrisham]

1 hour ago, Jj16 said:

As someone who was in fam med for a year before transferring into IM I would suggest not doing fam med. Yes its shorter, yes the hours are more flexible and the job prospects are great. But these are not the only reasons why you should pick a residency. I went into family for those reasons and I can tell you that the training is almost never enough to feel comfortable with anything and you do become a referologist. That is the nature of a two year program as a family doctor. 

I've worked with fam med who did hospitalist and GIM staff and I can tell you the knowledge base is simply not the same. Nor should anyone expect it to be. My FM hospitalist counterparts refer way more and do not follow as evidence based practice. But this is to be expected from someone who trained for four years in GIM vs. +1 hospitalist and maybe two CTU rotations in fam med residency. 

I'm curious where you are that GIM and FM are both doing hospitalist work together? In most provinces GIM is usually MRP on more complex acute care wards, and FM hospitalits on more chronic subacute care wards, and GIM acts as a consultant.


 

[medigeek]

6 hours ago, JohnGrisham said:

I'm curious where you are that GIM and FM are both doing hospitalist work together? In most provinces GIM is usually MRP on more complex acute care wards, and FM hospitalits on more chronic subacute care wards, and GIM acts as a consultant.


 

re Ontario - community jobs outside of Toronto/most but not all community hospitals outside of the immediate urban areas. 

[medigeek]

7 hours ago, Jj16 said:

As someone who was in fam med for a year before transferring into IM I would suggest not doing fam med. Yes its shorter, yes the hours are more flexible and the job prospects are great. But these are not the only reasons why you should pick a residency. I went into family for those reasons and I can tell you that the training is almost never enough to feel comfortable with anything and you do become a referologist. That is the nature of a two year program as a family doctor. 

I've worked with fam med who did hospitalist and GIM staff and I can tell you the knowledge base is simply not the same. Nor should anyone expect it to be. My FM hospitalist counterparts refer way more and do not follow as evidence based practice. But this is to be expected from someone who trained for four years in GIM vs. +1 hospitalist and maybe two CTU rotations in fam med residency. 

+1 hospitalist isn't closing the gap? American FM hospitalists and IM hospitalists are 1:1 equivalents when hired in the same setting (3 year residencies for each) which makes it interesting if 3 years (equal to the American side) isn't sufficient. 

In reality, I think this is all case by case. 

[1029384756md]

In Canada, doing GIM is the best route to doing hospitalist work. The length of training and exposure to complex acuity cannot be found in FM. In the past I've also interviewed at GTA community hospitals where IM and FM share the same acute medicine ward - they're there but not common.

Re: being a referologist in FM, while there is a gap in adult medicine knowledge between GIM vs FM, practically speaking how far I work up my own DDx on a complex pt was dependent on how much I was getting paid. Do I have the knowledge to work up resistant HTN? Sure, but I could just refer out to a HTN specialist too. I make more money and pt gets better care, nothing wrong with that!

[Edict]

4 hours ago, medigeek said:

+1 hospitalist isn't closing the gap? American FM hospitalists and IM hospitalists are 1:1 equivalents when hired in the same setting (3 year residencies for each) which makes it interesting if 3 years (equal to the American side) isn't sufficient. 

In reality, I think this is all case by case. 

I think it closes the gap, but I would be remiss if I didn't agree with his point that exposure =/= mastery. The expectations for an on service vs off service resident are different and the way most family medicine programs are structured, they aren't meant for mastery, mainly exposure. 

[medigeek]

4 hours ago, Edict said:

I think it closes the gap, but I would be remiss if I didn't agree with his point that exposure =/= mastery. The expectations for an on service vs off service resident are different and the way most family medicine programs are structured, they aren't meant for mastery, mainly exposure. 

No personal opinion on this since I'm American trained. It's variable in USA, but a decent portion of FM programs offer near equivalent training to many IM programs are far as inpatient competency goes. 

But when I see NPs and PAs running the ICU alone overnight or fully running medical wards (in the US)... makes me skeptical that FM can't do it as well. 

[ACHQ]

On 7/25/2021 at 3:25 PM, IM_student_111 said:

Hi @ACHQ, thank you for this wonderful informative thread. I'm a med student considering going into IM, specifically GIM. I have a few questions as well as thoughts I'd like to hear your opinion on. I apologize in advance for the long post, but I really appreciate your help and look forward to your reply.

1. One of the things that attracts me the most about GIM is the career flexibility. I'm planning on dedicating all my time to medicine for the next decade to train well and to make a good amount of money in my first few years of practice. After that however, I do plan on focusing on building a family. I also have various hobbies that are important to me, and throughout life I think I will go through fluctuating phases of wanting to spend more time on medicine VS more time on my personal projects. GIM, it seems to me, allows for this kind of flexibility: the job market for GIM is generally better than for subspecialized physicians, so there should be a decent chance of finding a hospital practice in which, on a year-to-year basis, we have some degree of control over how little or how much we want to work (e.g., working 15 VS 25 days a month), something we can continually adjust throughout our career to align with our life priorities at any given point in our lives. Is this a rosy misconception, or does GIM sound like a good fit for me given that flexibility is very important to me? Please correct me on where I'm misinformed!

2. When I was considering IM VS FM, one of the biggest things for me was that I can't imagine myself doing 30 consults a day in a FM clinic to make a decent income. Spending 10-15 minutes per patient sounds not only unsafe to me to a degree I'm not comfortable with, but also prevents me from enjoying a connection with my patients, which I value. I hate feeling like I have to rush through everything. I know we have more time per patient in IM, but these patients are also more complex, so do you end up feeling rushed anyway?

3. I've considered IM and FM for a long time because I enjoy the appeal of being a generalist and knowing a lot about medicine and health in general and being able to care for all sorts of problems. However, lately, I've been put off by the sheer degree of uncertainty and frustration my friends in FM struggle with daily because of their lack of expertise, and I don't feel like being a "referologist" would be very meaningful to me. I find that GIM seems to stand in a nice middle ground between generalist and subspecialist; they know enough about everything and can be confident in both the breadth and depth of their knowledge base. I read in one of your earlier posts that you had initially wanted to match into a medicine subspecialty. Now that you are in GIM, how satisfied do you feel about the degree of expertise you exercise in your daily practice? Do you find yourself frequently feeling frustration at lacking more expertise? Do GIMs often end up in a "consultologist" position, to mirror what is often said about FMs being "referologists"?

4. My final question pertains to income. You've said that GIMs in your center generally make 300-500k per year depending on how much they work. If I do the minimum your center requires (which it would seem gives you around 15 days off a month on average, going off another one of your previous posts?), is it realistic to expect 300k? Just sounds a little too good to be true so I wanted to ask. And has the pandemic affected GIM income for physicians in community centers like yours at all?

Again, sorry for the long post, but your insight is super super appreciated

1. GIM offers great flexibility. Most centres will make you commit to a certain amount of work though. If you fulfill that the rest of your time is as you like. The one thing is once you commit to a certain amount of work its may not be possible to just dial back as easily (but still possible), so what most people do is not commit to too much upfront and fill in their schedules with work PRN

 2. Family medicine don't necessarily need to spend as much time with their patients as they are usually familiar with their patients. When I see a consult I need to familiarize myself with the patient, as most patients are new to me (or that I haven't seen in a while) and so that means I have to spend more time. That being said, the volumes in GIM are very heavy, so I have to be efficient yet somehow thorough at the same time. So its natural to feel rushed in GIM especially when you have a ton of consults to see.

3. GIM's can unfortunately also become referologists, its part and parcel of being more of a generalist. Most of my colleagues and I try to manage patients as much as possible by ourselves. But referring patients is so much more complex than the referring clinician "not having enough expertise". Yes there will be more nuanced  scenarios/questions that only a sub-specialist will be able to address (need for Biologics in IBD or Chemotherapy for malignancy for example), others I know the answer and will start initial management but need someone to follow up and titrate/optimize therapy long term (e.g. chronic therapy for HFrEF or COPD/Asthma). Also there are medicolegal reasons to refer, and of course the biggest/most important one, but trying to get the best care for your patient. Personally I feel comfortable with my medical knowledge base, and although I may not know as much as my subspecialist colleagues in their area of expertise (duh), but I most times will know more about other areas much more than they do.

4. There was a time in the pandemic where volumes were a bit low, but that quickly got taken over by the surges/waves of cases which caused volumes to go up highly. So it really didn't make a huge difference in GIM incomes (if anything it may have bolstered them a bit). Volumes have come down a bit overall now that covid seems to have dampened down, and will probably return to prepandemic levels soon. Summers are usually quieter overall and Fall and Winter are busier. Anyways it is very feasible to make 300k (especially with stipend payments) and have a very good work life balance. That being said 300k isnt what it use to be about 10 years ago when I started medical school...

[HarrryMaguire]

Hi! Is it possible/feasible to work as a GIM (ER consults, clinic, etc.) while doing a subspecialty fellowship?

[ACHQ]

On 5/8/2022 at 12:21 AM, HarrryMaguire said:

Hi! Is it possible/feasible to work as a GIM (ER consults, clinic, etc.) while doing a subspecialty fellowship?

Its possible to do some locum work (mostly ER consults), but probably thats all (and even those would have to be on weekends, holidays). Depends on how much you value those days off vs the need for extra income/keep up GIM skill set.

[kitchenlover]

If you do IM training in the US, is a two year ACGME fellowship in any IM sub specialty enough to be qualified to do 4yr and 5yr GIM work in Canada? As you may know, IM is only 3 yrs in the US and there isn’t a thing such as a GIM fellowship.

[ACHQ]

17 hours ago, kitchenlover said:

If you do IM training in the US, is a two year ACGME fellowship in any IM sub specialty enough to be qualified to do 4yr and 5yr GIM work in Canada? As you may know, IM is only 3 yrs in the US and there isn’t a thing such as a GIM fellowship.

Yes, this will usually qualify you for the royal college certification (although no absolutely required for an independent license, but it makes CME easier).
 

If you do a 5 year subspecialty in the U.S. I would look into getting FRCPC status, which will require you to do the Royal college exam (which isn't easy), you can do it for both your specialties, this will require however an application to see if you "qualify" to write the exam and sometimes require you to submit your program training to the RC.