What is Internal Medicine residency like?

[alabaster]

21 hours ago, brady23 said:

Yes - I've heard about this program! Do you know anything about it? (ex: where COE physicians tend to work? do they have a place in geriatric wards of hospitals, or is that something more reserved for IM geriatricians?)

I'm graduating from FM this yearbook and going into this program so I'll know more then!

Grads tend to work in a variety of area so from solo practice with a focus on elder care to on inpatient rehab to community based geriatric programs. 

[psychiatry2017]

On 2/5/2018 at 1:11 AM, A-Stark said:

I have worked with and supervised numerous FM residents to say nothing of seeing referrals and taking outside calls from actual family docs. Most are pretty good but there’s a reason why primary care involves making referrals too. What’s more, there is something to be said for putting in more time and hours. What you get out of residency is about what you put in - and what you put in studying. 

And I’m saying it’s not at all comparable. That’s my point - that the comparison itself is silly given that GIM is not at all about doing routine low acuity inpatient work. That’s what FM hospitalists do. And they consult when they need to and the ACS and overdose and sick patients go to IM and the unit. 

After some researches, as I am doing FM residency in GTA, I have been biased about who usually provide inpatient care in community hospitals.

https://pdfs.semanticscholar.org/b1d4/f8a15d82a5b1401230037ba2bb617ce0b5ac.pdf

The majority of inpatient hospitalists in Canada are GP-trained, in community hospitals, General internists take care of ICU&CCU and consultants for acutely ill patients. Whereas in the States, it is the opposite. 

There have been increasing enhanced skill programs for FM residents interested in doing PGY3 in hospital medicine. The best way to get a job is actually to do an elective at a community hospital and get known. 

As to OP, the outcomes of patients taken care by hospitalists vs GIM are the same with reduced stay by hospitalists(GP-trained): https://psnet.ahrq.gov/resources/resource/6584/outcomes-of-care-by-hospitalists-general-internists-and-family-physicians-

Ultimately, general internists are trained to provide care to icu& CCU and act as consultant for complex patients & acutely ill; whereas GP-hospitalists act as the MRP.

It might not be the case we see as medical student in CTU, as the floor & ward is taken over by GIM in academic hospitals; which is not the case in community hospitals. There are even GTA hospitals with full-time GP hospitalists (Scarborough, Newmarket, William Osler, Markham, etc)

If you go to Health Force Ontario, there are more Hospitalists Job offers than GIM -hospitalists (full-time). The job market is more in demand for GP-trained hospitalists, I would assume it's due to funding. 

[Aconitase]

4 minutes ago, psychiatry2017 said:

After some researches, as I am doing FM residency in GTA, I have been biased about who usually provide inpatient care in community hospitals.

https://pdfs.semanticscholar.org/b1d4/f8a15d82a5b1401230037ba2bb617ce0b5ac.pdf

The majority of inpatient hospitalists in Canada are GP-trained, in community hospitals, General internists take care of ICU&CCU and consultants for acutely ill patients. Whereas in the States, it is the opposite. 

There have been increasing enhanced skill programs for FM residents interested in doing PGY3 in hospital medicine. The best way to get a job is actually to do an elective at a community hospital and get known. 

As to OP, the outcomes of patients taken care by hospitalists vs GIM are the same with reduced stay by hospitalists(GP-trained): https://psnet.ahrq.gov/resources/resource/6584/outcomes-of-care-by-hospitalists-general-internists-and-family-physicians-

Ultimately, general internists are trained to provide care to icu& CCU and act as consultant for complex patients & acutely ill; whereas GP-hospitalists act as the MRP.

It might not be the case we see as medical clerk, as the floor & ward is taken over by GIM.

If you go to health force ontario, there are more Hospitalists Job offers than GIM -hospitalists (full-time), the government also saves money as GP bill less than GIM for consult. The job market is more in demand for GP-trained hospitalists, I would assume it's due to funding. 

This is partly true. Almost often it’s 

 

GIM - ER consults and urgent clinics and In patient ortho consults

 

GP hospitalitist - MRP on ward 

 

ICU - ICU doctors 

CCU - cardiologists

less and less GIMs are covering the last two

[psychiatry2017]

Just now, Aconitase said:

This is partly true. Almost often it’s 

 

GIM - ER consults and urgent clinics and In patient ortho consults

 

GP hospitalitist - MRP on ward 

 

ICU - ICU doctors 

CCU - cardiologists

less and less GIMs are covering the last two

In smaller community hospitals, general internists cover ICU& CCU. Where I did my rural FM clerkship, the hospitalists are all GP-trained. General Internist act as consultant for complex case, and cover ICU & CCU, and do echo stress test (smaller community hospitals can't afford to have full-time ICU or cardiologist)

For ER consults, the GP-hospitalists do the consults and provide 24-hour call service, it's no different than a community general internist.

Internal medicine residency does prepare one better for acute ill patients & hospital medicine, but due to funding and Canadian traditional health models, GP-hospitalists still predominate. As there have been increasing emphasis on inpatient care by CFPC, there have been more and more PGY3 positions in hospital medicine.

Same thing goes for emergency medicine, the majority of ER chiefs in Canada, 75% are CFPC-trained: http://www.cfpc.ca/uploadedFiles/CWG0001_CWG-EM_Report-FINAL_WEB_Final_2.pdf

I guess that you would pursue IM residency: 1) Academic GIM position

2) Community hospital: act as consultant and taking over ICU & CCU and act as consultants for surgical patients

3) Sub-specialty 

[Aconitase]

8 minutes ago, psychiatry2017 said:

In smaller community hospitals, general internists cover ICU& CCU. Where I did my rural FM clerkship, the hospitalists are all GP-trained. General Internist act as consultant for complex case, and cover ICU & CCU, and do echo stress test (smaller community hospitals can't afford to have full-time ICU or cardiologist)

For ER consults, the GP-hospitalists do the consults and provide 24-hour call service, it's no different than a community general internist.

Internal medicine residency does prepare one better for acute ill patients & hospital medicine, but due to funding and Canadian traditional health models, GP-hospitalists still predominate. As there have been increasing emphasis on inpatient care by CFPC, there have been more and more PGY3 positions in hospital medicine.

Same thing goes for emergency medicine, the majority of ER chiefs in Canada, 75% are CFPC-trained: http://www.cfpc.ca/uploadedFiles/CWG0001_CWG-EM_Report-FINAL_WEB_Final_2.pdf

I guess that you would pursue IM residency: 1) Academic GIM position

2) Community hospital: act as consultant and taking over ICU & CCU and act as consultants for surgical patients

3) Sub-specialty 

Yep I am talking about larger community GTA hospitals 

[psychiatry2017]

6 minutes ago, Aconitase said:

Yep I am talking about larger community GTA hospitals 

It makes sense. I believe that the majority of residents prefer to practice in academic or larger community hospitals, it is what we are used to during clerkship+ residency. 

The reality is that jobs opens up less in academic hospitals + large community hospitals (mostly locum positions for GIM). If you want to have a full-time position, and not doing night locum shifts after graduating, you have to be willing to go further into the community. 

What they don't teach us during medical school, is the current physician job market. Everyone tells you to follow your heart and do what you love, but not having a full-time job in where you want, being away from family & friends and struggling to find a full-time position in 30s, with less interesting working conditions (you get the less interesting consults or social admissions, or locuming for night shifts) disheartens me. 

[A-Stark]

Locums can be a good way not to be tied down, though, and that may be desirable at least initially (e.g. no overhead). Otherwise they can and frequently do lead to full-time work. 

Anyway, the more "community" you get, the more your income can come from things like stress testing, outpatient clinics, ICU AFP weeks, +/- echo, device clinics, and endoscopy. Call can be lucrative in bigger places but if you want a nice lifestyle it can be a major tradeoff too. Those of us from "smaller" places tend to have a very different sense of scale, though. 

[A-Stark]

1 hour ago, psychiatry2017 said:

As to OP, the outcomes of patients taken care by hospitalists vs GIM are the same with reduced stay by hospitalists(GP-trained): https://psnet.ahrq.gov/resources/resource/6584/outcomes-of-care-by-hospitalists-general-internists-and-family-physicians-

That's in the US. Not relevant to Canada, even aside from all the differences in method of compensation, multiple insurers, etc. 

[medigeek]

1 hour ago, psychiatry2017 said:

After some researches, as I am doing FM residency in GTA, I have been biased about who usually provide inpatient care in community hospitals.

https://pdfs.semanticscholar.org/b1d4/f8a15d82a5b1401230037ba2bb617ce0b5ac.pdf

The majority of inpatient hospitalists in Canada are GP-trained, in community hospitals, General internists take care of ICU&CCU and consultants for acutely ill patients. Whereas in the States, it is the opposite. 

There have been increasing enhanced skill programs for FM residents interested in doing PGY3 in hospital medicine. The best way to get a job is actually to do an elective at a community hospital and get known. 

As to OP, the outcomes of patients taken care by hospitalists vs GIM are the same with reduced stay by hospitalists(GP-trained): https://psnet.ahrq.gov/resources/resource/6584/outcomes-of-care-by-hospitalists-general-internists-and-family-physicians-

Ultimately, general internists are trained to provide care to icu& CCU and act as consultant for complex patients & acutely ill; whereas GP-hospitalists act as the MRP.

It might not be the case we see as medical student in CTU, as the floor & ward is taken over by GIM in academic hospitals; which is not the case in community hospitals. There are even GTA hospitals with full-time GP hospitalists (Scarborough, Newmarket, William Osler, Markham, etc)

If you go to Health Force Ontario, there are more Hospitalists Job offers than GIM -hospitalists (full-time). The job market is more in demand for GP-trained hospitalists, I would assume it's due to funding. 

How much is a GP hospitalist making?

[Aconitase]

7 minutes ago, medigeek said:

How much is a GP hospitalist making?

About 1200-1500 a day 

[medigeek]

2 minutes ago, Aconitase said:

About 1200-1500 a day 

Is that a 12 hour day? 

[Aconitase]

2 minutes ago, medigeek said:

Is that a 12 hour day? 

It’s not really an hour type thing for a hospitalitist. For ER GIM you cover the ER for a set number of hours. For MRP work you round on your patients. 

 

Typical workday day probably 9-5. In reality the first few days while you get to know patients are longer and shorter towards end of the week

[psychiatry2017]

16 minutes ago, Aconitase said:

About 1200-1500 a day 

Usually 300 k and if you carry around 20 pts and above : 400k+

GIM hospitalist make around 500k-600k in community hospitals. 

You have to love inpatient medicine as career; because many of my FHO staff physicians who do out of basket practice (obs; psych; stds; ED)  make 400k easily with better lifestyle

I guess funding is the major reason why  government prefers gp hospitalists

[Aconitase]

21 minutes ago, psychiatry2017 said:

Usually 300 k and if you carry around 20 pts and above : 400k+

GIM hospitalist make around 500k-600k in community hospitals. 

You have to love inpatient medicine as career; because many of my FHO staff physicians who do out of basket practice (obs; psych; stds; ED)  make 400k easily with better lifestyle

I guess funding is the major reason why  government prefers gp hospitalists

For a GIM hospitalist to hit 5-600k they would need some ER consultive work as well. 

 

Its not not the easiest. ICU docs make 30k a week and can make 400k working 14-16 weeks a year 

[psychiatry2017]

Just now, Aconitase said:

For a GIM hospitalist to hit 5-600k they would need some ER consultive work as well. 

 

Its not not the easiest. ICU docs make 30k a week and can make 400k working 14-16 weeks a year 

GP hospitalists do ER consults to admit pts as well. The billing code is less lucrative than GIM for sure. 

ICU is very stressful and if you don't work in academic hospital with fellows; you basically sleep in the hospital the week you are on call. 30 k a week means a big closed unit; also a lot of pts in ICU are "chronic alc pts" needing advanced life support with difficult GOC discussion

[Aconitase]

Just now, psychiatry2017 said:

GP hospitalists do ER consults to admit pts as well. The billing code is less lucrative than GIM for sure. 

ICU is very stressful and if you don't work in academic hospital with fellows; you basically sleep in the hospital the week you are on call. 30 k a week means a big closed unit; also a lot of pts in ICU are "chronic alc pts" needing advanced life support with difficult GOC discussion

Yup it’s stressful but 400k for 16 weeks of work is pretty good

[psychiatry2017]

5 minutes ago, Aconitase said:

Yup it’s stressful but 400k for 16 weeks of work is pretty good

I think it's easier to do a 3 am DKA consult than ongoing GOC discussion with families who don't realize the poor prognosis of loved one . One super sick pt could take a good Chunk of day : calling consultants procedures update family (with no residents). It's a very challenging job with high burnout. Academic ICU staff is not representative of reality: its not going home at 5-7 and doing 1 hour teaching lol

If you like ICU go for it ! Mind you perhaps do 4 year GIM and opt to cover ICU in community hospitals for job purpose

[Aconitase]

7 hours ago, psychiatry2017 said:

I think it's easier to do a 3 am DKA consult than ongoing GOC discussion with families who don't realize the poor prognosis of loved one . One super sick pt could take a good Chunk of day : calling consultants procedures update family (with no residents). It's a very challenging job with high burnout. Academic ICU staff is not representative of reality: its not going home at 5-7 and doing 1 hour teaching lol

If you like ICU go for it ! Mind you perhaps do 4 year GIM and opt to cover ICU in community hospitals for job purpose

I am really worried about how prospects so I think doing GIM may be the best option. My goal is to work in a large community hospital in the GTA. I am looking to setup a community ICU elective to see if that may help me decide 

[psychiatry2017]

1 hour ago, Aconitase said:

I am really worried about how prospects so I think doing GIM may be the best option. My goal is to work in a large community hospital in the GTA. I am looking to setup a community ICU elective to see if that may help me decide 

Best of luck ! For community Jobs in GTA; I heard that GIM is quite saturated as recent grads pgy4 filled the locum positions of doing nocturnist and they are quite happy lol. The best way is to talk to recent grads and your staff physicians. You might have to go a bit further away from GTA for jobs tbh

[futureGP]

lots of nice discussions. I am biased as I am finishing up Internal Medicine but here are my thoughts.

To OP's qn, IM residency depends on where you go. Some residencies are more service-based and will have long-hours and busy days whereas others will be more-or-less chill and even comparable to FM in terms of lifestyle and hours. CTU will always be busy because of service-needs but depending on where you do your residency, subspecialty rotations like Nephro, GI, Resp, Endo, Allergy can be quite chill (8:30-4:30) and as a junior you may see 3-4 patients a day if inpatient (means a lot of lounging around, getting teaching etc), or a bit more if outpatient. Even CCU/ICU can be pretty chill during the day when you may have 3-4 patients to look after which as a senior (PGY2-3) is really not that time-consuming. Certain call shifts will be busy, such as CTU junior or Senior Medicine, Cardiology, GI. But others may not be as bad.

That said, at other more service-based IM locations, the hours may be different. So to the OP, you really need to ask the residents at each training site to understand what the lifestyle, work-hours are truly like to get a sense of residency lifestyle. Subspecialty life is a totally different topic as you can be busy as a Cardio/GI fellow doing city-wide coverage, or ICU overnight and a few sick patients take up your time. But most other specialties are pretty chill and have relatively low to no call burden. So you're really comparing 3-years IM (with PGY3 being pretty chill) vs 2-years of FM 

For some insight as to Endo, Allergy, Rheum (i.e. chill outpatient specialties) vs. FM. First, most people who do Endo, Allergy, Rheum do it for the lifestyle and are not working to make bang or full-time busy clinic (some maybe but most aren't). If money, working hard was their deal then during core IM they likely would lean more towards GIM/ICU/Cardio/GI/Nephro etc. So comparing Endo/Allergy/Rheum income to FM is not so easy. 

That said, if you go to allergy for $$$, there is so much in it - allergy consult + patch tests are easily >$200 per pt, just look at the provincial billing schedules, and if you are an efficient doc you can see a new consult in 15-20mins, very focused hx/px, review of past medical etc (can be 400-600/hr). Plus with the long waitlist of allergists, you will be seeing a lot of new consults as opposed to follow ups. A lot of the consults are also pretty straight forward too (as they should be because you are a subspecialist training in a focused area of medicine). You can do the math for monthly billings etc. Rheum can be interesting too as you can add joint injections to your billings but depending on your working environment (Academic vs community) consults could be either pretty quick (straight-forward RA) or long (vasculitis). Endo is also variable because bread-and-butter T2DM will be a quick consult but unlike Allergy/Rheum you don't have any other billing codes aside from just the usual consult fee (~160 depending on the province).

The key benefit of medicine subspecialty is that everything eventually becomes bread-butter to you and things will get very quick and efficiency can sky-rocket if you are smart about it which can translate into higher income at our current fee-for-service environment.

As for GIM, you can't compare GIM in GTA hospitals vs GIM in small-town community, the working environment, scope of practice is so much different. GIM in the large community hospitals are typically doing inpatient hospitalist work, medicine consults for surgical wards, GIM rapid assessment clinics, pre-op clinics ($$$), and outpatient Medicine clinics. Income for GIM is largely driven from outside of in-patient work in this setting unless you are running a CTU at a community hospital. GP-hospitalist on the other hand is mostly doing full-time hospitalist work. But even in the near future, with the oversaturation of 4-year GIM physicians in the GTA, I expect that the role for GP-hospitalist will become more limited as more GIM start working at major hospitals in the GTA. All IM residencies in the recent years have been pumping out a lot of 4-year GIMs who have been saturating the job market.

But if you are out in small-medium sized communities (~<100k), GP-hospitalists will still mostly be working as MRPs with GIM providing more of a consultant role and filling in the absence of any subspecialists. The scope of practice is broad and includes level 2 ICU, complex medicine consults, diagnostics (PFTs, ECG, stress +/- Echo), procedures (Endoscopy, bone marrows, PICC lines etc). But as you can imagine as population grows in these small centres, more subspecialists will join and slowly take away income-producing procedures from GIM (i.e. scopes to GI, diagnostics to Cardio/Resp etc). Then the practice style gradually approaches the scenario mentioned above.

So income for GIM can vary a lot anywhere from ~300-400k at big hospitals to 600-800k at small-medium sized hospitals. GIM really shines in the smaller communities where the needs are high, whereas in the large communities you are mostly seeing the complex/vague patients that don't clearly fit into a subspecialty scope of practice (i.e. complex, multiple medical problems, failure to cope NYD, fatigue NYD, etc).

[psychiatry2017]

17 hours ago, futureGP said:

lots of nice discussions. I am biased as I am finishing up Internal Medicine but here are my thoughts.

To OP's qn, IM residency depends on where you go. Some residencies are more service-based and will have long-hours and busy days whereas others will be more-or-less chill and even comparable to FM in terms of lifestyle and hours. CTU will always be busy because of service-needs but depending on where you do your residency, subspecialty rotations like Nephro, GI, Resp, Endo, Allergy can be quite chill (8:30-4:30) and as a junior you may see 3-4 patients a day if inpatient (means a lot of lounging around, getting teaching etc), or a bit more if outpatient. Even CCU/ICU can be pretty chill during the day when you may have 3-4 patients to look after which as a senior (PGY2-3) is really not that time-consuming. Certain call shifts will be busy, such as CTU junior or Senior Medicine, Cardiology, GI. But others may not be as bad.

That said, at other more service-based IM locations, the hours may be different. So to the OP, you really need to ask the residents at each training site to understand what the lifestyle, work-hours are truly like to get a sense of residency lifestyle. Subspecialty life is a totally different topic as you can be busy as a Cardio/GI fellow doing city-wide coverage, or ICU overnight and a few sick patients take up your time. But most other specialties are pretty chill and have relatively low to no call burden. So you're really comparing 3-years IM (with PGY3 being pretty chill) vs 2-years of FM 

For some insight as to Endo, Allergy, Rheum (i.e. chill outpatient specialties) vs. FM. First, most people who do Endo, Allergy, Rheum do it for the lifestyle and are not working to make bang or full-time busy clinic (some maybe but most aren't). If money, working hard was their deal then during core IM they likely would lean more towards GIM/ICU/Cardio/GI/Nephro etc. So comparing Endo/Allergy/Rheum income to FM is not so easy. 

That said, if you go to allergy for $$$, there is so much in it - allergy consult + patch tests are easily >$200 per pt, just look at the provincial billing schedules, and if you are an efficient doc you can see a new consult in 15-20mins, very focused hx/px, review of past medical etc (can be 400-600/hr). Plus with the long waitlist of allergists, you will be seeing a lot of new consults as opposed to follow ups. A lot of the consults are also pretty straight forward too (as they should be because you are a subspecialist training in a focused area of medicine). You can do the math for monthly billings etc. Rheum can be interesting too as you can add joint injections to your billings but depending on your working environment (Academic vs community) consults could be either pretty quick (straight-forward RA) or long (vasculitis). Endo is also variable because bread-and-butter T2DM will be a quick consult but unlike Allergy/Rheum you don't have any other billing codes aside from just the usual consult fee (~160 depending on the province).

The key benefit of medicine subspecialty is that everything eventually becomes bread-butter to you and things will get very quick and efficiency can sky-rocket if you are smart about it which can translate into higher income at our current fee-for-service environment.

As for GIM, you can't compare GIM in GTA hospitals vs GIM in small-town community, the working environment, scope of practice is so much different. GIM in the large community hospitals are typically doing inpatient hospitalist work, medicine consults for surgical wards, GIM rapid assessment clinics, pre-op clinics ($$$), and outpatient Medicine clinics. Income for GIM is largely driven from outside of in-patient work in this setting unless you are running a CTU at a community hospital. GP-hospitalist on the other hand is mostly doing full-time hospitalist work. But even in the near future, with the oversaturation of 4-year GIM physicians in the GTA, I expect that the role for GP-hospitalist will become more limited as more GIM start working at major hospitals in the GTA. All IM residencies in the recent years have been pumping out a lot of 4-year GIMs who have been saturating the job market.

But if you are out in small-medium sized communities (~<100k), GP-hospitalists will still mostly be working as MRPs with GIM providing more of a consultant role and filling in the absence of any subspecialists. The scope of practice is broad and includes level 2 ICU, complex medicine consults, diagnostics (PFTs, ECG, stress +/- Echo), procedures (Endoscopy, bone marrows, PICC lines etc). But as you can imagine as population grows in these small centres, more subspecialists will join and slowly take away income-producing procedures from GIM (i.e. scopes to GI, diagnostics to Cardio/Resp etc). Then the practice style gradually approaches the scenario mentioned above.

So income for GIM can vary a lot anywhere from ~300-400k at big hospitals to 600-800k at small-medium sized hospitals. GIM really shines in the smaller communities where the needs are high, whereas in the large communities you are mostly seeing the complex/vague patients that don't clearly fit into a subspecialty scope of practice (i.e. complex, multiple medical problems, failure to cope NYD, fatigue NYD, etc).

I agree with the GP-hospitalist job market in GTA area. Traditionally, the GP-hospitalists have mainly been working in smaller community hospitals and rural setting, where the need is high, where GIM works as consultant and covers ICU. I have friends who are moonlighting for hospitalists as residents in community hospitals 1 hour away from Toronto.

The only reason that a hospital would hire a GP-hospitalist over GIM might be governmental funding, it costs less even though general internist has more training and better prepared for acute sick patients.