IM specialist going back to general practice

[thebouque]

I've been training in Canada for the last year, so I'm not 'clueless' about anything.

 

Great, I'll tell my friend who's an IMG that there's still hope.

 

And good luck to you when you'll be a primary care internist at the end of your career. Someone comes in with an abcess on his ass and you'll be like: ''Nah, that's adult minor surgery, I'm only an adult primary care doc. Come back if you've got a problem with your blood pressure.''

[cheech10]

Yes, he'd turn away all the butt abscesses, because it's SO difficult to lance an abscess and give a short course of antibiotics...? Internists in the US do outpatient adult primary care all the time; no reason to think it couldn't be done here.

[rankin]

Yes, he'd turn away all the butt abscesses, because it's SO difficult to lance an abscess and give a short course of antibiotics...? Internists in the US do outpatient adult primary care all the time; no reason to think it couldn't be done here.

 

Exactly what Cheech said. Also if you did your residency in IM in the US and came back to Canada to practice... these procedures would absolutely be within your scope of training. In fact I can't think of any 'office surgical' procedure a family doc could do that a US trained IM doc couldn't.

 

internists don't even do a family medicine rotation in their residency. Doesn't seem responsible to call yourself primary care all of a sudden.

 

I can't speak for Canadian IM but in the US, there is regular outpatient/clinic training, I think at least 1/2 a day every week for your entire 3 year residency except for when you are doing MICU. And under CPSO pathway 4 US IM's can come back to Canada (speaking of Canadian citizens of course).

[lostintime]

The US is kind of different from Canada, in that internists act almost as GP's and if that's in their training fine. But Canada is different and while they do "ambulatory" it has very little to do with primary care unless the patient does not have a family doctor.

 

This isn't even my personal opinion, but at the end of the day, what you guys are saying is that there is almost no need for a family residency program minus the pediatrics because internists can handle all other things except for seeing children. Obviously the CCFP will disagree with that, whether valid or not.

[rankin]

The US is kind of different from Canada, in that internists act almost as GP's and if that's in their training fine. But Canada is different and while they do "ambulatory" it has very little to do with primary care unless the patient does not have a family doctor.

 

This isn't even my personal opinion, but at the end of the day, what you guys are saying is that there is almost no need for a family residency program minus the pediatrics because internists can handle all other things except for seeing children. Obviously the CCFP will disagree with that, whether valid or not.

 

No. According to IM training... IM would not deal with Psych, Ob/Gyn (which is a huge difference from FM) and Peds.

 

What amazes me about the Canadian residency system is the FM residency is only 2 years and IM is 4 years yet FM has a larger scope of practice than IM? How does that even make sense? The only way I can rationalize it is that FM docs deal with much more superficial medical problems and refer for most things to more trained physician. But I'm not sure.

[leviathan]

Great, I'll tell my friend who's an IMG that there's still hope.

 

And good luck to you when you'll be a primary care internist at the end of your career. Someone comes in with an abcess on his ass and you'll be like: ''Nah, that's adult minor surgery, I'm only an adult primary care doc. Come back if you've got a problem with your blood pressure.''

Hey, I didn't say I personally wanted to do this. I'm about inpatient medicine all the way; outpatient stuff is mostly boring to me (mais a chacun son gout). I'm just saying there are maybe internists out there who find hospital work too demanding in their older years who may want to tone it down and see simple outpatient stuff. I've trained in both Canada and the US and in the US internal medicine is a primary care specialty so I see no reason why Canadian internists could not do the same, when they have superior training to their US counterparts (in my opinion).

 

And what would they say on their door- simple issues only? Make it some random walk-in but specify they don't cover obs/gyn, surgical, psych, etc? Sure we're all supposed to learn primary care, but the way training works, internists don't even do a family medicine rotation in their residency. Doesn't seem responsible to call yourself primary care all of a sudden.

It sounds like you might not have much experience with clinic work yet, or at least in the more administrative / business side of things. It is easy to work in a clinic with multiple MDs and simply get the MOA to book you only adult patients. If you run your own clinic I agree it may be more difficult and you'd have to put a sign up or something saying you only treat adult patients, which many people would not read and they'd come in and get all confused.

[rankin]

What I don't get is that med school is three or four years and the CCFP still thinks you need two more years to learn basic general practice medicine. What I take from that is that 1. The CCFP are trying to hold onto their "power" and 2. Med school's educational quality is woefully inadequate.

 

You think you are going to start practicing even FM coming straight out of Med school? Sure FM is the most basic form of Medicine but to say you don't need formal training in a attending supervised setting is quite extreme. Modern medical school curricula always intended to prepare you for residency not immediate independent practice. And rotations/clerkships are a far cry from real residency.

[rankin]

Why not do associateships like they do in dentistry? It frees up more physicians for the primary care workforce, and is a far more attractive option for paying back exorbitant educational loans.

 

Probably because this is Medicine and not Dentistry. Medicine demands a much greater scope of knowledge and has a much greater liability. Yes, even FM.

[rankin]

It is this kind of misplaced pride that is reducing primary care access for patients. I also disagree about the liability and the scope of knowledge.

 

You are actually comparing a Dentist to a Medical Doctor? Seriously? Alright.

 

I would also like to add that it is this kind of thinking (against decades of Medical practice and medical school structuring) that will likely result in greater morbidity and mortality in all patients despite allowing for more primary care access.

 

In other words theres a reason the US and Canadian medical associations/boards/schools have been doing things this way for years.

[lostintime]

 

It sounds like you might not have much experience with clinic work yet, or at least in the more administrative / business side of things. It is easy to work in a clinic with multiple MDs and simply get the MOA to book you only adult patients. If you run your own clinic I agree it may be more difficult and you'd have to put a sign up or something saying you only treat adult patients, which many people would not read and they'd come in and get all confused.

 

Lol I love your condescending attitude towards all of this, continue carrying it in your electives and match, it'll be interesting to see how far it carries you.

 

That's right, just give the triage job of patients to the secretary. They're just as capable as any other Joe Blow about what's appropriate for an internist to see.

[rankin]

Yes. I am. A dentist is a specialist of teeth and the oral cavity. They really should be a subspecialty of medicine, but their professional organization wants to keep its autonomy. Proper thing seeing as how medical organizations couldn't advance their way out of a paper bag.

 

Nonetheless, a dentist goes through dental school learning how to be a dentist, so that when they graduate, they can actually be useful.

 

A medical student goes through medical school learning what PhDs think is important for the first half, and then learning how the rest of the "team" is so important the second. It's also a great way for them to learn how to suck up. But as for learning medicine, no. Our training system is terrible, and to allow it to continue to be so just so that the "family medicine" residency can continue to exist is preposterous!

 

I would strongly disagree with everything you have said here except for the notion that our Medical education system could be improved.

 

I think the basic sciences is far from clinically useless PhD science. I think it allows one to have a deeper understanding and foundation for the clinical medicine and ultimately allows most Physicians to also become pioneers in advancing medicine through clinical and non-clinical (molecular, in-vitro etc.) research.

 

Without this backbone of basic Science the Physician would be rendered quite a bit less knowledgeable, less able to adapt to clinical situations and ultimately less of a clinician (more like a mid-level provider).

[lostintime]

Yea the goal isn't exactly to make technicians, but to help make capable physicians who have a deeper understanding of what they're doing. Or else what's the difference b/w doctors and all the mid-levels who want their jobs? Making an internist deal with a much of obs/gyn and psych issues isn't part of their training. Most internists don't even do a pelvic exam after med school and even though they deal with a lot of psych/surgery issues on the side, never did a rotation in either as a resident. Making them deal with these issues as the MRP is kinda saying you only need med school knowledge to handle those issues. Not cool.

[thebouque]

Hey, I didn't say I personally wanted to do this. I'm about inpatient medicine all the way; outpatient stuff is mostly boring to me (mais a chacun son gout). I'm just saying there are maybe internists out there who find hospital work too demanding in their older years who may want to tone it down and see simple outpatient stuff.

 

As was mentioned previously, internists regularly do ''outpatient stuff''... And most of the time it is ''simple outpatient stuff''.

[thebouque]

Lol I love your condescending attitude towards all of this, continue carrying it in your electives and match, it'll be interesting to see how far it carries you.

 

He/she always had a condescending attitude on this forum, don't take it personal

[leviathan]

Lol I love your condescending attitude towards all of this, continue carrying it in your electives and match, it'll be interesting to see how far it carries you.

 

That's right, just give the triage job of patients to the secretary. They're just as capable as any other Joe Blow about what's appropriate for an internist to see.

Condescending? You need to be a little more open to criticism/debate if you're going to label everyone who disagrees with you or teaches you something as condescending. This is the internet of course but I lay it on pretty thick even adding a smiley face but somehow you still get offended. I would suggest you try not to carry this into your electives and match. Are you going to call your attendings condescending when they explain something to you on rounds?

 

The only condescending attitude I can see is you presuming an MOA is too uneducated to know how to do a simple job. Seriously, are you going to label it a triage situation if someone has to ask if #1 the patient is over the age of 18 and #2 they are here for something besides an OBGYN or psych issue. Get over yourself, man.

[leviathan]

As was mentioned previously, internists regularly do ''outpatient stuff''... And most of the time it is ''simple outpatient stuff''.

I know, what a conundrum. They can handle referrals from a GP for complicated adults, but they can't handle the adults that the GP doesn't need to refer? The logic in this, I love it.

[lostintime]

Uh maybe because not all "adult" issues are within the scope of INTERNAL medicine? And maybe some problems are multi-system and complex and require regular follow-up with various specialists and may be an obs/gyn issue in disguise? And maybe a GP would be much better at figuring that out because they deal with it day-in-day-out versus a "triage" SECRETARY? Right....

 

 

Nice that people forget there are many other specialties out there that deal with adults? It is quite condescending to tell other people they can't understand English and they need to understand the healthcare system, particularly to people who have actually trained in the system. And this coming from a med student who didn't even do their core training here, right. And actually I have already matched and done electives, which is why I'm kinda astonished at the attitude people carry here. Of course, it's the Internet, I've love to see this attitude in the real world lol.

[lostintime]

You should only need med school knowledge to handle basic primary care issues. Otherwise what is the point of medical school? Are we so high on ourselves to think that we need extra time to learn how to do paps and ask SIGECAPS?

 

Yes yes you've been suggesting the anti-family medicine residency training thing forever, and I used to agree with you, but after actually going on electives and starting residency, I disagree. If there was a general intern year, my specialty training would be delayed probably by another year. And I won't use that general stuff in my career. And you know what, maybe just ONE year isn't enough, maybe there's a reason people need 2 years. There's a lot of really good and really bad family doctors. 2 years is NOT a lot of time to learn how to be a good gate keeper and not miss stuff. I'd like the GP taking care of me and my family to have actually rotated through surgery, obs/gyn, internal medicine, psych etc. as a RESIDENT and had to make actual DECISIONS rather than just ask the resident what to do. And to get good training on top of clinic time within one year is just not enough.

[leviathan]

Uh maybe because not all "adult" issues are within the scope of INTERNAL medicine? And maybe some problems are multi-system and complex and require regular follow-up with various specialists and may be an obs/gyn issue in disguise? And maybe a GP would be much better at figuring that out because they deal with it day-in-day-out versus a "triage" SECRETARY? Right....

Any internist knows how to recognize when referrals to other services are appropriate. That is not an issue exclusive to an outpatient setting; lots of patients on a medicine service in the hospital may turn out to have other issues. I'm seeing a patient with encephalitis right now who we identified as having an ovarian tumor as the root cause. Gyn-onc is now following. So I fail to see how this is a problem.

 

Nice that people forget there are many other specialties out there that deal with adults? It is quite condescending to tell other people they can't understand English and they need to understand the healthcare system, particularly to people who have actually trained in the system.

I don't know man, I was trying to be friendly about it and find an explanation for how you could not realize such a simple solution, such as maybe you don't know what an MOA is or that they can easily book adults to the internist. And you still get offended , call me condescending, and give a ridiculous excuse that an MOA doesnt know how to refer appropriately 99.9% of the time . You sound like you'd be a joy to work with at 3 in the morning.

 

You're totally right too. The MOA might send an adult patient to the internist who has an ob/gyn issue in surprise, about 1 in 1000 times. And then he would refer the patient off to someone with more experience. I'm sure it would not be catastrophic for the system.

[lostintime]

Yeah but the 3 year model means no summers and the overall training time is about the same. So it's just a matter of whether you want your summers or not, you're not actually reducing the amount of time. I'm just failing to see what the point of the general internship year is, except to provide jobs for specialties without jobs. Otherwise, what specialist would WANT to work as a GP and bill as a GP voluntarily? I'm not against them offering extra training for those who want to pursue that but to force everyone to do it in sacrificing their specialty training is useless. And I'm not sure what specialty you are in brooksbane, but how exactly are family med clinics fluff/useless considering that's what GP's do their entire career and hence would be helpful in seeing those cases and how the clinic is run?

 

Of course people have to refer out when it's inappropriate, but why don't we send random all-purpose patients to surgeons then? When crap happens, too bad, people try to refer to the right place. But actually enforcing such a system is stupid. This is why emerg is run by triage NURSES (aka health care professionals) and not secretaries.

 

And leviathan, why don't you find me examples of this "simple solution" model besides the fact that these specialists can not find jobs and no one will refer to them in CANADA? Seriously, this is for your own good, maybe you just get off acting this way on the Internet, and good for you for trolling. But if you try to "teach" your residents and attendings in this method, good luck and have fun.

[leviathan]

No offense lostintime, but you really sound like you're just arguing for the sake of arguing. That's the problem and I hope you don't act like this in real life to your colleagues.

 

The fact that you're comparing a surgeon to a specialist who is trained in adult medical patients, in their ability to assess an adult medical patient, just boggles my mind. It shows you're either very out of touch with reality, or just trolling me. You know you're absolutely right, on occasion a patient will have a GYN issue underlying their problem. That's why an internist is aware of the differential for say, lower abdominal pain, and knows when they need appropriate referral the same as a GP would. Do you think the workup for lower abdominal pain is less comprehensive by an internist than a GP? I think it is actually more comprehensive given their longer training. Do you think an MOA is not aware that a patient with vaginal bleeding is a GYN complaint and should go to the GP? Again, this isn't "triage" it's common sense.

 

Honestly, I can't believe you're actually arguing that a specialist with 4-5 years of post-grad training cannot handle clinic complaints like sore throats. It really frustrates me that you don't see how irritating this argument is. Although if you're trolling, I guess you're achieving your goals.

[apache]

most don't remember basic science... by the time the're done 5 yrs res and a 2 year fellowship... you're referring to the exception rather than the rule...

 

I would strongly disagree with everything you have said here except for the notion that our Medical education system could be improved.

 

I think the basic sciences is far from clinically useless PhD science. I think it allows one to have a deeper understanding and foundation for the clinical medicine and ultimately allows most Physicians to also become pioneers in advancing medicine through clinical and non-clinical (molecular, in-vitro etc.) research.

 

Without this backbone of basic Science the Physician would be rendered quite a bit less knowledgeable, less able to adapt to clinical situations and ultimately less of a clinician (more like a mid-level provider).

[apache]

it'd also be cool if you could pick up some skills in generalist medicine before you decide to specialize so you don't end up in a miserable specialty you hate

 

Yes yes you've been suggesting the anti-family medicine residency training thing forever, and I used to agree with you, but after actually going on electives and starting residency, I disagree. If there was a general intern year, my specialty training would be delayed probably by another year. And I won't use that general stuff in my career. And you know what, maybe just ONE year isn't enough, maybe there's a reason people need 2 years. There's a lot of really good and really bad family doctors. 2 years is NOT a lot of time to learn how to be a good gate keeper and not miss stuff. I'd like the GP taking care of me and my family to have actually rotated through surgery, obs/gyn, internal medicine, psych etc. as a RESIDENT and had to make actual DECISIONS rather than just ask the resident what to do. And to get good training on top of clinic time within one year is just not enough.

[frozenarbitor]

Thanks everyone for their input. I think the title of the thread was a bit confusing. I was asking "can a internal sub-specialist practice as GIM" and I think it was answered as "yes" from the first several posts. Thanks!

 

Now, what does "primary care" mean exactly? Is it referring to GP/family doctor(CCFP) alone? Or is it referring to all the specialties that are "general", such as GIM, psychiatry, paediatrics, general surgery, etc?

[The Journey Man]

most don't remember basic science... by the time the're done 5 yrs res and a 2 year fellowship... you're referring to the exception rather than the rule...

 

Depends on the field, but basic science is the root/language for all the clinical talk done. All specialties need basic science UNDERSTANDING to interpret and understand clinical stuff. You need to understand that stuff to pass the Royal College exams. This is even more true for something like Path or Internal

 

As to the OP,

 

ID can definitely do IM, they would have taken the Royal College IM exam at the end of R4, and then likely their ID exams at the end of R5. general IM is heavily intertwined will all its subspecialties, but even more so with ID.

 

ID people definitely attend CTU, many even have general IM consults in outpatient. So you can definitely tailor your practice back to general IM but only thing is you would need referrals to do so.

 

IM can definitely do Family Medicine (excluding OB/Gyn, Peds and probably Ortho stuff), because Canadian IM residencies also get trained to take American boards in addition to the Royal College boards. American IM boards have heavy primary care content even though Canadian internists don't practice primary care. So IM people have to learn all the primary care stuff ON TOP of all the specialist medicine to finish residency. Without a doubt they could do family medicine, but few would want to.