Outpatient IM vs. FM

[ohgoshgolly]

Hello!

I'm an MS4 struggling with the decision between IM and FM and I would appreciate any advice. Here are some factors I'm considering in my decision:

1. I enjoy clinics and believe I would prefer a more outpatient IM specialty (rheum, endo, maybe med onc if that counts as outpatient) if I were to go the IM route. Can anyone speak to the differences in lifestyle, gross pay, and overhead between these IM sub-specs in particular and FM? 
2. I have enjoyed my family medicine rotation but am worried that I didn't get the full picture of the amount of paperwork involved as a med student who just sees the patients and writes notes. Is paperwork significantly less of an issue in the aforementioned IM sub-specs? 
3. I don't love CTU and believe IM residency would be a real struggle for me because of this. I'm not sure if the three years would be something I can struggle through or if I would absolutely hate my life during call.
4. I hope to take care of my parents financially. They have medical concerns and I worry that I will not be able to provide them with the life they deserve before they become too elderly/sick to travel, to enjoy a home that I purchase for them, etc. This is why income and the years it will take before I make attending money are important factors for me. Is the higher pay in IM worth it vs. earning attending income sooner in FM, especially in the context of purchasing property in this awful housing market?

I can see myself being happy in either specialty right now, but I'm terrified of somehow making a choice that I will regret in the future. Please let me know your thoughts! 

[bearded frog]

Not IM, or FM but familiar enough with specialty/subspecality outpatient clinics to give some general answers.

17 hours ago, ohgoshgolly said:

rheum, endo, maybe med onc...   Can anyone speak to the differences in lifestyle, gross pay, and overhead between these IM sub-specs in particular and FM?

Not familiar enough with adult med onc to know if it is possible to do exclusively outpatient, and not be attached to a hospital that requires inpatient stuff, etc. For rheum and endo you could in theory open your own clinic. The day to day of FM vs these is going to be quite different. FM will see all ages and all complaints, you'll see a healthy 4 month old for a check up and then immediately a 70 year old with heart failure and severe depression, and each will have 10-15 minutes of your time. The paperwork will be charting, which isn't too bad imho, as nowadays people do most of it in the room with the patient, but the majority of your paperwork will be referrals, forms, perceptions, calling back pts with results etc. There will be LOTS of referrals. For subspeciality, the focus is obviously much more narrow, and you will work as a consultant, ie your patents will have been referred to you with a specific question or concern that needs to be addressed. And while it will be narrow, it will need to be a lot more "deep", and some prefer broad and shallow to narrow and deep. As a consultant you will write a consult note which will be more detailed and comprehensive than a FM note, and then you will follow many patients along. For instance in endo you will be seeing a LOT of diabetes and have a big cohort of diabetes patients where you are managing their therapies on an ongoing basis, and it will be the ones that are not easy, as these can be generally manged by primary care. For rheum it will be arthritis, lupus, other inflammatory conditions, etc. Nowadays many patients are on biologics which may require infusions, so you may have to be affiliated with somewhere that could do at least day medicine if not inpatient, and therefore have some sort of call responsibility... But I am not an expert on the logistics of individual adult subspecialties. (In peds its generally rare to be a subspecialist and not hospital-affiliated).

17 hours ago, ohgoshgolly said:

1.  Is paperwork significantly less of an issue in the aforementioned IM sub-specs? 

See my answer above but its a different kind of paperwork. You will be doing longer consult notes but less referrals, and less generic insurance forms etc. but more specific stuff about applying for special access drugs, for example. Your follow-up charting can be simple like FM. The time it takes for both will be dependant on how good you are at your EMR and how you can streamline things with macros and forms, and how you use your office assistants, etc. I would say that the difference in time it takes to do paperwork depends more on your EMR and system than it does on your specialty, in my experience.

17 hours ago, ohgoshgolly said:

1. I don't love CTU and believe IM residency would be a real struggle for me because of this. I'm not sure if the three years would be something I can struggle through or if I would absolutely hate my life during call.

I believe most FM programs will have you doing some CTU or at least hospitality call, but IM certainly would be more. Yes, call sucks, but you realistically can't be a good outpatient rheumatologist without context of what acute rheumatological issues (or endo, oncology, etc) look like and how they're managed in an acute setting, and without the volume you would only get if you did some nights. Different programs will have different systems (night float), 16 hour call, etc. so if there is a specific system that works better for you it can be somewhat mitigated.

17 hours ago, ohgoshgolly said:

1. Is the higher pay in IM worth it vs. earning attending income sooner in FM, especially in the context of purchasing property in this awful housing market?

In general, you will make more as an outpatient subspecalist vs FM, but not as much more as you may think doing exclusively outpatient non-procedural subspecialty. A lot of the difference between specalists and FM is inpatient management and procedures, and it's even less of a delta if you factor in how much each works. The 2018, average medical specialist in Canada earned 400k compared to 327k for the equivalent amount of clinical activity, and again this includes inpatient and procedural work. That would seem to give an advantage to FM based on your context, but it is also important to consider your own age and when you plan to retire, and when you want to accomplish your financial goals, to see if the delay in staff salary is amortized enough over time.

[futureGP]

Money wise, you will be ahead in any outpatient subspec IM vs FM assuming same degree of work ethic, hours worked etc.

Unlike the above post, as outpatient Allergy, Rheum and Endo, it is highly unlikely that you will have to do any general medicine as staff unless you want to. Yeah you may be asked to see inpatients for consults but those are far in between and you will never have to do any MRP GIM work unless you decide to.

To comment on ‘breadth’ and ‘complexity’ of cases, these are relative terms. For a family physician, breadth could mean knowing a little bit of peds/adult/ob/surgery. A specialist could also have breadth within their field, eg as a rheumatologist, your breadth of knowledge within rheum is the immunology behind autoimmune diseases and the individual diseases and their managements from RA, lupus, scleroderma to myositis etc.

Also a ‘complex’ case to a family physician maybe a simple case to a specialist. 
 

So let me tell you that in real practice, an efficient subspecialist practice does not look much different from an efficient FP practice except that a subspec practice will have high volumes of similar issues vs a FP practice will have high volumes of many different issues.

so it is easier to scale up a specialist practice vs a family practice and overhead is generally lower. 
And generally specialist fee codes pay well vs FP so you will be financially ahead.

 

Some good examples of purely office based practice in IM are

- allergy clinic -> allergy test/consult is bread and butter. Absolutely no inpatient call reqmt.

- endo clinic -> diabetes, thyroid issues, obesity etc. no inpt call reqt. Low overhead.

- rheum clinic -> RA, OA, other connective tissue disease, psoriatic arthritis, joint injecfions etc. Again, no inpt call reqmt. Yeah a lot of them are on biologic but most of these are outpt injections and typically handled by the companies that inject them. Low overhead

- resp clinic -> cough, asthma, copd, ILD. Can choose not to affiliate with hospital and you have no call requirement. Low overhead.

- Medical Oncology -> hospital based clinic practice. 99% oncology practices at least in Ontario do not have inpatient MRP burden. May have to provide inpt consults but never overnight or weekends. No overhead.

- pure outpt cardiology clinic -> holter, echo, stress test, chest pain, afib, coronary artery disease. As a cardiologist, you don’t have to affiliate with a hospital if you decide not to -> thus no call burden.

- pure outpt GI endoscopist -> can choose not to affiliate with hospital. Work at private endoscopy clinic. Higher overhead but purely bread/butter EGD/colon.

- GIM clinic -> can practice pure outpt GIM specializing in areas like periop medicine, OB medicine, Hypertension, low risk cardiac.

- sleep clinic -> sleep apnea, insomnia, restless leg syndrome. Low overhead.

 

[bearded frog]

17 hours ago, futureGP said:

words

Thanks for clarifying on which subspecialties require hospital affiliation etc, as I said I was not as familiar with the adult side of things.

17 hours ago, futureGP said:

Unlike the above post, as outpatient Allergy, Rheum and Endo, it is highly unlikely that you will have to do any general medicine as staff unless you want to. Yeah you may be asked to see inpatients for consults but those are far in between and you will never have to do any MRP GIM work unless you decide to.

Nowhere in my post did I say that you had to do GIM stuff as a sub-specialist? I said if you were hospital affiliated you might have to do subspecialty call...