Demand for IM
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NRAI2001 said:
A general rule, IM docs with successful practices in rural areas make mucho dinero (for IM docs anyway). Don't know about $700-800K (seems doubtful without procedures), but $250-300K is possible. The limiting factor with IM is the number of pts you can see in a day. You can hire NPs or PAs to increase the number of people you see (or other docs too).
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NRAI2001 said:
Thats 700-800k GROSS billable.
Consider an above average collection ratio of 60% = 450K
Of the 450K you are able to collect insurance tries to pay you a fraction less and medicare reimburses the lowest-- in reality you'll get 80% of what you ask for, if lucky = 360K
After an overhead of 200K (Rent, 2 nurses, malpractice, CME, office staff, etc) = Your NET is 160K 👎.
If you increase the % with insurance and refuse to see those with medicare (you did go into medicine to help people, and not just the ones with good insurance, right? 😉 ) , dabble in pharm funded clinical trials, you might flirt with $300k. Usually, the markets with high% insurance (affluent suburbs) are very competitive.
Bottom line, you won't have any problem finding a job in internal medicine. But income may vary.
retroviridae said:
That 700-800k was after recieving back the billing. He said that he had an overhead of about 30%. He was in a semi rural area, and he had a very large patient volume, saw on average between 45-55 patients a day.
He said that he also did many procedures that other internists don't usually do (I forgot what procedures they were).
NRAI2001 said:
He probably does stress testing, sigmoidoscopies, bone densitometry, and minor derm procedures to supplement his income.
I am still skeptical of that figure. Not to rain on your parade, but 700K - 30% for over head = 490K take home is not the reality for ~100% of Internists. GI and Interventional cardiology salaries can commonly be in that range, but not general internal medicine.
As was said before, if you work like a dog and have a good payor mix, you can make $250k, and if lucky $300K.
hans19 said:
Is taht $300K pre tax or after taxes?
Yes the Doc does do a lot of minor derm procedures. He also does treadmill work, a few breathing machine procedures, and a few other procedures taht i will ask him about next time i see him. He showed me his monthly income statement (or whatever it was). He was making about $60-70K a month.
He said he made even more a few years ago when he was seeing more nursing home patients and when he was taking more hospital calls, but it got too burdensome.
I think how much ur willing to work and how u run ur business is a very large determinant of ur financial success.
You don't need to become a specialist to make heeps of money. 👍
But this definitely isn't the norm. This Doc has been practice for 15 years now and is pretty well established.
You don't need to become a specialist to make heeps of money. 👍
But this definitely isn't the norm. This Doc has been practice for 15 years now and is pretty well established.
doc05 said:
you know, it is true that docs is small towns do a lot of "specialist" procedures simply because there aren't any specialists. Maybe you can make that add upp to $700K ....
doc05 said:
It depends, if u ve observed some procedures sometimes thats enough, ( of course these are minor procedures nothing life threatening). Like this doctor does minor derm procedures (remove warts...etc). He also does a few things that pediatricians may do like vaccinations.
He spent a few weeks learning how to do treadmill tests and do some other tests that cardiologists might do. Hes just running tests, not like hes doing anything invasive. Some IM programs do spend time teaching how to do these tests, thats why they are different from family practice.
Are you also saying that a GS shouldn't do a lap-chole without first completing a laproscopic fellowship, or shouldn't do breast surgery without first completing a breast fellowship? Of course not.doc05 said:
Every doctor needs to know his/her own limitations, and specialists are very important. But it's common for IMs to develop proficiencies in specialty areas. This could includes stress testing, sigmoidoscopy, office gyn, derm, and others.
You may be doing a greater "disservice" to your patients if you needlessly fragment their care among specialists.
ntmed said:
I don't know about sigmoids, but stress tests and reading EKGs is what we go to IM residency for. It is a procedure that pays well. Many private practice IM docs do these, and I see nothing wrong with that. Sigmoids are really not that hard to do, but shouldn't most patients be getting colons instead?
I totally agree. You have to know when to refer and when to treat. We are not FP docs. There is a reasonable expectation to know what you are doing for most of IM. Then again, there are what one of my attendings calls "Harrison's Cowboys" who think they can treat anything and never refer (to the dertiment of their patients). I still find it amazing that a book as big as Harrison's can leave out so much info.
ntmed said:
a lap chole is one of the most common cases a GS does. Breast surgery is a key part of GS also, and frankly, breast fellowships are pretty much a joke anyway.
Sigmoidoscopy is an obsolete procedure. Your patients should be getting colonoscopies or you'll miss 50% of adenomas and carcinomas. And no general internist should be doing that.
Likewise, office gyn and derm shouldn't be done by internists either. There's a reason that gyn and derm have their own residencies. Now you could argue that "simple" cases don't require a specialist; then again, no internist has any formal training in either gyn or derm. 1-2 months of electives during residency is not sufficient.
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doc05 said:
Whoa, whoa, whoa. Now I think you've gone a bit too far with the above statements. Internists are definitely trained in routine office gyn and derm. My guess is that you haven't been exposed to this training, since you're not in IM and the only exposure most medical students have with IM is in the inpatient setting.
In fact, during IM residency, we have formal outpatient medicine training, and this training includes the most common gyn and derm conditions that will show up in the primary care office. I'm not talking about just 1-2 months of elective time -- this training we have is required, and occurs both during the relatively extensive required ambulatory time we have as well as during our weekly continuity clinics. In fact, we have to demonstrate competence in both basic Gyn and Derm in order to get Board certified in internal medicine.
Personally, I deal with gyn issues and do gyn exams and Pap smears every single week during my continuity clinic. In addition, about half of my patients that I see each week during my clinic have some sort of derm complaint. Like all other IM residents, I am trained to deal with the majority of the derm conditions that I see in clinic, and will treat these conditions myself. I certainly have no qualms about referring patients to an Ob/Gyn or dermatologist if I think they have a problem that I am not trained to deal with, however.
I would suggest that you learn a little bit more about IM before you decide what we are trained and not trained to do.
This is doc05's problem. He's not an IM resident, but he feels compelled to troll the IM forum.AJM said:
For example ...
In our categorical IM program, we also receive training in several ambulatory areas, including gyn, derm, optho, ent, neuro, and psych. Our ambulatory training includes several required rotations, continuity clinics, and electives. We also have an additional Chief Resident who is responsible for our training in ambulatory care, including various procedure workshops (skin biopsy, suturing, arthrocentesis, joint injection, etc.).AJM said:
Of course, a patient should be referred to a specialist if that is the patient's preference, if it is outside of the IM's area of competence, or if the IM doc feels he/she needs additional expertise.
But since we're on the subject, it might be worth considering why a patient might want an IM to work up a complaint, instead of seeing a specialist. For certain problems, a patient might be better served by someone with broad medical knowledge, diagnostic expertise with undifferentiated patients, and who has a long-term understanding of the patient's medical history, as opposed to someone with a higher level of expertise in one specific area.
For example, a friend of mine had some pretty impressive dermatitis on the flexor surfaces of her hands, that progressively worsened over several years. She went to a dermatologist, who diagnosed contact dermatitis, prescribed topical steroids, and recommended she stay away from whatever household agent caused the symptoms. After a year of visits with no resolution (or change in diagnosis), she went to an internist. The internist took more of a medical view, discovered she was HLA-B27 positive, sero-negative, had some signs of ankylosis in her hip, and correctly diagnosed psoriatic arthritis. With the proper treatment (methotrexate, etanercept), and the help of a rheumatologist, her psoriasis resolved within a month and her condition is now being properly managed.
doc05 said:
Or that specialists do not work in small towns. How many specialists are willing -- or financially able -- to work in eastern Oregon? PCP's and GS's have broader practices in rural America -- they have to.
retroviridae said:
Could you or anyone please explain how outpatient IM differs from FP? If I'm not mistaken, aren't you guys trained to treat inpatients and ICU pts more than learning procedures and screening exams?
How does that equate in the outpatient setting? And I can only say this about certain IM residencies.
Internal med has no pediatrics, obstetrics, or general surgery. FP is like IM except they do Peds, Ob including training in C-sections, and depending on the program different amounts of general surgery. Also FP does less inpatient medicine than IM. Also IM has a lot more in the way of subspecialty choices.
Furrball2 said:
Perfect reply. Generally, given the breadth of FP training, IM gets more in depth in adult matters, in addition to more inpatient management. But, in rural areas, FPs may be expected to manage complicated patients that IM docs would otherwise handle.
I was talking with one of the FP attendings at my med school who worked for 15 years in rural Oregon. They something like three or four FP's in the area and two general internists. It sounded like they all saw the same type of patients in their practice at as inpatients, but the IM docs took care of the real sickies --e.g. waiting for celestial d/c -- in the small community hospital they had.
IM and FP at the surface seem pretty similar. They are in fact quite different. IM is a narrower focus. IM people tend to be more detail oriented and in general are more comfortable taking care of sicker adult patients with multiple chronic and complex medical problems. These days upwards of 75% of IM residents continue on with subspecialty training (see Academic Medicine May of this year). I think the trend within IM will be towards specialization as the work hours for primary care continue to increase and the pay continues to decrease. When you are on your third year rotations it will become much more apparent how the "cultures" of IM and FP are quite different.
