Best sub-specialty for lifestyle?

[NewYorkDoctors]

Allergy $hots, I think

No wonder the allergists stoped waving to me in the hallway once I started our mutual patient on anti IL5 therapy

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[Kaustikos]

No wonder the allergists stoped waving to me in the hallway once I started our mutual patient on anti IL5 therapy

They hate me because I send all patients with 'multiple antibiotic allergies' to get tested. To my credit, it's only been 3 this past year. But they really don't like it.

 

[Osteoth]

They hate me because I send all patients with 'multiple antibiotic allergies' to get tested. To my credit, it's only been 3 this past year. But they really don't like it.

Wait why

 

[gutonc]

Wait why

The same reason that rheumatologists hate fibromyalgia referrals.

 

[bronx43]

The same reason that rheumatologists hate fibromyalgia referrals.

Fibro is fine. Easy RVU for the most part. You give your schpiel, have them pick a fibro med and return in 6 months.

Positive ANA plus fibro is where it’s not worth the money…

 

[Kaustikos]

Wait why

Because some don't understand that prior "allergies" to penicillin at the age of 10 may not be real allergies and should be tested to confirm which we could do just fine. But if they also report "gi upset" as allergy to sulfa and "hives" for ceph, it's just such an annoyance that we really need to confirm this for certain patients that are going to get infections so we can have options.
But meh

 

[bochaw]

endo..

 

[Splenda88]

Why is everyone after heme/onc? I am glad they are making a ton of $$$ in that bloated system.


Almost everyone in medicine can be financially independent in 10 yrs if they can sacrifice a little and their spouses (if they are married) dont take them to the cleaner.

 

[IM_is_cool_I_guess]

I know the future cannot be predicted, but onc seems like the pig with the most lard to be shaved, especially in a healthcare system increasingly cost conscious. Say for w/e reason, cancer drugs cost 1/10th the price they do now, does onc compensation stay the same or fall to the level of other outpatient specialties like rheum/endo? I'm wondering if the same thing could be said for GI and Cards if procedural compensation abruptly fell?

I've heard GI described as the derm of IM... any thoughts on how true that is?

 

[Siggy]

Because some don't understand that prior "allergies" to penicillin at the age of 10 may not be real allergies and should be tested to confirm which we could do just fine. But if they also report "gi upset" as allergy to sulfa and "hives" for ceph, it's just such an annoyance that we really need to confirm this for certain patients that are going to get infections so we can have options.
But meh

If only I could consult allergy for every "shell fish," "iodine," or "contrast" allergy.

1. How can you be allergic to iodine? You have a thyroid that's full of iodine. You eat salt in America that is fortified with iodine.
2. I'm convinced that most contrast "allergies" are "I got contrast once and felt warm, fuzzy, and weird." Yea... not an allergy.

 

[bronx43]

I know the future cannot be predicted, but onc seems like the pig with the most lard to be shaved, especially in a healthcare system increasingly cost conscious. Say for w/e reason, cancer drugs cost 1/10th the price they do now, does onc compensation stay the same or fall to the level of other outpatient specialties like rheum/endo? I'm wondering if the same thing could be said for GI and Cards if procedural compensation abruptly fell?

I've heard GI described as the derm of IM... any thoughts on how true that is?

Oncology has more fat than the rest of the system combined. But I highly doubt costs will be preemptively cut in oncology. It’s simply not politically tenable.

What I think will occur (if not already occurring) is that the rapidly rising cost of labor and supplies will destabilize bigger systems and it may come to a point where they stop functioning after they no longer can extract disproportionate amounts of resources from their own employees and the public at large.

 

[Kaustikos]

If only I could consult allergy for every "shell fish," "iodine," or "contrast" allergy.

1. How can you be allergic to iodine? You have a thyroid that's full of iodine. You eat salt in America that is fortified with iodine.
2. I'm convinced that most contrast "allergies" are "I got contrast once and felt warm, fuzzy, and weird." Yea... not an allergy.

Anecdotal from myself and other people around me; it just takes one person writing down the information to make this an "allergy". Not pointing fingers, but people really need to stop just putting in allergies just because the patient says so. Unless they say something legit. Contrast allergy included.

Though the funniest was a patient refusing to get pcn because her mother died from pcn. What happened? She doesn't know. But she doesn't want to die from it, either.

 

[Splenda88]

I know the future cannot be predicted, but onc seems like the pig with the most lard to be shaved, especially in a healthcare system increasingly cost conscious. Say for w/e reason, cancer drugs cost 1/10th the price they do now, does onc compensation stay the same or fall to the level of other outpatient specialties like rheum/endo? I'm wondering if the same thing could be said for GI and Cards if procedural compensation abruptly fell?

I've heard GI described as the derm of IM... any thoughts on how true that is?

You could say that. They are not being consulted by hospitalist for every single BS like hospitalist do for cardio. They spend most of their time scoping. There is one GI doc where I work (small city) that told one of my colleague that she makes > 600k.

In another note, I overheard the head radiologist said today that they have not been able to recruit radiologist because the salary they are offering is too low (500k/yr).. Radiologists are swimming in $$$ these days.

 

[cards67]

I know the future cannot be predicted, but onc seems like the pig with the most lard to be shaved, especially in a healthcare system increasingly cost conscious. Say for w/e reason, cancer drugs cost 1/10th the price they do now, does onc compensation stay the same or fall to the level of other outpatient specialties like rheum/endo? I'm wondering if the same thing could be said for GI and Cards if procedural compensation abruptly fell?

I've heard GI described as the derm of IM... any thoughts on how true that is?

GI can be highly job dependent. My GI friend went from a hospital-employed job w/ terrible call and consulted or "notified" non-stop for everything now at private practice purely scoping. Cardiology can be good lifestyle too. But for cards procedural compensation isn't necessarily that great. Certainly some are and EP can do alright, but there's been reimbursement cuts in the past and salaries are still some of the highest. But don't be fooled, they're working hard for that money. I mean no cardiologist is earning $500k on 5000rvu (per a job on hem/onc board)

 

[bronx43]

GI can be highly job dependent. My GI friend went from a hospital-employed job w/ terrible call and consulted or "notified" non-stop for everything now at private practice purely scoping. Cardiology can be good lifestyle too. But for cards procedural compensation isn't necessarily that great. Certainly some are and EP can do alright, but there's been reimbursement cuts in the past and salaries are still some of the highest. But don't be fooled, they're working hard for that money. I mean no cardiologist is earning $500k on 5000rvu (per a job on hem/onc board)

You can’t compare rvu to rvu. Getting e&m rvu rates for a complicated lymphoma patient with 12 different problems is wildly different from reading a handful of echos.

I’m not saying cardiology doesn’t work hard - simply that a cardiologist generating 10k rvus isn’t working twice as hard as an oncologist doing 5k rvus.

 

[CCM-MD]

GI can be highly job dependent. My GI friend went from a hospital-employed job w/ terrible call and consulted or "notified" non-stop for everything now at private practice purely scoping. Cardiology can be good lifestyle too. But for cards procedural compensation isn't necessarily that great. Certainly some are and EP can do alright, but there's been reimbursement cuts in the past and salaries are still some of the highest. But don't be fooled, they're working hard for that money. I mean no cardiologist is earning $500k on 5000rvu (per a job on hem/onc board)

Imagine cards got $500 each time they prescribed Brilinta, that’s essentially what’s happening with chemo.

 

[Drrrrrr. Celty]

You could say that. They are not being consulted by hospitalist for every single BS like hospitalist do for cardio. They spend most of their time scoping. There is one GI doc where I work (small city) that told one of my colleague that she makes > 600k.

In another note, I overheard the head radiologist said today that they have not been able to recruit radiologist because the salary is too low (500k/yr).. Radiologists are swimming in $$$ these days.

The GI lifestyle does not seem relaxed. Scoping active gi bleeders, occasionally hemodynamically unstable ones in the icu, cirrhosis and acute liver failure, etc are not exactly calm disease processes in my opinion.
Derm is almost entirely outpatient and people do a lot of procedures that are well compensated. The closest equivalents are rheumatology and allergy. Endocrine is similar but the pay is worse the the other two and is far less procedural.

 

[CCM-MD]

The GI lifestyle does not seem relaxed. Scoping active gi bleeders, occasionally hemodynamically unstable ones in the icu, cirrhosis and acute liver failure, etc are not exactly calm disease processes in my opinion.
Derm is almost entirely outpatient and people do a lot of procedures that are well compensated. The closest equivalents are rheumatology and allergy. Endocrine is similar but the pay is worse the the other two and is far less procedural.

The outpatient billing codes are the same and $/wRVU isn’t significantly different between the primarily outpatient fields. Earning potential is similar IMO - it’s not procedures that makes money, it’s the E&M codes. Endocrine seems to attract those that value lifestyle much more than $ and anecdotally speaking I know a lot of “not quite full-time” endocrinologists which likely impacts the compensation surveys.

 

[danchiao]

The outpatient billing codes are the same and $/wRVU isn’t significantly different between the primarily outpatient fields. Earning potential is similar IMO - it’s not procedures that makes money, it’s the E&M codes. Endocrine seems to attract those that value lifestyle much more than $ and anecdotally speaking I know a lot of “not quite full-time” endocrinologists which likely impacts the compensation surveys.

I second this. I know most of endocrines are women which likely will not do full time clinics and this will affect the average salary

 

[Splenda88]

The GI lifestyle does not seem relaxed. Scoping active gi bleeders, occasionally hemodynamically unstable ones in the icu, cirrhosis and acute liver failure, etc are not exactly calm disease processes in my opinion.
Derm is almost entirely outpatient and people do a lot of procedures that are well compensated. The closest equivalents are rheumatology and allergy. Endocrine is similar but the pay is worse the the other two and is far less procedural.

Work at a community hospital...

 

[hotsaws]

Allergy is a good gig. The lifestyle and money are good - most work 4-5 days per week and do not work on nights/weekends/holidays. Occasionally some practices will have a shot clinic open on a Saturday to accommodate patients who are busy during the week, but this is less common. We are able to improve the quality of life of most of our patients. Most PP docs rarely take true call or go into the hospital, and some never go to the hospital at all. We see kids and adults. The job market has been quite good the past year or so, at least based on my experience and those of my colleagues. By "good," I mean that everyone I know has been able to get a job that, at least seems good, in a desirable city/suburb. Obviously, highly competitive cities are always going to be tougher markets no matter what field you're in. It also is a field that still readily allows for solo practice or a couple docs opening a practice. However, private equity is attempting to invade the field, like it is with many other fields, and this is sad. Full disclosure, I'm very new at this and basing off my limited experience and that of those I know in the field. Take it for what it's worth.

 

[Drrrrrr. Celty]

Work at a community hospital...

I go to residency in a 'community hospital'. The GI team is the 3rd largest consult list at usually 10-20 pts. Lots of GI bleeding, lots of hepatology, lots of alcoholic cirrhosis, lots of stenting.

I don't want to wake up at 3am to try to stop a variceal bleed.

 

[Prehealth1011]

Allergy is a good gig. The lifestyle and money are good - most work 4-5 days per week and do not work on nights/weekends/holidays. Occasionally some practices will have a shot clinic open on a Saturday to accommodate patients who are busy during the week, but this is less common. We are able to improve the quality of life of most of our patients. Most PP docs rarely take true call or go into the hospital, and some never go to the hospital at all. We see kids and adults. The job market has been quite good the past year or so, at least based on my experience and those of my colleagues. By "good," I mean that everyone I know has been able to get a job that, at least seems good, in a desirable city/suburb. Obviously, highly competitive cities are always going to be tougher markets no matter what field you're in. It also is a field that still readily allows for solo practice or a couple docs opening a practice. However, private equity is attempting to invade the field, like it is with many other fields, and this is sad. Full disclosure, I'm very new at this and basing off my limited experience and that of those I know in the field. Take it for what it's worth.

Mind if I PM you?

 

[aafisahar]

Allergy is a good gig. The lifestyle and money are good - most work 4-5 days per week and do not work on nights/weekends/holidays. Occasionally some practices will have a shot clinic open on a Saturday to accommodate patients who are busy during the week, but this is less common. We are able to improve the quality of life of most of our patients. Most PP docs rarely take true call or go into the hospital, and some never go to the hospital at all. We see kids and adults. The job market has been quite good the past year or so, at least based on my experience and those of my colleagues. By "good," I mean that everyone I know has been able to get a job that, at least seems good, in a desirable city/suburb. Obviously, highly competitive cities are always going to be tougher markets no matter what field you're in. It also is a field that still readily allows for solo practice or a couple docs opening a practice. However, private equity is attempting to invade the field, like it is with many other fields, and this is sad. Full disclosure, I'm very new at this and basing off my limited experience and that of those I know in the field. Take it for what it's worth.

It's a shame that allergy is basically get some $hots, take zyrtec, or here's some fancy - mumab

 

[bronx43]

It's a shame that allergy is basically get some $hots, take zyrtec, or here's some fancy - mumab

That’s basically the recipe for a nice easy gig. Low risk, simple clinical presentation, routine high paying diagnostic procedure, high paying therapeutic “procedure” that isn’t even done by the doc, and a few fancy drugs to keep it “cool.”

Biggest thing with allergy is that 98% of the patients have environmental allergies and you can prob learn everything in a week. That prob sets it up for a good deal of encroachment.

 

[hotsaws]

Mind if I PM you?

Of course, happy to answer any questions you have.

 

[hotsaws]

It's a shame that allergy is basically get some $hots, take zyrtec, or here's some fancy - mumab

Nailed it.

That’s basically the recipe for a nice easy gig. Low risk, simple clinical presentation, routine high paying diagnostic procedure, high paying therapeutic “procedure” that isn’t even done by the doc, and a few fancy drugs to keep it “cool.”

Biggest thing with allergy is that 98% of the patients have environmental allergies and you can prob learn everything in a week. That prob sets it up for a good deal of encroachment.

Like many fields, investing in the infrastructure and having the necessary volume is what prohibits significant encroachment. Extract companies do try to recruit some PCPs to prescribe immunotherapy and ENT seems to have crunched the numbers and realize that allergy shots are worth their time. ENT is certainly more successful at encroaching on our gig, likely because they share a referral base for similar complaints. PCPs, less so. There are some prohibitive aspects to this: it requires established infrastructure to obtain/store/maintain allergen extracts and anaphylaxis. There are companies that will handle the extract stuff for you, but obviously this eats away at your margin, and then you gotta ask yourself if you want to hire the extra staff and all that. some do. If you're an ENT or PCP and you have a bad anaphylaxis outcome from immunotherapy, you're going to find it hard to defend in a malpractice suit. For this reason, most of these non-allergists tend to use very dilute extract that has much lower efficacy and they have patients coming in like every week for shots, without great results. It would be nice if they just left the treatment of atopic disease to us, selfishly and for the sake of patients.

This true with other fields as well. Derm for instance makes a good bit of money on high volume and quick bedside procedures like shave/punch biopsies and cryotherapy. That doesn't mean your local PCP can successfully capture that market share and turn the same profit. Derm makes the money because they only see skin complaints and can move through 40+ patients in a day. They also have staff that are trained to make doing all those procedures efficient. The volume and efficiency are key.

There's general surgeons and FM docs that can do colonoscopies but that's never going to be a major threat for GI.

Probably the biggest threat to A/I is private equity moving in and trying to take over our field. This is a threat to most fields now.

 

[chessknt]

The reason allergy does well is because young people who work and have private insurance get allergies. Pulmonary is on the other side of the spectrum where it is all old people on government insurance. It makes absolutely no ****ing sense in our stupid system that I can see two people for an identical issue, provide identical care but one pays 6-8x than the other. Allergy payor mix of 80% private vs pulmonary 30% private and you can bill exact same number of units and earn 1/4 of what the other does. Old people are sicker and need more care and pay the least so avoid them at all costs (which is why we went in to medicine right, to only treat the well off?)

They need to teach this in medical school--pick a specialty that effects young employed people only.

 

[hotsaws]

The reason allergy does well is because young people who work and have private insurance get allergies. Pulmonary is on the other side of the spectrum where it is all old people on government insurance. It makes absolutely no ****ing sense in our stupid system that I can see two people for an identical issue, provide identical care but one pays 6-8x than the other. Allergy payor mix of 80% private vs pulmonary 30% private and you can bill exact same number of units and earn 1/4 of what the other does. Old people are sicker and need more care and pay the least so avoid them at all costs (which is why we went in to medicine right, to only treat the well off?)

They need to teach this in medical school--pick a specialty that effects young employed people only.

This is 100% accurate. These type of things are not taught (almost deliberately...or maybe because academics are W2, take a salary, and are largely clueless) in med school and residency. It's a shame. If you train at most academic medical centers that have large multi specialty outpatient clinics, you'll often see A/I and Pulm sharing clinic space (probably because we both have spirometry as part of the physical...). Anyways, usually a common waiting room. I bet I could walk in to that waiting room and label the patients there to see Pulm and the ones there for Allergy with like 90% accuracy. See all those young, healthy looking patients (probably working on their laptops or finishing a zoom call)...ok, now see all those older, sickly looking patients with their O2 tanks...you can probably guess accurately too. Our clinical immuno patients are pretty sick but only a small minority of A/I docs see any significant portion of these as part of their panel. Allergy also has a few additional income streams to complement regular E&M-driven revenue.

I agree that the reimbursement discrepancy is a shame and disheartening. I'm IM trained and I know what it's like to care for complex patients. It's difficult to truly do it well and certainly time-consuming. The healthcare system actively disincentivizes it. This goes for PCPs as well. Combine this with the obscene student loans many of us carry and you just create an environment that sends people running.

 

[bronx43]

Nailed it.



Like many fields, investing in the infrastructure and having the necessary volume is what prohibits significant encroachment. Extract companies do try to recruit some PCPs to prescribe immunotherapy and ENT seems to have crunched the numbers and realize that allergy shots are worth their time. ENT is certainly more successful at encroaching on our gig, likely because they share a referral base for similar complaints. PCPs, less so. There are some prohibitive aspects to this: it requires established infrastructure to obtain/store/maintain allergen extracts and anaphylaxis. There are companies that will handle the extract stuff for you, but obviously this eats away at your margin, and then you gotta ask yourself if you want to hire the extra staff and all that. some do. If you're an ENT or PCP and you have a bad anaphylaxis outcome from immunotherapy, you're going to find it hard to defend in a malpractice suit. For this reason, most of these non-allergists tend to use very dilute extract that has much lower efficacy and they have patients coming in like every week for shots, without great results. It would be nice if they just left the treatment of atopic disease to us, selfishly and for the sake of patients.

This true with other fields as well. Derm for instance makes a good bit of money on high volume and quick bedside procedures like shave/punch biopsies and cryotherapy. That doesn't mean your local PCP can successfully capture that market share and turn the same profit. Derm makes the money because they only see skin complaints and can move through 40+ patients in a day. They also have staff that are trained to make doing all those procedures efficient. The volume and efficiency are key.

There's general surgeons and FM docs that can do colonoscopies but that's never going to be a major threat for GI.

Probably the biggest threat to A/I is private equity moving in and trying to take over our field. This is a threat to most fields now.

I didn’t mean encroachment by other specialties. That’s a rare phenomenon in medicine outside of a few turf wars. Most specialties have more than enough volume to run their own core business model.

Encroachment by midlevels is clearly the main issue. And honestly it’s not just private equity. There’s a huge allergy practice in my metro area where a business savvy allergist cornered the market by extremely good marketing. He has a huge army of midlevels and just a handful of docs who he never offers partnership. The job market in the city is shot due to this one guy. He’s pulling millions while the docs get paid a middle of the road salary. It’s basically the PE model on a smaller scale and I wouldn’t be surprised if he gets bought out by PE in the next few years.

And not all specialties are threatened by PE, whose business model is more or less profit by means of expanding midlevel encroachment. In fact most specialties in IM are not threatened. GI, cards, heme onc, rheumatology, endocrinology, pulmonary etc. The main reason is that the core competencies of these specialties are far more complex and isn’t just a small handful of highly reimbursed “procedures” (which again are not even done by the doc like scopes are).

As a rheumatologist, I would laugh if a PE firm tried to run a midlevel heavy practice just to push infusions. It would crash and burn and any half competent rheumatologist can hang a shingle across the street and take their all business within 6 months.

 

[grt398]

I didn’t mean encroachment by other specialties. That’s a rare phenomenon in medicine outside of a few turf wars. Most specialties have more than enough volume to run their own core business model.

Encroachment by midlevels is clearly the main issue. And honestly it’s not just private equity. There’s a huge allergy practice in my metro area where a business savvy allergist cornered the market by extremely good marketing. He has a huge army of midlevels and just a handful of docs who he never offers partnership. The job market in the city is shot due to this one guy. He’s pulling millions while the docs get paid a middle of the road salary. It’s basically the PE model on a smaller scale and I wouldn’t be surprised if he gets bought out by PE in the next few years.

And not all specialties are threatened by PE, whose business model is more or less profit by means of expanding midlevel encroachment. In fact most specialties in IM are not threatened. GI, cards, heme onc, rheumatology, endocrinology, pulmonary etc. The main reason is that the core competencies of these specialties are far more complex and isn’t just a small handful of highly reimbursed “procedures” (which again are not even done by the doc like scopes are).

As a rheumatologist, I would laugh if a PE firm tried to run a midlevel heavy practice just to push infusions. It would crash and burn and any half competent rheumatologist can hang a shingle across the street and take their all business within 6 months.

Only thing I'm going to point out here is I wouldn't be too confident about the core competency thing...the system doesn't actually care at all if the "provider" is competent, nor about long term outcomes for patients, and the executives are just running excel sheets that calculate the cost of lawsuit payouts vs savings from employing midlevels rather than actual doctors. And any medicare clawbacks etc due to retroactively denied testing etc. There's a whole set of people at large hospitals whose job involves this stuff.

So from residency, I learned from a GI doc that administration was literally tracking the time GI docs spent doing chart reviews for new patient consults and would notify them when they were spending too much time in the chart compared to the average for their peers. And was pushing them hard to see more patients per day, which meant more midlevel use. This was from one of the older faculty who was considering early retirement b/c they were fed up with it and felt they couldn't provide appropriate consult level care with the metrics being pushed.

In fellowship, I can only speak for my current location, but the majority of new patient consult notes I see from subspecialties including endocrine, pulm, cardiology, GI are all written by midlevels with an attending attestation. Like >2/3 of them at least. This is specifically from nearby non-academic centers, since obviously there are residents here to do that part. Rheumatology is less, but if I had to pick a number I'd say 1/3 of the new consult notes are written by a midlevel with an attending attestation.

As for what to do about it as a doc...I still sit in the FIRE, or "part time FIRE" ASAP camp, so you can work the hours you want to work, provide the level of care YOU as the physician feel is appropriate for your patients, and walk away when administration does their usual thing.

 

[AlteredScale]

I go to residency in a 'community hospital'. The GI team is the 3rd largest consult list at usually 10-20 pts. Lots of GI bleeding, lots of hepatology, lots of alcoholic cirrhosis, lots of stenting.

I don't want to wake up at 3am to try to stop a variceal bleed.

Interesting. Are the GI attending coming in every night?

At least at my institution, If there is a GI bleeder or liver pt, they need to be stabilized in the MICU first before GI even thinks about scoping. So most of the time, it is RARE for the fellow and attending to have to come in during the middle of the night to scope.

If it's lower GI bleed, need to prep. If it's brisk enough then they need to go to IR for CTA +/- embolization.
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In the setting of academics, I think GI attending life is probably the best both in reimbursement and lifestyle ease for the reasons above. Moreover, there's an associated ambulatory endoscopy center where the GI staff can "buy" into the practice and make a lot more to their salary. Cardiology seems to have more calls in the middle of the night to check out a patient, or be called in if you're IC. The HF attending get destroyed when on the inpatient HF/transplant service CVICU service but are on for a week at a time.

If talking just lifestyle and not compensation, honestly seems like allergy/immunology has an amazing gig. They don't even have a dedicated inpatient consults service and get out at 5pm.

 

[sloh]

The job market in the city is shot due to this one guy. He’s pulling millions while the docs get paid a middle of the road salary. It’s basically the PE model on a smaller scale and I wouldn’t be surprised if he gets bought out by PE in the next few years.

Crazy how it only takes 1 (or a couple) physicians to ruin the job market for a location.

 

[Drrrrrr. Celty]

Interesting. Are the GI attending coming in every night?

At least at my institution, If there is a GI bleeder or liver pt, they need to be stabilized in the MICU first before GI even thinks about scoping. So most of the time, it is RARE for the fellow and attending to have to come in during the middle of the night to scope.

If it's lower GI bleed, need to prep. If it's brisk enough then they need to go to IR for CTA +/- embolization.
-----
In the setting of academics, I think GI attending life is probably the best both in reimbursement and lifestyle ease for the reasons above. Moreover, there's an associated ambulatory endoscopy center where the GI staff can "buy" into the practice and make a lot more to their salary. Cardiology seems to have more calls in the middle of the night to check out a patient, or be called in if you're IC. The HF attending get destroyed when on the inpatient HF/transplant service CVICU service but are on for a week at a time.

If talking just lifestyle and not compensation, honestly seems like allergy/immunology has an amazing gig. They don't even have a dedicated inpatient consults service and get out at 5pm.

Truthfully it's hit or miss. And I don't even pretend to know what makes a GI doc decide to come in versus telling me to just stablize ad infinity. If someone's refractory bleeding that continues to bleed whatever I put into them they come in pretty regularly. Variceal bleeds or alcoholics with high enough suspicion for possibly a herald bleed, they come in.

Overall my hospital is a social welfare net though. So it probably affects things.

Idk, you couldn't pay me to take care of a list of uncompensated cirrhotics that just need a breeze in the wind to explosively bleed or go into hepatorenal syndrome. I actually like seeing my patients survive long enough for me to know them so it's not really a good field for me. I'd also do cardio before hand because truthfully their interventions have so much more bang for the buck.

 

[Osteoth]

Truthfully it's hit or miss. And I don't even pretend to know what makes a GI doc decide to come in versus telling me to just stablize ad infinity. If someone's refractory bleeding that continues to bleed whatever I put into them they come in pretty regularly. Variceal bleeds or alcoholics with high enough suspicion for possibly a herald bleed, they come in.

Overall my hospital is a social welfare net though. So it probably affects things.

Idk, you couldn't pay me to take care of a list of uncompensated cirrhotics that just need a breeze in the wind to explosively bleed or go into hepatorenal syndrome. I actually like seeing my patients survive long enough for me to know them so it's not really a good field for me. I'd also do cardio before hand because truthfully their interventions have so much more bang for the buck.

For varices you have 12 hours from the time they bleed to scope usually can punt to the AM unless hemodynamically unstable, at least that's my understanding.

The only other thing you have to come in for is impaction, but can try medications like glucagon, carbonated soda to buy you a few hours if its past midnight. If its a sharp or they have fever then you gotta come in though.

 

[bronx43]

If talking just lifestyle and not compensation, honestly seems like allergy/immunology has an amazing gig. They don't even have a dedicated inpatient consults service and get out at 5pm.

That’s all outpatient specialties. Majority of rheumatologists don’t do inpatient. And endocrinology is in such a dire shortage that outside of tier 1 cities you can basically call the shots and refuse to do inpatient if you want.

 

[bronx43]

Only thing I'm going to point out here is I wouldn't be too confident about the core competency thing...the system doesn't actually care at all if the "provider" is competent, nor about long term outcomes for patients, and the executives are just running excel sheets that calculate the cost of lawsuit payouts vs savings from employing midlevels rather than actual doctors. And any medicare clawbacks etc due to retroactively denied testing etc. There's a whole set of people at large hospitals whose job involves this stuff.

So from residency, I learned from a GI doc that administration was literally tracking the time GI docs spent doing chart reviews for new patient consults and would notify them when they were spending too much time in the chart compared to the average for their peers. And was pushing them hard to see more patients per day, which meant more midlevel use. This was from one of the older faculty who was considering early retirement b/c they were fed up with it and felt they couldn't provide appropriate consult level care with the metrics being pushed.

In fellowship, I can only speak for my current location, but the majority of new patient consult notes I see from subspecialties including endocrine, pulm, cardiology, GI are all written by midlevels with an attending attestation. Like >2/3 of them at least. This is specifically from nearby non-academic centers, since obviously there are residents here to do that part. Rheumatology is less, but if I had to pick a number I'd say 1/3 of the new consult notes are written by a midlevel with an attending attestation.

As for what to do about it as a doc...I still sit in the FIRE, or "part time FIRE" ASAP camp, so you can work the hours you want to work, provide the level of care YOU as the physician feel is appropriate for your patients, and walk away when administration does their usual thing.

Totally agree about the FIRE.

I can only speak from the outpatient side of things since that’s where I do my business. The inpatient side is more or less a prison once patients are admitted, as they have zero ability to flex their free market muscles.

It’s certainly true that the bean counters don’t care about outcomes. And why would they? They count beans and nothing more. But what I have witnessed over and over again in the outpatient setting is that patients aren’t oblivious to qualifications and overall “quality” (physician status, word of mouth, reviews, etc). For most IM specialties, patients have a problem which they expect to be solved. They realize the problem isn't simple, and that there is risk when it involves hormones, autoimmunity, cardiovascular, etc. I used to work for a private group where the other rheumatologist had a midlevel, and had we not stopped transfers of cares, half of the patients would have been seeing me after a few months.

In a competitive market, there is no way that one can run a successful practice by having a significantly higher midlevel ratio than your competitors. You would bleed patients nonstop until your midlevel numbers equilibrate with that of the market. What that means is that a new doc can always enter a market and draw patients from the midlevels.

The allergist that dominated our local market with midlevels would NOT have been able to do so as any other IM subspecialist. Ultimately, susceptibility to midlevel domination/encroachment is present across the board but it is not a binary phenomenon. It’s a spectrum that unfortunately for allergists, they are sitting at the vulnerable end.

 

[Drrrrrr. Celty]

For varices you have 12 hours from the time they bleed to scope usually can punt to the AM unless hemodynamically unstable, at least that's my understanding.

The only other thing you have to come in for is impaction, but can try medications like glucagon, carbonated soda to buy you a few hours if its past midnight. If its a sharp or they have fever then you gotta come in though.

That's for a generic upper gi bleed. Those patients I have enough time to get the trauma blood and rapid transfuser if I need. A variceal bleed is dead in 10 minutes without a blakemore and emergent scope with banding.

I never want to hear or see a blakemore ever again.

 

[Kaustikos]

That's for a generic upper gi bleed. Those patients I have enough time to get the trauma blood and rapid transfuser if I need. A variceal bleed is dead in 10 minutes without a blakemore and emergent scope with banding.

I never want to hear or see a blakemore ever again.

 

[deleted314957]

What's the "best" sub-specialty for lifestyle in current years and potentially, years to come?

Talking JUST lifestyle.
Path. Non-hospital position. Lots of 9-5 or 8-4 with zero patients, call or committees. But, the money is nothing like it used to be. ~average among the specialties now.

 

[AlteredScale]

That's for a generic upper gi bleed. Those patients I have enough time to get the trauma blood and rapid transfuser if I need. A variceal bleed is dead in 10 minutes without a blakemore and emergent scope with banding.

I never want to hear or see a blakemore ever again.

The 12 hours is actually guideline based EV management from the ASGE. You can Blakemore for about 24 hours.

 

[grt398]

Totally agree about the FIRE.

I can only speak from the outpatient side of things since that’s where I do my business. The inpatient side is more or less a prison once patients are admitted, as they have zero ability to flex their free market muscles.

It’s certainly true that the bean counters don’t care about outcomes. And why would they? They count beans and nothing more. But what I have witnessed over and over again in the outpatient setting is that patients aren’t oblivious to qualifications and overall “quality” (physician status, word of mouth, reviews, etc). For most IM specialties, patients have a problem which they expect to be solved. They realize the problem isn't simple, and that there is risk when it involves hormones, autoimmunity, cardiovascular, etc. I used to work for a private group where the other rheumatologist had a midlevel, and had we not stopped transfers of cares, half of the patients would have been seeing me after a few months.

In a competitive market, there is no way that one can run a successful practice by having a significantly higher midlevel ratio than your competitors. You would bleed patients nonstop until your midlevel numbers equilibrate with that of the market. What that means is that a new doc can always enter a market and draw patients from the midlevels.

The allergist that dominated our local market with midlevels would NOT have been able to do so as any other IM subspecialist. Ultimately, susceptibility to midlevel domination/encroachment is present across the board but it is not a binary phenomenon. It’s a spectrum that unfortunately for allergists, they are sitting at the vulnerable end.

Appreciate the thoughtful reply. And fwiw, when friends/family ask me about being sent to subspecialists, I always tell them that they need to request to see the physician solo for their first visit, and if the practice won't accommodate that, then they need to find a different doctor and tell the other practice why they no longer wish to be seen. I'm hoping that if enough people do that over time, it will make some difference.

 

[bochaw]

The outpatient billing codes are the same and $/wRVU isn’t significantly different between the primarily outpatient fields. Earning potential is similar IMO - it’s not procedures that makes money, it’s the E&M codes. Endocrine seems to attract those that value lifestyle much more than $ and anecdotally speaking I know a lot of “not quite full-time” endocrinologists which likely impacts the compensation surveys.

i second this. am a fellow, and on top of that most of my attending now still do virtual clinic and their income still well compensated. im curious if they work full time w/ similar hours to other subspec what their compensation would be

 

[dozitgetchahi]

I know the future cannot be predicted, but onc seems like the pig with the most lard to be shaved, especially in a healthcare system increasingly cost conscious. Say for w/e reason, cancer drugs cost 1/10th the price they do now, does onc compensation stay the same or fall to the level of other outpatient specialties like rheum/endo? I'm wondering if the same thing could be said for GI and Cards if procedural compensation abruptly fell?

I've heard GI described as the derm of IM... any thoughts on how true that is?

GI is absolutely not the “derm of IM”

Allergy and or rheumatology are.

 

[dozitgetchahi]

Interesting that no endo/rheum are posting an affirmative here.

Rheumatology here. Can confirm.

Right now I make $300k working 4.5 days a week with zero call, seeing about 16-18 patients a day. Not half bad. And I’m poised to make more once I become a partner next year, probably around $400k. I also never round in the hospital, which I think is damn sweet. Seeing hospitalized patients sucks. Clinic for life.

Would I like to make $800k? Sure - two points on that: 1) some rheumatologists do make $800k - those are the infusion heavy PP folks who have mastered the buy and bill process and 2) making $400k working 4-4.5 days a week sounds pretty good to me? I don’t want to take call, I don’t want to do procedures at 3am, and I don’t want to work 90+ hours a week. I’m not trading quality of life for any amount of money. It’s not always all about money.

 

[Osteoth]

Rheumatology here. Can confirm.

Right now I make $300k working 4.5 days a week with zero call, seeing about 16-18 patients a day. Not half bad. And I’m poised to make more once I become a partner next year, probably around $400k. I also never round in the hospital, which I think is damn sweet. Seeing hospitalized patients sucks. Clinic for life.

Would I like to make $800k? Sure - two points on that: 1) some rheumatologists do make $800k - those are the infusion heavy PP folks who have mastered the buy and bill process and 2) making $400k working 4-4.5 days a week sounds pretty good to me? I don’t want to take call, I don’t want to do procedures at 3am, and I don’t want to work 90+ hours a week. I’m not trading quality of life for any amount of money. It’s not always all about money.

You could basically have the same job as a PCP…

 

[rokshana]

You could basically have the same job as a PCP…

Other than partners, what pcp has the potential to make 800k?

Plus you would have to deal with everything… the rheum can be more focused on a subject matter.

 

[dozitgetchahi]

You could basically have the same job as a PCP…

Lol. No I do not “have the same job as a PCP”. Rheumatology deals with a lot of things, but I enjoy diagnosing inflammatory illnesses and treating them - I like the knowledge base and the thinking involved. I like seeing the patients get better. I like actually doing physical exams on patients (this is a specialty where that still counts). I also don’t have to deal with a lot of the primary care nuisances that the PCPs do. I sense that you’ve probably never spent much (or any) time in a rheumatology clinic. This is a specialized world with specialized knowledge, and I like it.

Nobody who has spent any time around rheumatologists (or the medicine we practice-or the pts we treat) would think this has much of anything in common with primary care. Most rheumatologists don’t want to be PCPs, either. For me, it was down to ID, onc or rheum-and I chose rheum for the reasons above and more.

 

[bronx43]

You could basically have the same job as a PCP…

PCPs can make 400k but NOT seeing 16-18 a day. You simply can’t generate that kind of revenue with that volume and seeing the kind of patients PCPs see.

Even though it’s becoming less lucrative every year, infusions can still be very profitable. Furthermore, the ancillary revenue generated from rheumatology patients (labs, imaging) is also much higher.

Now I will say it matters ALOT where one practices rheum. If you’re in a major metro where it’s saturated then not only is 400k unlikely but you’ll be knee deep in high maintenance chronic pain, fatigue and positive ANAs. In these locations, you’re better off as a pcp. In a low supply area, rheumatologists are making really good $ while bursting at the seams with real disease and high quality cases.

 

[bochaw]

PCPs can make 400k but NOT seeing 16-18 a day. You simply can’t generate that kind of revenue with that volume and seeing the kind of patients PCPs see.

Even though it’s becoming less lucrative every year, infusions can still be very profitable. Furthermore, the ancillary revenue generated from rheumatology patients (labs, imaging) is also much higher.

Now I will say it matters ALOT where one practices rheum. If you’re in a major metro where it’s saturated then not only is 400k unlikely but you’ll be knee deep in high maintenance chronic pain, fatigue and positive ANAs. In these locations, you’re better off as a pcp. In a low supply area, rheumatologists are making really good $ while bursting at the seams with real disease and high quality cases.

How far should you live from metro area to be able to open these kind of private infusion business? I know some hospitalists earn $500-600k/year in Montana.