Specialty Profile

General Internal Medicine

GENERAL INFORMATION (Sources: Pathway Evaluation Program, American College of Osteopathic Internists & the Canadian Medical Residency Guide) Internal medicine is a broad-based specialty that has its roots in primary care and is dedicated to providing primary and specialty care to adults. General internists diagnose and manage diseases involving any of the organ systems and are specially trained to manage seriously ill patients suffering from advanced illness and/or diseases of more than one system. General internists provide care in an office setting, in hospitals and on a continuing ambulatory basis. They tend to the general medical needs of their patients in the office, including disease prevention, early detection of disease, screening, patient education and follow-up care from hospitalization. In the hospital and ambulatory setting, internists manage acute and chronic illness of their patients and other patients that have been referred to them by other practitioners such as family physicians. They are also trained to meet the special needs of the geriatric population. General internists are trained in many procedures from many different disciplines and they perform these independently. They may also take additional training and subspecialize in the following areas of internal medicine:

• Critical care medicine • Cardiology • Infectious diseases • Neurology • Respiratory medicine • Rheumatology • Endocrinology and metabolism • Gastroenterology • Geriatrics • Hematology • Medical oncology • Clinical allergy and immunology • Dermatology • Nephrology

In addition to their medical work, general internists also organize and co-ordinate their patient’s care and ensure that they gain access to the care they need. After completing medical school, to become a general internist requires additional training that takes 4 years. Those who choose to subspecialize are required to complete 2 years of subspecialty training, which they can begin once completing the three core

years of the general internist program, for a total of 5 years of postgraduate education. For more detailed information on the specialty training requirements go to: http://rcpsc.medical.org/residency/certification/training/intmed_e.pdf There are currently 2,444 general internists practicing in Canada. Of these, 8% are under the age of 35, 41% are between 35-54 and 48% are age 55 and older. The majority (78%) of practicing general internists are male and 22% are female. (Source: 2008 CMA Masterfile) DETAILED INFORMATION The remainder of the data contained in this specialty profile has been extracted from the 2007 National Physician Survey (NPS), unless otherwise stated. All percentages are for respondents only. A total of 589 internists responded (for a response rate of 27%). Complete data tables for general internal medicine from the 2007 NPS are available at: http://www.nationalphysiciansurvey.ca/nps/2007_Survey/Results/physician3.2_sp-e.asp For an index to all specialties, go to: http://www.nationalphysiciansurvey.ca/nps/2007_Survey/2007results-e.asp Choosing internal medicine (2004 NPS Data) In 2004, a majority of internists (67%) reported that they decided on this specialty career choice during their residency, while 21% decided in their clerkship year and 11% during medical school but before their clerkship. The most frequently cited reason for deciding to become an internist was for the intellectual stimulation/challenge this specialty provides (86%). Also cited as factors were the quality of the doctor-patient relationship (61%) and the influence of a mentor (41%). Intellectual stimulation/challenge was identified by nearly half (49%) as the single most important career decision-making factor. Practice Setting Most general internists work in more than one setting. Over half report working in a private office/clinic (53%). Nearly as many work in a community hospital (51%), while 40% work in academic health sciences centres. Over a quarter 28% work in a university/faculty of medicine setting. General internists see patients in a variety of settings, with academic health sciences centres being the main patient care setting for about one-third (32%), followed closely by a private office/clinic (31%) and the community hospital (25%). Liking the area was the major influence (61%) on general internists’ selection of their current practice location, but the availability of a practice opportunity (52%) and the

availability of a medical support system/resources (49%) were also cited as important influences. Practice Profile An equal number of general internists (37%) work in a solo practice setting as work in a group practice where on-call duties, equipment, office space and/or staff are shared amongst the physicians. A total of 30% of general internists said they are in an interprofessional practice setting where physicians and other health professionals have their own caseloads. In their main patient care setting, most (78%) share patient care with other types of health care providers, including:

• family physicians (83%) • pharmacists (70%) • dieticians/nutritionists (68%) • nurses (66%).

During a typical week, a general internist will see approximately 64 patients. The majority (62%) serve an urban/suburban population. General internists work an average of 56 hours per week on professional activities (excluding on-call). The majority of this time (34 hours per week) is devoted to direct patient care, with or without a teaching component. An additional 6 hours per week is spent on indirect patient care, such as making appointments with specialists, charting, meeting a patient’s family, etc. The remainder of the time is spent on CME/CPD, administration and research. Most general internists (72%) make themselves available to their patients (i.e., on-call) outside of their regularly scheduled hours. Nearly all (95%) provide on-call for hospital in-patients, but a fair number (62%) also provide emergency room on-call. Another 30% make themselves available to non-hospitalized patients either by telephone or seeing the patient if required. Of those that do on-call, the majority (58%) spend up to 120 hours per month on-call for their patients, while 19% put in between 121 and 180 hours per month. Almost one fifth (18%) spend more than 180 hours per month on-call. During the time that the general internists is on-call each month, they spend an average of 58 hours on direct patient care and see an average of 60 patients. Income More than half of general internists (53%) receive 90+% of their income from fee-for-service, while almost a third (30%) receive their income from a blended source (i.e., made up of a combination of 2 or more payment methods like fee-for-service, salary, capitation, sessional, contract, benefits/pensions, on-call remuneration or some other form). When asked their preferred method of remuneration, 42% of general interists preferred some form of blended remuneration, 28% want fee-for-service only and 15% would prefer a salary.

According to the Canadian Institute for Health Information’s Average Gross Fee-for-Service Payment Report 2005-2006, the average gross fee-for-service payment per general internist in 2005-2006 was $297,563. Note that this is gross billings and does not take into account deductions for overhead expenses, taxes, etc. To protect their income, physicians take out medical liability coverage in the event that a patient is harmed in a medical misadventure. According to The Canadian Medical Protective Association’s Fee Schedule for 2009 the annual cost for insurance for a general internist is:

Quebec Ontario Rest of Canada $ 2,564 $ 2,856 $ 1,260

Satisfaction Most (75%) internists are very or somewhat satisfied with their current professional life. The vast majority ( 85%) are very or somewhat satisfied with their relationship with their patients, with their relationship with specialist physicians (79% ) and with their relationship with family physicians (72%). General internists are less likely to be very or somewhat satisfied with finding a balance between personal and professional commitments (53%). Only 47% are very or somewhat satisfied with their net revenue as compared with other internists and 34% are very or somewhat satisfied with their net revenue compared to other specialists. A total of 18% said they are somewhat or very dissatisfied with the ability to find locum tenens coverage for CME/CPD, holidays or personal time. ADDITIONAL INFORMATION Additional information on this specialty can be found from the: Canadian Society of Internal Medicine: http://csim.medical.org/ American College of Osteopathic Internists: http://www.acoi.org/StudentWhat.html