Private Practice USA vs Canada?

[usatocanada]

Hello.

I am a PGY2-IM resident in the USA (Canadian Citizen who went to a Caribb school).

I am in the midst of debating returning to Canada vs staying in the US and need some assistance in my decision making.

At the moment, I am likely not going to do a subspecialty because I am in a HCOL area with lower than the national average pay (For residents, not GDP). I am having a very hard time taking care of my 2 kids/wife on my resident salary (wife not allowed to work under our visa restrictions).

 

After having worked in the US system, I'm not sure if I enjoy it here. There is a sickly amount of hassle with insurance companies. 

My ultimate goal is to start my own private practice and was recently informed that Canada is apparently friendlier than the US to private practice since it hasn't been ripped apart by private equity/venture capital.

In that respect, I am interested in starting a stress-test/ECHO clinic (I have the funding via family). However, I was always told that in Canada, I cannot do anything outside of a hospital AND bill for it. Is this true? Or will I be allowed to bill for it? 

At the same time, I have been approached by recruiters in the GTA area (think Pickering, Peterborough, and Hamilton), who are offering me salaries of 450-550K CAD for GIM work... I am stunned because US counterparts are clearing 250k and if lucky, 300-350k (night calls, working 20+ shifts/month)... Are these numbers true?

Please advise. I am constantly being told to do a subspecialty but I'm not sure if I can bear another 3-4 years in poverty and drive my family through this extremely painful process.

Thank you.

TLDR - Canadian citizen US IMG with IM residency wanting to return to Canada to open a private clinic + stress test/ECHO lab and wanting to know if I can bill for those diagnostic procedures?

Yes I am aware I will need to join via one of the pathways - I will be doing my first Canadian exam shortly after ABIM and will be ok with working under supervision if needed.

[bearded frog]

7 hours ago, usatocanada said:

I am interested in starting a stress-test/ECHO clinic

The billing codes are available online so you can look up yourself what the criteria are. There is no reason you can't hang a shingle and take GIM consults. In terms of procedures, the bottleneck with hostpials you refer to is for procedures that require sedation/an OR (cardiac cath, endoscopy etc.). For echo, a quick review of the relevant section (Page J21 of https://www.health.gov.on.ca/en/pro/programs/ohip/sob/physserv/sob_master_20221201.pdf) says that your facility will have to be accredited and you will have to have specific training (it talks about at least level II proficiency, which I don't know if is a thing in the US, but according to the guidelines at the Canadian Society of Electrocardiography (https://csecho.ca/) it seems possible for a internal medicine graduate without cardiology fellowship to be eligible for the training, but does require additional specific training. So I would say do some research before jumping in!

[shikimate]

Physician payments are public in provinces like BC and NB. I can verify that GIM in my vicinity make anywhere from 300K to 600K CAD. Of course that depends on how much work you are willing to do and what type of work.

In fact there is a shortage of GIM where I practice and family docs are being pulled to do hospitalist work, so there is great demand for GIM.

Also I tell this to every med student/resident: people in academia will want you to do as many fellowships as you are willing, because they can get 500K of RVU meanwhile pay you 80K salary. Capitalism at its best!

So if you are not picky about location or type of work, why waste 2-3 years in fellowship? Each fellowship year could theoretically cost you $500K had you being doing busy full practice. So after that shiny 2 year fellowship you could be short changed up to 1 million dollars.

 

[ACHQ]

On 3/26/2023 at 6:42 PM, usatocanada said:

Hello.

I am a PGY2-IM resident in the USA (Canadian Citizen who went to a Caribb school).

I am in the midst of debating returning to Canada vs staying in the US and need some assistance in my decision making.

At the moment, I am likely not going to do a subspecialty because I am in a HCOL area with lower than the national average pay (For residents, not GDP). I am having a very hard time taking care of my 2 kids/wife on my resident salary (wife not allowed to work under our visa restrictions).

 

After having worked in the US system, I'm not sure if I enjoy it here. There is a sickly amount of hassle with insurance companies. 

My ultimate goal is to start my own private practice and was recently informed that Canada is apparently friendlier than the US to private practice since it hasn't been ripped apart by private equity/venture capital.

In that respect, I am interested in starting a stress-test/ECHO clinic (I have the funding via family). However, I was always told that in Canada, I cannot do anything outside of a hospital AND bill for it. Is this true? Or will I be allowed to bill for it? 

At the same time, I have been approached by recruiters in the GTA area (think Pickering, Peterborough, and Hamilton), who are offering me salaries of 450-550K CAD for GIM work... I am stunned because US counterparts are clearing 250k and if lucky, 300-350k (night calls, working 20+ shifts/month)... Are these numbers true?

Please advise. I am constantly being told to do a subspecialty but I'm not sure if I can bear another 3-4 years in poverty and drive my family through this extremely painful process.

Thank you.

TLDR - Canadian citizen US IMG with IM residency wanting to return to Canada to open a private clinic + stress test/ECHO lab and wanting to know if I can bill for those diagnostic procedures?

Yes I am aware I will need to join via one of the pathways - I will be doing my first Canadian exam shortly after ABIM and will be ok with working under supervision if needed.

I'm a GIM that trained in Canada and work in a large suburban centre in the GTA.

No this is not true. Not sure the requirements for echo readings (if there is even any), extremely few GIM read echos, especially now with enough cardiologists available. I doubt you'll be able to do this in a large urban/suburban centre. Reading stress testing or Holter's maybe possible though.

 

No hospital group can off any salary, we are all fee for service (plus a small stipend with each shift). But what I am assuming those "recruiters" are referring are the amount you could bill for doing full time GIM work. Those numbers are not off especially if you work hard and alot, remember that range in CAD calculates to 290-400 US (which is still higher than the US pay, but we also get taxed way more and get 0 benefits)

[usatocanada]

On 3/27/2023 at 2:33 AM, bearded frog said:

The billing codes are available online so you can look up yourself what the criteria are. There is no reason you can't hang a shingle and take GIM consults. In terms of procedures, the bottleneck with hostpials you refer to is for procedures that require sedation/an OR (cardiac cath, endoscopy etc.). For echo, a quick review of the relevant section (Page J21 of https://www.health.gov.on.ca/en/pro/programs/ohip/sob/physserv/sob_master_20221201.pdf) says that your facility will have to be accredited and you will have to have specific training (it talks about at least level II proficiency, which I don't know if is a thing in the US, but according to the guidelines at the Canadian Society of Electrocardiography (https://csecho.ca/) it seems possible for a internal medicine graduate without cardiology fellowship to be eligible for the training, but does require additional specific training. So I would say do some research before jumping in!

So I have a friend who is a board-certified cardiologist who would be the one signing off. I am the one forking the capital to start it and taking the business risk. He lacks business accumen, hence our partnership.

While I did go through the document briefly, I am still unsure of the laws around starting my own echo clinic.

[usatocanada]

On 3/28/2023 at 4:49 PM, ACHQ said:

I'm a GIM that trained in Canada and work in a large suburban centre in the GTA.

No this is not true. Not sure the requirements for echo readings (if there is even any), extremely few GIM read echos, especially now with enough cardiologists available. I doubt you'll be able to do this in a large urban/suburban centre. Reading stress testing or Holter's maybe possible though.

 

No hospital group can off any salary, we are all fee for service (plus a small stipend with each shift). But what I am assuming those "recruiters" are referring are the amount you could bill for doing full time GIM work. Those numbers are not off especially if you work hard and alot, remember that range in CAD calculates to 290-400 US (which is still higher than the US pay, but we also get taxed way more and get 0 benefits)

I don't wish to read the ECHO, but more so own the laboratory/diagnostic center.

As for working in Canada, do you know any good techniques to avoid tax? I want to return home but I don't think the real estate prices allow me to even afford a shoebox...

[usatocanada]

On 3/27/2023 at 9:07 PM, shikimate said:

Physician payments are public in provinces like BC and NB. I can verify that GIM in my vicinity make anywhere from 300K to 600K CAD. Of course that depends on how much work you are willing to do and what type of work.

In fact there is a shortage of GIM where I practice and family docs are being pulled to do hospitalist work, so there is great demand for GIM.

Also I tell this to every med student/resident: people in academia will want you to do as many fellowships as you are willing, because they can get 500K of RVU meanwhile pay you 80K salary. Capitalism at its best!

So if you are not picky about location or type of work, why waste 2-3 years in fellowship? Each fellowship year could theoretically cost you $500K had you being doing busy full practice. So after that shiny 2 year fellowship you could be short changed up to 1 million dollars.

 

Where do you work? If it's BC, I am considering moving there (All dependent on pay). 

As for academia, I have friends who have spent 6-9 years in residency, absolutely broke, and finally are making a few pennies.

I think if I don't start practicing soon, I will lose my own health. We are surviving on a thread at the moment in our current situation.

[GH0ST]

On 3/30/2023 at 12:01 PM, usatocanada said:

Where do you work? If it's BC, I am considering moving there (All dependent on pay). 

As for academia, I have friends who have spent 6-9 years in residency, absolutely broke, and finally are making a few pennies.

I think if I don't start practicing soon, I will lose my own health. We are surviving on a thread at the moment in our current situation.

Can I just say how awful that is... a doctor barely making it with the current living situation. 

- G

[usatocanada]

11 hours ago, GH0ST said:

Can I just say how awful that is... a doctor barely making it with the current living situation. 

- G

I am at one of the lowest paid hospitals in the US. All my colleagues are either single, have parental support, taken out EXTRA loans, OR have working spouses - everyone wants to do GI/Cardiology, and are willing to spend 6-8 years to get there. I don't know if I can. Wife wants me to do it but I see it in her eyes that she's tired and suffering with me. This is why I am extremely adamant to go into business. This entire landscape changed me after subjecting me through the worst trauma - all while being at a malignant program.

 

For your interest: 

1 month's salary is not enough to cover a 1 bedroom apartment (average $3000 USD while income is $4400 USD).

We live in the absolute worst condition right now and have delayed gratification in every single way.

The only guilty pleasure we have left is the occasional fast food (not fine dining because over $30-40 USD would rip apart my 2 week paycheck).

Bi-weekly income - $2200 USD 

Family Health Insurance (mandatory for our visa) - $300 USD bi-weekly

Grocery costs/2 weeks - $500 USD ($300 on produce/daily supplies and + $150-200 on meat).

Gasoline/ 2weeks - $100 USD

Internet - ~$100 USD (bought the cheaper package)

Telephone Bills - ~$100 USD 

Rent - $1000 USD (we live in subsidized housing)

As you can see = +2200 - ( 1000+300+500+100+100+100) = $100 left. This is my spending money to take out my wife and kids to eat and this usually gets eaten up by another cost - recently oil change for my car.

If I did not live in subsidized housing, I would be on the street. 

When brought up with my hospital, was told to suck it up.

 

[usatocanada]

bump

[rmorelan]

On 4/2/2023 at 10:50 AM, usatocanada said:

I am at one of the lowest paid hospitals in the US. All my colleagues are either single, have parental support, taken out EXTRA loans, OR have working spouses - everyone wants to do GI/Cardiology, and are willing to spend 6-8 years to get there. I don't know if I can. Wife wants me to do it but I see it in her eyes that she's tired and suffering with me. This is why I am extremely adamant to go into business. This entire landscape changed me after subjecting me through the worst trauma - all while being at a malignant program.

 

For your interest: 

1 month's salary is not enough to cover a 1 bedroom apartment (average $3000 USD while income is $4400 USD).

We live in the absolute worst condition right now and have delayed gratification in every single way.

The only guilty pleasure we have left is the occasional fast food (not fine dining because over $30-40 USD would rip apart my 2 week paycheck).

Bi-weekly income - $2200 USD 

Family Health Insurance (mandatory for our visa) - $300 USD bi-weekly

Grocery costs/2 weeks - $500 USD ($300 on produce/daily supplies and + $150-200 on meat).

Gasoline/ 2weeks - $100 USD

Internet - ~$100 USD (bought the cheaper package)

Telephone Bills - ~$100 USD 

Rent - $1000 USD (we live in subsidized housing)

As you can see = +2200 - ( 1000+300+500+100+100+100) = $100 left. This is my spending money to take out my wife and kids to eat and this usually gets eaten up by another cost - recently oil change for my car.

If I did not live in subsidized housing, I would be on the street. 

When brought up with my hospital, was told to suck it up.

 

Ok of course that all sounds generally horrible. 

Obviously the current painful situation is clouding the process. What are you ultimately trying to accomplish here? So far you haven't stated an actual interest in any of the subspeciality options for their own sake - considering you will be starving for years doing it that does seem to be relevant factor. Is the starting of a clinic (which is of course a crowded space and biased towards people subspeciality trained in that area, and also securing a referral base can be a challenge) purely a profit focused activity? Why does your wife want you to do GI/cardiology - if the point it is likely a logical pathway to getting out the hellscape you are in then that has to be balanced against the well 500K you seem like you can earn very shortly already. What additional income to that are you expecting with the additional training (yes in Canada it is possible for those fields to exceed what you are being offered but how many years will you be working to do it over what you seem to be able to do right now and at what price.)

You are adamant to go in to business - understandable, although I will point out that the vast majority of all doctors in Canada by default are in business. I am a one person medical corporation as a radiologist as an example. Salary is a rare thing in Canada, in part because we don't want to lose control of things - like what has happened in the US. I can take my corporation and over time do whatever logical medical business move I want with it - buy radiologist clinics,  run a nighthawk company....whatever. Following that I have multiple revenue streams, corporate assets, and so on. You can start with your GIM activities and expand from there (with the backing of cash flow for that matter). You can take your time picking a location, putting out feelers for how likely your business enterprises would work and move when logical - no rush in other words. 

so....what do you want? for today, for 5 years from now, and for 20 years from now? 

 

 

 

 

 

 

 

[usatocanada]

9 hours ago, rmorelan said:

Ok of course that all sounds generally horrible. 

Obviously the current painful situation is clouding the process. What are you ultimately trying to accomplish here? So far you haven't stated an actual interest in any of the subspeciality options for their own sake - considering you will be starving for years doing it that does seem to be relevant factor. Is the starting of a clinic (which is of course a crowded space and biased towards people subspeciality trained in that area, and also securing a referral base can be a challenge) purely a profit focused activity? Why does your wife want you to do GI/cardiology - if the point it is likely a logical pathway to getting out the hellscape you are in then that has to be balanced against the well 500K you seem like you can earn very shortly already. What additional income to that are you expecting with the additional training (yes in Canada it is possible for those fields to exceed what you are being offered but how many years will you be working to do it over what you seem to be able to do right now and at what price.)

You are adamant to go in to business - understandable, although I will point out that the vast majority of all doctors in Canada by default are in business. I am a one person medical corporation as a radiologist as an example. Salary is a rare thing in Canada, in part because we don't want to lose control of things - like what has happened in the US. I can take my corporation and over time do whatever logical medical business move I want with it - buy radiologist clinics,  run a nighthawk company....whatever. Following that I have multiple revenue streams, corporate assets, and so on. You can start with your GIM activities and expand from there (with the backing of cash flow for that matter). You can take your time picking a location, putting out feelers for how likely your business enterprises would work and move when logical - no rush in other words. 

so....what do you want? for today, for 5 years from now, and for 20 years from now? 

 

 

 

 

 

 

 

I very much enjoyed reading your post as it has allowed me to both validate and question my current thought process.

My very own honest and blunt truth is that I do not have a genuine passion for any subspecialty. I have friends who are DIE hard GI/Cardio people. They sleep to their Cardio textbooks and will regurgitate studies that I've never heard of. I am not like that. My pursuit for a fellowship would be solely financial, and like you mentioned, would require absolute extensive hell.

I am pleased to hear that you are in private practice and choose to do so voluntarily to maintain autonomy. You are correct of US physicians losing their autonomy. 

I am currently thinking of working for 1-2 years, raising liquid cash assets in my corporation, and then investing into an urgent care model similar to the US (mini-ER) and then other activities. I am also interested in radiological clinics and looking to partner with a radiologist as I have friends who are venture capitalists/angel investors and can likely raise capital to obtain MRI/Xray/US machinery. I am far more interested in the business aspect than any fellowship. 

I read one quote one time - whatever you think about in the shower, that's what you care the most about. I only think about business and how to get there.