INTERNAL MEDICINE

(1) INTRODUCTION

Internal Medicine and it’s Subspecialties

An internist is a specialist trained in the diagnosis and treatment of a broad range of diseases involving all organ systems, and is especially skilled in the management of patients who have undifferentiated or multi-system disease processes. An internist cares for hospitalized and ambulatory patients and may play a major role in teaching or research.

The general internist provides longitudinal care to the adult patient with both acute and chronic diseases. They generally treat non-surgical diseases such as diabetes, hypertension, and congestive heart failure on both an inpatient and an outpatient basis. General Internal Medicine is often described as “less procedural and more cerebral” than other specialties. This does not apply to the subspecialties of internal medicine, which are often heavily procedure based (see below for the list of subspecialties of Internal Medicine). The large number of options available following residency is one of the big advantages of Internal Medicine.

Subspecialties in Internal Medicine include:

9 Cardiology 9 Clinical Immunology/Allergy 9 Critical Care Medicine 9 Endocrinology/Metabolism 9 Gastroenterology 9 Geriatric Medicine 9 Hematology 9 Infectious Diseases 9 Medical Oncology 9 Nephrology 9 Neurology 9 Physical Medicine/Rehab 9 Respiratory 9 Rheumatology

Specialty Training Requirements

A minimum of four years of approved residency to include:

1) Three years of core residency

a) A minimum of 12 months of this training must take place in General Internal Medicine, either on a General Medicine clinical teaching unit, a General Medicine consultation service, or an Ambulatory Care block rotation. b) i. All residents must have a significant experience in the following subspecialty fields: a. Critical Care Medicine b. Cardiology, including the Coronary Care Unit ii. All residents should have a significant experience in the following subspecialty fields: 1 a. Infectious Diseases b. Neurology c. Respiratory Medicine d. Hematology e. Endocrinology/Metabolism f. Gastroenterology g. Geriatric Medicine h. Hematology i. Medical Oncology j. Clinical Allergy & Immunology k. Dermatology l. Nephrology c) All residents must have an adequate general internal medicine ambulatory care experience which could occur, either in association with a general medicine CTU experience, or as a block rotation, or as a separate continuity clinic. Each subspecialty rotation should also have an ambulatory care experience. d) All residents must receive training and experience with patients presenting with internal medicine problems to the Emergency room.

2) The final year of residency

This may occur in the following areas, relevant to the objectives of Internal Medicine and approved by the Internal Medicine Program Director.

a) Further residency in General Internal Medicine which may include up to six months experience in the community in a consultant practice under supervision, b) One full year of clinical residency in any of the subspecialty areas listed in 1(b), c) Up to six months in other areas such as health care delivery, clinical epidemiology, medical education, basic sciences, clinical or basic research (done within the Residency Training Program), or other related areas upon approval by the Internal Medicine Program Director and the Credentials Committee.

Subspecialty Training In order to assure an adequate breadth of training, the maximum experience in any one subspecialty must be limited as follows:

1) Six months during the core internal medicine rotations (first three years). 2) Eighteen months during the four years of internal medicine specialty training.

(2) INTERNAL MEDICINE PROGRAMS ACROSS CANADA

Memorial University Dalhousie University, Halifax Dalhousie University, Saint John Université Laval Université de Sherbrooke Université de Montréal McGill University University of Ottawa 2 University of Ottawa, NESR Queen's University University of Toronto McMaster University McMaster University, Thunder Bay University of Western Ontario University of Manitoba University of Saskatchewan University of Alberta University of Alberta, MCP University of Calgary University of British Columbia

(3) UNIVERSITY OF MANITOBA PROGRAM

Program Contact

Dr. K. Kasper Department of Medicine GC440, General Hospital Health Sciences Centre 820 Sherbrook St. Winnipeg, MB R3A 1R9

E-mail: [email protected]

PROGRAM INFORMATION

Approximate Quota: 12

Number of applicants 2005/2006: 131 Number of interviews 2005/2006: 118 Average out-of-town applicants matched 2004-2006: 24%

Resources

The Internal Medicine Training Program consists of two teaching hospitals and one community hospital in Winnipeg. The catchments’ area for the teaching hospitals includes all of Manitoba and parts of Northwestern Ontario, Saskatchewan, Nunavut and the North West Territories (approx. 1.5 million people). The large catchment guarantees that residents receive a variety of clinical experience from a diverse patient population. The University of Manitoba is well known for the diverse pathology of its patients.

3 Quick Facts:

¾ There are opportunities for up to two inter-provincial and international electives in the core years, depending on trainee's performance. ¾ There are no mandatory rural rotations, but residents are strongly encouraged to complete a rural rotation by their R3 year. ¾ Residents may choose to do a 1-2 period research elective in the core three years, in lieu of doing a subspecialty rotation (at the discretion of the program director). ¾ The average patient load per resident by location varies with each rotation (approx 5 -10 while on CTU). ¾ Our institution provides residents with access to electronic medical resources (Up To Date, MD Consult, e-journals). ¾ There is mandatory presentation of research at the annual Resident Research Day. ¾ There are a wide variety of educational rounds. ¾ Half-Day is based on a core curriculum that rotates on a 3 year schedule. ¾ Our Night Float system dramatically reduces the number of overnight call shifts

Curriculum

The program consists of three core years. Each year is divided into 13 four week periods. The program is designed to provide residents with a broad clinical experience to attain the knowledge, skills, and attitudes to practice internal medicine in an exemplary manner. There is an emphasis on becoming a strong clinical physician. As residents progress through the program, they assume increasing responsibility under appropriate supervision with the flexibility to be self- directed in defining their own educational needs. Ambulatory care is emphasized in our program to expand the patient spectrum upon which to learn.

PGY-1 (core) Clinical Teaching Unit Intern- 8 weeks Clinical Teaching Unit Resident- 4 to 8 weeks Cardiology - 8 weeks Emergency Medicine - 4 weeks Night Float - two 2-week blocks Elective Subspecialty Rotations** - 20 to 24 weeks periods Vacation - 4 weeks

PGY-2 (core) Clinical Teaching Unit Ward Resident- 16 to 20 weeks Coronary Care Unit - 8 weeks Elective Subspecialty Rotations** - 16 to 20 weeks Night Float - two 2-week blocks Vacation - 4 weeks

PGY-3 (core) Clinical Teaching Unit Ward Resident - 0 to 4 weeks Medical Intensive Care Unit - 8 weeks Night Float - 2 weeks Senior Rotation* - 24 weeks Elective Subspecialty Rotations** - 10 to 14 weeks Vacation - 4 weeks

* The senior rotation includes ambulatory care clinics (8 weeks, plus one 'continuity clinic' which runs the entire 6 months), the general internal medicine consult service and screening in the emergency rooms (16 weeks).

4 **Elective Subspecialty rotations are offered in every subspecialty of internal medicine and related fields. It is possible to do elective rotations in other centres. The residents may also do a 1-2 period research elective in place of doing a subspecialty rotation. Opportunities are available for doing rural internal medicine electives in several smaller Manitoba communities, as well as short visits to the Northern Medical Units in remote health centres in Manitoba and Nunavut.

(4) INTERNAL MEDICINE PRACTITIONER’S SURVEY

There are 139 internal medicine specialists in Manitoba. 70 were sent surveys and 16 responded. The results are presented according to the specific internal medicine subspecialty.

What is your special focus?

Public health 1 General internal medicine 7 Critical care medicine 1 Hematology 1 Hepatology 1

How many years have you been in practice?

4

3

2

1

0 1 to 5 6 to 10 11 to 15 16 to 20 21 to 25 26 to 30 above years 30

Population Setting

Winnipeg 11 Brandon 0 Rural So 0 North of 0

Where are they predominantly practicing?

Private practice with hospital 5 Private practice without hospital 1 Community clinic 1 Hospital -Academic hospital 5 -Community hospital 4 Teaching 6 Other –public health

Gender

Male 11 Female 0

5 Marital Status Single 1 Married 9 Divorced 1 Separate 0 Common-Law 0

Do you have children/how many?

Yes 9 No 2

1 child 1 2 children 3 3 children 4 4 children 1

How much do you interact professionally with other physicians? (1-on my own most of the time 10- as a part of a group)

3

2

1

0 12345678910

Are you in a solo practice or group practice?

Solo 4 Group 6

If in a group, how many doctors do you share a practice with?

1 to 3 1 4 to 6 0 7 to 10 0 Above 10 3

PHYSICIAN’S AVERAGE DAY - INTERNAL MEDICINE

How many patients do you see on an average per day?

5

4

3

2

1

0 0 t o 5 6 to 10 11 to 20 21 to 30 Above 30

6 How many hours do you work per week - not including call time? (I.e. including CME, clinical work, administration, teaching)

7 6 5 4

3 2

1 0 1 to 20 21 to 30 31 to 40 41 to 60 61 to 80 above 80

What sort of schedule do you have in your work? (1- irregular/unpredictable, 10-regular/predictable)

5 4

3

2

1 0 12345678910

Are you ever on remunerated call?

Yes 8 No 3

How many days are you on call?

#days/month 1 to 5 4 everyday 0 6 to 10 4 11 to 20 0 21 to 30 0

How many hours per shift?

#hours/shift 1 to 10 0 11 to 16 0 16 to 23 0 24 8 How much routine (similar work or diversity (different tasks, activities) do you have in your work? (1-great deal of routine, 10- great deal of diversity)

6

5

4

3

2

1

0 12345678910

7 What type of intellectual approach to problem solving do you need to have to perform your work duties? (1-specific problem approach, 10-theoretical)

4

3

2

1

0 1234 56 78910

Do you have a sharply defined area of expertise or general expertise? (1-General expertise, 10 - Sharply defined expertise)

3

2

1

0 1234567 8910

How much do you need to use manual/mechanical activities for highly skilled tasks? I.e. doing procedures, performing operations (1-never, 10- most of the time)

6

5

4

3

2

1

0 12345678910

PHYSICIAN’S JOB SATISFACTION - INTERNAL MEDICINE

Overall, how satisfied are you with your career? (1- dissatisfied 10- very satisfied)

4.5 4 3.5 3 2.5 2 1.5 1 0.5 0 12345678910

8 What is the most appealing aspect of your job?

Patient interaction- problem solving Teaching house staff Administration Helping to relieve pain and discomfort Exposure to people 2 Variety of problems Interesting and stimulating work Intellectually appealing Reasonable hours allowing for quality family time Fair remuneration Stimulating variety of clinical scenarios to solve; teaching medical students Helping people Diversity and teaching Healthy people with medical problems Teaching, intellectual stimulation, and newly developing discipline (hepatologist)

What is the least appealing aspect of your job?

Finding beds with the nursing shortage Having to practice defensive medicine Hours required Night time work Long hours and lack of time for outside activities (solo practitioner) Unsatisfied clients who are frustrated with our health care system Dealing with incompetent physicians (fortunately there are only a few in Wpg.) Paperwork "Medical 'politics'" Administration/ bed pinching etc. Dealing with government for support for medications Bureaucracy and administration.

PATIENT CHARACTERISTICS

Presenting complaints most often seen?

Palpitations Difficulty breathing Chest Hypertension 4 Gastro-intestinal problems pain 2 Irritable bowel syndrome Depression Bleeding Shortness of breath 2 Anxiety disorders 2 Cholesterol 2 Diarrhea Diabetes 2 Acute Myocardial infarction Chronic fatigue Weight loss Chronic obstructive pulmonary disease Thyroid disease Acute respiratory shock Pneumonia Soft tissue infection Weakness Skeletal pain Swelling Fatigue Pruritis Abdominal discomfort Malaise Jaundice

Age group most often treated?

Infants 0 Adults 11 Children 0 Elderly 4

9

General Health Status of Patient Population?

Generally Healthy 3 Chronically ill 8 Terminally ill 0 Acutely ill 2 All groups 1

Do you have short-term or long-term relationships with patients? (1-short term, 10-long-term)

4

3

2

1

0 1234 56 78910

How much time do you spend in direct contact with patients? (no time at all – 0, most of my time - 10)

4

3

2

1

0 12345678910

How much opportunity to see end results do you have in your work? (1- little opportunity, 10- great deal of opportunity)

7

6 5

4 3

2 1

0 12345678910

10

FINANCIAL

What is your income bracket after taxes and overhead, etc?

5

4

3

2

1

0 below 50,000 50-70,000 70-100,000 100-150,000 150-200,000 200-300,000 above 300

What income level do you feel you have in comparison to other specialties? (1-lower 10- higher)

5

4

3

2

1

0 12345678910

Are you satisfied with your income?

Very satisfied 0 Satisfied 4 Somewhat satisfied 5 Dissatisfied 1 Extremely dissatisfied 0

One is not paid to think in medicine. One is paid to do some physical intervention, ie. remove cataracts, endoscopy etc.

In absolute terms, satisfied. In relative terms, dissatisfied

Do you feel your current income compensates your workload?

Yes 6 No 4

What is the Basis of your current income?

Fee-for-service 9 Salary 2 Independent contract 0 Sessional 2 Other 0

11

PERSONAL

How much time does work allow for family/leisure activities? (1- little free time, 10- ample free time)

3

2

1

0 1234 56 78910

Are you satisfied with the amount of free time you have?

Very satisfied 0 Satisfied 4 Somewhat satisfied 1 Dissatisfied 4 Extremely dissatisfied 1

Do you have the ability to limit your workload should you need more free time?

Yes 6 No 5

Do you take vacations?

Yes 11 No 0

Planning your future as a doctor in Manitoba 12

Careers in Internal Medicine

9 (1) Introduction 9 (2) Internal Medicine Programs across Canada 9 (3) University of Manitoba Program Information 9 (4) Survey of Internal Medicine Practitioners

November 1st, 2006

13