Perennial question updates: salary/competitiveness

[tenesmus-x]

Hey all I know there are multiple threads on similar subjects, but as the years go by these things are a dynamic process and I would love to get a feel for the current pulse.

I have waffled back and forth on sleep most of my residency, and recently was shocked to get diagnosed with moderate sleep apnea, which i can now retrospectively conclude may be in large part connected to my chronic fatigue (which i have blamed on med school/residency) and mood (again blamed training).
Given the new diagnosis I have a renewed interest in sleep in large part because I sympathize/worry for those those who "fall thought the cracks". Im only 30 and in the last year have found i have BP's of 160's over 95 consistently, my fitbit has told me I get half as much REM as the average guy my age does, and while I am not in anything close to peak physicals condition I think my BMI is something like 26-28, and don't really snore (no witnessed apneic episodes). If I wasn't in medicine and didn't have a wife who was pretty pushy about me getting a sleep study it is quite likely I could have gone another 10-20 years without a diagnosis. Given how bad my pressure is already at 30 I can only imagine the physical damage I would have taken with another 10 years of this. I think hunting through and finding people like me would be really rewarding.

1. Salary: everything seems somewhat like doom and gloom in the prior threads. I did a little homework and it looks like the reimbursements continued to go down just a little. For context if someone was doing 100% sleep medicine what should they expect (from the homework I've done maybe 300k?), and therefore if someone splits 50/50 they should expect about 150k from their sleep practice and whatever their other specialty of choice pays on the other side? Also I was hearing that the market was somewhat saturated with clinicians but this seems very counter intuitive as AASM also says that there are MILLIONS of undiagnosed individuals with OSA. Is it then just not enough infrastructure? To me it almost seems like it should be like addiction where there is so much out there you have no issues finding a job just about anywhere.
- sub question: How much do y'all get paid reading home sleep studies vs non home? how many can you read in an hour? is the culture trending towards mostly home SS with office SS for the odd cases?

2. Competitiveness: How competitive is the specialty; I am sure it is nothing like what it was 10 or 15 years ago during the "golden era". However, there are a lot of classically competitive specialties that apply (namely ENT and pulm/crit), and I am curious what the application landscape is like, for those who are relatively strong residents from specialties such as IM, FM, Neuro, and Psych or IM/Psych. If I wanted to match for 2023 I would have to start my apps very soon and while I have done well during residency with a few posters and a 2 or 3 pubs, none of it has really been sleep focused. If I apply I would likely be shooting for the usual big name suspects (thinking a career in academics) and am wondering if I should take a year and get a more sleep oriented application established before I throw my hat in the ring.

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[Faebinder]

Mm...

First I should say don't feel bad about the diagnosis, it's actually classic for men in their 30s and residents specifically to discover this as residency is the first time you have had medical insurance and can actually financially work up a medical complaint. Hopefully as you treat the problem you will become a better physician for it. I keep trying to tell my residents, at some point age becomes more important than BMI when it comes to OSAS.

Second with regards to salary, the world is changing a lot and inflation is causing all sorts of problem. $300k sounds reasonable for a start to me and it's what I see being offered. The market is not saturated. The market is just not recognizing the need. Hospitals in general are focused on surgical procedures to make money. Where ever you set up shop, your clinic will get slammed.

Third, with regards to competitiveness of the fellowship, you're gonna need to apply broadly. Gone are the days of applying to 1 or 2 programs and getting in IMO. Sure you don't need 50 but it seems the ratio of applicants to program openings is 1:1 if you do your homework.
https://www.nrmp.org/wp-content/uploads/2022/03/2022-SMS-Results-Data-FINAL.pdf 14 positions went unfilled for 38 unmatched. The number of applicants for each position keeps rising annually since 2019. This is despite the number of programs in the match rising. Its not as competitive however as trying to get from internal medicine to pulmonary medicine.

Best of luck.

 

[Attending1985]

Just curious. What effect has cpap had on your fatigue mood and Htn?

 

[lafamilia]

Bump. I’m considering applying this cycle as a rising 3rd year fellow, but have concerns that PP are not interested in the skill set and it won’t translate to a significant incr in salary as Pulm/CCM/Sleep trained. Any advice is greatly appreciated.

 

[Sushirolls]

Sleep Medicine is its own specialty. No prior base specialty will garner more pay.

Some departments or groups want a Pulm/Sleep or neurology/sleep etc.

Typically its because the others in the group are the same and they want help with cross coverage of IP, or the other clinic.

Rarely do you find the dinosaurs who still think that sleep is just Pulm/sleep and owned by them.

More FM/IM are going into the field. Psych is staying pretty stagnant. Less pulm/cc are going into it. Definitely less ENT. Neurology is staying steady.

 

[sloh]

Sleep Medicine is its own specialty. No prior base specialty will garner more pay.

Some departments or groups want a Pulm/Sleep or neurology/sleep etc.

Typically its because the others in the group are the same and they want help with cross coverage of IP, or the other clinic.

Rarely do you find the dinosaurs who still think that sleep is just Pulm/sleep and owned by them.

More FM/IM are going into the field. Psych is staying pretty stagnant. Less pulm/cc are going into it. Definitely less ENT. Neurology is staying steady.

Do you find sleep medicine is as lucrative now as before? I remember reading some of your previous posts and it seems like it's not

 

[Sushirolls]

A sleep doc I know shared a recent contract offer, and was better than a contract offer I had with psych. Just a little bit better.
Without getting into nitty gritty details, overall, sleep is a bit better than garden variety psych Big Box shop employed jobs.

But there is starting to be some down pressure from Big Box shops requiring more wRVUs or paying at lower conversion factors, etc, similar to what you see in Psych and all other fields. So you'll want to interview at a few places to get a good sample. There are some Sleep jobs out there definitely passing on. There are some locations that are having turn over because of the employer, too. Essentially the field isn't immune to the same Scat plaguing other fields, but overall - little better on pay than psych.

I know one doc who worked one employed job in the past at a Big Box shop and was just taken advantage of. Thankfully wised up and moved across country for greener pastures. Another doc in the past, just billed 99213 on every follow up. Minimalist notes and saw patients every 15 minutes for follow ups. Did consults similar fashion every 20 minutes. Patients hated this doc, even years later when name was brought up - but the sheer volume, put this doc in NSx level income.

Sleep jobs on sites like Practice Link have ticked up. Just a year or so ago it was pretty steady 30, and 5-10 "agency jobs". Looking right now, 49 posted jobs and 43 agency jobs. So things might be picking up? I'd need some fresh grads to comment on their interview circuit to gauge if these are legit jobs or just old listings that aren't dropping off.

 

[tenesmus-x]

Thought i would give an update. especially as attending 1985 asked about my outcomes... So i did not tolerate CPAP very well at all, and would be up for 3 hr's waiting to fall asleep with it on my face until i would give up take it off and fall asleep within minutes.

I ended up going to an ENT to get my tonsils out (which i have needed since i was a kid) before i finished residency, because I had the OSA diagnosis i got put with the sleep ENT. Upon evaluation it turns out I had about 20-30% clearance in my nasal passage with massive conchae throughout, I had a "floppy nose" where if I pull too deep with inspiration it pinches my nose together and thus stops breathing, and the aforementioned tonsils. I ended up having reconstructive surgery on all the above (we spared the breaking of the jaw to move my chin forward a few centimeters) a few weeks before the end of residency.

Lo and behold, I no longer fall asleep when i get on the floor to play cars with my toddler, i no longer fall alseep when i rock the youngest to to bed at night, only to be woken up by my wife when its been 45 min, my adderall dose has been cut down by 75% the prior dose and my mood has improved a great deal. BP's still havnt been awesome but Im hoping that may take a little longer to self correct. Im supposed to get another sleep study in about 5 months and at that time i will really be able to see what difference was made objectively. My fitbit however tells me my REM is much more in line with the general population and my deep sleep has improved as well.

In hindsight i now have a lot of "what if" type questions looking back on the past, for example i was never good at doing high intensity sports, I always thought i was because I was a wimp, now i wonder if it was really i just couldn't get enough oxygen. As i look back i wonder how much of my ADHD is really sleep disturbance, and wonder if I would have ever needed stimulant at all had my sleep been checked. I have had a low T diagnosis since my first year of med school which I got working up my profound fatigue, and I will be getting a T draw in the next month or two too see how that has resolved since my HPA axis is no longer getting clobbered every night.

As for application/career, I ended up just going straight in to PP psych, but continue to flirt with the idea of sleep. I am ALWAYS sniffing out sleep pathology and really wish i could just read and treat all the home sleep studies I order because sleep is booked out about a year for new patients where i am at so i will order home sleep studies and then have to sit on my hands until the patient can actually get in with sleep.

Doing a sleep fellowship would mean moving the family to a whole new place for a year with minimal change in salary, which is not incentivizing but I must admit having already been passionate about sleep before my discovered OSA I have become tenacious since that time. I just finished the book "why we sleep" which is what brought me back to this thread, for a specialty that a lot of people can think of as "boring", it sure does impact a MASSIVE swath of the population.

 

[michaelrack]

In hindsight i now have a lot of "what if" type questions looking back on the past, for example i was never good at doing high intensity sports, I always thought i was because I was a wimp, now i wonder if it was really i just couldn't get enough oxygen.

Anatomical anomalies/upper airway floppiness while asleep does not typically lead to oxygenation or ventilation problems while awake

 

[Super Turrican]

I have been in this forum for over a decade!

Well it’s worth it.

It’s about 15% of my income, but alllows me some tax write offs, I read my own and my partners, own a sleep lab, extra source of referrals. Alllowed me not to do ICU anymore and sleep in my bed every night.

I didn’t want to do the specialty but had left a job and had a year of non compete. So it was either this or Neuro ICU fellowship. Did work as a pulmonologist/Intensivist before and after and it’s much better after.

 

[The kitchen sink]

I have been in this forum for over a decade!

Well it’s worth it.

It’s about 15% of my income, but alllows me some tax write offs, I read my own and my partners, own a sleep lab, extra source of referrals. Alllowed me not to do ICU anymore and sleep in my bed every night.

I didn’t want to do the specialty but had left a job and had a year of non compete. So it was either this or Neuro ICU fellowship. Did work as a pulmonologist/Intensivist before and after and it’s much better after.

Nice! From a compensation standpoint, do you make more than you did practicing pulm/crit or at least the same comp?