GIM FAQ thread

[kitchenlover]

8 hours ago, ACHQ said:

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.

What are the benefits of having FRCPC status versus merely an independent license? 

[ACHQ]

12 hours ago, kitchenlover said:

What are the benefits of having FRCPC status versus merely an independent license? 

other than saying your a Royal college certified?? nothing ahhaha.

No in all honesty though, the CPSO (the governing body that gives licenses out) requires all physicians (regardless of designation, specialty etc...) to maintain CME. They don't care how you do it just so long as you do it. Otherwise you wont be able to really get a license renewal if they found out you were not maintaining your CME.

Given that the majority of specialists are trained in Canada, we go through the royal college process. The only tangible benefit it has it allows you to maintain your CME status/credits in an organized way. Is the the $900/yr membership worth that? that I can't answer

 

If you are able to get an independent license without royal college status (many non-canadian trained physicians do), then you just have to have a way to maintain your CME's. Correct me if I am wrong but I think U.S. trained IM's can get around this by going through there ABIM/FACP society.

[shikimate]

Well your hospital or department may stipulate that you hold FRCPC status.

Aside from that, the American board MOC process I participate in also stipulates I either do RC or the American CME thing, neither of which is cheap. So it's a "cost of doing business".

[kitchenlover]

Is the job market competitive in the Prairies (AB, SK, MB) or is this talk about GIM getting competitive limited to Ontario?

[ACHQ]

17 hours ago, kitchenlover said:

Is the job market competitive in the Prairies (AB, SK, MB) or is this talk about GIM getting competitive limited to Ontario?

I don't think the market is uber competitive in Ontario... there are jobs available for sure even in larger urban places (can't comment about academic centres though).

I can't say this for sure but I would *assume* AB/SK/MB have more opportunities given their lower number of trainees graduated per year and the general issue with overall physician retention for those provinces (but this is all speculation and I could be way off).

[HarrryMaguire]

What is the minimum time spent using a A133 if a GIM is "acting as a GP" and seeing walk-ins? Would it be comparable in time to a A007 for a Family Doc? 

[Bluberblubo]

On 7/15/2022 at 8:19 PM, HarrryMaguire said:

What is the minimum time spent using a A133 if a GIM is "acting as a GP" and seeing walk-ins? Would it be comparable in time to a A007 for a Family Doc? 

I'm pretty new to billing so someone more experienced please feel free to correct me if I am wrong. 

1. There is no minimum time that you need to spend with a patient to bill an A133

2. I think you would still need some sort of referral to bill an A133 and it needs to be document (on the ward it would be like "nurse asked to assess the patient for headache") 

3. Last time I read the OHIP SOB I remember it saying that if you are doing primary care you should bill the primary care codes i.e. A007 and apparently anyone can bill those codes.

All that being said, I heard that no one really cares to audit the A133 codes compared to the A130 codes and that there was a walk-in clinic somewhere in the GTA run by an internist who bills it for the patients they see. If anyone knows about more about this setup, please do share!

[ACHQ]

On 7/15/2022 at 8:19 PM, HarrryMaguire said:

What is the minimum time spent using a A133 if a GIM is "acting as a GP" and seeing walk-ins? Would it be comparable in time to a A007 for a Family Doc? 

No minimum time required, you can see these patients as "walk-ins" and Bill an A133.

Caveat is that an A133 requires a PMHx, MEDs, HPI/Exam/Labs along with the A+P. Although more brief and concise than a full consult the documentation required is not too dissimilar (especially if a patient has a million co-morbidities), some people for meds will say meds reviewed (and I've even seen that in full consults.... not sure if I'd do that for a consult though). 

From a medical-legal stand-point though, I would be very very careful for seeing a "walk-in" request by a patient. A request from a nurse/other health care professional for medical inpatient is MUCH different than someone coming to a clinic as a walk-in for "medical problem". Although as GIM's we tend to get undifferentiated patients, walk-ins are complete unknowns, and you carry the full medio-legal responsibilities for the encounter (i.e. if you miss something non-medical and they have a bad outcome/sue). If you feel comfortable with that go right ahead, but as a GIM I'm not a family physician/ER doctor so I don't know how to deal with peds/Gyne/Psych/surgical issues (for the most part).

[grapz]

Hi ,

thanks for your post really appreciate all the information. 
 

few questions 

1) in the GTA as a community GIM, based on your experience , is doing nights (midnight to7 or 8 am) a requirement ? Do you know of any hospitals that don’t have their GIMs cover this period of time

2) how often do you bill comprehensive consult code?

[ACHQ]

On 1/2/2023 at 4:10 PM, grapz said:

Hi ,

thanks for your post really appreciate all the information. 
 

few questions 

1) in the GTA as a community GIM, based on your experience , is doing nights (midnight to7 or 8 am) a requirement ? Do you know of any hospitals that don’t have their GIMs cover this period of time

2) how often do you bill comprehensive consult code?

1. I don't know of any hospital that will let someone not do any overnight shifts... at my site we are quiet equitable where we all do minimum 1 overnight a month, and if others want to do more they can. Other sites are not so equitable and make the newer hires/locums do more of the nights/holidays/weekends than the full time staff.

 

2. Variable, its hard to quantify tbh. I do it when I spend alot of time with the patient (which is what it is intended for)

[Jarisch]

On 6/23/2022 at 11:42 AM, ACHQ said:

I don't think the market is uber competitive in Ontario... there are jobs available for sure even in larger urban places (can't comment about academic centres though).

I can't say this for sure but I would *assume* AB/SK/MB have more opportunities given their lower number of trainees graduated per year and the general issue with overall physician retention for those provinces (but this is all speculation and I could be way off).

Jobs in Calgary are very competitive for GIM. They're basically restricted to 5 year GIM only. 

[lune89]

On 2/21/2020 at 10:36 AM, 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.

Hello. Thanks a lot for this post. A lot of intresting informations. 

Do you know if what you said in this post applies to Québec?

 

Thank you

[ACHQ]

13 hours ago, lune89 said:

Hello. Thanks a lot for this post. A lot of intresting informations. 

Do you know if what you said in this post applies to Québec?

 

Thank you

Quebec is a whole different beast, so I cannot accurately say that this reflects GIM there.

 

I'll even put a disclaimer that the above can only really be said about large community hospitals in the GTA

[MED2023.]

Im an MS4 looking for some additional advice on FM versus GIM. Any input would be really appreciated before my final decision for CARMS rankings need to be submitted. 

Really torn between FM and GIM. In clerkship I felt really burned out from call as a med student. I did a Master's before med school so there has been a lot of school leading up to this decision. Overall, I find IM much more stimulating and overall enjoy ward work as well as ambulatory GIM. Still unsure if I would end up specializing, but presently enjoy the concept of being a generalist. On the other side, the lifestyle and residency of FM is more appealing, though don't know that I love everything that is seen by a family doc. I am location tied, and don't know that I can go through another CARMS match as an R-3 in GIM (and risk having to be re-located again). Ideally, would like to stay within the urban city that I am in. 

Looking for help deciding which route makes most sense. I am aware of the FM+1 hospitalist route, I just worry about regretting this decision 5 years down the line (feeling unfulfilled) or in contrast, being incredibly exhausted from a 4-5 year residency route + studying for royal college exam. Having time for myself outside of medicine is something that is highly important to me in making this decision. 

[ACHQ]

18 hours ago, MED2023. said:

Im an MS4 looking for some additional advice on FM versus GIM. Any input would be really appreciated before my final decision for CARMS rankings need to be submitted. 

Really torn between FM and GIM. In clerkship I felt really burned out from call as a med student. I did a Master's before med school so there has been a lot of school leading up to this decision. Overall, I find IM much more stimulating and overall enjoy ward work as well as ambulatory GIM. Still unsure if I would end up specializing, but presently enjoy the concept of being a generalist. On the other side, the lifestyle and residency of FM is more appealing, though don't know that I love everything that is seen by a family doc. I am location tied, and don't know that I can go through another CARMS match as an R-3 in GIM (and risk having to be re-located again). Ideally, would like to stay within the urban city that I am in. 

Looking for help deciding which route makes most sense. I am aware of the FM+1 hospitalist route, I just worry about regretting this decision 5 years down the line (feeling unfulfilled) or in contrast, being incredibly exhausted from a 4-5 year residency route + studying for royal college exam. Having time for myself outside of medicine is something that is highly important to me in making this decision. 

GIM staff at a large/tertiary community hospital in the GTA. Did med school and residency at UofT. Most of what I have said above applies to the GTHA and Ontario, I can't say for sure everything I've said applies to other provinces.

Tough decision for sure. I think you accurately described the pros and cons. I think I can at least help point out a few other factors:

FAMILY MEDICINE VS GIM/INTERNAL MEDICINE:

- Do you like/enjoy/need to see patients with Psych/OBGYN/Peds issues?? Conversely do you find that you really don't enjoy (or even hate) those areas? IF you are on either side of the spectrum then it might help sway you towards or against family medicine, given you have to see all types of issues that walk through the door.

- Do you want to do purely ambulatory non-acute work? or do you need/love/thrive on acuity in your practice? That may also sway you against or for family medicine (of course you could do ER or Hospitalist as a family physician but the scope sometimes is different, and the acuity for Hospitalists on the ward vs GIM in the ER doing consults is vastly different). Conversely in GIM/Medicine you can do very low acuity stuff in an ambulatory setting too, but again this isn't common.

- Do you only want to work weekday/daytimes and mostly be off on weekends/evenings/nights?? That might sway you towards or against family medicine too. Mind you many family doctors are doing some work "after hours" and some GIM's don't do many holidays/weekends/nights (but then there pay suffers), but overall GIM work more holidays/weekends/nights/evenings then family physicians.

- Does pay at all matter to you? Overall GIM makes more than family physicians by anywhere from 0-200k (especially because most GIM's don't have overhead). Again there are exceptions to this, some family docs work insanely and make almost/same as Medicine physicians, but I'm talking on average. Of course there are some subspecialty medicine physicians that make around the same as a family doc too (but again on avg the subspecialists make more)

- If you do decide to go down the hospitalist route, is that the only aspect of Internal medicine you enjoy? Do you not like resuscitations? Do you not like the acutely unwell patients in the ER that need a medicine consult/admission? Do you not like the weird/undifferentiated cases that need you to put away your efficiency cap and put on your thinking cap? Not to say you can't do that on hospitalist, and definitely do to some extent, but by far as a full breadth GIM that does ER consults, GIM clinic, and inpatient ward work, you do much more of the above.

 

I hope that clarifies things a bit for you. You have to realize residency is a small fraction of your whole career. But also there are factors that maybe more important to you (lifestyle, time off, location) that I cannot factor into this (as that is a personal take). Residency sucks, period. But it is shorter and more bareable overall than a 4-5+ year residency in Internal medicine. We see the highest volume of patients and with a solid amount of acuity, which makes the shifts draining. You have to really enjoy it to get through. Everyone at the end is a bit bitter/burnt out. But staff life is overall better (but much of that is due to increased respect). However, still work weekends, nights and holidays, which sucks, but does pay the bills well. Its a trade off, and its hard for me to say which one you would rather prefer.

 

[indefatigable]

Great points raised so far.  A couple of other add-ons.

• Family medicine residents often (not always) are sheltered from some of the staff work vs IM residents are there first on consults etc..  So FM residency may be somewhat "softer" than responsibilities as staff vs IM residents who are notoriously overworked and for whom staff life generally seems to be better appreciated.  
• As a last resort, if you're still on the fence, it's generally easier to switch from IM to FM than vice versa.  I wouldn't count on this, but if you think there's a chance you'll have regrets of not choosing IM then the transfer possibility could be helpful.  But, if you're on the fence with IM, it might also be hard to push through too, so it's hard to say.   

[MED2023.]

Thank you for the input- these are very helpful points to consider. How difficult is it to only do GIM clinic in large urban centers like Toronto? Is it common to set up a self-run ambulatory clinic, or are there opportunities to join clinics that hire a GIM doc (not specialized)? Wondering how difficult it is to find work outside of a hospital setting with GIM.

[ACHQ]

21 hours ago, MED2023. said:

Thank you for the input- these are very helpful points to consider. How difficult is it to only do GIM clinic in large urban centers like Toronto? Is it common to set up a self-run ambulatory clinic, or are there opportunities to join clinics that hire a GIM doc (not specialized)? Wondering how difficult it is to find work outside of a hospital setting with GIM.

Its not hard per-say, but the vast majority of GIM's practice in a hospital setting for certain reasons:

- NO overhead

- the acuity that comes with doing hospital based work

- the cases you get as an outpatient GIM physician working outside the hospital setting in a large/urban city is going to be lets say as "not as stimulating". I did work early on as a GIM at a private clinic owned by a nurse who had a lot of sub-specialty doctors (endo, rheum, cardio, GI), and the although there would be some actual medicine (hypertension, Diabetes, Anemia), there was a good chunk of: Fatigue/weakness NYD, Obesity, weight loss NYD, random *minimal* elevation (or depression) of [insert random lab here] that done for unknown reasons... 100% of those cases had the full work up by there GP for no good reason *anyways* with no cause found for [insert reason above here] and wanted a specialist opinion to tell them everything is OK. Although reassuring patients/families was easy money, it felt mind numbing. This doesn't as much to hospital based GIM clinics, as these are usually rapid referrals/urgent medicine consultation clinics, where the vast majority are patients who presented to the ER with an actual problem and found some abnormality that needs further work up/diagnosis/management.

Those are at least my reasons, I'm sure there are others.

[kitchenlover]

Is it feasible for a US trained IM doctor to practice in Alberta? The College of Physicians and Surgeons of Alberta stipulates:

For Specialty Practice you must have successfully completed a specialty residency in Canada or a continuous, university-affiliated discipline-specific specialty postgraduate training program of at least 48 months and equal to Royal College Specialty Training Requirements and have specialist certification.
(NOTE: Fellowship training, community service, public service, national service, house officer, medical officer posts and practice experience do not satisfy the postgraduate training requirements.)

https://cpsa.ca/physicians/registration/apply-for-registration/apply-for-independent-practice/

Even if you do a fellowship on top of the 3 year US IM residency, you’re out of luck as fellowships don’t count!

[bearded frog]

On 3/1/2023 at 2:33 PM, kitchenlover said:

Is it feasible for a US trained IM doctor to practice in Alberta? The College of Physicians and Surgeons of Alberta stipulates:

For Specialty Practice you must have successfully completed a specialty residency in Canada or a continuous, university-affiliated discipline-specific specialty postgraduate training program of at least 48 months and equal to Royal College Specialty Training Requirements and have specialist certification.
(NOTE: Fellowship training, community service, public service, national service, house officer, medical officer posts and practice experience do not satisfy the postgraduate training requirements.)

https://cpsa.ca/physicians/registration/apply-for-registration/apply-for-independent-practice/

Even if you do a fellowship on top of the 3 year US IM residency, you’re out of luck as fellowships don’t count!

My understanding that US IM residency would be "a continuous, university-affiliated discipline-specific specialty postgraduate training program of at least 48 months and equal to Royal College Specialty Training Requirements", the only issue is if they count US boards or if you have to write the RC boards (I assumed you did but v:/v)

[Aurelius]

From a financial standpoint, what's the disadvantage of pursuing 4-yr GIM vs sub specializing in let's say cardiology (stereotypical high-billing specialty)? I'm looking at the Toronto Star Doctor's Database and a lot of community GIM's are billing $500-600k which seems to be on par with the average cardiologist? I guess the ceiling may be higher in cardiology but earning staff income 3-5 years earlier may negate that to some extent?

[ACHQ]

On 5/12/2023 at 5:51 PM, Aurelius said:

From a financial standpoint, what's the disadvantage of pursuing 4-yr GIM vs sub specializing in let's say cardiology (stereotypical high-billing specialty)? I'm looking at the Toronto Star Doctor's Database and a lot of community GIM's are billing $500-600k which seems to be on par with the average cardiologist? I guess the ceiling may be higher in cardiology but earning staff income 3-5 years earlier may negate that to some extent?

Community cardiologist usually make more than 500-600k pre-overhead. Most make in the 750+, depending on how much they work.

Now depending on how much there overhead is will determine their pre-tax income. But it'll range between 500-600 like some community GIM.

 

That being said if you are billing 500-600 in community GIM you are working A LOT, and probably alot of nights/weekends/holidays

[Aurelius]

3 hours ago, ACHQ said:

Community cardiologist usually make more than 500-600k pre-overhead. Most make in the 750+, depending on how much they work.

Now depending on how much there overhead is will determine their pre-tax income. But it'll range between 500-600 like some community GIM.

 

That being said if you are billing 500-600 in community GIM you are working A LOT, and probably alot of nights/weekends/holidays

I see, so the community cardiologist will make that 500-600 (or more) while working less?

[ACHQ]

On 5/15/2023 at 1:58 PM, Aurelius said:

I see, so the community cardiologist will make that 500-600 (or more) while working less?

Probably less call/off hours, I wouldn't necessarily say "less".

[CGreens]

On 5/15/2023 at 1:58 PM, Aurelius said:

I see, so the community cardiologist will make that 500-600 (or more) while working less?

As a cardiologist you also get to restrict your practice to just cardiology… which assumingly as a cardiologist you prefer over GIM. Same obviously goes for any specialty. Not your organ, not your problem…