Why Make 150k When 450k Is Out There?

[deleted87716]

Be careful about putting too much faith into salary guarantees. Salary guarantees are usually loans that have to be paid back.

I'm not sure I'd say "usually." In fact, that's probably the exception. That being said, always read the fine print.

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[MOHS_01]

I'm not happy always playing the part of contrarian, but "usually" is "generally" the case when the term "guarantee" is used. Guarantee = loan; there is no salary per seimplied here.

This is not to say, however, that one always has to pay back the loan with dollars; the customary wording is such that the guarantee runs for a finite period of time (generally 1 to 3 years), after which time any unpaid portion of the guarantee is forgiven for an additional time commitment (the length of which is based upon the length of the guarantee). You owe the money if there is any uncovered balance on the guarantee amount should you decide to leave.

What Dr. Rack was attempting to point out (I believe) is that more than one doc has been suckered into accepting a guarantee that is outside of the realm of reason (beyond that which they should reasonably expect to cover). Hospitals have traditionally been bad about this -- they dangle a sizable carrot out in front of some naive physician who signs on only to find that they are unable to cover their guarantee, inevitably becoming stuck in the community because they cannot afford to leave.

A basic tenet of life holds true in medical contract negotiations -- if something sounds too good to be true, it probably is.

 

[deleted87716]

A basic tenet of life holds true in medical contract negotiations -- if something sounds too good to be true, it probably is.

Of course.

However, the numbers Sophiejane quoted aren't unrealistic for the sort of opportunities that she described.

As for the payback clause, my group doesn't use them. I'd never sign a contract that included one, and I wouldn't expect anyone that I partnered with to sign one, either.

 

[MOHS_01]

Of course.

However, the numbers Sophiejane quoted aren't unrealistic for the sort of opportunities that she described.

As for the payback clause, my group doesn't use them. I'd never sign a contract that included one, and I wouldn't expect anyone that I partnered with to sign one, either.

Agreed, 100%. I only want everyone to be aware of one of the more common pitfalls in physician contracting.

I would also be willing to bet that your group would not offer a larger guarantee to a candidate than you realistically expect them to cover; the rules of the game are quite different when the recruiting entity is physician practice vs hospital. In a physician practice if the new recruit does not cover his or her "salary" it constitutes a loss in income that is felt by the producing physicians of the practice -- something that is not necessarily the case in hospital recruitment situations.

 

[deleted87716]

your group would not offer a larger guarantee to a candidate than you realistically expect them to cover

No, we wouldn't. We aim to help new physicians become full partners as quickly as possible, and to minimize risk to the group. Unrealistic remuneration is not conducive to that.

the rules of the game are quite different when the recruiting entity is physician practice vs hospital.

That's because hospitals typically have no idea how to manage doctors, and have much greater incentives to drive ancillary revenues than to fairly compensate ambulatory care practices. Caveat emptor.

Edit: I should add that unrealistic salary guarantees are a much bigger problem when recruiting specialists than they are when recruiting primary care physicians. I'm afraid I'm going to have to "blame the victim" a little bit here. You need to know what you're worth, but don't get greedy, and never, under any circumstances, make the mistake of thinking that your employer won't hold you to the letter of your contract.

 

[Old_Mil]

Until physicians are able to regain control of the healthcare discussion, we are destined for problems.

That's really the root of the problem. The AMA needs to start acting less like the AMA and more like the Teamsters.

 

[sophiejane]

If anything, the guarantees are on the low-ball side. Most I know docs in practice now easily surpassed their guarantee after the first year.

 

[andwhat]

Just wanted to say, for you doubters....just got back from a recruiting fair for FM. The numbers batted around were between $185K to start (guarantee only, likely more after your first year) and $370K for someone who had been in practice about 5 years. Several mentioned easily doubling your guarantee after a few years.

These are 4-4.5 day weeks with home call and no ER coverage, about 1 in 6-one in 10. This is not anywhere near 80-90 hours a week.

All's I'm sayin' is, it's out there. And I intend to cut myself a nice fat piece of that pie.

And I'm not at all bitter about my loans because everyone I spoke to was ready to deal on loan repayment as well.

This is the truth, as it stands today in the FM marketplace, not hearsay from an anesthesiologist. Enough said.

this is true, even in larger places in Texas, FM docs are making mid 300K with no ER visits whatsoever. 4 to 4.5 day workweek. Those that incorporate Derm and Stress tests make even more. Only telephone call every 7th day.
I have no idea where this 150 K number came about, and you get a warning on this thread if you say anything to the contrary.
This should be more of an informative thread, and not a threatening one.

 

[ComicBookHero20]

this is true, even in larger places in Texas, FM docs are making mid 300K with no ER visits whatsoever. 4 to 4.5 day workweek. Those that incorporate Derm and Stress tests make even more. Only telephone call every 7th day.
I have no idea where this 150 K number came about, and you get a warning on this thread if you say anything to the contrary.
This should be more of an informative thread, and not a threatening one.

where in TX exactly? are these by big cities?

 

[sophiejane]

where in TX exactly? are these by big cities?

I'm not divulging exact locations of the ones I mentioned because I am applying to some of these places, ahem...most were within 1.5 hours of a major metropolitan area. One was an hour from a moderate-sized city. Most are smaller towns, but that's what we want, so we're happy either way.

 

[jetproppilot]

I owed nearly 200K in student loans when I graduated from med school.

After deferring said loans in residency, that amount was a solid 200K.

Yep, like alotta you out there, I had to personally pay for my education.

As a fourth year med student, I thought pragmatically....

hmmm.....

I owe X amount.

Debt is an anchor.

I wanna pay off my debt, but still be happy.

BOOM!!!

A light goes off in my head.

Now 11 years into private practice.....student loans paid off years ago....money no longer an issue...

I wanna hear from the med students going into primary care with 200K in student loans.

What motivates a dude/dudette to go into a specialty where monetary reimbursement is less than some nurses?

Are there really philanthropic people left out there, concerned about societal issues in medicine?

If you are a med student reading this, do you think you'll think the same way after your residency is over?

Can one be comfortable with the fact that after 4 years of college, 4 years of med school, then residency, you've selected primary care as your profession which puts you behind the eight ball financially?

BTW....one of the most conflicting issues in marriages is....MONEY.

So, again, why would a med student select primary care?

(rich family prodigies out there, you dont count)

Five years outta residency your focuses will be different.....family.....hobbies....

I read a post in this FM section about personal finance.....went something like...."its OK to rent..."

WTF?

You're gonna endure pre-med/med school....business major colleagues are sittin' out by the pool while you're in the study lounge cramming for an organic chem final...or 1st year med school biochem....2nd year pathophys... endure 3rd year clinicals......then select a career where the reimbursement suks to the point where you haffta rent?

Cummon....

This post is not for the FP people who have already selected their fate.

This post is for med students reading this who are trying to figure out what they want to do with the rest of their lives....

I'm 11 years out of residency. Specialist. Love my job. Plenty of time off. Money not an issue anymore.

My student loans are long gone.

I didnt make the rules.....

....the rules are.....

...specialists make more than twice that of primary care docs.

And pick your specialty wisely, you'll make twice-bank with 9-12 weeks vacation.

So I'm wondering why med students would want to go into primary care.

Yep, an inflammatory thread.

But I wanna know.

P.S. : If your dad has paid for college/med school/condo during residency, your opinion doesnt count.

http://news.yahoo.com/s/ap/20080909/ap_on_he_me/med_fewer_docs

 

[Leukocyte]

Jet, I an a FM resident, and I probably HATE (H-A-T-E) Family Medicine 10 times more than you do...but lets get realistic here. Family Medicine is REAL medicine. Real hardcore medicine. Ignorant people/docs in other specialties who have no idea what FM is think that all what a FM does is OP clinic, and runny noses. I wish it was that way, otherwise I would not be biching and moaning on how hard FM is. No offence to the Anesthesiologists or specialists out there, but ANY of my Family Medicine attendings at my program can blow any specialist out of the water, and make him feel like a medical student.

Tell me, what ONE doc can work on the floors, in the ICU, Labor & Deliver, NICU, endoscopy suit, ER, and do tons of procedures in the OP clinic ALL IN ONE DAY?!!!! Answer: ONLY a Family Medicine attending at an Unopposed program.

Specialists play an important role, but what they do is very focused, and to be honest with you, easy compared to the generalist approach. One of my easiest rotations are the specialty rotations. They only care about one thing, and address one specific issue. FM docs on the other hand address EVERYTHING. Our problem list, under the assessment and plan section, is usually 10 problems or more long.

It is funny when there is a CODE BLUE in the MICU, and the Anesthesiologist comes, intubates, then leaves....while we, the FM residents run the code. Sometimes we intubate the patient before the Anesthesiologist shows up, so he says, "ok", then leaves

Yes FM is not an attractive specialty... But this is inpart because it requires a lot of work and reading. It is real hardcore medicine. The real deal. It is tough. It is hard. It REQUIRES the absorption and implementation of a HUGE amount of medical knowledge the spans ALL medical specialties. If that is not hard, I do not know what is. I would challenge any specialist to sit down with any of my FM attendings and discuss random clinical cases that come through the hospital's doors. They would send him/her crying back to their first year of medical school.

The medical payment system is FU@KED UP. How and why in the world would you pay a Radiologist, Dermatologist, Anesthesiologist, Pathologist more than a FM doc who works looooooog hours covers multiple services, knows a wide veriety of skills and procedures, and no offence to the specialists, knows more about general practical clinical medicine than any specialist?

If you had to choose ONE doctor to be standed with you on an un-inhabitted island in the middle of no-where, who would you pick..a Radiologist, a Dermatologist, an Anesthesiologist, an Orthopedic Surgeon, a Neurologist.....Who would you value the most? Common Guys...lets call a spade a spade.

 

[jetproppilot]

Jet, I an a FM resident, and I probably HATE (H-A-T-E) Family Medicine 10 times more than you do...but lets get realistic here. Family Medicine is REAL medicine. Real hardcore medicine. Ignorant people/docs in other specialties who have no idea what FM is think that all what a FM does is OP clinic, and runny noses. I wish it was that way, otherwise I would not be biching and moaning on how hard FM is. No offence to the Anesthesiologists or specialists out there, but ANY of my Family Medicine attendings at my program can blow any specialist out of the water, and make him feel like a medical student.

Tell me, what ONE doc can work on the floors, in the ICU, Labor & Deliver, NICU, endoscopy suit, ER, and do tons of procedures in the OP clinic ALL IN ONE DAY?!!!! Answer: ONLY a Family Medicine attending at an Unopposed program.

Specialists play an important role, but what they do is very focused, and to be honest with you, easy compared to the generalist approach. One of my easiest rotations are the specialty rotations. They only care about one thing, and address one specific issue. FM docs on the other hand address EVERYTHING. Our problem list, under the assessment and plan section, is usually 10 problems or more long.

It is funny when there is a CODE BLUE in the MICU, and the Anesthesiologist comes, intubates, then leaves....while we, the FM residents run the code. Sometimes we intubate the patient before the Anesthesiologist shows up, so he says, "ok", then leaves

Yes FM is not an attractive specialty... But it is real hardcore medicine. It is tough. It is hard. It REQUIRES the absorption and implementation of a HUGE amount of medical knowledge the spans ALL medical specialties. If that is not hard, I do not know what is. I would challenge any specialist to sit down with any of my FM attendings and discuss random clinical cases that come through the hospital's doors. They would send him/her crying back to their first year of medical school.

The medical payment system is FU@KED UP. How and why in the world would you pay a Radiologist, Dermatologist, Anesthesiologist, Pathologist more than a FM doc who works looooooog hours covers multiple services, knows a wide veriety of skills and procedures, and no offence to the specialists, knows more about general practical clinical medicine than any specialist?

If you had to choose ONE doctor to be standed with you on an un-inhabitted island in the middle of no-where, who would you pick..a Radiologist, a Dermatologist, an Anesthesiologist, an Orthopedic Surgeon, a Neurologist.....Who would you value the most? Common Guys...lets call a spade a spade.

I never said I hated family medicine.

I hate the fact that med student specialty selection for the majority of med students is steered by spiraling student loan debt.

My debt certainly did.

Obviously I'm not alone.

Nice post.

 

[lilnoelle]

I wanna hear from the med students going into primary care with 200K in student loans.

That would be me. Actually, my loans could be as little as $100K and as much as $400K when I am done with residency depending on if I get the state of Kansas to waive most of my loans or not.

What motivates a dude/dudette to go into a specialty where monetary reimbursement is less than some nurses?

That seems like an exageration to me. Perhaps the best paid nurses are paid more than the worst paid Family practitioners - but I'm pretty sure the worst paid family docs are that way for a reason. (Poor billing, unwise business practice, determined to live in a poorly reimbursed region, etc)

Personally, as long as I'm not deep in debt (and I plan to pay off my loans as quickly as possible) and I'm able to maintain my current standard of living, I'm pretty certain I'll be a whole lot happier in primary care than I would in any specialty.

Are there really philanthropic people left out there, concerned about societal issues in medicine?

Definitely. Thats exactly why I like primary care. Life is messy.... and I love it. I want to be a part of people's lives and if they'll let me, I want to do what I can to help them.

If you are a med student reading this, do you think you'll think the same way after your residency is over?

I'm sure that I will be less niave and probably a little more scarred, but I hope that I never lose my compassion and heart to help those in need.
Honestly, this is my whole reason for going into medicine, and if its lost, then I should have done something else.

Can one be comfortable with the fact that after 4 years of college, 4 years of med school, then residency, you've selected primary care as your profession which puts you behind the eight ball financially?

Well, it beats working as a manager at Wendy's.... where I was working after 4 years of college.
As I said before, I don't think I could be comfortable choosing any other field of practice.

BTW....one of the most conflicting issues in marriages is....MONEY.

Only if your spending more than your making.

So, again, why would a med student select primary care?

Because for me, there is nothing more fulfilling than taking care of a community's health.

(rich family prodigies out there, you dont count)

Ha! How about a poor farmer's daughter?

Five years outta residency your focuses will be different.....family.....hobbies....

Nah, I already got 'em.

 

[Dr McSteamy]

what jpp says makes sense. and he has the personal experience to back it up.

but some people just don't like anesthesiology, even if it does pay 2x.

i would rather see more pts and spend as little time on each pt.
or bill more or something.

something has to work........ or else that regular old family doc in Brooklyn wouldn't be making $350,000+ a year.

In the same neighborhood, I've seen 2 pediatricians.
One works out of a tiny dilapidated office/exam room, and barely makes enough.
The other ped has the whole neighborhood coming to him, and he pays 6 junior doctors under him. So he's gotta be making well over a mil a year.
he's doing something right.

 

[michaelrack]

deleted.

 

[deleted87716]

what jpp says makes sense. and he has the personal experience to back it up.

With all due respect, JPP has no experience as a family physician.

 

[andwhat]

With all due respect, JPP has no experience as a family physician.

It is about lifestyle. Do you want to work for a Surgeon and specialist for the rest of your life? The Specialists and Surgeon literally run your life in Anesthesia -- nurses tell you what to do, and others make a significant influence on all of your decisions in Medicine. I certainly would not want to be at someone else's beck and call forever.
Independence is part of why I chose to become a physician. Lifestyle and money also.
I definitely have no problems at all, and whatsoever with my current paycheck and lifestyle!
Paying off my student loans in 2.5 years. 250 K plus out of medical school.
I don't really care honestly, about a few philanthropic and/or societal issues that I may or may not agree with in Medicine. You see I am not a Philanthropist. I do my work, go home and earn my nice paycheck.
I would love to meet a nurse that earns more than I do. Interesting.
Sad and misconstrued perspectives, by the recurrent Anesthesia person.

 

[Dr McSteamy]

With all due respect, JPP has no experience as a family physician.

personal experience being an anesthesiologist..... and justifying his 450k salary

 

[deleted87716]

personal experience being an anesthesiologist..... and justifying his 450k salary

Oh, then...yes.

 

[andwhat]

personal experience being an anesthesiologist..... and justifying his 450k salary

I could make more than that right now -- if I truly wanted to. I have plenty of time to do it, as I work a little over 40 hours per week, and make well above the national average.
One of the guys who is working in my program does 1.5 shifts (36 hr on 12 off, plus extra shifts per mo.)... pays nearly $500 K.
What is the point of more money and more work?
I would rather chill, work my own hours, and go home at 2 or 3 p.m. almost every day. Only admit days do I truly stay the full eleven to twelve hours in the hospital. I work about 5 to 7 admitting shifts per month, the rest are backup shifts, as well as rounding shifts.
I do one and a half to three nights per month. How many nights per month does Anesthesia guy do? Almost three to five a week more like. NOO thank you not for me.
I work half the month, to barely two thirds of the month, rest of the time off.
You should be happy doing what you are doing -- that is the key and paramount thing, as well as making a decent living out of it.
True clinic medicine doesn't pay nearly as well as it should. This is however, no justification to belittle another specialty constantly. It just doesn't make any sense??
You don't like Primary Care, good for you?! Good grief already?????
It is true that Surgeons and Specialists run your life in Anesthesiology. I observed very little autonomy in the O.R. that Anesthesiologists had.
This is not the fault of Family Medicine or Primary Care.

 

[snowhard]

I think JPP is making a noble and honest effort to inform the next generation of physicians the realities of primary care. Why is everyone so defensive? He's not against primary care - he's against the fact that they get paid so little!

Primary care needs all the help it can get. When a specialist (who obviously has little to gain from a post like this) is fighting for primary care, why is everyone so against him?

 

[mikereno1]

I think JPP is making a noble and honest effort to inform the next generation of physicians the realities of primary care. Why is everyone so defensive? He's not against primary care - he's against the fact that they get paid so little!

Primary care needs all the help it can get. When a specialist (who obviously has little to gain from a post like this) is fighting for primary care, why is everyone so against him?

2nd, I think the whole point of this post was to bring up that we as primary care physicians are underpaid, not to belittle our decision to enter the field. Its getting a little redundant to keep repeating that 1. Anesthesiologists make more than primary care physicians 2. Primary care physicians still make good money 3. Primary care physicians love what they do and can make plenty of money

 

[deleted87716]

Its getting a little redundant to keep repeating that 1. Anesthesiologists make more than primary care physicians 2. Primary care physicians still make good money 3. Primary care physicians love what they do and can make plenty of money

Redundant? You can say that again.

 

[snowhard]

2nd, I think the whole point of this post was to bring up that we as primary care physicians are underpaid, not to belittle our decision to enter the field. Its getting a little redundant to keep repeating that 1. Anesthesiologists make more than primary care physicians 2. Primary care physicians still make good money 3. Primary care physicians love what they do and can make plenty of money

Redundant? You STILL have not made your point.

Primary care physicians don't make "good money" considering the massive amount of debt they accrue as well as the years of lost revenue while in training. They DON'T make "good money"...

That being said, my ONLY point was to defend JPP in saying that the above-mentioned needs to change!

I feel like I am being belittled for simply agreeing with another member

 

[skypilot]

Jet, I an a FM resident, and I probably HATE (H-A-T-E) Family Medicine 10 times more than you do...but lets get realistic here. Family Medicine is REAL medicine. Real hardcore medicine. Ignorant people/docs in other specialties who have no idea what FM is think that all what a FM does is OP clinic, and runny noses. I wish it was that way, otherwise I would not be biching and moaning on how hard FM is. No offence to the Anesthesiologists or specialists out there, but ANY of my Family Medicine attendings at my program can blow any specialist out of the water, and make him feel like a medical student.

Tell me, what ONE doc can work on the floors, in the ICU, Labor & Deliver, NICU, endoscopy suit, ER, and do tons of procedures in the OP clinic ALL IN ONE DAY?!!!! Answer: ONLY a Family Medicine attending at an Unopposed program.

Specialists play an important role, but what they do is very focused, and to be honest with you, easy compared to the generalist approach. One of my easiest rotations are the specialty rotations. They only care about one thing, and address one specific issue. FM docs on the other hand address EVERYTHING. Our problem list, under the assessment and plan section, is usually 10 problems or more long.

It is funny when there is a CODE BLUE in the MICU, and the Anesthesiologist comes, intubates, then leaves....while we, the FM residents run the code. Sometimes we intubate the patient before the Anesthesiologist shows up, so he says, "ok", then leaves

Yes FM is not an attractive specialty... But this is inpart because it requires a lot of work and reading. It is real hardcore medicine. The real deal. It is tough. It is hard. It REQUIRES the absorption and implementation of a HUGE amount of medical knowledge the spans ALL medical specialties. If that is not hard, I do not know what is. I would challenge any specialist to sit down with any of my FM attendings and discuss random clinical cases that come through the hospital's doors. They would send him/her crying back to their first year of medical school.

The medical payment system is FU@KED UP. How and why in the world would you pay a Radiologist, Dermatologist, Anesthesiologist, Pathologist more than a FM doc who works looooooog hours covers multiple services, knows a wide veriety of skills and procedures, and no offence to the specialists, knows more about general practical clinical medicine than any specialist?

If you had to choose ONE doctor to be standed with you on an un-inhabitted island in the middle of no-where, who would you pick..a Radiologist, a Dermatologist, an Anesthesiologist, an Orthopedic Surgeon, a Neurologist.....Who would you value the most? Common Guys...lets call a spade a spade.

nice post

 

[bigdan]

Jet, I an a FM resident, and I probably HATE (H-A-T-E) Family Medicine 10 times more than you do.

Wait. You're doing something you hate? Regardless of "who knows more" or "who makes more" or "who you want on as your doc on an island", won't that suck after a while?

dc

 

[andwhat]

Wait. You're doing something you hate? Regardless of "who knows more" or "who makes more" or "who you want on as your doc on an island", won't that suck after a while?

dc

residency is tough, you cannot blame him for not liking certain aspects of his profession.
Does everyone love each and every single little detail of his or her residency program?
I do not think so.
Show me one person that says
"I love night call and I am a resident!!"
I do not think that will happen.
I did not really like certain aspects of clinic as a resident, and it was about 70 to 80 percent of what I did in residency.
Now I am a Hospitalist.
That is like blaming an Ortho doc, for not enjoying rounding on his patients post op, because they are in pain. "Why can't they just not have any pain, and be 100% after I operated on them"
Isn't that an ideal world?
Point being, there is no such thing as ideal.

Correct me if I am mistaken, but don't nurses put in IV lines, and Orogastric tubes and NG? I have observed this directly, that CRNAs do EXACTLY the same thing as Anesthesiologists. I would go the CRNA route myself if I was an administrator, and cut costs significantly -- if they are this arrogant. Maybe one or two Anesthesiologists for observation, or cleaning things up.
If Anesthesiologists are truly this arrogant, then I would not want any of my patients going through with that experience.
Bragging about money, this just brings the whole M.D. profession down.
It makes everyone look bad.
The sentiment expressed here is not at all about "I care about Primary Care and compensation"
It is about directly disrespecting another specialty.
Either offer ways to solve the problem of "Primary Care payment" system if you truly care so much as you claim to, or go about your ways.
For some people I suppose this is entertaining.

 

[Dr McSteamy]

Bragging about money, this just brings the whole M.D. profession down.
It makes everyone look bad.

wait. don't lawyers and bankers do that too?

i don't find anything wrong with talking or bragging about money. it just makes medicine more desirable.

it seems doctors talk too little about money, and take it up the butt, like the tshirt above

 

[jetproppilot]

It is about directly disrespecting another specialty.

Sorry Slim, you're dead wrong about that.

 

[Consigliere]

I think it is absolutely wonderful that a fellow anesthesiologist has started a thread that has received almost TWICE as many views as the next closest thread.

When an anesthesiologist can generate this much interest on a family medicine forum it helps restore my faith in the modern medical establishment.

 

[NewmansOwn]

Perhaps it is time to be honest with ourselves and admit that this discussion is going nowhere. People tend towards disorder and chaos, just like every other particle in the universe, and so this thread has outlived its shelf life.

Jet, you have my and many others' respect. You bring dedication and honesty to these forums and we're very grateful -- not everyone would write a 10,000 word primer on entering private practice, or openly explain the intricacies of his contract termination for the benefit of young students. People need to back off a little and see that we all want the same things, we're all fighting the same good battle and this thread is nothing more than differences in communication style. Cocky vs. laconic. Happens every day.

So Jet, with all the respect in the world, we have an experienced FP who is actively involved in the political and medical communities in Kent and his advice is trusted here as much as yours is in the Gas forum. By now, those who would take your good advice from this thread have done so and I would entreat you to consider that maybe it's time to close things down on this one for a while.

 

[GassiusClay]

residency is tough, you cannot blame him for not liking certain aspects of his profession.
Does everyone love each and every single little detail of his or her residency program?
I do not think so.
Show me one person that says
"I love night call and I am a resident!!"
I do not think that will happen.
I did not really like certain aspects of clinic as a resident, and it was about 70 to 80 percent of what I did in residency.
Now I am a Hospitalist.
That is like blaming an Ortho doc, for not enjoying rounding on his patients post op, because they are in pain. "Why can't they just not have any pain, and be 100% after I operated on them"
Isn't that an ideal world?
Point being, there is no such thing as ideal.

Correct me if I am mistaken, but don't nurses put in IV lines, and Orogastric tubes and NG? I have observed this directly, that CRNAs do EXACTLY the same thing as Anesthesiologists. I would go the CRNA route myself if I was an administrator, and cut costs significantly -- if they are this arrogant. Maybe one or two Anesthesiologists for observation, or cleaning things up.
If Anesthesiologists are truly this arrogant, then I would not want any of my patients going through with that experience.
Bragging about money, this just brings the whole M.D. profession down.
It makes everyone look bad.
The sentiment expressed here is not at all about "I care about Primary Care and compensation"
It is about directly disrespecting another specialty.
Either offer ways to solve the problem of "Primary Care payment" system if you truly care so much as you claim to, or go about your ways.
For some people I suppose this is entertaining.

CRNAs do everything an anesthesiologist does? Hmm. Maybe some technical things, but what about the preop assessment. How about the note from the "primary" physician saying "OK for anesthesia"? What is that!

Not to bring down you down but you are doing just what you blamed JPP for without him ever directly insulting FM/IM. I mean he can come right back and say that there are NPs who could do your job. This is the problem with medicine in general. People lack understanding of what the other person does. I GUARANTEE you as a primary care provider would piss in your pants if someone desats to 80. Most don't know what to do. Can't blame them because that is not the focus of their training.

It sounds like you ended up in a pretty good gig and not in one of those burnout hospitalist jobs (like one of my family friends). And by the way, money matters otherwise you would have been a peds doc in an underserved urban area making less than 80K/yr. This is the unfortunate situation (financially, not necessarily mentally) for some.

 

[andwhat]

CRNAs do everything an anesthesiologist does? Hmm. Maybe some technical things, but what about the preop assessment. How about the note from the "primary" physician saying "OK for anesthesia"? What is that!

Not to bring down you down but you are doing just what you blamed JPP for without him ever directly insulting FM/IM. I mean he can come right back and say that there are NPs who could do your job. This is the problem with medicine in general. People lack understanding of what the other person does. I GUARANTEE you as a primary care provider would piss in your pants if someone desats to 80. Most don't know what to do. Can't blame them because that is not the focus of their training.

It sounds like you ended up in a pretty good gig and not in one of those burnout hospitalist jobs (like one of my family friends). And by the way, money matters otherwise you would have been a peds doc in an underserved urban area making less than 80K/yr. This is the unfortunate situation (financially, not necessarily mentally) for some.

NPs typically do not perform significant Hospitalist duties. I have not heard much about this, please enlighten me.... If anything, I would LOVE it if more NPs admitted patients -- which would allow me more time allocated to deal with codes, difficult time challenging patient situations, ICU patients, discharging and rounding.
You are TOTALLY correct about burnout Hospitalist jobs, I know of a few Hospitalists that work 100 hours per week, that is brutality.
Certain programs are shortstaffed also, the doctors do quite a bit of night call, in addition to extended hours.
There is no "protected time" in the real world unfortunately.
I have a very reasonable schedule usually, that allows me freedom and flexibility, which was NOT generated overnight. Thank goodness it has been modified a few times over.
Preop assessment, as I recall from my Surgery rotation NPs did that.
Someone desats to the 80s??? Cummon dude I run at least a code every third or so shift....
Keep in mind please, that I am saying that I "deal" with them, I don't necessarily enjoy these situations at all -- plus they are usually quite complicated.
These code situations usually happen overnight, on the well described "graveyard shift"
Unfortunately we do not yet have a dedicated ICU doctor -- this would obviously be a dream come true. If we consult them great, otherwise we are on our own.
How about Hypotensive, Septic without pressor support yet; CHF exacerbation with dyspnea, hypoxia, admixed COPD with Hypercarbic respiratory failure; PE with severe cardiac strain, and Cardiomegaly; Chest pain MI etc...
I do not at all prefer these complicated cases. If I did do these cases every day I would be burned out... As a matter of fact, if I saw these cases on a television show, I would probably be inclined to change the channel..
This work would be like someone in the ICU every day, doing Critical care only... that would be miserable and tough in my opinion. Some people love the adrenaline though. I will stick with certain reality television shows.
I think that financial consideration is a HUGE issue, that is not being addressed properly at all in Primary Care reimbursement.
It is very tough nowadays to make money in the office starting out, no doubt.
Undervalue of services rendered -- it is an every day thing in office Medicine. This is a tremendous disappointment.
The payment system is not fair at all -- unjust and unfair.

Is it such a horrible thing, that most people are choosing specialty based Medicine?
I do not think that it is necessarily a bad thing overall.
I do not think that most places understand the true implications of the primary care shortage as of yet, it has to happen I suppose.
The significant Primary Care shortage has not affected compensation changes at all in my opinion.
What we will be facing soon, will be like a nationwide gas shortage.
Where do you go to see a doctor?
Get really really sick, because they are all specialists in the Hospital. Oh yeah sometimes they are in clinic, but you have to have a certain problem in order to be seen.
I do not see anything wrong with that necessarily, because that is where things are headed.
It is horrible for society. However, if anybody actually cared that needed to care, the necessary changes would have occurred by now.
Interest in Primary Care and Family Medicine and Internal Medicine would be booming.
Primary Care and Preventive Medicine are just not the "hot" broadway tickets nowadays -- not in the past, not now, and probably not in the near future, or possibly in the future at all.
There are certain places that I mentioned previously, that pay very well for outpatient FM.
I love Family Medicine - the challenges of the field, the rewards. However financially a private practice just cannot generate enough revenue, unless you are part of a large managed multispecialty group.
Kent is going to kill me for saying that, but this is coming directly from the Primary Care physicians in practice.

 

[Leukocyte]

I GUARANTEE you as a primary care provider would piss in your pants if someone desats to 80. Most don't know what to do. Can't blame them because that is not the focus of their training.

Desats to 80s?! Come on dude, we deal with this every night we are on-call. That is the least of my worries.

I had an experience with shoulder distocia once when delivering one of my continuities...now that my friend was F@ck'in scary. Thankfully it all ended well, thanks to my experienced Family Medicine attending.

 

[MedicineDoc]

I GUARANTEE you as a primary care provider would piss in your pants if someone desats to 80. Most don't know what to do. Can't blame them because that is not the focus of their training.

Why do I get the image of you sitting around talking some nonsense too loudly while a bunch of nerdy first year residents snicker at your comments while counting the seconds until they can justifiably dismiss you from their presence.

 

[jetproppilot]

.

 

[Leukocyte]

The significant Primary Care shortage has not affected compensation changes at all in my opinion.
What we will be facing soon, will be like a nationwide gas shortage.
Where do you go to see a doctor?

Actually the shortage of primary care FM/IM is a reallity in the city I am currently in, especially for Medicaid patients. Almost all of the primary care FM/IM offices here are "FULL", and "NOT ACCEPTING NEW PATIENTS".

We, in our residency FM clinic, are no longer accepting new patients. For the very few practices that do, the wait is long. Yesturday, I was discharging a patient (Medicaid) from the ER, and wanted him to F/U with his PCP regarding his continuous unexplained weight loss. I call all over town trying to get him an appointment with a FM or primary care IM doctor, but was unsuccessful. Finally, I was able to get him an appointment to see a NEW FM doc. The earliest I could get him in to see that PCP was December 17! We got a GI consult for that patient while he was in the ER (bull**** GI consult, that my paranoid EM attending wanted me to get for him), and the F/U appointment with this GI specialist was EASILY scheduled 2 weeks from now!

It seems that in my city, it is easier to schedule an appointment with a specialist than it is to schedule an appointment with a PCP as a new medicaid patient! That is why we keep seeing more and more medicaid patients coming to the ED for their primary care needs. The ED is a horrible place to go for primary care. The ER doctors I worked with are VERY paranoid, and seem to have limmited experience in dealing with chrionic or "inpatient type" medical problems. They get bull**** consults on almost every body (I was FORCED to get a surgery consult by my EM attending, for an incedental finding of small gallstones on a CT scan for a young health asymptomatic patient!!! Also, they tend to have a VERY low thrushold for admitting patients to our FM inpatient service...the EM docs I worked with just seem to be uncomfortable in handeling even the slightly complicated chronic medical patient.

 

[MOHS_01]

The inappropriate Medicaid reimbursement in many parts of the country is very much to blame for the inability to get an appointment. Physicians in private practice, without hospital or some other institutional subsidies, should not be forced into shouldering the burden of care.

As for the inappropriate consults from the ER -- that is an ER training problem. Perhaps they should increase the residency to four years and give them more exposure to the sort of things that they will be seeing.

The market defines the profession -- not the other way around.

 

[andwhat]

Actually the shortage of primary care FM/IM is a reallity in the city I am currently in, especially for Medicaid patients. Almost all of the primary care FM/IM offices here are "FULL", and "NOT ACCEPTING NEW PATIENTS".

We, in our residency FM clinic, are no longer accepting new patients. For the very few practices that do, the wait is long. Yesturday, I was discharging a patient (Medicaid) from the ER, and wanted him to F/U with his PCP regarding his continuous unexplained weight loss. I call all over town trying to get him an appointment with a FM or primary care IM doctor, but was unsuccessful. Finally, I was able to get him an appointment to see a NEW FM doc. The earliest I could get him in to see that PCP was December 17! We got a GI consult for that patient while he was in the ER (bull**** GI consult, that my paranoid EM attending wanted me to get for him), and the F/U appointment with this GI specialist was EASILY scheduled 2 weeks from now!

It seems that in my city, it is easier to schedule an appointment with a specialist than it is to schedule an appointment with a PCP as a new medicaid patient! That is why we keep seeing more and more medicaid patients coming to the ED for their primary care needs. The ED is a horrible place to go for primary care. The ER doctors I worked with are VERY paranoid, and seem to have limmited experience in dealing with chrionic or "inpatient type" medical problems. They get bull**** consults on almost every body (I was FORCED to get a surgery consult by my EM attending, for an incedental finding of small gallstones on a CT scan for a young health asymptomatic patient!!! Also, they tend to have a VERY low thrushold for admitting patients to our FM inpatient service...the EM docs I worked with just seem to be uncomfortable in handeling even the slightly complicated chronic medical patient.

This is an everyday thing unfortunately man. Terrible admissions at times that are hospitalized by the ER docs -- who are afraid of liability issues, or just too lazy to deal with social situations. It is much easier to admit, than to just deal with it.
I learned my lesson the first week as an attending -- EVALUATE the patient myself, before accepting a b.s. admission.
I turned quite a few down, now the ED usually THINKS before they --knee jerk-- call the Hospitalist service to admit.
Some docs are still ridiculous though, but they are a pain for everyone and not just me.
Yes there are several that are admitted for uncontrolled DM or HTN.
It is not because they cannot find a doctor usually, it is because they are too lazy to find a physician.
That is insane, how difficult it is for people to find a Physician in your town. If there was a true need for Physicians in Primary Care, and there most certainly is, then it would not be so complicated to reimburse them properly.
People nowadays should feel very very lucky and fortunate to have a doctor. My family doctor is talking about switching to Nursing Home, Hospitalist or Urgent Care. That is the great thing about Family Medicine, flexibility. You are not stuck doing one single thing -- like the O.R., and angry surgeons that dictate your every move and breath, and O.R. nurses -- who run your life also ESPECIALLY during night call, for the rest of your life.
A patient desatting in the 80s, as the previous poster pointed out. Certainly it is ok to assume that most Primary Care docs do not deal with this sort of situation, as they are in the clinic most of the time.
However we deal with many more complicated issues -- such as severely noncomliant Ob patients (in residency that is, some continue to do Ob NOT ME!!). These young ladies usually show up to the hospital in labor, with no prenatal care whatsoever, and expect to be delivered by us -- because they made an appointment with us 8 months back. Talk about liability issues there, that is literally a landmine!

What motivates a dude/dudette to go into a specialty where monetary reimbursement is less than some nurses?

Monetary reimbursement for me, right now between 200-250$ K easily more if I wanted to put in more hours. I get half the month off almost.

Are there really philanthropic people left out there, concerned about societal issues in medicine?

I would hope so, if you actually care about civilization and are not solely fixated on money. Plus you should love what you do.

If you are a med student reading this, do you think you'll think the same way after your residency is over?
I am very happy with my choice.

Can one be comfortable with the fact that after 4 years of college, 4 years of med school, then residency, you've selected primary care as your profession which puts you behind the eight ball financially?
oh man, again which eight ball are you referring to, the one that says that I earn over $200 K working 12 hours per day, with almost half the month off?

BTW....one of the most conflicting issues in marriages is....MONEY.
Again I make plenty of it.

So, again, why would a med student select primary care?
Money, lifestyle.

(rich family prodigies out there, you dont count)
Five years outta residency your focuses will be different.....family.....hobbies....
I read a post in this FM section about personal finance.....went something like...."its OK to rent..."
WTF?
You're gonna endure pre-med/med school....business major colleagues are sittin' out by the pool while you're in the study lounge cramming for an organic chem final...or 1st year med school biochem....2nd year pathophys... endure 3rd year clinicals......then select a career where the reimbursement suks to the point where you haffta rent?
I dont have to rent anything???

Cummon....

This post is not for the FP people who have already selected their fate.

Oh, you mean people that already have been in the profession and know what they are talking about?

This post is for med students reading this who are trying to figure out what they want to do with the rest of their lives....
I'm 11 years out of residency. Specialist. Love my job. Plenty of time off. Money not an issue anymore.

I am 2 and a half months out of residency. Love my job also. Half the month off. Money is definitely not an issue.

My student loans are long gone.
I have a 2.5 year plan.

I didnt make the rules.....

....the rules are.....

...specialists make more than twice that of primary care docs.

not true, Hospitalists earn quite well nowadays. Is it NOT true, that Opthalmologists start out at 180K -- and more based upon productivity? Does this make them substandard doctors?

And pick your specialty wisely, you'll make twice-bank with 9-12 weeks vacation.
Who in the world needs vacation, when I get almost half the year off anyways? 3 months off?? Are you kidding me? I get double that off almost.

So I'm wondering why med students would want to go into primary care.
Money and lifestyle, if you pick your career wisely.

Yep, an inflammatory thread.

And to the OP, once again, I get paid plenty of money too, almost half the month off, and love what I do also.
Hospitalist reimbursement has increased 13% in the last two years.
I do not have to answer to anybody, I can work at my own pace.
I can dictate who needs to be admitted and who does not.
I do not have to be on call EVER.
I have almost complete autonomy, and I dictate and control my own hours.
The MAXIMUM number of hours that I ever work is 12 per day -- I usually work less than 8 hours per day.
I have patient contact, which is great. I actually get to know my patients, I like to get to know my patients.
I don't have to do paperwork in clinic, and do not have to deal with office politics every day.
Clinic is awesome, and I do miss it however.
When I get on solid footing, I will moonlight in Urgent Care.
I have plenty of time for it ;-)

 

[ghost dog]

I owed nearly 200K in student loans when I graduated from med school.

After deferring said loans in residency, that amount was a solid 200K.

Yep, like alotta you out there, I had to personally pay for my education.

As a fourth year med student, I thought pragmatically....

hmmm.....

I owe X amount.

Debt is an anchor.

I wanna pay off my debt, but still be happy.

BOOM!!!

A light goes off in my head.

Now 11 years into private practice.....student loans paid off years ago....money no longer an issue...

I wanna hear from the med students going into primary care with 200K in student loans.

What motivates a dude/dudette to go into a specialty where monetary reimbursement is less than some nurses?

Are there really philanthropic people left out there, concerned about societal issues in medicine?

If you are a med student reading this, do you think you'll think the same way after your residency is over?

Can one be comfortable with the fact that after 4 years of college, 4 years of med school, then residency, you've selected primary care as your profession which puts you behind the eight ball financially?

BTW....one of the most conflicting issues in marriages is....MONEY.

So, again, why would a med student select primary care?

(rich family prodigies out there, you dont count)

Five years outta residency your focuses will be different.....family.....hobbies....

I read a post in this FM section about personal finance.....went something like...."its OK to rent..."

WTF?

You're gonna endure pre-med/med school....business major colleagues are sittin' out by the pool while you're in the study lounge cramming for an organic chem final...or 1st year med school biochem....2nd year pathophys... endure 3rd year clinicals......then select a career where the reimbursement suks to the point where you haffta rent?

Cummon....

This post is not for the FP people who have already selected their fate.

This post is for med students reading this who are trying to figure out what they want to do with the rest of their lives....

I'm 11 years out of residency. Specialist. Love my job. Plenty of time off. Money not an issue anymore.

My student loans are long gone.

I didnt make the rules.....

....the rules are.....

...specialists make more than twice that of primary care docs.

And pick your specialty wisely, you'll make twice-bank with 9-12 weeks vacation.

So I'm wondering why med students would want to go into primary care.

Yep, an inflammatory thread.

But I wanna know.

P.S. : If your dad has paid for college/med school/condo during residency, your opinion doesnt count.

Hi there Joker,

I went to med school and residency in Canada, so things are quite different here. Here a few figures for you to consider:

I specialize in family medicine and chronic non-malignant pain. Interestingly, family medicine residency is 2 years in Canada , as compared to 3 years in the U.S. I did a 3rd year fellowship in interventional pain medicine. I find combining these two medical fields a very interesting and rewarding experience, with a low potential for "burnout".

I went into private practice with a debt load of $120,000.

I make an average income of $380,000 per year.

I paid my loan off within 1.5 years, and will have paid off my $500,000 house within 2.5 -3 years.

I have NO CALL and no hospital responsibilities.

I work 25 hours per week.

I would say my lifestyle is very good. Wouldn't you jetproppilot?


To all medical students and family medicine residents,

Family medicine is what you make of it. There are a tremendous number of diverse opportunities available in the field of family medicine. If you want to make a lot of money, this can be done. If you want to relax and enjoy life, family medicine lends itself to this lifestyle as well.

Ghost dog.

 

[medicineman1]

Ghost Dog -where did you do your pain fellowship? In the US I think that it is safe to say most FPs would have a hard time landing a fellowship in pain. Do you half and half- FP/pain? or?

 

[Dr McSteamy]

I make an average income of $380,000 per year.

Ghost dog.

of the 380k, how much of it comes from pain?

 

[ghost dog]

Ghost Dog -where did you do your pain fellowship? In the US I think that it is safe to say most FPs would have a hard time landing a fellowship in pain. Do you half and half- FP/pain? or?

Hi medicineman,

I don't know much about american medicine as I practice in Canada. I understand it is very competitive to obtain fellowships in the U.S.


I worked under a well known doctor in Toronto (I don't really want to identify him on a public forum). I spent 3 years practicing with him, and learnt a tremendous amount. I have also rotated through a number of other well known pain clinics in Toronto.

I currently spend my days practicing both family and chronic pain medicine. It's difficult to say what proportion of my time is spent doing what; if I had to guess, I would say: 30-40 % family, 60-70% pain.

GD.

 

[ghost dog]

of the 380k, how much of it comes from pain?

Hi Dr McSteamy,

I apologize to my family medicine colleagues for the crudeness of the initial message. However, the initial post by "jetpilot" was fairly irritating and I thought he should be put in his place.

Money / income is rarely discussed in medicine for some strange reason; it seems to be a "taboo" subject. I'm not sure why this is the case.

Anyways, a very significant portion of my income comes from my chronic pain work (maybe 70-75%?). I see my family medicine patients because I practiced in a group practice initially and then moved to my own private practice. I didn't want to leave them stranded, and I enjoy family medicine. I am still accepting new family medicine patients. They also help pay the clinic overhead!

Another unexpected bonus of practicing in the lucrative field of pain medicine: it allows me to see my patients at a SLOW RELAXED PACE. I spend as much time as I like with my patients. This allows for a relaxed feel in the office that my patients, myself and secretary all appreciate and enjoy. It's a good place to work. I have found that this sort of atmosphere really allows me to focus on the clinical issues at hand, and attend to my patients appropriately.


This brings up another topic: doctors practicing on their own (i.e. solo practice) vs in a group practice. Once I opened up my own clinic, I realized how much I was getting SCREWED on overhead by my previous group / faceless corporation . I pay about 16-18% of my total billings in overhead, compared to 30% of total billings at the group practice.

Those big group practices are around for a reason!! However, I suppose my practice is unique in that my billing profile is different from the usual family practice.


GD.

 

[deleted87716]

I pay about 16-18% of my total billings in overhead, compared to 30% of total billings at the group practice.

The average in the U.S. is approximately 60%.

It's possible to do better. These low-overhead practices may catch on eventually.

 

[andwhat]

Hi Dr McSteamy,

I apologize to my family medicine colleagues for the crudeness of the initial message. However, the initial post by "jetpilot" was fairly irritating and I thought he should be put in his place.

Money / income is rarely discussed in medicine for some strange reason; it seems to be a "taboo" subject. I'm not sure why this is the case.

Anyways, a very significant portion of my income comes from my chronic pain work (maybe 70-75%?). I see my family medicine patients because I practiced in a group practice initially and then moved to my own private practice. I didn't want to leave them stranded, and I enjoy family medicine. I am still accepting new family medicine patients. They also help pay the clinic overhead!

Another unexpected bonus of practicing in the lucrative field of pain medicine: it allows me to see my patients at a SLOW RELAXED PACE. I spend as much time as required. This allows for a relaxed feel in the office that my patients, myself and secretary all appreciate and enjoy. It's a good place to work. I have found that this sort of atmosphere really allows me to focus on the clinical issues at hand, and attend to my patients appropriately.


This brings up another topic: doctors practicing on their own (i.e. solo practice) vs in a group practice. Once I opened up my own clinic, I realized how much I was getting SCREWED on overhead by my previous group / faceless corporation . I pay about 16-18% of my total billings in overhead, compared to 30% of total billings at the group practice.

Those big group practices are around for a reason!! However, I suppose my practice is unique in that my billing profile is different from the usual family practice.


GD.

yeah but it is the moderator here also. If you bother to argue a great point in favor of Family Medicine, you get dinged.
It is totally totally biased here, and I for one am tremendously disappointed. You are looked at questionably, if you post objective data. My philosophy is why even bother.
It is really really bothersome, because this forum can be used so so well and constructively educationally. Yet it is not, only abused -- and if you dare say anything to the contrary, you will get threatened.

 

[ghost dog]

The average in the U.S. is approximately 60%.

It's possible to do better. These low-overhead practices may catch on eventually.

An overhead of 60%! WHaT!? Are you using gold speculums ?

I find it interesting that the "low overhead practice" , which is supposed to be some sort of "bargain" for direct paying patients charges more than I get paid by the Ontario government. This low overhead practice charges $ 45 per patient, while I charge $ 31 per family practice patient.

GD.

 

[deleted87716]

An overhead of 60%! WHaT!? Are you using gold speculums ?

No, it's mostly waste and inefficiency.

I charge $ 31 per family practice patient.

You're undervaluing your services.

 

[ghost dog]

No, it's mostly waste and inefficiency.



You're undervaluing your services.

Can't do much about this. The Ontario government sets the fees.

The upside is that I rarely (if ever) get billing rejections. When I do, I just re-submit the billing, and then it's paid.

Another definite benefit is that I have only one entity to which I bill to: the government. No complex billing procedures. I understand things can get pretty hairy in the U.S. on that end of things.

GD.