CSIMMembersofCouncil Message from the Editor-in-Chief

Dr. Stephen Hwang

President IToronto, ON

Dr. Benjamin Chen

Past President INapanee, ON

Dr. Neil Gibson

Seaetay Treasll'er

Western Region Representative IStll'geon Coll'lty, AB

Dr. Amy Hendricks

Western Region Representative IYellowknife, NT

Dr. David Simpson

Eastern Region Representative IHalifax, NS

Dr. Nadine Lahoud

Quebec Region Representative ILaSalle, QC

Dr. Donald Echenberg

Chair, CPO Subcommittee

Quebec Region Representative ISherbrooke, QC

Dr. Bert Govig

Quebec Region Representative

Vice-President, Health Promotion Committee IAmos, QC

Dr.Tom Maniatis

2016 Chair, Annual Meeting Committee

Representative on the RCPSC Specialty Committee in Internal Medicine

Quebec Region Representative IMontreal, QC

Dr. William Coke

Ontario Region Representative IToronto, ON

Dr. Celine Leger-Nolet

Ontario Region Representative INew Liskeard, ON

Dr. Stephen Duke

Eastern Region Representative IDartmouth, NS

Dr.Ameen Patel

Ontario Region Representative IHami on.

Dr.John Macfadyen

Ontario Region Representative IOrillia, ON

Dr.Maria Bacchus

Western Region Representative ICalgary, AB

Dr. Glen Drobot

Western Region Representative IWinnipeg MB

Dr.Meghan Ho

Resident Representative IVancouver, BC

Dr. MichelSauve

Representative to the CMA

Council Member·at large IFort McMurray, AB

Other CSIM Positions


VKe President, Membership Affairs IMarkham, ON

Dr.lrfan Dhalla

Vice·President, Research and Ql Committee

Toronto, ON

Dr.Jim Nishikawa

Vice Presiderrt, Education Committee

Representative to the

GIM Subspecialty Committee IOttawa, ON

Dr.Mitch Levine

CJGIM Editor in Chief I Hami n.

The Effects of the Ambulatory General Internal Medicine (GIM) Clinical Teaching Unit

In the current issue of the C]GIM Dr. M. Panju et al describe the implementation of an ambulatory GIM clinical teaching unit. Moving the internal medicine clinical teaching environment from the hospital in-patient setting to an enhanced out-patient experience is an important step in broadening the training of GIM residents. While the in-patient setting is still a busy site for the practice of GIM, it is not where most of the activity occurs. Once residents in internal medicine complete their residency training, as consultant physicians they will be more likely be asked to see patients in an ambulatory environment than in a hospital setting. Less urgent or less serious medical conditions have always been assessed in consultant clinics, and now with resource pressures to discharge patients from hospital sooner, or to avoid their admission altogether, the internists' role in keeping patients out of hospital has increased. Thus this new educational setting seems highly desirable.

The "ambulatory GIM clinical teaching unit" is different from simply having a

resident assigned to a GIM or specialty clinic for their outpatient experience. There is a more structured educational environment, with dedicated educational curriculum and graduated learner-specific responsibilities.The addition of this experience clearly provides a new learning opportunity for residents in internal medicine, but is there any downside?

These new clinics are not intended to replace the still very necessary in-patient training where residents manage acutely ill patients often with very serious medical problems. But is the in-patient CTU in jeopardy with the advent of the ambulatory GIM clinical teaching unit? As a consequence of these new teaching units there will certainly be new pressures on the in-patient CTUs. As some trainees are withdrawn from the in­ patient experiences and inserted into these new and enhanced out-patient settings there is a risk that the loss of in-patient trainee numbers will limit the educational viability of the traditional in-patient CTU. That traditional formula has always been heavily dependent upon a hierarchy of teaching and learning, from attending physician, to senior medical resident, to junior medical resident, to clinical clerk medical student The ability to deliver timely high-quality tertiary care is also dependent upon sufficient physician numbers assigned to the in-patient CTU team. While internal medicine is practiced very efficiently in the community hospital setting without the benefit of residents, it may not be possible to provide tertiary care in-patient services without a large cadre of residents.

So while we herald the beginning of this new and interesting educational opportunity in the out-patient setting it behooves us to carefully monitor the consequences involving the other essential component of training in the internal medicine realm. Progress and change should be embraced, but not without consideration of the impact upon co­ related opportunities.

Mitch Levine

4 Volume 11, Issue 3, 2016 Canadian Journal of General Internal Medicine

Message du redacteur en chef

Les retombees de l'unite d'enseignement clinique en medecine interne generate (MIG) ambulatoire

Dans le present numero de la Revue canadienne de medecine interne generale (RCMIG), le Dr M. Panju et autres decrivent la mise en ceuvre d'une unite d'enseignement clinique en MIG ambulatoire. Le deplacement du lieu de l'enseignement clinique de la medecine interne de l'hopital vers des services de consultation externe constitue une etape importante dans

1'elargissement de la formation des residents en MIG.Le milieu

hospitalier est certes un lieu tres important pour l'exercice de la MIG, mais n'est pas l'endroit oil se deroule la plupart des activites de MIG. En effet, les residents en medecine

interne seront probablement plus appeles a exercer en milieu

ambulatoire qu'en milieu hospitalier une fois leur residence terminee et en tant que medecins consultants. Les cas moins urgents ou graves ont toujours ete evalues en clinique par des medecins consultants et, avec la pression exercee sur les

ressources hospitalieres pour retourner les patients a la maison

plus hativement, ou meme d'eviter leur admission, le role des internistes dans le maintien des patients en dehors du milieu hospitalier s'est accru. Par consequent, cette nouvelle avenue pedagogique nous apparait hautement souhaitable.

Le concept d' « unite d'enseignement clinique en MIG ambulatoire » ne consiste pas sirnplement a affecter un resident a une clinique de MIG ou de specialite pour sa formation

en medecine ambulatoire. Le concept exige un encadrement pedagogique structure, avec un programme de formation specifique et des responsabilites qui evoluent graduellement pour les apprenants. L'ajout de cette experience fournit manifestement une nouvelle occasion d'apprentissage pour les residents en medecine interne, mais cela comporte-t-il certains inconvenients?

Ces nouvelles formations ne soot pas destinees a remplacer

la formation en milieu hospitalier. Celle-ci demeure tout a fait indispensable et permet aux residents de prendre en charge des patients gravement malades et presentant souvent des

problemes de sante tres importants. Mais, avec l'avenement du concept d'unite d'enseignement clinique en MIG ambulatoire, les unites d'enseignement clinique en milieu hospitalier sont­ elles menacees? Ces nouvelles unites d'enseignement creeront fort probablement des pressions supplementaires sur les unites d'enseignement en milieu hospitalier. Les apprenants se retirant progressivement du milieu hospitalier pour integrer ces nouveaux milieux ambulatoires offrant une experience plus riche, il y a un risque que la baisse du nombre d'apprenants en milieu hospitalier ne vienne limiter la viabilite educative des unites d'enseignement traditionnelles.

(Suite ii Ia page 41)

CSIM Mission Statement

Mission Statement

The CSIM is a non-profit professional society that promotes the health and well being of Canadian patients, their communities, and their health
care systems. We seek to foster leadership and excellence in the practice of General Internal Medicine (GIM) through research, education, and advocacy for health promotion and disease management


We believe that General Internal Medicine in Canada plays a central role in the training of current and future clinicians, in clinical research,
in patient care, in health promotion, and in health advocacy; and that it unites a body of knowledge, values, and principles of care that lay the foundation for excellence in the Canadian health care system.


We embrace the ethical and professional standards that arecommon to all healing professions,as well as the specific values of generalism, teamwork,
competency-based training, life-long learning, evidence-based medicine, holism, and humane, patient-centered care.


La Societe canadienne de medecine interne (SCM!)est une association

professionnellesansbut lucratif qui entend promouvoir Ia sante et le bien­ etre des patients, des collectivites et des systemes de sante canadiens.Elle souhaiteegaiement promouvoir le leadership et I'excellence dans I'exercice de Ia medecine interne generale en favorisant Ia recherche,!'education, Ia promotion de Ia sante et Ia gestion des soins therapeutiques.


La Societe a l'intime conviction que Ia medecine interne generale occupe une place centrale dans Ia formation des cliniciens aujourd'hui et a

l'avenir, dans Ia recherche clinique, dans Ia prestation des soins et des
services de sante et dans Ia promotion de Ia sante, et que Ia discipline se fonde sur un savoir, des valeurs et des principes therapeutiques essentiels
a Ia poursuite de I'excellence dans le systeme de sante canadien.


La Societe fait sienne les normes ethiques et professionnelles communes

aux professions de Ia sante ainsi que les valeurs particulieres du generaiisme,du travail d'equipe, de Ia formation axeesur les competences, de I'education permanente, de Ia medecine factuelle, de l'holisme et des soins et des services de sante humains,centres sur le patient.

CSIM Continuing Professional Development Mission Statement Our ultimate goal is to go beyond the simple transmission of information.

Our goal is to make a lasting impact on the knowledge, skills and attitudes
of clinicians and future clinicians; to narrow the theory to practice gap; to

improve the health of our patients and of all Canadians.

Mission de la SCMI sur le plan du developpement professionnel continu

Notre but ultime deborde du cadre de Ia
simple transmission d'information. II consiste a
produire un effet durable sur le savoir, les competences et les attitudes du medecin, a rn nhl<>r l'ecart qui separe Ia theorie de Ia pratique, a ameliorer
Ia sante de nos patients et de tous les Canadiens.

Canad i an Jou r na l o f General I nt er na l Med i ci ne