General Internal Medicine in Ontario

[Samic1988]

Hello everyone,

Incoming PGY1 IM here, I have a question regarding future IM practice in Ontario, I’v heard that GIM who do purely outpatients in private clinics in Ontario can even see patients without referral from FM, kind of acting like primary care physicians, but it will be with ohip cheaper codes, wondering if anyone has any insight 

[ameltingbanana]

You can do this - I'd be very careful about doing this as we do not get sufficient training in things like: Ob, Pediatrics, fractures, etc and if you are seeing patients without referral you'd have to restrict your practice.

This is speaking as a general internist who was offered the chance to do some of this in PGY5, in a virtual med capacity, and I said no. We function best in a consultant role in my opinion and shouldn't be going into primary care and that's not how we're trained.

[Samic1988]

Thank you very much for the info, I have aimed for GIM 4 years, going to UofT and a little worried about job market, what is your thoughts about 4 years GIM job market in GTA wanting to have mixed inpatient / outpatient practice?

[ameltingbanana]

I'll be honest, it seems in the GTA that outpatient GIM doesn't get to do a ton of management - the major role for outpatient GIM clinics is in the style of "rapid assessment clinics" where people present to ER; determined they don't need admission but need urgent followup for their issue --> see GIM as an outpatient within 1-2 weeks. I will say this type of clinic can be pretty fun to do depending on the setup. Otherwise it's fairly vague stuff that comes up, or very multimorbid patients where every organ is sort of slowly failing and the subspecialists are all focusing on their own system and the real discussion is probably about palliative care. 

For full scope longitudinal  outpatient care, I think you'll have to go away from the GTA a bit and/or be comfortable setting up your own shingle. Or do a PGY5 year/AFC like thrombo/hepatology/something less formal like obstetric medicine/cardiodiagnostics etc and have that be your outpatient "niche".

I get the sense the job market is still decent for GIM as long as you're willing to do some after hours call and be flexible. 4 year will likely be primary community hospitals in the GTA, but there's tons to choose from and a lot of community GIM docs seem quite happy.

I know @ACHQ posts here and is a general internist in the community and may be able to answer some more questions - I went back and did some more training after GIM so I'm just intermittently locuming at the moment, he/she may be able to provide more info. My perspective is coming from someone who doesn't really like clinic outside of rapid access clinic that much, so I focused a lot more on inpatient - just noting my bias here.

[ACHQ]

On 3/30/2023 at 3:00 PM, ameltingbanana said:

I'll be honest, it seems in the GTA that outpatient GIM doesn't get to do a ton of management - the major role for outpatient GIM clinics is in the style of "rapid assessment clinics" where people present to ER; determined they don't need admission but need urgent followup for their issue --> see GIM as an outpatient within 1-2 weeks. I will say this type of clinic can be pretty fun to do depending on the setup. Otherwise it's fairly vague stuff that comes up, or very multimorbid patients where every organ is sort of slowly failing and the subspecialists are all focusing on their own system and the real discussion is probably about palliative care. 

For full scope longitudinal  outpatient care, I think you'll have to go away from the GTA a bit and/or be comfortable setting up your own shingle. Or do a PGY5 year/AFC like thrombo/hepatology/something less formal like obstetric medicine/cardiodiagnostics etc and have that be your outpatient "niche".

I get the sense the job market is still decent for GIM as long as you're willing to do some after hours call and be flexible. 4 year will likely be primary community hospitals in the GTA, but there's tons to choose from and a lot of community GIM docs seem quite happy.

I know @ACHQ posts here and is a general internist in the community and may be able to answer some more questions - I went back and did some more training after GIM so I'm just intermittently locuming at the moment, he/she may be able to provide more info. My perspective is coming from someone who doesn't really like clinic outside of rapid access clinic that much, so I focused a lot more on inpatient - just noting my bias here.

This sums up my thoughts re outpatient GIM. Unless you are in a rural or severely under-serviced region, true outpatient GIM isn't as good as the rapid referral/hospital based clinics. I *usually* have a good time with our urgent GIM clinic with the type of pathology and acuity we see (and I'm sure its similar at other centres).

 

GIM job market is really good right now in the GTHA (at least as I can see), a lot of big centres (including mine) are hiring. In fact we have had to compete with other centres and have had a hard time hiring new grads as a result.

[Samic1988]

Thank you very much both of you for valuable information!

[usatocanada]

Canadian Citizen US GIM here in PGY2. 1 year away from finishing. May return to Canada vs US (Solely dependent on income potential).

In regards to job market, it seems to be very good. I am hearing numbers ranging from $350-600k (most have been hovering around $450-500k CAD) for what is inpatient EM consults, possible admissions, emergent admissions, and etc. I have recruiters message everyday. I have also seen some people mention that it is not unusual to bill $5-10k per shift if you have a busy ER.

As for outpatient, in the US, we are trained to do both PCP/general IM (restriction being OB/Gyn/Peds - but we just refer out). HOWEVER, US GIM PCP is essentially a secretary for specialists - you refer out for everything. Chronic back pain? PMR/Ortho. Chest pain in a 19 year old? Forget even getting an EKG, cardio referral URGENT (for what a med student can diagnose as anxiety). Belly pain? Don't prescribe PPI, refer the 18 year old to GI for scope. 

Everything is about referring out, letting them handle it, and essentially mitigating your litigation risk. US is litigation heavy and part of our medical management is about litigation management.

In Canada, I believe you CAN operate as a PCP AND do peds/ob but you need to be comfortable with it. If you are not, you are risking your license/patient care. You can probably follow the US model and refer out any slightly complicated peds/OB stuff. However, I believe your billing code will be in the FM end which will reimburse you lower than if you saw 3 patients in an hour at the hospital - WITHOUT overhead.

The main reason to open a clinic in USA is to 1) Be your own boss, 2) own your incorporation and benefit from tax laws, and 3) own your patients. Majority of US physicians are employees and do NOT own their practice. That train ended almost 20-30 years ago when private equity/venture capital bought out most clinics and integrated them with a local hospital system that they also own.

This does not seem to be a problem in Canada since all physicians are independent contractors, regardless of specialty, who PROVIDE services to the GOVERNMENT, and therefore you are your own boss, and can refer the inpatient people to your outpatient clinic for F/U.

If your goal is compensation, stick to GIM inpatient and have an outpatient clinic for F/Us and take them from there. Your practice will be full of adult patients who are non ob/peds. Your hospital will be your number 1 marketing tool if you aren't marketing savvy and using other avenues like social media.

[Samic1988]

These are very useful info, I believe sticking in GIM and having mixed inpatient/ outpatient clinics would be one of best models for GIM. You can also get the GIM with 1 extra year (total 4 years) which is not bad. Regardless of personal preference for IM, I have been thinking that there should be more compensation for physicians with at least 2 years more training compared to FM docs in Canada.

[ACHQ]

On 4/4/2023 at 10:22 AM, usatocanada said:

In Canada, I believe you CAN operate as a PCP AND do peds/ob but you need to be comfortable with it. If you are not, you are risking your license/patient care. You can probably follow the US model and refer out any slightly complicated peds/OB stuff. However, I believe your billing code will be in the FM end which will reimburse you lower than if you saw 3 patients in an hour at the hospital - WITHOUT overhead.

I don't know any GIM that would be willing to take the risk of doing PCP like work and being OK with seeing peds or OB (outside of medical OB i.e. PET) or psych patients. Regardless of if you are "comfortable" or not. We literally get 0% of our training towards that in residency. High risk, zero reward. No thanks

[usatocanada]

18 hours ago, ACHQ said:

I don't know any GIM that would be willing to take the risk of doing PCP like work and being OK with seeing peds or OB (outside of medical OB i.e. PET) or psych patients. Regardless of if you are "comfortable" or not. We literally get 0% of our training towards that in residency. High risk, zero reward. No thanks

I personally would not do it either. 

For the OP, why not start the clinic and have an OB or Pediatric NP work under you? They are licensed I believe under their own name, no?

[ACHQ]

7 hours ago, usatocanada said:

For the OP, why not start the clinic and have an OB or Pediatric NP work under you? They are licensed I believe under their own name, no?

or if they want to see peds or OB in a primary care setting (which is not what I think they want) then why not just do family medicine...

[usatocanada]

1 hour ago, ACHQ said:

or if they want to see peds or OB in a primary care setting (which is not what I think they want) then why not just do family medicine...

I agree, they should do FM. I'm suggesting possible alternatives if OP is adamant of doing GIM and requires outpatient access too. But definitely should do FM.

[ameltingbanana]

On 4/7/2023 at 5:18 PM, ACHQ said:

I don't know any GIM that would be willing to take the risk of doing PCP like work and being OK with seeing peds or OB (outside of medical OB i.e. PET) or psych patients. Regardless of if you are "comfortable" or not. We literally get 0% of our training towards that in residency. High risk, zero reward. No thanks

Yeah, I completely agree with this. We are not primary care in Canada nor are we trained to be. Doesn't matter if our archaic billing code lets you do so. OP if this is your jam family med +/- hospitalist is a better fit.

[Samic1988]

Thank you

 

[futureGP]

If u want to do primary care, wouldnt waste time doing canadian IM, just do GP.

 

You can theoretically be ambitious and set up a ‘private community GIM clinic’ and market towards GPs. But your referral pool will probably be whatever is left over from the region that other subspecs don’t see.

That said, as GIM trained in Canada you can easily to low-risk cardiology and work for a busy cardiology clinic as the GIM with interest in cardiology. You can bill consults, interpret stress test/Holters but not Echo and pay some overhead to the cardiologist. 
 

also if you are enterpreneurial, find a region with relatively long subspec waitlist, find a GP group, join their office and pay overhead and offer to see simple things to help with GP clinic workflow (eg anemia mgmt, diabetes, hypertension). It makes financial sense as GP that owns the office makes money off of you and you also provide specialty service for relatively simple medical problems.