Purely from a financial perspective, how much more money do pulm/crit attendings roughly make than hospitalists?

[wamcp]

I have changed my mind and completely agree, absolutely do not subspecialize. Just do hospitalist--the opportunity cost is 7+ figures and you'll never recover it with guaranteed 10% returns year over year with your 100% stock portfolio that you keep all the way to retirement and no sequence risk. If I knew that I wouldn't have done it either.

Everyone’s own experience is n=1. If i did pulmcc (i considered it as pgy2) i would be in far worse financial shape than today.

But the general principle is true whether you like it or not. For docs who are focused on long term finances/investing, on paper, the opportunity cost is pretty big for a specialty like pulmcc vs hospitalist. Not to mention one needs to stomach higher burnout risk. Cards, hemeonc GI seems better on paper to me. Endo rheum etc are definitely not financially worth it.

---

Members don't see this ad.

 

[Splenda88]

Everyone’s own experience is n=1. If i did pulmcc (i considered it as pgy2) i would be in far worse financial shape than today.

But the general principle is true whether you like it or not. For docs who are focused on long term finances/investing, on paper, the opportunity cost is pretty big for a specialty like pulmcc vs hospitalist. Not to mention one needs to stomach higher burnout risk. Cards, hemeonc GI seems better on paper to me. Endo rheum etc are definitely not financially worth it.

I dont think cards make sense financially unless you will pursue interventional or EP... Most physicians have an unhealthy fear for elevated troponin. The number of daily consults these guy got is insane.

 

[wamcp]

I dont think cards make sense financially unless you will pursue interventional or EP... Most physicians have an unhealthy fear for elevated troponin. The number of daily consults these guy got is insane.

The easy bread and butter consults aren't worth the RVU $$ to gen cards?

 

[James_MD]

Critical care makes more than hospital medicine in our current fee-for-service system that assigns higher value to billing critical care time. For someone who is currently a resident, I don't think you can use this fact to clearly project higher career earnings however as the organization who responsible for designing and implementing this system, CMS, is fairly clear in their plans to eliminate it outright with a strategic plan of reaching zero fee-for-service payments by 2030. (https://innovation.cms.gov/strategic-direction).

In an accountable care payment model with capitated risk will a pulm CC specialist out-earn a hospitalist? Who knows, I'd guess both will probably make less with less variation in pay between specialist in general (similar to something like Kaiser). Of course, there are powerful interests resisting this plan, but at some point we will have to address Medicare Part A Trust insolvency.

 

[rockstar88]

I have changed my mind and completely agree, absolutely do not subspecialize. Just do hospitalist--the opportunity cost is 7+ figures and you'll never recover it with guaranteed 10% returns year over year with your 100% stock portfolio that you keep all the way to retirement and no sequence risk. If I knew that I wouldn't have done it either.

I can't tell if this is sarcasm or if you really mean it.

 

[aafisahar]

I dont think cards make sense financially unless you will pursue interventional or EP... Most physicians have an unhealthy fear for elevated troponin. The number of daily consults these guy got is insane.

Cards is great financially. Haven't done the math, but make 410k+rvu first couple years out of fellowship. Made just over 500k annualized last year. Once "partner" should make 650k+ (2-3 years), though partner a bit of a misnomer as still employed by hospital. Get out by 430pm on clinic days, 330pm on imaging days, 5-6pm on consults days. 1 weekend every 6-8 weeks, round and go, usually home by 2 or so so far.

 

[CCM-MD]

Cards is great financially. Haven't done the math, but make 410k+rvu first couple years out of fellowship. Made just over 500k annualized last year. Once "partner" should make 650k+ (2-3 years), though partner a bit of a misnomer as still employed by hospital. Get out by 430pm on clinic days, 330pm on imaging days, 5-6pm on consults days. 1 weekend every 6-8 weeks, round and go, usually home by 2 or so so far.

Nah dude according to SDN that's awful compared to hospitalist.

 

[bronx43]

Cards is great financially. Haven't done the math, but make 410k+rvu first couple years out of fellowship. Made just over 500k annualized last year. Once "partner" should make 650k+ (2-3 years), though partner a bit of a misnomer as still employed by hospital. Get out by 430pm on clinic days, 330pm on imaging days, 5-6pm on consults days. 1 weekend every 6-8 weeks, round and go, usually home by 2 or so so far.

Those hours are chill. My friend in pp cardiology tells me he works way more, easily 60-70 hours a week for about 600-650k but you’re basically banker hours.

 

[Aldertonghen]

MGMA 2022: CCM 455k, pulm: crit 462k, hospitalist 320k. The difference can be quite a bit more with 1099/locum work, rates are almost double for CC work compared to hospitalist work. At my current institution I can drop to 0.5 FTE and make the same as our hospitalists. IMO pulm crit is probably the most satisfying between them. Who works “harder”? Probably crit because of the acuity/procedures, but my census is half of our hospitalists and I have a midlevel. I also don’t discharge anyone and probably deal with much less BS. One could work significantly fewer CC shifts to make same pay as a hospitalist if less work is the goal.

Doing ICU work without the boards is probably the worst idea due to liability. And don’t expect intensivist pay because the primary reason these jobs exist is due to hospitals wanting to save a buck.

Unrelated to post, but do you happen to know what the numbers are for Neurocritical care (for neurology PGY1 here)? How bad is the workload for your ncc colleagues, and what good things/bad things do you see in ncc compared to pulm crit?

 

[aafisahar]

Those hours are chill. My friend in pp cardiology tells me he works way more, easily 60-70 hours a week for about 600-650k but you’re basically banker hours.

ya maybe; I see 22-26 patients a day in clinic, on imaging days, read 25 outpatient echoes, 50 stresses, about 100 ekgs, and do 2-5 TEEs. Inpatient, can see 20-30 consults, do 2-5+ TEEs and read like 50 inpatient echoes/stresses and 100 inpatient EKGs. So definitely feels like hard work, but since the pain is spread out fairly equitably, it doesn't hit so hard. I have two APPs that skeletonize most notes and I dictate the rest.

 

[CCM-MD]

Unrelated to post, but do you happen to know what the numbers are for Neurocritical care (for neurology PGY1 here)? How bad is the workload for your ncc colleagues, and what good things/bad things do you see in ncc compared to pulm crit?

I'm neurocritical care boarded as well. Most of the pure neurocritical care jobs I know of exist in academia, it is rare to see them in the community and MGMA also does not report neurocritical care so it is hard to comment. Probably compensated similarly in academia to pulm/crit if I had to take a guess. If you're looking for $ in neurology, become a neurointerventionalist.

 

[FutureInternist]

The few (4) ICU docs that I know (all at different hospitals) work around 21 days per month.
1 week each of ICU, Pulm & clinic.

2 have an RVU clause by which they have to “pay back” if they get higher than threshold RVU first 3 quarters, but then are below by a # greater than what they were up previously.

1 has clinic pts being paid by RVU only.
Pt cancels, you don’t get paid.

I like my 7on-7off, in at 7 out by 2 (in a “12 hour” shift), and then that leaves me fresh enough to do rehab on my weeks off and get around $100K via the side-gig

 

[Señor S]

And would likely still take 10+ years post-residency to hit the break-even point.

...good thing the average career lasts 30 years then.

This comparison isn't even close and I don't know why people are pretending otherwise: H/O, Cards and GI absolutely blow hospitalist medicine out of the water financially. PCCM is not in the same league but you will still almost certainly, all other things being equal, come out ahead of a comparable (location-wise) hospitalist. Being a hospitalist is not some shrewd financial decision; in fact, compared to what you can make as a sub specialist, it's a dumb financial decision.

 

[NewYorkDoctors]

I run my own office based PFT lab and also do home sleep studies (but not a full sleep center for full PSG, MSLT, etc... sine I am not sleep certified) in my office.

The one benefit of being an outpatient pulmonologist is most of these studies do not need prior authorization and I tend to do them on the same day as the initial consultation (to improve patient satisfaction and minimize no shows on a second appointment date).

PFTs, spiros, bronchoprovocation testing, HAST, 6MWT, FENOs, CPETs, chest physiotherapy, nebulizer education, sputum induction, lung U/S (yes the same ICU POCUS lung US is a billable outpatient procedure) all do not need PA.
The only thing I get PAs for (besides radiology for CTC but that doesnt really count for my practice) are the home sleep studies.

All I will say is I make more as an outpatient pulmonologist than I would as a PMD by virtue of just having more CPT codes to bill for.

Granted this is my n=1 experience and I know not every physician can open a practice off the bat

 

[Splenda88]

The few (4) ICU docs that I know (all at different hospitals) work around 21 days per month.
1 week each of ICU, Pulm & clinic.

2 have an RVU clause by which they have to “pay back” if they get higher than threshold RVU first 3 quarters, but then are below by a # greater than what they were up previously.

1 has clinic pts being paid by RVU only.
Pt cancels, you don’t get paid.

I like my 7on-7off, in at 7 out by 2 (in a “12 hour” shift), and then that leaves me fresh enough to do rehab on my weeks off and get around $100K via the side-gig

Leaving at 2pm is great. You are basically working 7-8 hrs while getting paid for 12.

I hereby declare hospital medicine is one of the best jobs in term of lifestyle and salary in medicine. Lol

My next gig should be one in which I can leave at 3 pm.

 

[chessknt]

Leaving at 2pm is great. You are basically working 7-8 hrs while getting paid for 12.

I hereby declare hospital medicine is one of the best jobs in term of lifestyle and salary in medicine. Lol

My next gig should be one in which I can leave at 3 pm.

That's hospital admin

 

[Entadus]

This is just plain wrong. If you want to make things actually fair, the hospitalist should be working as hard as pulmcc fellow and they would be making attending money on those extra hours for the first three years.

Spoiler alert: the power of compound interest is greater than you expect. You’ve completely underestimated the opportunity cost of fellowship.

Hospitalist can exceed pulmcc for an entire career lifetime. Pulmcc could never catch up financially.

Assume both work 72 hours a week and take 4 weeks vacation each for the first three years.

510K for 3 years as a hospitalist = 843K “take home” after taxes
70k for 3 years as pulm cc fellow = 147K “take home” after taxes

Assume the hospitalist and pulmcc have equal living expenses. Pulm cc spend every penny of the 147K on their 3 kids and wife and hospitalist will spend 147K equally on their family for the first 3 years.

so this means 696K the hospitalist is investing after three years. Pulmcc has 0 invested after three years.
Assume both have zero student loans.

Let’s make this simple and say the hospitalist begins investing (kept the 696K saved as cash until year 4) after year 3 and both of them earn 10% returns a year.

So when the hospitalist in year 4 and onward goes back to $330K (now normal working hours) and pulm cc becomes an attending making $450K (normal working hours), let’s suppose both only spend $100K a year.
So after taxes and living expenses, pulmcc is putting 147.5K a year to retirement and hospitalist adds 98K, starting in year 4.

Hospitalist
Year 4: 696K
Year 10: 2.066M
Year 14: 3.557M
Year 24: 11.3M
Year 30: 21.3M

Pulmcc
Year 4: 0
Year 10: 1.189M
Year 14: 2.456M
Year 24: 8.828M
Year 30: 16.8M

Glad someone makes this argument. But some of the assumptions are a tad extreme.

1.) I highly doubt a PCCM fellow would average 72 hr/week for the entire 3 years of fellowship. As others have said, what about research blocks, outpatient blocks, electives, etc? A more realistic number would probably be closer to 60 hours, no?
2.) I highly doubt a hospitalist will work 72 hours per week. That's 12 shifts per 2 weeks (1.0 FTE is 7 shifts per 2 weeks). A more realistic number would probably be less than 60 hours.
3.) 70k per year on fellow salary pays way less than 21K per year in taxes. In your example the fellow is married with kids. Assuming spouse stays at home, taxes would be significantly less than 10K per year. (I was a fellow last year with 1 kid and paid under 8K in federal tax. Add a bit due to living in CA)
4.) Highly doubt there would not be ANY lifestyle inflation for the hospitalist. Who makes 510K per year and spends <$50K? Admirable but just not realistic.
5.) 10% average return, as others have stated, depends on future returns matching historical returns. When you look at current inflation, 8% real return seems like an optimistic and way more realistic assumption.

Overall I would expect that specializing primarily for financial reasons would be unwise. I doubt one path is always a winner. Depends on so many factors.

 

[MD46]

Heme Onc here,
During fellowship after 6 months into 1st year, I started moonlighting as a hospitalist.

During research months could do nights 7p-7a, no cross cover. Only admits 7-8 a night max
Got Paid $1800

Otherwise weekend shifts rounding:18-20pts.
In by 9am out by 2-3pm got paid $1500
No codes or cross calls.

So on top of about $70k a year fellow salary one could easy double if not more that during fellowship (PCCM, Gi, Onc etc) and not be too much behind a hospitalist after graduation.

My 2 cents.

 

[Splenda88]

For the hospitalist medicine (HM) doc who is looking. This is from FB hospital medicine group.


Hello all! I am a practicing emergency physician and launched my own staffing company, Locums United, 5+ years ago to put integrity and honesty back in locums. I have access to several high-paying jobs and my aim is to ensure my fellow physician colleagues get paid a fair market wage. I have the following job available, please email me your CV ASAP if interested to [email protected]
Location: Pocatello, Idaho
Pay - $225/hr ($2700/shift)
12 hour shifts
Level 2 trauma facility
Inpatient
Procedures NOT required
EMR - Epic
Patients per shift - 15-20
Hospital beds - 180
Board certification NOT required
Support - NP support available
Subspecialty coverage - includes anesthesia, CT surgery, Cath lab, Surgery, Neurosurgery, Ortho, Vascular.
Accepts IMLC license. If not licensed, we will get the license for you.
Malpractice and Tail provided
Travel covered (flight, hotel, car rental/mileage)

Nearest airport - 2 hrs drive
Multiple local hotel options

 

[Ubba]

This is just plain wrong. If you want to make things actually fair, the hospitalist should be working as hard as pulmcc fellow and they would be making attending money on those extra hours for the first three years.

Spoiler alert: the power of compound interest is greater than you expect. You’ve completely underestimated the opportunity cost of fellowship.

Hospitalist can exceed pulmcc for an entire career lifetime. Pulmcc could never catch up financially.

Assume both work 72 hours a week and take 4 weeks vacation each for the first three years.

510K for 3 years as a hospitalist = 843K “take home” after taxes
70k for 3 years as pulm cc fellow = 147K “take home” after taxes

Assume the hospitalist and pulmcc have equal living expenses. Pulm cc spend every penny of the 147K on their 3 kids and wife and hospitalist will spend 147K equally on their family for the first 3 years.

so this means 696K the hospitalist is investing after three years. Pulmcc has 0 invested after three years.
Assume both have zero student loans.

Let’s make this simple and say the hospitalist begins investing (kept the 696K saved as cash until year 4) after year 3 and both of them earn 10% returns a year.

So when the hospitalist in year 4 and onward goes back to $330K (now normal working hours) and pulm cc becomes an attending making $450K (normal working hours), let’s suppose both only spend $100K a year.
So after taxes and living expenses, pulmcc is putting 147.5K a year to retirement and hospitalist adds 98K, starting in year 4.

Hospitalist
Year 4: 696K
Year 10: 2.066M
Year 14: 3.557M
Year 24: 11.3M
Year 30: 21.3M

Pulmcc
Year 4: 0
Year 10: 1.189M
Year 14: 2.456M
Year 24: 8.828M
Year 30: 16.8M

Investment portfolios don't just go up every year at a predetermined percentage. There are pullbacks and negative years. Those inevitable pullbacks disrupt the compounding process and favor the individual who can put more money in during those years to "buy the dip"

The important question that hasn't been directly addressed yet in this discussion is: when do you want to have your money (whatever the total ends up being by retirement)? If you want to have fun in your 30s traveling and collecting some fantastic adventure memories, there's a strong argument to be made for being a hospitalist. If you've got a more conservative plan in mind and want to have a family-oriented life with strong, long-lasting earning potential to ensure a very comfortable retirement and perhaps enough wealth to leave significant amounts to your children, a high-paying specialty with delayed gratification makes sense. Hell, if we assume disciplined investment habits with steady 10% returns, all of we physicians are suckers who should've gone for plumbing.

There is no "right" answer. Only tradeoffs.

 

[end stage fibro]

The general hospitalist track is doomed. In the eyes of our administrators, we're paid too well, to do a job that can likely be fully automated with the assistance of mid-levels and the other consulted physicians. I think we'll last maybe another 10-15 years, 20 at best. We're just not economically viable. I'll be retired by then.

This needs to be discussed more on this forum. I used to be bullish on being a hospitalist as a career but now I am not so sure. The big corporate player in town used to advocate for hospitalists but now favors NPs. Their reason being that you can get at least 2 NPs for 1 doc, they consult the same amount, and are better at following protocols, ticking boxes, answering queries etc. They also don't mind being on campus as long. An administrators wet dream! My current more high-end shop still contracts out all the hospitalist services because they just do not generate revenue. they have had early rumblings about hiring more midlevels (which I don't think will go anywhere; our particular clientele still wants to see an MD). All the money making specialities are already employed and have an army of midlevels that are meat shields for the physicians. I think there will eventually be a 4:1 supervision system like anesthesia

Hospitalists need to understand that we have no medical value to the hospital system, just some shiny letters after your name. all the mental masturbation about low sodium isn't billable and you're going to consult nephro anyways. What moat do we have to guard against midlevels? Better start saying "how high" when admin asks you to jump

 

[DrMetal]

This needs to be discussed more on this forum. I used to be bullish on being a hospitalist as a career but now I am not so sure. The big corporate player in town used to advocate for hospitalists but now favors NPs. Their reason being that you can get at least 2 NPs for 1 doc, they consult the same amount, and are better at following protocols, ticking boxes, answering queries etc. They also don't mind being on campus as long. An administrators wet dream! My current more high-end shop still contracts out all the hospitalist services because they just do not generate revenue. they have had early rumblings about hiring more midlevels (which I don't think will go anywhere; our particular clientele still wants to see an MD). All the money making specialities are already employed and have an army of midlevels that are meat shields for the physicians. I think there will eventually be a 4:1 supervision system like anesthesia

Hospitalists need to understand that we have no medical value to the hospital system, just some shiny letters after your name. all the mental masturbation about low sodium isn't billable and you're going to consult nephro anyways. What moat do we have to guard against midlevels? Better start saying "how high" when admin asks you to jump

Yeah, pretty much. The only thing that might save us is if we stop consulting, and do things ourselves (simple infection, need not consult ID . . . mild hypoNa, need not Nephro . . . BS TIAs, need not neurology . . .etc).

I've tried to be an advocate of this, of actually playing doctor, doing things yourself, not consulting so much. But it usually falls on deaf ears. In some cases I've even been chastised for not consulting enough. Such is life.

If you're north of 45 yo, you'll probably be ok. Think the life expectancy of the general hospitalist career track is another 10-20 years (20 at best). If you're younger than that, have a good Plan B.

 

[NewYorkDoctors]

Yeah, pretty much. The only thing that might save us is if we stop consulting, and do things ourselves (simple infection, need not consult ID . . . mild hypoNa, need not Nephro . . . BS TIAs, need not neurology . . .etc).

I've tried to be an advocate of this, of actually playing doctor, doing things yourself, not consulting so much. But it usually falls on deaf ears. In some cases I've even been chastised for not consulting enough. Such is life.

If you're north of 45 yo, you'll probably be ok. Think the life expectancy of the general hospitalist career track is another 10-20 years (20 at best). If you're younger than that, have a good Plan B.

gotta get those consult CPT codes in for the hospital. generate that revenue!

When I see primary care patients ( I have a handful) in my office, i never refer out unless I know its for a defined specialist disease (like for neurology, I can handle migraine with aura just fine. i can't handle MS must refer that) or for a procedure. I can handle IBS just fine thank you (not that the GIs want anything to do with the IBS patients after they did the scopes lol... sad). If I see Type 1 DM, I'm on it along with my nurse for getting continuous glucose monitoring set up! I mean yes I do refer to endocrine but... 3 month wait time... patient does not like going there... etc...

I often find when I refer a patient to another subspecialist for a disease, they come back more confused and less happy than they were to start with. Plus I seldom get consult notes from other doctors.

This is why when I consult on pulmonary patients, I make it clear to patient not to bother his/her PMD about this subspecialty issue. Your PMD sent you here so he/she can focus on your back pain and depression you know?!? I also spend good money ensuring my consult notes are all send to all PMDs and other providers related (usually the cardiologists).

Then again, I am subspecialized and critical care trained (though i seldom do ICU work anymore) so it might just be that "i got this mentality."

Perhaps the moral of the story is everyone should subspecialize in something, do hospitalist, when that fails fall back onto your subspecialty or GIM. Maybe those nephro programs will fill now lol.

 

[chessknt]

I do see hospitalists as potentially endangered in their current iteration. They used to be about getting patients high quality care and discharge faster but the goalposts have moved and the hospital forgot how crappy it used to be and think they do nothing now.

 

[SXMMD]

I do see hospitalists as potentially endangered in their current iteration. They used to be about getting patients high quality care and discharge faster but the goalposts have moved and the hospital forgot how crappy it used to be and think they do nothing now.

Going through this with my employer currently, the writing is on the wall

 

[chessknt]

Going through this with my employer currently, the writing is on the wall

I hope the specialists come to bat for you. I saw this happen at a facility near where I trained--the hospitalists got gutted and the specialists stood by because they were scared they'd be next if they spoke up. The whole field has been effectively neutered.

 

[Nocturnist]

This is just plain wrong. If you want to make things actually fair, the hospitalist should be working as hard as pulmcc fellow and they would be making attending money on those extra hours for the first three years.

Spoiler alert: the power of compound interest is greater than you expect. You’ve completely underestimated the opportunity cost of fellowship.

Hospitalist can exceed pulmcc for an entire career lifetime. Pulmcc could never catch up financially.

Assume both work 72 hours a week and take 4 weeks vacation each for the first three years.

510K for 3 years as a hospitalist = 843K “take home” after taxes
70k for 3 years as pulm cc fellow = 147K “take home” after taxes

Assume the hospitalist and pulmcc have equal living expenses. Pulm cc spend every penny of the 147K on their 3 kids and wife and hospitalist will spend 147K equally on their family for the first 3 years.

so this means 696K the hospitalist is investing after three years. Pulmcc has 0 invested after three years.
Assume both have zero student loans.

Let’s make this simple and say the hospitalist begins investing (kept the 696K saved as cash until year 4) after year 3 and both of them earn 10% returns a year.

So when the hospitalist in year 4 and onward goes back to $330K (now normal working hours) and pulm cc becomes an attending making $450K (normal working hours), let’s suppose both only spend $100K a year.
So after taxes and living expenses, pulmcc is putting 147.5K a year to retirement and hospitalist adds 98K, starting in year 4.

Hospitalist
Year 4: 696K
Year 10: 2.066M
Year 14: 3.557M
Year 24: 11.3M
Year 30: 21.3M

Pulmcc
Year 4: 0
Year 10: 1.189M
Year 14: 2.456M
Year 24: 8.828M
Year 30: 16.8M

It baffles me to see the lengths some folks here would go through to poke holes in what is otherwise pretty solid math with some very reasonable assumptions.

Trying to argue over future stock market returns (both specialties are subject to the same market returns yearly, whether its -10% or 30% some years), or "sequence risk if you do invest up front" (time in the market is more important than timing the market. Since 2/3 are up years and 1/3 are down years you're statistically more likely to see a sequence reward than risk), and for the grand finale "in the end nobody knows nothing" when you're really hanging onto straws for dear life.

If anything, the most significant assumption you've omitted here is the employer match and additional tax advantaged retirement savings like the 457 I've been maxing out in addition to my 401k that fellows are missing out on. My employer contributed somewhere between 50-75k in those first 3 years. Add the 40% stock market returns in my first 3 years out of residency and that's north of 100k ahead. Not even going to go into backdoor Roth or HSA.

 

[wamcp]

It baffles me to see the lengths some folks here would go through to poke holes in what is otherwise pretty solid math with some very reasonable assumptions.

Trying to argue over future stock market returns (both specialties are subject to the same market returns yearly, whether its -10% or 30% some years), or "sequence risk if you do invest up front" (time in the market is more important than timing the market. Since 2/3 are up years and 1/3 are down years you're statistically more likely to see a sequence reward than risk), and for the grand finale "in the end nobody knows nothing" when you're really hanging onto straws for dear life.

If anything, the most significant assumption you've omitted here is the employer match and additional tax advantaged retirement savings like the 457 I've been maxing out in addition to my 401k that fellows are missing out on. My employer contributed somewhere between 50-75k in those first 3 years. Add the 40% stock market returns in my first 3 years out of residency and that's north of 100k ahead. Not even going to go into backdoor Roth or HSA.

I get it though - some people don't like to feel bad about their life decisions. Mental gymnastics help people cope. But facts are facts. Pulm/cc, as it stands, is not financially worth it versus doing hospitalist work - for the average doc, but again, only if your goal is strictly about finances.

Cards, GI, heme onc on the other hand - as I said above, are all likely better than hospitalist work if the goal is $$$

 

[Nocturnist]

I get it though - some people don't like to feel bad about their life decisions. Mental gymnastics help people cope. But facts are facts. Pulm/cc, as it stands, is not financially worth it versus doing hospitalist work - for the average doc, but again, only if your goal is strictly about finances.

Cards, GI, heme onc on the other hand - as I said above, are all likely better than hospitalist work if the goal is $$$

This.

When you've spent 3 extra years of your life just to still work 40% nights in rural America, and still make 50k a year less than me- resorting to ****tjng on hospitalists seems to be their most mature coping mechanism.

Sorry you didn't go into cards or GI.
Sorry you've gotta trudge through 3 times my volume while I catch up on my Netflix.
Play stupid games, win stupid prizes. Nobody but yourself to blame.
Just don't take out your frustrations on us.

 

[timpview]

I hope the specialists come to bat for you. I saw this happen at a facility near where I trained--the hospitalists got gutted and the specialists stood by because they were scared they'd be next if they spoke up. The whole field has been effectively neutered.

As a specialist I’ve switched my tune.

Although I would 100x over prefer to have a hospitalist manage or co-manage my patients I’m at the point where the incessant whining (from both sides) and back and forth just isn’t worth it.

In my view I’ll take my chances from a quality standpoint with an NP that’s primary and that’s easy to work with and that provides the night coverage for the basics. Our group has advocated that to admin

I think that model will work better going forward for most specialties given the current burnout and attitudes of most of us these days (Hospitslists and specialists alike).

With that said I do think Hospitslists will always have a role with their primary patients. I just prefer not to have to deal with them and they prefer not to deal with us.

 

[SXMMD]

I hope the specialists come to bat for you. I saw this happen at a facility near where I trained--the hospitalists got gutted and the specialists stood by because they were scared they'd be next if they spoke up. The whole field has been effectively neutered.

Unfortunately no one going to bat for us- it's a free for all. I'm not surprised it's happening elsewhere too

Edit: see timpview opinion above. Burnout has us fighting each other.

 

[CCM-MD]

It baffles me to see the lengths some folks here would go through to poke holes in what is otherwise pretty solid math with some very reasonable assumptions.

Trying to argue over future stock market returns (both specialties are subject to the same market returns yearly, whether its -10% or 30% some years), or "sequence risk if you do invest up front" (time in the market is more important than timing the market. Since 2/3 are up years and 1/3 are down years you're statistically more likely to see a sequence reward than risk), and for the grand finale "in the end nobody knows nothing" when you're really hanging onto straws for dear life.

If anything, the most significant assumption you've omitted here is the employer match and additional tax advantaged retirement savings like the 457 I've been maxing out in addition to my 401k that fellows are missing out on. My employer contributed somewhere between 50-75k in those first 3 years. Add the 40% stock market returns in my first 3 years out of residency and that's north of 100k ahead. Not even going to go into backdoor Roth or HSA.

One of the many "very reasonable" assumptions in that "pretty solid math" is working an average of 72 hours per week as a hospitalist for 48 weeks of the year x 3 years.

 

[chessknt]

One of the many "very reasonable" assumptions in that "pretty solid math" is working an average of 72 hours per week as a hospitalist for 48 weeks of the year x 3 years.

Not to mention the incredible endless bull run stock market during those 3 years and beyond for all time. But I digress it is all my mental gymnastics. I am just jealous of all the lambos the hospitalists are gonna get to drive in NYC after their 3 hours of work each day while I eat ramen our of my hollowed out tree in bum**** nowhere and can't even afford my Flinstones car after my 16 hour shift in house the whole time.

 

[NewYorkDoctors]

perhaps the moral of the story (the thread) is that NPs with their DNP doctorate degree can easily encroach on hospital medicine and its gonna happen eventually for "cost savings."

But DNPs are unlikely to encroach and become solo intensivists and pulmonary providers.


I mean I know some rural hospitals use NP / PA run ICUs with teleICU physician coverage. But at least the physician still has a job in that case... somewhat...

 

[BicepsTriceps]

My hospital transitioned to more APPs due to lack of physicians.

I work the admitting shift.

The amount of re-admissions I've seen after APP implementation is staggering. Flat out insane. Half my admissions are re-admissions now. Most re-admitted due to improper management last admission.

The people who think PA or NP can replace an MD with 3 years of intense training and provide the same quality are flat out delusional.

Hospitals that implement independent APP program will wake up soon to reality of all their patients being readmissions with flat Zero payment from Medicare for all the care they provide hence costing way more than hospitalist programs.

APP should be paired 1:1 with a hospitalist who oversees all the patients with a max census of 20-24.

Other than that I know for a fact implementing independent APPs will save the hospitals Jack **** due to extremely poor quality and insanely high readmissions rate.

My 2 cents.

 

[Señor S]

As a specialist I’ve switched my tune.

Although I would 100x over prefer to have a hospitalist manage or co-manage my patients I’m at the point where the incessant whining (from both sides) and back and forth just isn’t worth it.

In my view I’ll take my chances from a quality standpoint with an NP that’s primary and that’s easy to work with and that provides the night coverage for the basics. Our group has advocated that to admin

I think that model will work better going forward for most specialties given the current burnout and attitudes of most of us these days (Hospitslists and specialists alike).

With that said I do think Hospitslists will always have a role with their primary patients. I just prefer not to have to deal with them and they prefer not to deal with us.

If you don't mind could you give some examples of the "whining" you deal with from hospitalists? I can imagine a lot of reasons that somebody would prefer their own NPs versus a hospitalist but I'm curious which ones bother you specifically.

 

[Nocturnist]

One of the many "very reasonable" assumptions in that "pretty solid math" is working an average of 72 hours per week as a hospitalist for 48 weeks of the year x 3 years.

72 hours would have been a light week in residency. I think the spirit of the assumption was that both bust their butts like a fellow for 3 years. If every fellow can and must do it, why can't the hospitalist?

The very reasonable assumption and solid math here isn't so much the exact hours per week, it's the staggering pay difference and savings rate easily achievable in the first 3 years. To make 510k i'd have to work around 50-55 hours a week at my rate of $180-220/hr, not including any bonuses. That's actually right around how much I work (with much more than 3 weeks vacation) and I'm at 600k yearly. If I worked 72 hours a week for 48 weeks, after bonuses I'd be looking at 700-750k conservatively, which a couple locums I work with that want to work that much I know for a fact do make.

 

[gutonc]

The whole premise of this thread is ridiculous. Outside of cash pay cosmetic derm or plastics, nobody should be deciding on a career in medicine from a purely financial perspective. Choose something you can stand to do despite the fact that you will get paid less for it as time goes on. Because that's how it's all headed.

 

[Splenda88]

This.

When you've spent 3 extra years of your life just to still work 40% nights in rural America, and still make 50k a year less than me- resorting to ****tjng on hospitalists seems to be their most mature coping mechanism.

Sorry you didn't go into cards or GI.
Sorry you've gotta trudge through 3 times my volume while I catch up on my Netflix.
Play stupid games, win stupid prizes. Nobody but yourself to blame.
Just don't take out your frustrations on us.

I really dont think cards worth it either. These guys/gals work a lot.

I would say hospital medicine right now is top 5 in medical specialties when it comes to lifestyle and $$$. Made 405k last year working a low stress job 17 days/month. I am already home today at 4pm drinking scotch. Lol

 

[Splenda88]

The whole premise of this thread is ridiculous. Outside of cash pay cosmetic derm or plastics, nobody should be deciding on a career in medicine from a purely financial perspective. Choose something you can stand to do despite the fact that you will get paid less for it as time goes on. Because that's how it's all headed.

You can say that since you are hemonc, but CCM docs are glorified hospitalists with more added stress.

 

[chessknt]

I really dont think cards worth to either. These guys/gals work a lot.

I would say hospital medicine right now is top 5 in medical specialties when it comes to lifestyle and $$$. Made 405k last year working a low stress job 17 days/month. I am already home today at 4pm drinking scotch. Lol

I think a key metric is $/hr (a d that should I clude call) which is what is not being discussed here but is the only how at metric. I'm guessing onc has everyone beat there.

 

[DrMetal]

nobody should be deciding on a career in medicine from a purely financial perspective.

Well, I can't blame one for having such considerations if you have a 0.5 million-dollar debt. The real question is why do we make it so damn hard and expensive to become a doctor?

Choose something you can stand to do despite the fact that you will get paid less for it as time goes on. Because that's how it's all headed.

Quite true.

 

[CCM-MD]

72 hours/week x 48 weeks = 288 shifts/year. Maybe doable for some of the hospitalists on this website but unrealistic for the rest of us mortals. You also have a very high paying pure nocturnist job. And you’re comparing that to the average rates for pulm/crit. Realize that there are jobs that pay at the 90th percentile in crit care too, and pure nights jobs in the ICU pay a ridiculous amount. Locum jobs also exist in CC and pay significantly more.

But sure, if you make the “very reasonable assumption” of above avg rates as a nocturnist and/or work like a dog, you will definitely come out ahead of a pulm crit doc working mostly days at normal hours at an average rate.

72 hours would have been a light week in residency. I think the spirit of the assumption was that both bust their butts like a fellow for 3 years. If every fellow can and must do it, why can't the hospitalist?

The very reasonable assumption and solid math here isn't so much the exact hours per week, it's the staggering pay difference and savings rate easily achievable in the first 3 years. To make 510k i'd have to work around 50-55 hours a week at my rate of $180-220/hr, not including any bonuses. That's actually right around how much I work (with much more than 3 weeks vacation) and I'm at 600k yearly. If I worked 72 hours a week for 48 weeks, after bonuses I'd be looking at 700-750k conservatively, which a couple locums I work with that want to work that much I know for a fact do make.

 

[Splenda88]

72 hours/week x 48 weeks = 288 shifts/year. Maybe doable for some of the hospitalists on this website but unrealistic for the rest of us mortals. You also have a very high paying pure nocturnist job. And you’re comparing that to the average rates for pulm/crit. Realize that there are jobs that pay at the 90th percentile in crit care too, and pure nights jobs in the ICU pay a ridiculous amount. Locum jobs also exist in CC and pay significantly more.

But sure, if you make the “very reasonable assumption” of above avg rates as a nocturnist and/or work like a dog, you will definitely come out ahead of a pulm crit doc working mostly days at normal hours at an average rate.

$180/hr might be the average rate for nocturnist these days.

 

[gutonc]

You can say that since you are hemonc, but CCM docs are glorified hospitalists with more added stress.

I think I could say it if I was cosmetic derm, or hospital employed outpatient FM.

The point is not who works too hard for too little money, the point is that all of us work too hard for too little money and it's only getting worse. So choosing a specialty strictly for the money (my derm/plastics examples notwithstanding) is doomed to failure and unhappiness.

 

[Splenda88]

I think I could say it if I was cosmetic derm, or hospital employed outpatient FM.

The point is not who works too hard for too little money, the point is that all of us work too hard for too little money and it's only getting worse. So choosing a specialty strictly for the money (my derm/plastics examples notwithstanding) is doomed to failure and unhappiness.

You are being extreme here. There is a happy medium in everything.

If you give some workers a few millions, 90%+ of them will stop working.

If they cut heme/onc reimbursement to the point you guys are making 200-250k, these Ivory towers will be FMG/IMG galore (nothing against IMG/FMG by the way). You really think these specialties are competitive because people LOVE them.

Look at radonc: 10+ years ago, you needed a PhD on top of your MD to get into radonc, but the moment the job market was bad, most US students deserted.

 

[CCM-MD]

$180/hr might be the average rate for nocturnist these days.

Sure. But again, if you’re going to do a fair comparison, compare it to a pulm crit doc working pure nights. It’s very lucrative, trust me. Also much less work IMO - grinding out 10 admits as a nocturnist versus 0-3 with some procedures as an intensivist.

I agree CCM is basically a glorified IM doc that manages the vent and does life saving procedures. In the same breath, gen cards is a glorified IM doc that reads echo; nephro is a glorified IM doc that does dialysis; and onc is an IM doc that prescribes anti-cancer drugs. I can keep going. Aside from the financial stuff, there’s some pretty cool stuff in crit care like ecmo, ecco2r, multimodal monitoring bolts that will probably become treatment standards in our lifetime. It’s also not necessarily harder work because volume is also much lower, and no discharging. Even just the routine procedures and intellectual stimulation of managing very severe pathology provides a nice change from just grinding out H&Ps and progress notes like a hospitalist. Finally, we are also often the last line of defense for the complications resulting from procedural specialists so most of them like to be nice to us, can’t say that’s the case for other fields. So overall, yes, a very glorified hospitalist.

 

[sloh]

I think I could say it if I was cosmetic derm, or hospital employed outpatient FM.

The point is not who works too hard for too little money, the point is that all of us work too hard for too little money and it's only getting worse. So choosing a specialty strictly for the money (my derm/plastics examples notwithstanding) is doomed to failure and unhappiness.

Grinding for ~5 years in a specialty that one doesn't hate, sock 1 million in VTSAX, and a physician will have achieved coastFIRE. Doesn't sound too bad to me.

 

[Splenda88]

Grinding for ~5 years in a specialty that one doesn't hate, sock 1 million in VTSAX, and a physician will have achieved coastFIRE. Doesn't sound too bad to me.

It's not even grinding. You just work your regular job and a few extra hours here and there and achieve coastFIRE.

 

[timpview]

Unfortunately no one going to bat for us- it's a free for all. I'm not surprised it's happening elsewhere too

Edit: see timpview opinion above. Burnout has us fighting each other.

I think hospitalists should reframe their arguments of their

If you don't mind could you give some examples of the "whining" you deal with from hospitalists? I can imagine a lot of reasons that somebody would prefer their own NPs versus a hospitalist but I'm curious which ones bother you specifically.

When they’re primary
what they’ll admit and don’t admit (which changes based on who’s in)
If they’re “capped” at 2 am
what they won’t follow if nurses call them at night (basic stuff like afib)..
If they want the ER to run every pt by us first regardless of the acuity and time of night

Many of us who aren’t on shifts (working the next day) and have frequent and heavy call just need someone to tuck in the patients and minimize calls at night. These are mostly low acuity uncomplicated patients that take 10-15 min to admit.

I get that a hospitalist doesn’t want to be some specialists resident. I get it. I’ve done that too. That’s why I now argue to admin that we need just a dedicated APP service that will do that and be easier to work with. Obviously this is group/location dependent,

Hospitslists and other MDs often play the quality card to justify their value over APPs. That’s obviously true but the reality is admin doesn’t care…

The real value imo is we can handle volume a lot better than midlevels so I would demonstrate that value by showing that it’ll take 3 poorly trained and unreliable (high turnover) APPs to replace me. That’s not as straightforward financial decision for admin.