A PRIVATE PRACTICE DOCS RESPONSE TO "REALITY"

[jetproppilot]

Alright Dudes/Dudettes, heres some info from the real world about the reality thread.
I've been in practice for eight years now. Initial job was in a small town in the southeast. I came out in 1996 when jobs were OK but noone was starting at 300k. I had a buddy who came out 2 years ahead of me, went to Las Vegas, started at 270k, which was the highest for the times.
Times have changed. Anesthesiologists are in demand now. Its not uncommon for residents to start at 300k; I'd say thats the most common number, some higher, some lower. My buddy in Las Vegas is making around 4. Keep in mind Las Vegas is all MD anesthesia, save some CRNAs in scattered surgery centers. I know a dude out there making over 6, but he is never home. If you are in an all MD area the money you make is commensurate with time spent at work. You are your own moneymaker, an independent contractor. Yes, you may be in a group that shares call, but you are the primary holder of your monetary destiny. So if you wanna work all the time (which I wanted to do early in my career), you can make great $$.

Contrast that business model to a private practice group where you have 6 docs (or whatever), you do a buy-in of time and money (typically 1-2 years and the money buy in is variable from almost none to around 150k, depending on the practice). When you are a full partner, your corporation (that you are now 1/6 owner if there are 6 docs) pays all the bills (business manager, girls/guys in your office, CRNAs) then you split up what is left.

The second model is common in the southeast, where the MD-CRNA approach is predominant. In MD only groups, you take home what you bill, minus a percentage that goes for business expenses (malpractice, billing office, retirement accounts).

I humbly am in disagreement with the "philanthropists", who bark at an individual when they mention money as a concern when they emerge from residency. Medicine, although an altruistic career, has its pitfalls as well, i.e. long hours, nights (which make you old before your time, believe me), and the litiginous state of society. I think its important to like what you do, but not at the expense of living in debt for the rest of your life. HOW MUCH OF OUR LIVES DID WE SACRIFICE TO GET WHERE WE ARE?? While I was busting my ass in college/med school/residency, many of my homies were living life to its fullest. Partying. Travel. The good life. I'm sorry, folks, I wouldnt've gone into peds/medicine/family practice, even if it was my life long dream. I couldnt. I emerged from U of Miami with a ton of debt. After residency, that debt (which you cant pay during residency unless you have rich parents, which I didnt) had risen to almost 200k. SO, I'm gonna spend my 20s learning my trade and go into a specialty that pays 150K? Sorry. I have a wife and kids. I swore to myself my children would not have to beg/borrow/steal for their education like I did. MY MESSAGE? Yes, pick something you like. But pick wisely. Any specialty becomes a job after a while. After your honeymoon years are over (read the first couple years outta residency where you're just glad to be a real doctor), are you gonna be satisfied with what your job is giving YOU? Are you making enough on your investment? Yes, my opinion will aggravate certain groups of people, but lemme tell you folks, people that say money shouldnt be the determining factor have never lived in Florida as a kid without air-conditioning like I did. Money will not buy you happiness. But it will buy you security for you and your family. And the more money you make, the quicker you will erase your debt. Debt is an anchor in life. It wears on you. So "philanthropists", I respect your position. But please do not kick mud in the face of people who are concerned about money. I was one of those people. I thankfully liked a specialty that allowed me to pay off all my debt, live a great life where money isnt really an issue anymore, and build a big retirement account. My wife and children are comfortable. So am I. Don't kick mud in my face or in your colleagues faces who are concerned about money.

Now that I'm off my soapbox, yes, there are very nice packages out there. I don't see them going anywhere soon. No one is offering a 200K signing bonus, even in Vegas. But you can make 600-700K in various parts of the country if you pick the right practice. 400-500 is more common as a full partner.

Money is an issue, dudes/dudettes. It ranks in the top 2 things that married people fight about. You can be cognizant about your income and still give high quality peri-operative care. I do it every day.

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[Sunz81]

Encore! Encore! That was an amazing post that really hit home. I must admit that I was always one of those people that said, "but I'm not in it for the money!" when people told me that pediatricians don't make any money. But the more and more I thought, I began to realize. At the end of the day, a job is a job. Some love it, some hate it, but you have it so you can pay your bills. No one goes through all those years of school and works for FREE! I completely agreed with your entire post and I applaude you for coming out and saying it.

 

[KCOM2006]

Thanks for sharing your thoughts!

I too agree that money is not a primary motivator. However it probably ranks in the top 5 reasons someone uses for deciding a residency. Regardless I do not want to be "subservient" to my debt!

The average student these days are graduating with 100-200k in debt. I’ll be $135,000 and unfortunately that will accrue interest throughout the four years of residency. Easily reaching 175k by the time I complete residency. When you start paying back the loan you have to remember you have to pay ~9k in interest + whatever you can pay on principle. If you want to pay off your loan in 10 years you’ll need to pay 17k (principle) + 9k (interest) = 26k per year.

Remember this is after taxes and unfortunately you’ll be in a high tax bracket… at least 28%. So in actuality you will need to make 37k before taxes to pay 26k. If this is only one of the stressors on a 100-150k job, you could argue that it is manageable. It just depends how you want to live for 10 years of your life.

American Medical Associaion. Physician Socioeconomic Statistics 2000-2002. Chicago, IL: AMA, 2001.
Cardiology ------------ 300K
Diagnosit Radiology -- 300K
Orthopedic Surgery -- 298K
Urology --------------- 270K
Dermatology --------- 270K
Gastroenterology ---- 260K
Pathology ------------- 250K
Anesthesiology ------- 236K
General Surgery ----- 232K
Emergency Medicine - 214K
OBGYN ---------------- 203K
Otolaryngology ------- 200K
Opthalmology --------- 200K
Neurology ------------- 170K
Internal Medicine ----- 160K
Pediatrics ------------- 145K
Psychiatry ------------ 140K
Family Practice ------- 135K

I’d much rather choose a specialty that I enjoy in the 200-300k range and financially be able to pay off my loan in one year!

As a philanthropist, you can look at both scenarios as decisions to either 1) spend your life as a servant to others or 2) spend your time and money to be a servant to others. I’ll be choosing the later.

 

[Trismegistus4]

I humbly am in disagreement with the "philanthropists", who bark at an individual when they mention money as a concern when they emerge from residency. Medicine, although an altruistic career, has its pitfalls as well, i.e. long hours, nights (which make you old before your time, believe me), and the litiginous state of society. I think its important to like what you do, but not at the expense of living in debt for the rest of your life. HOW MUCH OF OUR LIVES DID WE SACRIFICE TO GET WHERE WE ARE?? While I was busting my ass in college/med school/residency, many of my homies were living life to its fullest. Partying. Travel. The good life. I'm sorry, folks, I wouldnt've gone into peds/medicine/family practice, even if it was my life long dream. I couldnt. I emerged from U of Miami with a ton of debt. After residency, that debt (which you cant pay during residency unless you have rich parents, which I didnt) had risen to almost 200k. SO, I'm gonna spend my 20s learning my trade and go into a specialty that pays 150K? Sorry. I have a wife and kids. I swore to myself my children would not have to beg/borrow/steal for their education like I did. MY MESSAGE? Yes, pick something you like. But pick wisely. Any specialty becomes a job after a while. After your honeymoon years are over (read the first couple years outta residency where you're just glad to be a real doctor), are you gonna be satisfied with what your job is giving YOU? Are you making enough on your investment? Yes, my opinion will aggravate certain groups of people, but lemme tell you folks, people that say money shouldnt be the determining factor have never lived in Florida as a kid without air-conditioning like I did. Money will not buy you happiness. But it will buy you security for you and your family. And the more money you make, the quicker you will erase your debt. Debt is an anchor in life. It wears on you. So "philanthropists", I respect your position. But please do not kick mud in the face of people who are concerned about money. I was one of those people. I thankfully liked a specialty that allowed me to pay off all my debt, live a great life where money isnt really an issue anymore, and build a big retirement account. My wife and children are comfortable. So am I. Don't kick mud in my face or in your colleagues faces who are concerned about money.

I am not even in med school yet, so I hope no one minds me posting in one of the residency forums. But I just wanted to say I feel that this paragraph should be saved and quoted in response every time someone advocating socialized medicine says that anyone who cares in the slightest about remuneration doesn't deserve to be a doctor, as often happens in some of the other forums. Thanks for your perspective.

 

[CambieMD]

Great post!!!!!

CambieMD

 

[Furious_D]

Dude,

What a fantastic post. The amazing thing when you read something like this is when you have had the EXACT same thoughts for years. I have been in private practice for a few years and feel exactly the way you do. Nice post

 

[jetproppilot]

American Medical Associaion. Physician Socioeconomic Statistics 2000-2002. Chicago, IL: AMA, 2001.
Cardiology ------------ 300K
Diagnosit Radiology -- 300K
Orthopedic Surgery -- 298K
Urology --------------- 270K
Dermatology --------- 270K
Gastroenterology ---- 260K
Pathology ------------- 250K
Anesthesiology ------- 236K
General Surgery ----- 232K
Emergency Medicine - 214K
OBGYN ---------------- 203K
Otolaryngology ------- 200K
Opthalmology --------- 200K
Neurology ------------- 170K
Internal Medicine ----- 160K
Pediatrics ------------- 145K
Psychiatry ------------ 140K
Family Practice ------- 135K

These figures, at least anecdotally, dudes/dudettes, are way off, at least for procedure oriented specialties. They must combine academic doc's salaries when arriving at these salaries. In the southeast, busy interventional cardiologists/ortho dudes/interventional radiologists make twice whats listed.

Wanna here the biggest travesty of all time? Heart Surgeons. Sorry folks, heart surgeons should be the highest paid doctors out there. They shoud make a mil a year. Their residency/fellowship is one step above burning in hell. Their lives in private practice typically have longer hours than us, and alot of them care for their patients post-op, which means for 24-48 hours after a CABG they get incessant phone calls about vents, hemodynamic support, urine output, chest tube drainage, etc. The travesty lies in their patient population, and how they have been stripped of most insurance (read well paying) cases. By no fault of their own, the invasive cardiologists have benefited from the revolutionary stent/PTCA technology. Nowadays, most people with CAD can have their stenoses addressed with stents, at least for a little while. So people in their 50s/early 60s, who would've had single/double vessel bypass 20 years ago, can now be sustained without surgery for years- and when they finally do need surgery, they are usually older than 65. Why is age 65 relevant? Because thats when medicare covers an American's health care bills, and medicare reembursement to most doctors pays terrible. Now if you are a heart surgeon, that means most of your patients are now >65, which means your rembursement for most of your cases sucks. Know what a heart surgeon gets for doing a medicare CABG,the grueling post op 24-72 hours, and subsequent hospital floor/office visits? About 1800 bucks. And a busy heart surgeon likes to do 150-200 hearts a year. You do the math. Now of course this doesnt include carotids/fem-pops/thoracotomys, but the bulk of a heart surgeon's income usually comes from CABGs. No, the heart surgeons arent starving by any stretch of the imagination, but they should be near seven figures annually for their work. Some are, if they are in the right part of the country at institutions who get alot of the coveted younger hearts, but most are not.
Now tell me, why is it an ENT dude can do a 40 minute FESS on your twenty year old cheerleader sister and make almost as much as a heart surgeon does on an 80 year old CABG with preoperative A-fib, HTN, DM, CRF, an ejection fraction of 25%, and pulmonary artery pressures in the 40s? (geez, I should go into politics as a doctor advocate...haha)
Yeah, the neurosurgeons will look at this and scream their residency is just as hard and they work just as hard. I concur. But they have outs that the heart surgeons dont. Neurosurgeon dudes/dudettes can (and most do) do the very lucrative spine procedures. Most people having 1-2 level discectomies/ACFs are still in the insurance age group, which pays very well. Heart surgeons have no outs.

 

[GMO2003]

American Medical Associaion. Physician Socioeconomic Statistics 2000-2002. Chicago, IL: AMA, 2001.
Cardiology ------------ 300K
Diagnosit Radiology -- 300K
Orthopedic Surgery -- 298K
Urology --------------- 270K
Dermatology --------- 270K
Gastroenterology ---- 260K
Pathology ------------- 250K
Anesthesiology ------- 236K
General Surgery ----- 232K
Emergency Medicine - 214K
OBGYN ---------------- 203K
Otolaryngology ------- 200K
Opthalmology --------- 200K
Neurology ------------- 170K
Internal Medicine ----- 160K
Pediatrics ------------- 145K
Psychiatry ------------ 140K
Family Practice ------- 135K

These figures, at least anecdotally, dudes/dudettes, are way off, at least for procedure oriented specialties. They must combine academic doc's salaries when arriving at these salaries. In the southeast, busy interventional cardiologists/ortho dudes/interventional radiologists make twice whats listed.

Wanna here the biggest travesty of all time? Heart Surgeons. Sorry folks, heart surgeons should be the highest paid doctors out there. They shoud make a mil a year. Their residency/fellowship is one step above burning in hell. Their lives in private practice typically have longer hours than us, and alot of them care for their patients post-op, which means for 24-48 hours after a CABG they get incessant phone calls about vents, hemodynamic support, urine output, chest tube drainage, etc. The travesty lies in their patient population, and how they have been stripped of most insurance (read well paying) cases. By no fault of their own, the invasive cardiologists have benefited from the revolutionary stent/PTCA technology. Nowadays, most people with CAD can have their stenoses addressed with stents, at least for a little while. So people in their 50s/early 60s, who would've had single/double vessel bypass 20 years ago, can now be sustained without surgery for years- and when they finally do need surgery, they are usually older than 65. Why is age 65 relevant? Because thats when medicare covers an American's health care bills, and medicare reembursement to most doctors pays terrible. Now if you are a heart surgeon, that means most of your patients are now >65, which means your rembursement for most of your cases sucks. Know what a heart surgeon gets for doing a medicare CABG,the grueling post op 24-72 hours, and subsequent hospital floor/office visits? About 1800 bucks. And a busy heart surgeon likes to do 150-200 hearts a year. You do the math. Now of course this doesnt include carotids/fem-pops/thoracotomys, but the bulk of a heart surgeon's income usually comes from CABGs. No, the heart surgeons arent starving by any stretch of the imagination, but they should be near seven figures annually for their work. Some are, if they are in the right part of the country at institutions who get alot of the coveted younger hearts, but most are not.
Now tell me, why is it an ENT dude can do a 40 minute FESS on your twenty year old cheerleader sister and make almost as much as a heart surgeon does on an 80 year old CABG with preoperative A-fib, HTN, DM, CRF, an ejection fraction of 25%, and pulmonary artery pressures in the 40s? (geez, I should go into politics as a doctor advocate...haha)
Yeah, the neurosurgeons will look at this and scream their residency is just as hard and they work just as hard. I concur. But they have outs that the heart surgeons dont. Neurosurgeon dudes/dudettes can (and most do) do the very lucrative spine procedures. Most people having 1-2 level discectomies/ACFs are still in the insurance age group, which pays very well. Heart surgeons have no outs.

 

[ReMD]

What will you do if reimbursement for anesthesia drops? Will you quit and switch fields to do something that is more lucrative? Probably not.

You should choose a profession based on your interest for the field. And for those who say that they are not really interested in any medical field, probably they just don't have enough experience. Medical school definitely does not give us experience in every aspect of medicicine.

If your interested in anesthesia and can see yourself doing it for the rest of your life, then great. If not, then be careful choosing it b/c if the money is not there one day, then you could be miserable. Plus, anesthesia does not have many options to expand into other areas, without doing additional training. So if you don't like it, you could be stuck doing it.

I have an option to go work striaght after residency, making close to $+600,000 by 3 yrs out, taking over a family medical business. The pt population and type of work sucks but the money/lifestyle is great. I decided to do additional training after residency that has nothing to do with the family business b/c that's what interested me. Would you do the same? Is it worth the extra time and effort? I hope so b/c that what I'm interseted in and enjoy.

 

[DocBrown]

Nice post! How many hours a week do you work?

 

[jetproppilot]

Nice post! How many hours a week do you work?

Two weeks of days, averaging about 55 hours, then a night week which is 48 hour weekend call and subsequent Mon-Fri 5pm-0630, then a week off. Our hospital doesnt do alot of nighttime work in the OR, but our OB unit does about 180/month, so OB keeps you up on your night week. Can't argue with 13 weeks vacation, though.