Switching from derm to IM late in med school -red flag?

[Seattle.brittle]

Was hoping someone could give me perspective on how my app may be viewed by IM PDs at top programs given that I've decided to switch from applying derm to now applying IM with the hope of pursuing fellowship (likely heme onc) in the future. I'm making the switch now that I am almost complete with my research year (in derm-onc, w a derm PI) and after having done rotations in both IM/subspecialties and derm, realized that my future interests and goals are actually more aligned with the IM route. My main fear applying soon is that PDs will think I am dual applying, when I am actually not. Is there anything I can do to demonstrate IM interest in my application? I will of course not include my experience in derm interest groups, but I also wasn't heavily involved in any IM interest groups.

For reference:
T15 west coast MD program, step 2 was 250-255
P/F clinicals
Research: 10-15 manuscript publications (first authors in a IF>10 cancer journal, another in a smaller clinical study in a derm-onc journal, and two other small derm specific pubs). Other non-first author pubs include some middle author in big journals (C/N/S) and some second author reviews in various specialties including derm, onc, gen surg. Probs have ~10 abstracts/presentations as well.

I'm having trouble figuring out what LoR's I should use since my best letter will be from my derm PI who is well known in the derm space. I could have another strong derm research/clinical letter from a different derm attending as well but not sure I should use this. I can likely get a strong research based LoR from an oncologist, and I'll have my IM chair letter. I could try and squeeze another IM letter from my home institution subI or away rotation, but IDK how strong that will be given I only worked with some attendings for like 1-2 weeks max.

---

Members don't see this ad.

 

[The kitchen sink]

An IM program will definitetly take you if you choose to implement the above plan. You are a very strong US MD applicant.

But I think you should apply derm route. And them doing derm onc. Or derm with IM back up.

Maybe you can take the rare Derm-IM combined residency route.

IM to Heme onc is quite lucrative as well and in some regions almost the same pay ranges.

 

[Ubba]

First of all, it's not really my business but I happen to think that you're making a mistake in not going for Derm. Your call, though.

Second, the top IM residencies will definitely extend interviews to you because they know that even highly qualified Derm applicants often end up not matching and require backup plans. And if you write in your IM personal statement why you've decided to pursue Heme/Onc, they'll be easily convinced.

You have a better chance of getting interviews at MGH, NYU, UCSD, Stanford, etc than you do at community programs, since the latter know that you're way out of their league.

There is nothing wrong with listing your involvement in the Derm interest groups if there wa leadership activity. Otherwise, useless for any applications.

Ask your letter-writers to specify that they are recommending you for the recipients' IM residencies. If you dual-apply, just have each writer create two separate letters, one for each specialty, and make sure that you assign the letters to the correct programs on ERAS.

 

[DrMetal]

First of all, it's not really my business but I happen to think that you're making a mistake in not going for Derm. Your call, though.

Why? Maybe the OP decided he/she wants to do more meaningful work for advanced cancer patients. That equals medical/surgical oncology (not derm).

Look, we all know everybody loves Derm b/c of the quality of life (don't look now, their specialty is becoming very saturated, and not as well reimbursed). But there's also something to be said about taking care of real sick patients.

 

[Ubba]

Why? Maybe the OP decided he/she wants to do more meaningful work for advanced cancer patients. That equals medical/surgical oncology (not derm).

Look, we all know everybody loves Derm b/c of the quality of life (don't look now, their specialty is becoming very saturated, and not as well reimbursed). But there's also something to be said about taking care of real sick patients.

I don't disagree with what you said. My opinion remains that people who can get into the perennial lifestyle specialties should do so. I haven't met a single person in Rads, Ophtho, or Derm who regrets having gone that route, whereas about 98% of people in IM wish they had chosen or gotten into one of those specialties. I don't see anything about Derm becoming saturated. Wait time for an appointment in our system is >6 months. Base pay for Practicelink positions appears to be 400s for 4-day weeks, and the jobs advertised there are usually bottom-of-the-barrel. If dermatologists are declaring saturation of the field, they're likely trying to pre-empt residency expansion, not stating present reality.

Maybe the OP is an exception and has an extremely personal reason for doing Onc such as a family member with h/o cancer, but (s)he did say that (s)he was between IM and Derm, and appears to have started med school off planning to be a dermatologist. In such instances, a "tie" goes to Derm without question.

I don't feel that strongly about the choice, which is why I also gave recs for the IM application process.

 

[DrMetal]

Be Dr. Cox:

 

[CCM-MD]

First of all, it's not really my business but I happen to think that you're making a mistake in not going for Derm. Your call, though.

Agreed.

 

[MifflinDunder]

Me and most of my classmates spent the last 3 years trying to get out of IM into a financially viable fellowship. Definitely would've applied to optho/derm/rads if I had the credentials for it.

 

[Seattle.brittle]

I don't disagree with what you said. My opinion remains that people who can get into the perennial lifestyle specialties should do so. I haven't met a single person in Rads, Ophtho, or Derm who regrets having gone that route, whereas about 98% of people in IM wish they had chosen or gotten into one of those specialties. I don't see anything about Derm becoming saturated. Wait time for an appointment in our system is >6 months. Base pay for Practicelink positions appears to be 400s for 4-day weeks, and the jobs advertised there are usually bottom-of-the-barrel. If dermatologists are declaring saturation of the field, they're likely trying to pre-empt residency expansion, not stating present reality.

Maybe the OP is an exception and has an extremely personal reason for doing Onc such as a family member with h/o cancer, but (s)he did say that (s)he was between IM and Derm, and appears to have started med school off planning to be a dermatologist. In such instances, a "tie" goes to Derm without question.

I don't feel that strongly about the choice, which is why I also gave recs for the IM application process.

Thanks for your input and advice! Ultimately, I'd like to pursue a career in academics to do research with a strong immunology focus (such as cancer-immunology), and have a clinical practice that lets me work with the cutting edge immunotherapies and patients who are most at risk of having poor outcomes, something that I feel I could more feasibly obtain in med onc. While the complex derm issues interest me (primarily onc and rheum overlap cases that have a strong immunology focus), I feel that the rest of the field is not as interesting, relying heavily on external pattern recognition, and this makes me question whether I'd enjoy a derm residency where I'd be forced to learn every skin condition regardless of if I'd ever even see it in practice. Perhaps I'm being short sighted, since I could probably still be happy practicing in derm, I would just need to be specialized in something like derm-onc or rheum-derm to avoid being inundated with bread and butter cosmetic-type cases. Additionally, doing research within derm is something I enjoy since there's plenty of immunology (including cancer-immunology), but I like that onc lets me actually work with cutting edge immunotherapies and help patients most at risk for having poor oncologic outcomes. There's also a big part of me that feels I'd regret not getting trained in medicine, given that I really enjoyed all subjects in med school and the process of disease workup and lab value interpretation in IM.

Would appreciate your and others further input though since it seems that even though I would be a competitive applicant for top IM programs, I may be short sighted in not pursuing derm despite my reservations.

 

[DrMetal]

Agreed.

Agree that's it's not his business? Or that the OP is making a mistake? (I'd argue that it is his business, it's all of ours, since it was posted here.)

academics to do research with a strong immunology focus (such as cancer-immunology), and have a clinical practice that lets me work with the cutting edge immunotherapies and patients who are most at risk of having poor outcomes, something that I feel I could more feasibly obtain in med onc.

Good, follow your interests and passions. What you've described above is indeed done best in medical (or surgical) oncology. It's ok to be interested in other things (Derm) but not necessarily make a profession out of it.

 

[Angler]

have a clinical practice that lets me work with the cutting edge immunotherapies and patients who are most at risk of having poor outcomes, something that I feel I could more feasibly obtain in med onc. While the complex derm issues interest me (primarily onc and rheum overlap cases that have a strong immunology focus), I feel that the rest of the field is not as interesting, relying heavily on external pattern recognition, and this makes me question whether I'd enjoy a derm residency where I'd be forced to learn every skin condition regardless of if I'd ever even see it in practice.

Clinical practice is primarily bread and butter non-complex patient problems. Unless and until you are in an academic position. IM, you are going to see tons of patients with med noncompliance, psychosocial issues, etc. You get this regardless of IM vs Derm, with its eczema, seb k’s, ak’s, on and on. So residency will, by its very nature, not have everything you crave.

 

[Seattle.brittle]

Agree that's it's not his business? Or that the OP is making a mistake? (I'd argue that it is his business, it's all of ours, since it was posted here.)



Good, follow your interests and passions. What you've described above is indeed done best in medical (or surgical) oncology. It's ok to be interested in other things (Derm) but not necessarily make a profession out of it.

Thanks for your input! Do you think I'd be impacted negatively at all if I had LoRs from derm faculty such as my PI, and some research that is specifically in derm? Mainly asking since I feel most applicants have solely IM or IM-subspecialty letters, and wondering if I should try and get the same in the time I have left before apps.

 

[DrMetal]

Thanks for your input! Do you think I'd be impacted negatively at all if I had LoRs from derm faculty such as my PI, and some research that is specifically in derm? Mainly asking since I feel most applicants have solely IM or IM-subspecialty letters, and wondering if I should try and get the same in the time I have left before apps.

Would not be a negative impact, not at all. What counts is the quality of the letter. Do also try to get letters from an IM faculty or preceptor.

 

[CCM-MD]

Agree that's it's not his business? Or that the OP is making a mistake? (I'd argue that it is his business, it's all of ours, since it was posted here.)



Good, follow your interests and passions. What you've described above is indeed done best in medical (or surgical) oncology. It's ok to be interested in other things (Derm) but not necessarily make a profession out of it.

I think OP is making a mistake.

 

[bronx43]

I think OP is making a mistake.

Almost everyone and their grandmothers know OP making a mistake.

 

[NotAProgDirector]

Not sure what's up with all the IM hate. IM can be a great career. And if a career making $250K+ isn't financially viable, then we have different definitions of "viable".

Sure, can probably make more money in Derm. Maybe working less hard. But if you don't enjoy it, it can be a very long and boring career.

To the OP:

If you want to apply to top programs in IM, you definitely need to address the fact that your app looks like derm, and you don't want to have them think you're applying as a backup. There are two things you need to do:

1. Have your Derm PI write you an LOR, stating in it that "we are sad that @Seattle.brittle has decided to pursue IM instead of derm, but our loss is your gain" (anything like this).

2. In the description of your Derm research year on your ERAS application, state "After my research year, I determined my career interests better aligned with training in IM and ultimately Heme/Onc" or something similar.

Since your ERAS application is universal, #2 will make it clear you're not applying to derm. With these two tweaks, it won't be a "red flag". It will be seen as a positive.

 

[Seattle.brittle]

Not sure what's up with all the IM hate. IM can be a great career. And if a career making $250K+ isn't financially viable, then we have different definitions of "viable".

Sure, can probably make more money in Derm. Maybe working less hard. But if you don't enjoy it, it can be a very long and boring career.

To the OP:

If you want to apply to top programs in IM, you definitely need to address the fact that your app looks like derm, and you don't want to have them think you're applying as a backup. There are two things you need to do:

1. Have your Derm PI write you an LOR, stating in it that "we are sad that @Seattle.brittle has decided to pursue IM instead of derm, but our loss is your gain" (anything like this).

2. In the description of your Derm research year on your ERAS application, state "After my research year, I determined my career interests better aligned with training in IM and ultimately Heme/Onc" or something similar.

Since your ERAS application is universal, #2 will make it clear you're not applying to derm. With these two tweaks, it won't be a "red flag". It will be seen as a positive.

Thanks for the helpful tips! Would you recommend I still include my leadership in derm interest groups or should I take that out? Also, would you recommend I try and add additional activities like IM interest groups/volunteer events?

 

[bronx43]

Not sure what's up with all the IM hate. IM can be a great career. And if a career making $250K+ isn't financially viable, then we have different definitions of "viable".

I do reckon that younger doctors who have a ton of student loans and don’t own a home have different definitions of “viable” from a mid career physician with no to little student loans, *probably a hefty retirement account and house in a good school district.

$250k with student loans and living in a tier 2 or higher city means not owning property or having a good standard of living… especially if one is the sole breadwinner.

Based on OP’s name, possible that he/she lives in Seattle which is one of the highest COL areas in the country. Yea, that $250k is not viable.

 

[Seattle.brittle]

I do reckon that younger doctors who have a ton of student loans and don’t own a home have different definitions of “viable” from a mid career physician with no to little student loans, *probably a hefty retirement account and house in a good school district.

$250k with student loans and living in a tier 2 or higher city means not owning property or having a good standard of living… especially if one is the sole breadwinner.

Based on OP’s name, possible that he/she lives in Seattle which is one of the highest COL areas in the country. Yea, that $250k is not viable.

Is your opinion of choosing derm over IM/heme-onc mostly based on monetary/lifestyle reasons? If so I feel that academics or PP would pay similarly (300-350 academics, vs 500+ PP). I agree derm will have a better lifestyle regardless, but will it really be that much better than say outpatient heme/onc? Regardless, monetary reasons aren't a huge motivator for me since I have a partial scholarship from my school and my partner will also be in a health-care related field (dental) making at least 250+.

 

[bronx43]

Is your opinion of choosing derm over IM/heme-onc mostly based on monetary/lifestyle reasons? If so I feel that academics or PP would pay similarly (300-350 academics, vs 500+ PP). I agree derm will have a better lifestyle regardless, but will it really be that much better than say outpatient heme/onc? Regardless, monetary reasons aren't a huge motivator for me since I have a partial scholarship from my school and my partner will also be in a health-care related field (dental) making at least 250+.

Derm is just much more flexible and I would argue the ceiling is higher. With the same amount of work you would put in heme onc for 500k in a big city, you would likely make more in derm.

The finances in a tier 1 city get dicey really quickly if you do indeed live there. Two healthcare professionals probably would have tough time buying into one of the nicer suburbs in tier 1 unless both were banking.

 

[sloh]

The finances in a tier 1 city get dicey really quickly if you do indeed live there. Two healthcare professionals probably would have tough time buying into one of the nicer suburbs in tier 1 unless both were banking.

100%. I live in SoCal and until you’re an attending in a tier 1 city, you truly don’t know how much it costs. It may sound like I’m exaggerating but it’s not worth it to live here if HHI isn’t at least 1M, preferably 1.25-1.5M.

 

[ShuperNewbie]

What the.... You guys are corrupting the youth. I'm gonna have to call BS.

I've lived very comfortably in Manhattan off of a bit over 230k a year. My colleagues have comfortably supported families in Manhattan off a bit more than 250k a year. I've lived very comfortably in orange county off less than 200k.

If a city requires >1million to live comfortably in it, that city would not exist. Silicon valley / Bay area is probably the closest place I've seen to having a ridiculous barrier to entry but even the bay area has PLENTY of places you could live very comfortably for 150k or less. Most of this "I'm not making enough" mentality is more a toxic cultural trait (gotta keep up with Joneses) than a true necessity to entry.

Don't let money control you guys. I've dated plenty of folks in Manhattan who chased after the dollar signs and it's unbelievably toxic and pathetic (in hindsight, I can't believe I lasted as long as I did in those relationships)

 

[NotAProgDirector]

Thanks for the helpful tips! Would you recommend I still include my leadership in derm interest groups or should I take that out? Also, would you recommend I try and add additional activities like IM interest groups/volunteer events?

You can leave in the derm leadership positions. No one is really going to care about IM interest groups -- those are a preclinical thing mostly and have little weight.

 

[whoknows2012]

What the.... You guys are corrupting the youth. I'm gonna have to call BS.

I've lived very comfortably in Manhattan off of a bit over 230k a year. My colleagues have comfortably supported families in Manhattan off a bit more than 250k a year. I've lived very comfortably in orange county off less than 200k.

If a city requires >1million to live comfortably in it, that city would not exist. Silicon valley / Bay area is probably the closest place I've seen to having a ridiculous barrier to entry but even the bay area has PLENTY of places you could live very comfortably for 150k or less. Most of this "I'm not making enough" mentality is more a toxic cultural trait (gotta keep up with Joneses) than a true necessity to entry.

Don't let money control you guys. I've dated plenty of folks in Manhattan who chased after the dollar signs and it's unbelievably toxic and pathetic (in hindsight, I can't believe I lasted as long as I did in those relationships)

Gotta wholeheartedly agree with the above. I get where a lot of y’all are coming from here with Derm being a cushier lifestyle, but you already read in several of the OP’s posts that they really would prefer academic-ish hem/onc. I just don’t get all the anti IM sentiment to be honest.

FWIW, my perspective as academic hem/onc in nyc metro; I live in an expense suburb of NYC, purchased a house after COVID have 2 kids with 3rd on the way. My wife works, does decently well for part time and we combined make nowhere close to 1M, yet, we live comfortably. We have space (large yard/property) a large house that we can grow into and though lots of expenses (and things genuinely are very costly, ie childcare which is $4000/mo), we have a high enjoyment of life. We don’t have $10,000 at the end of the month extra savings but for us it works and we both grew up in the area and wanted to remain here. I commute to the city on a 45 minute train every day something I don’t mind doing.

Even if you decide city living is better, again as @ShuperNewbie mentioned above, it is absolutely doable on an academic hem onc salary especially if your spouse is also a high earner. No you will likely not be taking $10,000 vacations, buying a house in the Hamptons or driving a Range Rover, but a comfortable life especially if there’s some built in salary growth is absolutely the norm. Money is important but so much is made of it on SDN and I think it does a disservice to not have an honest and nuanced conversation about it. Hopefully this adds to it in some helpful way.

Lastly, I have some Derm friends, academic, hybrid and true pp. Money is nice in all 3, in particular hybrid and pp but it’s not mind blowing, and to be completely honest, isn’t particularly exciting, at least in my opinion. Lots of boring consults , skin checks, etc. Not hating on Derm it’s just really nice to make good money AND love what you do…

 

[TexasMed22]

As someone who has also made the derm:hem/onc comparison, I think people are overstating the differences in private practice between the two. According to MGMA, derm and onc salaries are basically identical (~550ish). It is true that most derms work less hours, but oncs aren't working THAT much more. Onc seems to be 4 days a week clinic these days (though with added weekend and call coverage). Additionally, derm has massive midlevel creep problems, which is basically non existent in onc.

I think it would be silly to choose between these two just based on lifestyle/income, they're close enough. Pick which one you are more passionate about.

 

[IM_to_ortho_hopeful]

Derm is just much more flexible and I would argue the ceiling is higher. With the same amount of work you would put in heme onc for 500k in a big city, you would likely make more in derm.

The finances in a tier 1 city get dicey really quickly if you do indeed live there. Two healthcare professionals probably would have tough time buying into one of the nicer suburbs in tier 1 unless both were banking.

What if OP decides to go to other high earning Im subspecialties, cardiology or GI? Do you think the math would change?

 

[IM_to_ortho_hopeful]

To OP. I think it’s telling if you go into an IM forum and 80% of the people tell you not to do it, and the other 20% that tell you to do it are older docs who are probably already FIRE.

If you go in the derm forum do you think derms would be so negative about dermatology?

If you go in the radiology forum do you think they would be so negative about radiology?

If I were you I’d go into derm, then do Mohs surgery in the middle of nowhere for a few years. You’ll have enough to retire and if you want go do onc research track, your intern year will count, 1 year of IM (it’s a waste of time to do anymore training in Im tbh) and then 3 years of onc. Your CV is already ready with a nature pub for that, basically guaranteed.

 

[dozitgetchahi]

I do reckon that younger doctors who have a ton of student loans and don’t own a home have different definitions of “viable” from a mid career physician with no to little student loans, *probably a hefty retirement account and house in a good school district.

$250k with student loans and living in a tier 2 or higher city means not owning property or having a good standard of living… especially if one is the sole breadwinner.

Based on OP’s name, possible that he/she lives in Seattle which is one of the highest COL areas in the country. Yea, that $250k is not viable.

Strongly agree.

Fresh out of fellowship, I was making about $250k with student loans in the Cleveland metro area. And it sucked. I felt surprisingly pinched, and I was in no position to buy property.

$250k as a sole breadwinner in Seattle? NYC? Bay Area? With loans? LMFAO. Not unless you want roommates.

Usually the docs who are “doing well” at $250k in these areas have some secret advantages - they started with no student loan debt, or mommy/daddy fronted them a ****load of money for a down payment on a house, or spouse makes way more than they let on, etc. (It’s not usually “cool” to talk about these things, especially among doctors who usually want to act as if they were completely self made from start to finish, but I’ve seen it happen way more than anyone seems to realize.)

Later I went rural and started making >$500k and life got way better. But if I was still trying to get by on high $200k bucks in a metro area? My life would legit be crap.

Know that if you go semi-rural etc and get the right job, with the right earning potential, you can do really well for yourself. In an urban area, it can definitely be more challenging unless you came in with zero debt or have another high earning spouse.

 

[Splenda88]

Strongly agree.

Fresh out of fellowship, I was making about $250k with student loans in the Cleveland metro area. And it sucked. I felt surprisingly pinched, and I was in no position to buy property.

$250k as a sole breadwinner in Seattle? NYC? Bay Area? With loans? LMFAO. Not unless you want roommates.

Usually the docs who are “doing well” at $250k in these areas have some secret advantages - they started with no student loan debt, or mommy/daddy fronted them a ****load of money for a down payment on a house, or spouse makes way more than they let on, etc.

Later I went rural and started making >$500k and life got way better. But if I was still trying to get by on high $200k bucks in a metro area? My life would legit be crap.

250k after deductions (taxes, 401k etc...) should be 150k/yr. That is 12.5k/month and after paying student loan, you are left with 9.5-10k/month. That will place family in the mid middle class (not lower or upper) in these big cities. Not good IMO.

If you live in a medium/low cost of living area, that might place you in the upper middle class.

 

[NewYorkDoctors]

Strongly agree.

Fresh out of fellowship, I was making about $250k with student loans in the Cleveland metro area. And it sucked. I felt surprisingly pinched, and I was in no position to buy property.

$250k as a sole breadwinner in Seattle? NYC? Bay Area? With loans? LMFAO. Not unless you want roommates.

Usually the docs who are “doing well” at $250k in these areas have some secret advantages - they started with no student loan debt, or mommy/daddy fronted them a ****load of money for a down payment on a house, or spouse makes way more than they let on, etc.

Later I went rural and started making >$500k and life got way better. But if I was still trying to get by on high $200k bucks in a metro area? My life would legit be crap.

Know that if you go semi-rural etc and get the right job, with the right earning potential, you can do really well for yourself. In an urban area, it can definitely be more challenging unless you came in with zero debt or have another high earning spouse.

totally agreed

NYC prices are out of control thanks to (let's not get too off track now on SDN) . $250K in NYC CANNOT reasonably raise a family with kids in NYC without making major concessions to quality of life

I just got a "no turn on red except in right lane" violation in which I WAS indeed in the right lane and I had the right to turn. But they gave me $150 ticket knowing it would be worth a lot of time spent to challenge this and show up in court.

someone has to feed the "newcomers." but hey I see lots of "newcomers" and their managed Medicaid (Metroplus is the one here in NYC given to "newcomers") so I just do my best to maintain my Hippocratic oath no matter, earn money, and put it back into the system. Futile cycle indeed.

 

[Splenda88]

totally agreed

NYC prices are out of control thanks to (let's not get too off track now on SDN) . $250K in NYC CANNOT reasonably raise a family with kids in NYC without making major concessions to quality of life

I just got a "no turn on red except in right lane" violation in which I WAS indeed in the right lane and I had the right to turn. But they gave me $150 ticket knowing it would be worth a lot of time spent to challenge this and show up in court.

someone has to feed the "newcomers." but hey I see lots of "newcomers" and their managed Medicaid (Metroplus is the one here in NYC given to "newcomers") so I just do my best to maintain my Hippocratic oath no matter, earn money, and put it back into the system. Futile cycle indeed.

NYC is expensive but there are no better place to live than NYC, LA etc... if you have the $$$.

I can see why people with the mighty $$$ love these cities. However, I don't understand why people who make < 150k with no ties to these places stay there. I feel like 2/3 of 150k would give one a better quality of life in other big attractive cities (eg, Atlanta, Dallas, Phoenix, Fort Lauderdale, Charlotte, Las Vegas etc...)

 

[whoknows2012]

To OP. I think it’s telling if you go into an IM forum and 80% of the people tell you not to do it, and the other 20% that tell you to do it are older docs who are probably already FIRE.

If you go in the derm forum do you think derms would be so negative about dermatology?

If you go in the radiology forum do you think they would be so negative about radiology?

If I were you I’d go into derm, then do Mohs surgery in the middle of nowhere for a few years. You’ll have enough to retire and if you want go do onc research track, your intern year will count, 1 year of IM (it’s a waste of time to do anymore training in Im tbh) and then 3 years of onc. Your CV is already ready with a nature pub for that, basically guaranteed.

i get what you’re saying but gotta LOL at the bolded part. 🤦‍♂️

FWIW I had suggested the OP continue on path to IM, and for full transparency I’m nearly 4 years into academic practice, am nowhere close to FIRE. Personally I am just happy with my academic job and know others who share the feeling and don’t make every decision based on money. Oh the humanity!

 

[whoknows2012]

Where did we settle on 250k for academic hem onc in nyc? That is basically the bare minimum starting salary. Sure use it to make a point but that is not the reality for most, especially once you have 3-5 years under your belt

 

[dozitgetchahi]

What the.... You guys are corrupting the youth. I'm gonna have to call BS.

I've lived very comfortably in Manhattan off of a bit over 230k a year. My colleagues have comfortably supported families in Manhattan off a bit more than 250k a year. I've lived very comfortably in orange county off less than 200k.

If a city requires >1million to live comfortably in it, that city would not exist. Silicon valley / Bay area is probably the closest place I've seen to having a ridiculous barrier to entry but even the bay area has PLENTY of places you could live very comfortably for 150k or less. Most of this "I'm not making enough" mentality is more a toxic cultural trait (gotta keep up with Joneses) than a true necessity to entry.

Don't let money control you guys. I've dated plenty of folks in Manhattan who chased after the dollar signs and it's unbelievably toxic and pathetic (in hindsight, I can't believe I lasted as long as I did in those relationships)

I have a friend who is a neuro oncologist - wife is a rheumatologist - he started off in Orange County making more than the $230k you cite, and then got married when his wife was done with fellowship. They left the OC when they realized their incomes put together weren’t going to yield a decent (not even flashy or fancy) house. They moved to DFW, gave up on that too on account of $$$, and now went to a midsized town in the Midwest.

It’s not “corrupting the youth”, it’s educating people about reality. Some of us came in with a ****load of loans, and we would like to be able to pay them off before we’re eligible for the senior discount at Denny’s (never mind living the basics of at least a middle class life).

 

[NewYorkDoctors]

NYC is expensive but there are no better place to live than NYC, LA etc... if you have the $$$.

I can see why people with the mighty $$$ love these cities. However, I don't understand why people who make < 150k with no ties to these places stay there. I feel like 2/3 of 150k would give one a better quality of life in other big attractive cities (eg, Atlanta, Dallas, Phoenix, Fort Lauderdale, Charlotte, Las Vegas etc...)

Debatable . I’ve lived in nyc most of my life . Live in suburbs now outside nyc now but still frequent the city. Did the whole high culture nightlife thing . Meh . Sure I’m older now and that might be part of it . While nyc is not the he llhole that X makes it out to be , there is a grain of truth in how quality of life in nyc is just not what it used to be even twenty years ago .

 

[bronx43]

What the.... You guys are corrupting the youth. I'm gonna have to call BS.

I've lived very comfortably in Manhattan off of a bit over 230k a year. My colleagues have comfortably supported families in Manhattan off a bit more than 250k a year. I've lived very comfortably in orange county off less than 200k.

If a city requires >1million to live comfortably in it, that city would not exist. Silicon valley / Bay area is probably the closest place I've seen to having a ridiculous barrier to entry but even the bay area has PLENTY of places you could live very comfortably for 150k or less. Most of this "I'm not making enough" mentality is more a toxic cultural trait (gotta keep up with Joneses) than a true necessity to entry.

Don't let money control you guys. I've dated plenty of folks in Manhattan who chased after the dollar signs and it's unbelievably toxic and pathetic (in hindsight, I can't believe I lasted as long as I did in those relationships)

under 200k in OC?

Nowadays, an acceptable (not flashy) house in a tier 1 city with a good school district is at least $1.2-1.5M. That’s being conservative and not even figuring in the interest rates.
I guess one option is never buying and renting 900 sqft apartment for $3.5k at age 45.

Go ahead. Tell the youth that’s what they’re looking at if theyre not above top 1% income in a “desirable” city.

For what it’s worth, I grew up poor in an urban area and lived in an apartment. I have absolutely no problem living frugally (currently do live under my means). But I would bet money that the vast majority of med students/residents/fellows would not accept renting forever as the fruit of their years of hard work.

 

[whoknows2012]

I have a friend who is a neuro oncologist - wife is a rheumatologist - he started off in Orange County making more than the $230k you cite, and then got married when his wife was done with fellowship. They left the OC when they realized their incomes put together weren’t going to yield a decent (not even flashy or fancy) house. They moved to DFW, gave up on that too on account of $$$, and now went to a midsized town in the Midwest.

It’s not “corrupting the youth”, it’s educating people about reality. Some of us came in with a ****load of loans, and we would like to be able to pay them off before we’re eligible for the senior discount at Denny’s (never mind living the basics of at least a middle class life).

Agree! My balance as of Dec 11th 2023, $288,000, Dec 12th? 0, thanks to PSLF. This is a minor point bc that alone shouldn’t factor in to decision making either way, though it did factor into mine at least as a minor consideration (ie jobs that qualify for pslf vs ones that don’t)

 

[bronx43]

What if OP decides to go to other high earning Im subspecialties, cardiology or GI? Do you think the math would change?

I mean, I guess if OP really really wants to be a scope jockey then GI would be fine but at that point, why not just do derm, save 2 years of training (financial equivalent of $1M in extra earnings) and do some cosmetics instead?

 

[dozitgetchahi]

under 200k in OC?

Nowadays, an acceptable (not flashy) house in a tier 1 city with a good school district is at least $1.2-1.5M. That’s being conservative and not even figuring in the interest rates.
I guess one option is never buying and renting 900 sqft apartment for $3.5k at age 45.

Go ahead. Tell the youth that’s what they’re looking at if theyre not above top 1% income in a “desirable” city.

For what it’s worth, I grew up poor in an urban area and lived in an apartment. I have absolutely no problem living frugally (currently do live under my means). But I would bet money that the vast majority of med students/residents/fellows would not accept renting forever as the fruit of their years of hard work.

Yeah. Exactly.

I hear stories from docs making $200-300k in these VHCOL locales “living very comfortably”, but then you hear that they’re renting for $4-5k+ a month, have zero savings, etc.

For whatever reason, a lot of people seem to be weirdly ok with this in VHCOL areas…but I think that if you’re a physician in the US there should be no reason whatsoever that you can’t expect to be able to purchase yourself a decent house. (And if you live somewhere that you can’t, it’s time to move…)

 

[NewYorkDoctors]

Yeah. Exactly.

I hear stories from docs making $200-300k in these VHCOL locales “living very comfortably”, but then you hear that they’re renting for $4-5k+ a month, have zero savings, etc.

For whatever reason, a lot of people seem to be weirdly ok with this in VHCOL areas…but I think that if you’re a physician in the US there should be no reason whatsoever that you can’t expect to be able to purchase yourself a decent house. (And if you live somewhere that you can’t, it’s time to move…)

totally that's the big part

no / minimal savings

if one does not have a family yet (or does not want one), then this works fine enough. everyone's life goals are different. some people like that city life and living it up. cool

but raising multiple kids, I would not be able to provide the best of anything for my kids living in a dingy overprice apartment with (let's not get political but let's just say less than ideal circumstances in Manhattan these days) substandard living conditions, not having the best schools anymore (due to equity, the "enhanced classes" in public school are being eliminated), and having to worry about subway crime.

(let me get it out there I am not a white male so for any of doctors here who are part of the down with the patriarchy crowd can just move on along nothing to see here)

 

[hotsaws]

Was hoping someone could give me perspective on how my app may be viewed by IM PDs at top programs given that I've decided to switch from applying derm to now applying IM with the hope of pursuing fellowship (likely heme onc) in the future. I'm making the switch now that I am almost complete with my research year (in derm-onc, w a derm PI) and after having done rotations in both IM/subspecialties and derm, realized that my future interests and goals are actually more aligned with the IM route. My main fear applying soon is that PDs will think I am dual applying, when I am actually not. Is there anything I can do to demonstrate IM interest in my application? I will of course not include my experience in derm interest groups, but I also wasn't heavily involved in any IM interest groups.

For reference:
T15 west coast MD program, step 2 was 250-255
P/F clinicals
Research: 10-15 manuscript publications (first authors in a IF>10 cancer journal, another in a smaller clinical study in a derm-onc journal, and two other small derm specific pubs). Other non-first author pubs include some middle author in big journals (C/N/S) and some second author reviews in various specialties including derm, onc, gen surg. Probs have ~10 abstracts/presentations as well.

I'm having trouble figuring out what LoR's I should use since my best letter will be from my derm PI who is well known in the derm space. I could have another strong derm research/clinical letter from a different derm attending as well but not sure I should use this. I can likely get a strong research based LoR from an oncologist, and I'll have my IM chair letter. I could try and squeeze another IM letter from my home institution subI or away rotation, but IDK how strong that will be given I only worked with some attendings for like 1-2 weeks max.

I have some frame of reference because I was planning on applying to a very competitive field and then made a late third year switch to IM. I was competitive (step 1 >250, step 2 >260, AOA, some BS research stuff, etc) but long story short I was couples matching and suddenly decided I wanted a nice lifestyle and not the life of a surgeon. I was coming from a very mid tier state school. Anyways I had no problem getting interviews and I didn't lie or omit anything. I basically said "hey I don't wanna do X anymore and I'd like to become a rheumatologist or allergist because X, Y, and Z" I was pretty sincere about my reasons without openly being like "look I wanna work 4 days a week, make good money, live/work in the suburbs, and never step foot in academics again when this is all done." Obviously, you still gotta tell them what they want to hear a little but but I think you are being neurotic and way over thinking your situation. If you're a competitive applicant applying IM because you had a change of heart and you legit (like fr fr) want to do academic heme/onc in some kind of immuno flavored niche....they will love you. IM knows they can't compete with derm/ortho/ent/plastics/etc. They're not stupid. They will be aware that competitive students (meaning you've worked hard for years) are probably going to be hard working residents and fellows. I think you'll be absolutely fine applying IM. Matter of fact, you can probably pump the brakes a little from here on out if you're really just trying to do IM. I would just keep it very sincere and honest or else you will appear neurotic and arrogant. Why wouldn't you be honest? Why would anyone look down on you for trying your hardest for derm and then having the realization that you want something else?

With all that said, I would totally apply derm and then just keep IM as a back up. There's a chance you are right about your aspirations regarding heme/onc but I'd venture to say there's a better chance that you are wrong and you would be happier after completing derm residency. I could be wrong. This is all a job. The happiest docs I know are mostly the ones who have good schedules and make good money. The second happiest have one or the other. I'm sure an academic oncologist who loves research and doesn't mind the politics of academia could be happy too. Would be terrible to find out 5 years from now that you're kind of over it. Life happens. Spouses, kids, burn out, aging, realizing that there's so much else going on outside of the rat race of medical training. I'm quite happy with my outcome but if I could go back to early med school, I would have just planned on derm or ENT. A/I was an excellent pivot but a pivot nonetheless.

 

[The kitchen sink]

I have some frame of reference because I was planning on applying to a very competitive field and then made a late third year switch to IM. I was competitive (step 1 >250, step 2 >260, AOA, some BS research stuff, etc) but long story short I was couples matching and suddenly decided I wanted a nice lifestyle and not the life of a surgeon. I was coming from a very mid tier state school. Anyways I had no problem getting interviews and I didn't lie or omit anything. I basically said "hey I don't wanna do X anymore and I'd like to become a rheumatologist or allergist because X, Y, and Z" I was pretty sincere about my reasons without openly being like "look I wanna work 4 days a week, make good money, live/work in the suburbs, and never step foot in academics again when this is all done." Obviously, you still gotta tell them what they want to hear a little but but I think you are being neurotic and way over thinking your situation. If you're a competitive applicant applying IM because you had a change of heart and you legit (like fr fr) want to do academic heme/onc in some kind of immuno flavored niche....they will love you. IM knows they can't compete with derm/ortho/ent/plastics/etc. They're not stupid. They will be aware that competitive students (meaning you've worked hard for years) are probably going to be hard working residents and fellows. I think you'll be absolutely fine applying IM. Matter of fact, you can probably pump the brakes a little from here on out if you're really just trying to do IM. I would just keep it very sincere and honest or else you will appear neurotic and arrogant. Why wouldn't you be honest? Why would anyone look down on you for trying your hardest for derm and then having the realization that you want something else?

With all that said, I would totally apply derm and then just keep IM as a back up. There's a chance you are right about your aspirations regarding heme/onc but I'd venture to say there's a better chance that you are wrong and you would be happier after completing derm residency. I could be wrong. This is all a job. The happiest docs I know are mostly the ones who have good schedules and make good money. The second happiest have one or the other. I'm sure an academic oncologist who loves research and doesn't mind the politics of academia could be happy too. Would be terrible to find out 5 years from now that you're kind of over it. Life happens. Spouses, kids, burn out, aging, realizing that there's so much else going on outside of the rat race of medical training. I'm quite happy with my outcome but if I could go back to early med school, I would have just planned on derm or ENT. A/I was an excellent pivot but a pivot nonetheless.

everyone tends to say make your decision based on pay, schedule and location.. and they usually say if you can get 2 out of 3 you will be content and 3 out of 3 you will be happy

After being 3 years out, I will say it is still generally true

i am all for follow your passion, but if i could go back, i would talk to as many attendings in my fields of interest in different practice settings (academics, community employed, private practice etc) and ask them logistically how their day to day life is, schedules, pay, reimbursement, autonomy and really take that into consideration

Bc at the end of the day, it’s just a job and there is a long gap between residency +/- fellowship >>> your real life job, and you should really know what you are getting yourself into lifelong

Good luck!

 

[hotsaws]

It's crazy how much money it takes to live comfortably in a suburb of a decent city. I'm in a two doctor home and I'm not making partner money yet but we still do quite well. I can't even imagine living somewhere like San Diego or an LA suburb. I will say that if we didn't have massive student debt, we'd be doing quite a bit better. Still, I think we'd need to making well over 1M as a household to live in a city like that with the comfort we have now. We still live in a nice suburb of large city but money just doesn't go as far as it used to. I don't think there's a house in my neighborhood for less than $850 and you can easily spend 1-2mil for a single family home. You want a fancy custom home with all the bells and whistles, you're spending 2-3M easy. Vehicles are crazy expensive now and you might as well lease something if you have to finance a purchase. Anyone who was out of training prior to 2020 had a huge advantage but unless there's a major change in the economy, current trainees should definitely be thinking about money. If you got family money and no debt, then I guess go do whatever the hell you want.

 

[dozitgetchahi]

Anyways I had no problem getting interviews and I didn't lie or omit anything. I basically said "hey I don't wanna do X anymore and I'd like to become a rheumatologist or allergist because X, Y, and Z" I was pretty sincere about my reasons without openly being like "look I wanna work 4 days a week, make good money, live/work in the suburbs, and never step foot in academics again when this is all done."

Yeah it’s funny how this works among academic types…shortly after I started rheum fellowship, one of my co-fellows made a comment in passing at a morning conference about how great rheumatology was because of the good lifestyle and solid pay, and how that would be appealing to applicants going forward…she was shot some of the dirtiest looks ever by the department leadership, and after the conference some gasbag attending got up to lecture us on the importance of research and academia and how much time you have to invest in a good career in rheumatology and how academia is the highest aspiration of any physician etc etc🙄

Admitting that you wanted a good lifestyle and time off was something that was very much “out of bounds” in my fellowship department, which I think is crazy given that several of the attendings were mommy-track part timers…but I digress…

 

[Splenda88]

It's crazy how much money it takes to live comfortably in a suburb of a decent city. I'm in a two doctor home and I'm not making partner money yet but we still do quite well. I can't even imagine living somewhere like San Diego or an LA suburb. I will say that if we didn't have massive student debt, we'd be doing quite a bit better. Still, I think we'd need to making well over 1M as a household to live in a city like that with the comfort we have now. We still live in a nice suburb of large city but money just doesn't go as far as it used to. I don't think there's a house in my neighborhood for less than $850 and you can easily spend 1-2mil for a single family home. You want a fancy custom home with all the bells and whistles, you're spending 2-3M easy. Vehicles are crazy expensive now and you might as well lease something if you have to finance a purchase. Anyone who was out of training prior to 2020 had a huge advantage but unless there's a major change in the economy, current trainees should definitely be thinking about money. If you got family money and no debt, then I guess go do whatever the hell you want.

We, as physicians, still find things pricey even if most of us are in the top 5%.

How a household of 4 that makes the US median (75k/yr) income does?

Things have become so expensive. I remember our household of 4 was doing extremely well in 2013 on a salary 110-120k. I feel like my life has not changed that much even if I make 400k+/yr.

Inflation from 2019-2024 got to be > 40%

 

[hotsaws]

Yeah, at that point the academics are pot committed and face some cognitive dissonance. I'm sure they've spent much of their career convincing themselves they made the right choice. Of course, they hear about colleagues and old fellows that are making great money, have good schedules, and not dealing with the BS. They probably get defensive or have to demonize community PP guys. We would sometimes hear them talk s*** about community allergists (which admittedly some can just be shady shot mills). The faculty at my training program were pretty cool and I was always quite honest about my intentions.

 

[ShuperNewbie]

Oh my gosh what did I start here lol.

Yeah shoutout to a couple of you guys on this thread, we're gonna have to agree to disagree here. Partly because we're straying too far from OP's initial point but also partly because I'm embarrassed we're even having this conversation in the first place (like holy s*** guys if the general public read some of these posts I think they'd have a f***ing fit about how out of touch doctors are financially and rightfully so). I'm not gonna deny that things have gotten untenably expensive and that this is a major issue and priority nation-wide, but I'm also not gonna try to justify my own lived experience to a bunch of randos on the internet. Bye-bye

 

[dozitgetchahi]

Oh my gosh what did I start here lol.

Yeah shoutout to a couple of you guys on this thread, we're gonna have to agree to disagree here. Partly because we're straying too far from OP's initial point but also partly because I'm embarrassed we're even having this conversation in the first place (like holy s*** guys if the general public read some of these posts I think they'd have a f***ing fit about how out of touch doctors are financially and rightfully so). I'm not gonna deny that things have gotten untenably expensive and that this is a major issue and priority nation-wide, but I'm also not gonna try to justify my own lived experience to a bunch of randos on the internet. Bye-bye

The problem is that we’re responding with our own lived experiences, and you’re discrediting those.

And I think most of us are aware of what the average American making $70k or whatever is dealing with. We see them in our exam rooms. They’re broke, they can’t afford medications, they’re drowning in debt and getting by with credit cards and robbing Peter to pay Paul.

The crazy thing is that the current environment can be quite tough even if you’re making substantially more money than that. I totally agree with the above poster that even $300-400k doesn’t feel like it’s THAT much money in the current environment, especially if you carry a big student loan burden and you’re trying to live in a HCOL area. At $250k I didn’t feel that much better off than I did as a resident at $50k, mostly because the rest of the student loans came due (it just meant that I wasn’t asking my parents for help every month anymore). It wasn’t until now - at about $550k - that I actually feel like I’m getting control of things, paying debt down, buying a house, and actually feeling financially comfortable.

There was a survey recently where Millenials reported that the amount of money needed to feel happy in America was $525k/year. This was derided and laughed at in the media, but in my own lived experience - I actually think it’s spot on. And I don’t even live in a HCOL area, and I live below my means - my recently purchased house, which is pretty decent (~2000 sq ft), cost me $200k. I make payments currently on a $50k minivan. My other car is paid off. The thought of making payments on an $800k house and two $75-100k cars (a situation that more than a few doctor friends from training are in) really gives me heartburn.

 

[sloh]

The problem is that we’re responding with our own lived experiences, and you’re discrediting those.

This is a really good discussion just for other readers. It's difficult for trainees, residents, and even attendings (much less the public) to appreciate what a ~250-300k income actually means in the context of at least ~7 years post-college training (massive late start compared to other white collar professionals like lawyers, tech, finance). Many of us finish training just around the time where we also have to seriously start entertaining starting families, buying houses. The mindset of a resident "getting by just fine" on a resident salary of < 60-70k (even in a tier 1 city) is very different than completing training with the expectation that we can finally elevate our lifestyles, meaningfully contribute to savings/retirement, raise families, buy houses, buy reasonable cars after all those years of sacrifice. While many can get caught up keeping up with the Joneses, it's not uncommon for many attendings to feel the sting (and reasonably so) when they see their other peers in other white collar professions establishing their family lives and building retirement portfolios of significance way ahead of them.

 

[Splenda88]

The problem is that we’re responding with our own lived experiences, and you’re discrediting those.

And I think most of us are aware of what the average American making $70k or whatever is dealing with. We see them in our exam rooms. They’re broke, they can’t afford medications, they’re drowning in debt and getting by with credit cards and robbing Peter to pay Paul.

The crazy thing is that the current environment can be quite tough even if you’re making substantially more money than that. I totally agree with the above poster that even $300-400k doesn’t feel like it’s THAT much money in the current environment, especially if you carry a big student loan burden and you’re trying to live in a HCOL area. At $250k I didn’t feel that much better off than I did as a resident at $50k, mostly because the rest of the student loans came due (it just meant that I wasn’t asking my parents for help every month anymore). It wasn’t until now - at about $550k - that I actually feel like I’m getting control of things, paying debt down, buying a house, and actually feeling financially comfortable.

There was a survey recently where Millenials reported that the amount of money needed to feel happy in America was $525k/year. This was derided and laughed at in the media, but in my own lived experience - I actually think it’s spot on. And I don’t even live in a HCOL area - my recently purchased house, which is pretty decent (~2000 sq ft), cost me $200k. The thought of making payments on an $800k house and two $75-100k cars (a situation that more than a few doctor friends from training are in) really gives me heartburn.

You bought a house for ONLY 200k!

You are doing extremely well, if your house cost 200k,and you make 525k/yr. You can literally pay off your place in 1 yr.