American vs Canadian IM Training

[GeriGIM]

Are American-trained internists equipped to work in Canadian hospitals?

It sounds like American-trained residents spend considerably less time in the CCU. We, in general, also do fewer procedures. For example, I have never attempted a chest tube and I’m not proficient in central line placement. I cannot intubate. 

We certainly see sick patients. But we have loads of subspecialty support.

I intend to return to Canada, with the intent to practice GIM. Are Canadian GIMs placing tubes and lines all day? 

 

[blah1234]

Depends on the centre, what your coverage requirements are, and amount of support you have. At a lot of smaller hospitals you may need to cover a small ICU so you will need comfort with the procedural aspects. You could also find hospitalist roles and only manage more stable patients. I think central line comfort is needed though if you are covering sick patients.

[medigeek]

On 1/8/2021 at 8:39 AM, GeriGIM said:

Are American-trained internists equipped to work in Canadian hospitals?

It sounds like American-trained residents spend considerably less time in the CCU. We, in general, also do fewer procedures. For example, I have never attempted a chest tube and I’m not proficient in central line placement. I cannot intubate. 

We certainly see sick patients. But we have loads of subspecialty support.

I intend to return to Canada, with the intent to practice GIM. Are Canadian GIMs placing tubes and lines all day? 

 

I think most canadian IM docs come out of residency able to do things like paras/thoras, lines, and maybe chest tubes/pigtails. Intubation is a huge plus/minus and I'd say the solid majority will not be highly skilled at airway management, though I'm sure many do it anyway later on.

Lines aren't hard to get good at if you've done some already. Maybe take a course to supplement? Chest tubes are easy. 

And yes you will not have nearly as much subspecialty support in most Canadian hospitals. In many hospitals, you're the actually consultant and the specialty support. Filling the role for subspecialties that aren't there. So the variability is high and can be as intense as starting dialysis or doing EGDs/scopes or bronchs (obviously one single IM doc doesn't do all, but it spans that range). 

[guy30]

It's interesting to hear the differences in American GIM training compared to Canadian training.

 

Other than the residency time difference of 3 years in the USA vs 5 years in Canada  (or 4 years for some community sites), American GIM's have much more of a focus on being primary care physicians whereas in Canada, GIM's are trained more as consultants and GIM subspecialists.

[cotecc]

Can an American GIM with a PGY3 come practice in Canada without additional training?

[JohnGrisham]

2 hours ago, cotecc said:

Can an American GIM with a PGY3 come practice in Canada without additional training?

Province dependent, but the safest bet is to do a PGY4 fellowship/chief year, to at least match the 4 years of GIM minimum...

[GeriGIM]

22 hours ago, cotecc said:

Can an American GIM with a PGY3 come practice in Canada without additional training?

The Royal College requires at least 4 years of training. They'd accept a clinically-focused Chief year (most Chief years in America are administrative jobs). They'd accept any ACGME-accredited fellowship (except sleep medicine). I'm dong a geriatrics fellowship with a focus on pre-op medicine. 

[GeriGIM]

On 1/10/2021 at 2:41 AM, medigeek said:

I think most canadian IM docs come out of residency able to do things like paras/thoras, lines, and maybe chest tubes/pigtails. Intubation is a huge plus/minus and I'd say the solid majority will not be highly skilled at airway management, though I'm sure many do it anyway later on.

Lines aren't hard to get good at if you've done some already. Maybe take a course to supplement? Chest tubes are easy. 

And yes you will not have nearly as much subspecialty support in most Canadian hospitals. In many hospitals, you're the actually consultant and the specialty support. Filling the role for subspecialties that aren't there. So the variability is high and can be as intense as starting dialysis or doing EGDs/scopes or bronchs (obviously one single IM doc doesn't do all, but it spans that range). 

GIM in Canada sounds fun. In America, we're the MRP on all admits --- from the simple CAP PNA to the decompensated cirrhotic. But, we promptly send anyone requiring pressors (centrally) or invasive vents to the ICU. Most hospitals here have ICUs adequately-staffed by intensivists. Some ICUs are co-managed by GIM and intensivists. Very very few ICUs are run solely by GIMs. I can't imagine any GIM in America doing EGDs/scopes/bronchs lol (unless they're in RURAL rural America). 

Ugh. It sounds like I won't be comfortable in a community-based Canadian hospital right off the bat. 

[GeriGIM]

On 1/10/2021 at 3:01 PM, guy30 said:

It's interesting to hear the differences in American GIM training compared to Canadian training.

 

Other than the residency time difference of 3 years in the USA vs 5 years in Canada  (or 4 years for some community sites), American GIM's have much more of a focus on being primary care physicians whereas in Canada, GIM's are trained more as consultants and GIM subspecialists.

What kinda consults are you getting from the hospitalists? 

[JohnGrisham]

40 minutes ago, GeriGIM said:

GIM in Canada sounds fun. In America, we're the MRP on all admits --- from the simple CAP PNA to the decompensated cirrhotic. But, we promptly send anyone requiring pressors (centrally) or invasive vents to the ICU. Most hospitals here have ICUs adequately-staffed by intensivists. Some ICUs are co-managed by GIM and intensivists. Very very few ICUs are run solely by GIMs. I can't imagine any GIM in America doing EGDs/scopes/bronchs lol (unless they're in RURAL rural America). 

Ugh. It sounds like I won't be comfortable in a community-based Canadian hospital right off the bat. 

EGDS, Scopes, Bronchs is not common place in all community hospitals, not by a long shot for GIM.    If you are within an hour of a major metropolitan centre, there will be someone to send non-urgent stuff to like GI or Gen surg who does EGDs/Scopes. Further out, sure there are GIMs doing them, but its not super common still - and certainly you can negotiate what you will offer as service, if it's not comfort level. This might be province specific however. Certainly the tertiary hospitals I have worked in, the GIMs still have access to subspecs for punting certain procedural work too.   Rural and semi-rural certainly is very different. And lets not forget scope of practice is often broad - a GIM in theory should be able to do all those procedures under scope of practice. But having scope, and feeling confident based on having had enough procedural skill during training, are two different things. 

[JohnGrisham]

23 minutes ago, GeriGIM said:

What kinda consults are you getting from the hospitalists? 

In Canada, majority of  hospitalist services are run my FM trained docs, and GIM are consultants(not always) who also follow their own patients, so if you have a complex multi-system issue, or if things get dicey, you can consult Internal medicine, and they either provide direction or take over care.   

A lot of it is site-specific and centre specific, and often for a flow perspective. Academic centre hospitalists are often covering 12-20 patients and new admits for their shifts, so theres no sense managing a DKA patient which is mostly time/checkinglabs/adjusting mgmt and not necessarily complex, and instead send that to the IM team, so their junior resident/intern can manage it.  In fact, in an academic centre, if the DKA patient was already presented as such(and not a new issue during their other unrelated admission), the Emerg doc wouldn't even send it to the hospitalist in the first place, and triage it for the Internal medicine team.  

In a community setting, the scope of what Hospitalists cover and what GIM covers varies, in some sites it can be night and day. Usually if its a multi-system issue that needs diagnostic clarification, GIM will take it directly from the EM doc, but if the diagnosis and management pathway is more clear, or if its more 1 system issues, hospitalists will take it.  If its a simple DKA, then yes the hospitalist is likely just covering it. 

A lot of the time, certain patient types are passed on to GIM from hospitalist, not because they can't handle it from a medical perspective- but more so they already have enough on their plate, and may as well provide the patient with a higher level of care. Again, a big aspect of culture and institution specific pathways.

[medigeek]

5 hours ago, JohnGrisham said:

In Canada, majority of  hospitalist services are run my FM trained docs, and GIM are consultants(not always) who also follow their own patients, so if you have a complex multi-system issue, or if things get dicey, you can consult Internal medicine, and they either provide direction or take over care.   

A lot of it is site-specific and centre specific, and often for a flow perspective. Academic centre hospitalists are often covering 12-20 patients and new admits for their shifts, so theres no sense managing a DKA patient which is mostly time/checkinglabs/adjusting mgmt and not necessarily complex, and instead send that to the IM team, so their junior resident/intern can manage it.  In fact, in an academic centre, if the DKA patient was already presented as such(and not a new issue during their other unrelated admission), the Emerg doc wouldn't even send it to the hospitalist in the first place, and triage it for the Internal medicine team.  

In a community setting, the scope of what Hospitalists cover and what GIM covers varies, in some sites it can be night and day. Usually if its a multi-system issue that needs diagnostic clarification, GIM will take it directly from the EM doc, but if the diagnosis and management pathway is more clear, or if its more 1 system issues, hospitalists will take it.  If its a simple DKA, then yes the hospitalist is likely just covering it. 

A lot of the time, certain patient types are passed on to GIM from hospitalist, not because they can't handle it from a medical perspective- but more so they already have enough on their plate, and may as well provide the patient with a higher level of care. Again, a big aspect of culture and institution specific pathways.

The shift from academic center/metro center hospitals in Canada to smaller community and rural is pretty drastic compared to USA. I'd say scope of practice is USA is somewhat consistent across the board until you get very rural. Open ICUs are fairly common in busy metro areas (not just small community/rural) so IM/FM hospitalists can be managing vented patients, placing lines, intubating etc as needed. Of course many hospitals also have closed ICUs (especially academic centers) so ICU doctors have full control and hospitalists only do general floor medicine. And IM/FM would always be on shared hospitalist teams (which seems to be the case at *some* medium sized hospitals in Canada but not all?). 

It's very rare for an IM doc to be doing advanced procedures in USA. I think bronchs is as far as it may get in some rural ICU settings, but haven't heard of diagnostic EGDs/colonoscopies. But have seen it for several job ads for GIM docs in Canada including places that are ~2 hours from Toronto and other provinces too. Procedural skill in USA can also vary from being very comfortable with difficult lines all the way to barely being able to do an LP or paracentesis. It's actually not uncommon for a GIM grad in USA to be uncomfortable with doing even an easy paracentesis. IR tends to take these procedures in many hospitals. 

As a side note, I would assume that FM hospitalists have the option of consulting GIM for complex patients rather than it being set strict protocol? In USA, some consults are essentially mandated (especially in some private hospitals). These are usually subspecialty consults and can be as wild as any new onset Afib needing a cardio consult. 

[JohnGrisham]

14 hours ago, medigeek said:

The shift from academic center/metro center hospitals in Canada to smaller community and rural is pretty drastic compared to USA. I'd say scope of practice is USA is somewhat consistent across the board until you get very rural. Open ICUs are fairly common in busy metro areas (not just small community/rural) so IM/FM hospitalists can be managing vented patients, placing lines, intubating etc as needed. Of course many hospitals also have closed ICUs (especially academic centers) so ICU doctors have full control and hospitalists only do general floor medicine. And IM/FM would always be on shared hospitalist teams (which seems to be the case at *some* medium sized hospitals in Canada but not all?). 

It's very rare for an IM doc to be doing advanced procedures in USA. I think bronchs is as far as it may get in some rural ICU settings, but haven't heard of diagnostic EGDs/colonoscopies. But have seen it for several job ads for GIM docs in Canada including places that are ~2 hours from Toronto and other provinces too. Procedural skill in USA can also vary from being very comfortable with difficult lines all the way to barely being able to do an LP or paracentesis. It's actually not uncommon for a GIM grad in USA to be uncomfortable with doing even an easy paracentesis. IR tends to take these procedures in many hospitals. 

As a side note, I would assume that FM hospitalists have the option of consulting GIM for complex patients rather than it being set strict protocol? In USA, some consults are essentially mandated (especially in some private hospitals). These are usually subspecialty consults and can be as wild as any new onset Afib needing a cardio consult. 

Generally yes, it would be up to the Hospitalist to decide if they want to consult. Again, when you're being paid hourly, and managing 15+ patients, you tend to err on the side of maybe consulting out 1-2 of your super complex patients to GIM if you can, to ease your load and manage your 7 days on service more sustainably. While some will continue to manage the complex patients, others realize burning out from overworking isn't the most sustainable to maintain a full time hospital based practice for the long term.

[JohnGrisham]

As for AFIB, definitely not auto-consulted cardio, but at the same time if its a new onset - they will probably need to see cardio (or GIM if you dont have cardio) eventually, to arrange for the further non-acute investigations/workups and follow-up. Just a matter of when, not if.

[medigeek]

4 hours ago, JohnGrisham said:

As for AFIB, definitely not auto-consulted cardio, but at the same time if its a new onset - they will probably need to see cardio (or GIM if you dont have cardio) eventually, to arrange for the further non-acute investigations/workups and follow-up. Just a matter of when, not if.

Yeah it was an example of little things that need auto-consults. A lot of the protocols are there to up the billing and keep the specialty services busy. Even small rural hospitals in USA often have pretty decent subspecialty availability (state dependent) and advanced imaging available. The rural patient population isn't as big so these consult services essentially will be consulted whenever possible.