Question about Internal Medicine and Family Medicine

[Patellaboy]

Hi Everyone,

Third year medical student here deciding between family medicine and internal medicine and I have a few questions I would like to clarify for each specialty:

 

Internal Medicine 

1. it seems that at minimum the training in Canada is 3 years + 1 year. I'm wondering if there are any resources regarding what can actually be done in the +1 year. I've seen hypertension clinics, thrombosis clinics but I would love to learn more about the specifics of the extra year. Is it completely flexible in that I can take 3-4 mo and work on a side gig - cosmetics for eg during that extra year of training?

2. I love internal medicine but the hospital environment/overnight call can be quite burdensome as I get older. I'm wondering if it is possible to completely practice in an outpatient setting as general internist and if this is common to do? It would also be great if any internists in the community can share what a typical month looks like for them and how they split their time with clinic and hospital, and their call schedules.

 

Family Medicine

1. I've seen family physicians work in specialty clinics, with or without a +1 extra training year, such as sports medicine, weight loss clinics, mental health. Do these physicians get access to special billing codes? Would the pay be comparable to the specialist billing codes for doing the same work? - Eg a GP providing psychotherapy and mental health counselling in a specialized clinic vs a Psychiatrist working in the same clinic?

Thank you very much!

[Supervenience]

For family medicine, physicians with plus 1 training or significant experience can get a focused practice designation. This does give them access to special billing codes. However it makes no difference in practice because the special codes bill the same amount as an A007 (intermediate assessment) that any FP can bill.

 

Their billing codes are not the same as specialists. For example, a psychiatrist doing psychotherapy with outpatients bills K197. A GP psychotherapist bills K005. The psychiatrist makes more money. This is generally the case for specialist vs FP billing.

[ACHQ]

On 12/15/2022 at 11:31 AM, Patellaboy said:

Hi Everyone,

Third year medical student here deciding between family medicine and internal medicine and I have a few questions I would like to clarify for each specialty:

 

Internal Medicine 

1. it seems that at minimum the training in Canada is 3 years + 1 year. I'm wondering if there are any resources regarding what can actually be done in the +1 year. I've seen hypertension clinics, thrombosis clinics but I would love to learn more about the specifics of the extra year. Is it completely flexible in that I can take 3-4 mo and work on a side gig - cosmetics for eg during that extra year of training?

2. I love internal medicine but the hospital environment/overnight call can be quite burdensome as I get older. I'm wondering if it is possible to completely practice in an outpatient setting as general internist and if this is common to do? It would also be great if any internists in the community can share what a typical month looks like for them and how they split their time with clinic and hospital, and their call schedules.

 

Family Medicine

1. I've seen family physicians work in specialty clinics, with or without a +1 extra training year, such as sports medicine, weight loss clinics, mental health. Do these physicians get access to special billing codes? Would the pay be comparable to the specialist billing codes for doing the same work? - Eg a GP providing psychotherapy and mental health counselling in a specialized clinic vs a Psychiatrist working in the same clinic?

Thank you very much!

GIM staff at a large tertiary centre in the GTA.

 

1. yes you are correct that is the minimum training to get a license for GIM in Canada. that "extra" year is not an extra year at all, it is a full year of clinical training that is required for your IM certification (both by the royal college and CPSO). Subspecialists are allowed to use 1 year of their subspecialty training to fulfill that requirement and therefore get a license/certification in IM. Generally that year is pretty open though, but is school dependent. If i recall I had to do 2 months of GIM in the community, 1 month of ICU, 1 month of ID and 1 month of Stroke/Neuro. The rest was elective time. Most people try to max out there electives at community sites that will be hiring so they can get a position in GIM. 

 

2. Unfortunately that is the drawback of GIM, in the hospital setting. At the centre I work at we do 8 hour shifts (0800-1600, 1600-0000. 0000-0800), and as a GIM staff we do a balance of each shift. We all do at least 1 night (0000-0800) a month, and depending on how many total ER consults shifts you are contracted to do, anywhere from 1-3 evenings a month. My typical schedule is roughly 1 week a month of MRP/Hospital ward GIM work (including the weekend), 5 x8 hour ER/ED consult shifts a month, 4 weeks/yr of Urgent GIM hospital based clinic and 3 weeks/yr of Inpatient medical consults (consults to the surgical, OB, psych and rehab wards). I often fill in some open spots I have in my schedule. Most GIM's (in Ontario at least) do hospital based work and not outpatient practice. It would be pretty easy to get an outpatient GIM practice in the community, but the overhead of 20-33% is a killer, and you make substantially more doing acute care medicine in the hospital (which means evenings, nights, weekends, holiday work which pays the most). When I mean substantially I mean like 200-300 k more. Also when you have your *own* clinic/practice people don't realize this but those patients are yours, its hard to take vacation/time off because you need to find coverage for those patients.

[Patellaboy]

6 hours ago, ACHQ said:

GIM staff at a large tertiary centre in the GTA.

 

1. yes you are correct that is the minimum training to get a license for GIM in Canada. that "extra" year is not an extra year at all, it is a full year of clinical training that is required for your IM certification (both by the royal college and CPSO). Subspecialists are allowed to use 1 year of their subspecialty training to fulfill that requirement and therefore get a license/certification in IM. Generally that year is pretty open though, but is school dependent. If i recall I had to do 2 months of GIM in the community, 1 month of ICU, 1 month of ID and 1 month of Stroke/Neuro. The rest was elective time. Most people try to max out there electives at community sites that will be hiring so they can get a position in GIM. 

 

2. Unfortunately that is the drawback of GIM, in the hospital setting. At the centre I work at we do 8 hour shifts (0800-1600, 1600-0000. 0000-0800), and as a GIM staff we do a balance of each shift. We all do at least 1 night (0000-0800) a month, and depending on how many total ER consults shifts you are contracted to do, anywhere from 1-3 evenings a month. My typical schedule is roughly 1 week a month of MRP/Hospital ward GIM work (including the weekend), 5 x8 hour ER/ED consult shifts a month, 4 weeks/yr of Urgent GIM hospital based clinic and 3 weeks/yr of Inpatient medical consults (consults to the surgical, OB, psych and rehab wards). I often fill in some open spots I have in my schedule. Most GIM's (in Ontario at least) do hospital based work and not outpatient practice. It would be pretty easy to get an outpatient GIM practice in the community, but the overhead of 20-33% is a killer, and you make substantially more doing acute care medicine in the hospital (which means evenings, nights, weekends, holiday work which pays the most). When I mean substantially I mean like 200-300 k more. Also when you have your *own* clinic/practice people don't realize this but those patients are yours, its hard to take vacation/time off because you need to find coverage for those patients.

Appreciate the insight. Couple of follow up questions - 

1. That elective time in the fourth year of GIM - can you technically do whatever you want with it? For example a focus on obesity medicine? It would be great if you can give some examples of niche areas you've seen people focus on. I've seen thrombosis clinic, hypertension clinics and I'm curious to know what else is out there. Also some provinces give special billing codes to GIM specialists for complex patients (ie 3 or more chronic diseases) - is it the same in Ontario?
2. Would you mind clarifying the point you made on "the patient is yours?". I've read this a lot, particularly with regards to one of the drawbacks of FM, but is it actually true that you cannot take 1-2 weeks of consecutive vacation time without finding a locum? I understand that the patient is connected to you and your clinic, but if something were to happen to your patients, are you actually responsible for their health 24/7? Can they just not go to an urgent care clinic or the ED? Apologies if this sounds like a dumb question, genuinely curious if this is some sort of unwritten CMA rule when providing longitudinal care that I did not know about.

[gangliocytoma]

8 hours ago, Patellaboy said:

Appreciate the insight. Couple of follow up questions - 

1. That elective time in the fourth year of GIM - can you technically do whatever you want with it? For example a focus on obesity medicine? It would be great if you can give some examples of niche areas you've seen people focus on. I've seen thrombosis clinic, hypertension clinics and I'm curious to know what else is out there. Also some provinces give special billing codes to GIM specialists for complex patients (ie 3 or more chronic diseases) - is it the same in Ontario?
2. Would you mind clarifying the point you made on "the patient is yours?". I've read this a lot, particularly with regards to one of the drawbacks of FM, but is it actually true that you cannot take 1-2 weeks of consecutive vacation time without finding a locum? I understand that the patient is connected to you and your clinic, but if something were to happen to your patients, are you actually responsible for their health 24/7? Can they just not go to an urgent care clinic or the ED? Apologies if this sounds like a dumb question, genuinely curious if this is some sort of unwritten CMA rule when providing longitudinal care that I did not know about.

If you disappeared for 2 weeks you'd have a 2 week backlog of work to return to. This includes all the inbox items such as prescription renewal, labs, imaging, consult reports, forms to sift through and some of these things need to be dealt with in a timely manner. You start someone on a new antihypertensive ask them to get BW done, labs come back and they have an AKI with a potassium of 8 and you've just hopped on a plane and don't see it until you get back, pt becomes anuric and dies from a hyperkalemic arrest. Pt has Afib on apixaban and their meds run out, the pharmacy sends a prescription renewal request to you but you're gone on a wilderness retreat and not checking inbox. Patient has a disabling stroke because they've been off their anticoagulation for two weeks. Not common scenarios by any means but you'd absolutely be liable.

Also, pushing back appointments 2 weeks (in addition to all the people that try and book in with you for 2 weeks) would make your wait times quite long. You are not responsible for their care 24/7, but sending patients to the ED for things that are better suited for a FP will either lead to nothing being done or them being done poorly. As an FP you'll have a ton of appointments that are booked far ahead of time to follow up people's chronic diseases like diabetes, BP, mental health issues, well baby checks, OB visits, etc. so it isn't just whoever wanted to see you because of an acute ailment that started while you were on vacation. These things will not be dealt with in the ED and you'll just a get a snarky note back from the EP. It will also teach your patients to go to the ER or UC rather than reach out to you, and perhaps use it for the wrong things. In ON your capitation fee will get chomped if they are rostered and go to walk in clinics (and I think as well if they go to ER). 

And while this mainly applies to FM, this would also apply to specialists with a large roster of patients they follow as well.

[ACHQ]

On 12/19/2022 at 10:33 PM, Patellaboy said:

Appreciate the insight. Couple of follow up questions - 

1. That elective time in the fourth year of GIM - can you technically do whatever you want with it? For example a focus on obesity medicine? It would be great if you can give some examples of niche areas you've seen people focus on. I've seen thrombosis clinic, hypertension clinics and I'm curious to know what else is out there. Also some provinces give special billing codes to GIM specialists for complex patients (ie 3 or more chronic diseases) - is it the same in Ontario?
2. Would you mind clarifying the point you made on "the patient is yours?". I've read this a lot, particularly with regards to one of the drawbacks of FM, but is it actually true that you cannot take 1-2 weeks of consecutive vacation time without finding a locum? I understand that the patient is connected to you and your clinic, but if something were to happen to your patients, are you actually responsible for their health 24/7? Can they just not go to an urgent care clinic or the ED? Apologies if this sounds like a dumb question, genuinely curious if this is some sort of unwritten CMA rule when providing longitudinal care that I did not know about.

1. As long as you can set up the elective you can generally do it in any area. in Ontario everyone under Internal medicine can bill the IM codes and there isn't a special code for complex patients (like multiple co-morbidities), I think BC has something like this. In Ontario if we spend 75min with a patient that can be billed as a "complex" consult, but it is time based not based off of how complex the patient is.

 

2. See above posters response. Although I agree that is mostly for FM. That being said with being a specialist you also can't just take off for prolonged periods of time without having a covering physician, but 2 weeks is probably possible (3 might be stretching it). But if you get urgent results and your on vacation well your F$%$$@, also the backlog of patients will grow.