Best sub-specialty for lifestyle?

[Clarus]

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

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[Kaustikos]

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

Nephrology

Depends. ID can have a nice lifestyle depending on the region. Allergist is outpatient. Geriatrics isn't so bad. But also depends on what you prefer; outpatient vs inpatient, location and etc.

 

[CCM-MD]

Endocrinology

 

[Prehealth1011]

L in Allergy stands for Lifestyle

 

[bronx43]

Allergy, rheum, endo are all pretty similar. All are banker hours with little to no call. Just how cushy the job is depends more on the particular job and not which of these specialties you choose.

 

[chessknt]

Gi/Cards/Oncology because you can retire faster which beats having any job.

 

[Prehealth1011]

Gi/Cards/Oncology because you can retire faster which beats having any job.

Not PCCM?

 

[gutonc]

Not PCCM?

Compensation doesn't match the lifestyle hit you take if you're covering the ICU.

Gi/Cards/Oncology because you can retire faster which beats having any job.

Onc by a mile. GI and cards obviously have a higher compensation opportunity, but you're going to work hard for that. Onc on the other hand is an almost completely outpatient specialty with good hours and (generally) grateful patients. And it pays well too. 2 of my partners who work part-time (3 clinic days a week) will clear >$500K this year, and another couple who work FT (4d/wk) are looking to be in the $600-650K range...and we're having a hard time recruiting because we "don't pay well enough".

This is for ~1.5 weeknight on call each month and 4 weekends a year. I've been doing this for a decade and have never gone in after clinic hours...I guarantee you won't find a GI or cards doc who can say that.

 

[chessknt]

Compensation doesn't match the lifestyle hit you take if you're covering the ICU.

Onc by a mile. GI and cards obviously have a higher compensation opportunity, but you're going to work hard for that. Onc on the other hand is an almost completely outpatient specialty with good hours and (generally) grateful patients. And it pays well too. 2 of my partners who work part-time (3 clinic days a week) will clear >$500K this year, and another couple who work FT (4d/wk) are looking to be in the $600-650K range...and we're having a hard time recruiting because we "don't pay well enough".

This is for ~1.5 weeknight on call each month and 4 weekends a year. I've been doing this for a decade and have never gone in after clinic hours...I guarantee you won't find a GI or cards doc who can say that.

Yep chemo infusion commissions and incomprehensibly high rvu rates. Will that hold forever? Who knows but onc is easily highest return on time for now.

Pccm is all poorly insured patients and in Murca that means you don't get paid ****.

 

[bronx43]

Yep chemo infusion commissions and incomprehensibly high rvu rates. Will that hold forever? Who knows but onc is easily highest return on time for now.

Pccm is all poorly insured patients and in Murca that means you don't get paid ****.

Nothing in this unsustainable system will hold forever. But there’s no reason to believe that GI and their high colonoscopy reimbursement rates will hold any better than oncology infusion profits.

 

[CCM-MD]

Nothing in this unsustainable system will hold forever. But there’s no reason to believe that GI and their high colonoscopy reimbursement rates will hold any better than oncology infusion profits.

The $/wRVU being significantly higher for heme/onc in comparison to other outpatient specialties is due to the referrals/imaging/chemo... and that feels a lot like "kickback" if one is employed by a hospital. Idk how it is justified that a specialist using the billing same codes, working the same hours, and generating the same RVUs gets paid almost double. I see that coming under scrutiny.

Colonoscopy reimbursement isn't that much higher than bronchoscopy, its the volume. Alternative colon cancer screening tools are the threat to GI but I'm sure they will be just fine.

 

[CCM-MD]

Not PCCM?

If we're talking money and retiring early. Everyone in my 5 person intensivist group made between 500-600k last year working 180-190 shifts. And regardless of whether you have enough money put away, you almost can guarantee early retirement as an intensivist, cuz you're gonna be burnt. One of my colleagues is 66 years old though, probably just a weird anomaly.

 

[bronx43]

The $/wRVU being significantly higher for heme/onc in comparison to other outpatient specialties is due to the referrals/imaging/chemo... and that feels a lot like "kickback" if one is employed by a hospital. Idk how it is justified that a specialist using the billing same codes, working the same hours, and generating the same RVUs gets paid almost double. I see that coming under scrutiny.

Colonoscopy reimbursement isn't that much higher than bronchoscopy, its the volume. Alternative colon cancer screening tools are the threat to GI but I'm sure they will be just fine.

It’s all kickback to a certain extent. Like you said, the kickback is higher than other outpatient specialists but hospital systems have to go by national averages. Onc in private practice also make bank so that drives the higher comp/RVU that hospitals have to pay out. I highly doubt it’ll ever come under scrutiny by CMS, especially since oncology is the poster child for the health care system.

The moment that CMS even suggests some kind of reimbursement cut or changes to buy and bill model for outpatient drugs, oncologists throw a fit and they back off.

 

[HemeOncHopeful19]

The $/wRVU being significantly higher for heme/onc in comparison to other outpatient specialties is due to the referrals/imaging/chemo... and that feels a lot like "kickback" if one is employed by a hospital. Idk how it is justified that a specialist using the billing same codes, working the same hours, and generating the same RVUs gets paid almost double. I see that coming under scrutiny.

We all generate millions of dollars in revenue for hospital systems, even our Peds colleagues. It’s interesting that you think we’re getting paid double when I would argue they’re actually paying everyone else half of what they deserve...

 

[Prehealth1011]

We all generate millions of dollars in revenue for hospital systems, even our Peds colleagues. It’s interesting that you think we’re getting paid double when I would argue they’re actually paying everyone else half of what they deserve...

He/she thinks Oncologists compensation, in general, is weird

"I get that but no other specialty sees money from prescribing meds. Its akin to a PCP getting paid for prescribing Lipitor or an endocrinologist getting paid for starting a novel diabetic agent... oncology is the only specialty that has that, and its weird. Would be odd if I got 50 bucks each time I bolused someone with normal saline or started on norepinephrine."

 

[chessknt]

We all generate millions of dollars in revenue for hospital systems, even our Peds colleagues. It’s interesting that you think we’re getting paid double when I would argue they’re actually paying everyone else half of what they deserve...

Pulm generates a **** ton of cash for a hospital as well through labs imaging and pfts but they get reimbursed the same as endocrinogy on a per rvu basis. The reason oncology gets paid a lot is because people view cancer as the ultimate disease that should have unlimited resources thrown at it and oncologists are the beneficiaries of this public sentiment. That hasn't changed for decades but in the land of dropping reimbursements it sure looks far easier to go after oncology reimbursement rates than pediatric rates.

Since the 80s nobody has been paid what they deserve outside of the kingmaker specialties that designed the modern reimbursement system.

 

[CCM-MD]

He/she thinks Oncologists compensation, in general, is weird

"I get that but no other specialty sees money from prescribing meds. Its akin to a PCP getting paid for prescribing Lipitor or an endocrinologist getting paid for starting a novel diabetic agent... oncology is the only specialty that has that, and its weird. Would be odd if I got 50 bucks each time I bolused someone with normal saline or started on norepinephrine."

This exactly.

 

[HemeOncHopeful19]

He/she thinks Oncologists compensation, in general, is weird

"I get that but no other specialty sees money from prescribing meds. Its akin to a PCP getting paid for prescribing Lipitor or an endocrinologist getting paid for starting a novel diabetic agent... oncology is the only specialty that has that, and its weird. Would be odd if I got 50 bucks each time I bolused someone with normal saline or started on norepinephrine."

I mean I agree that Onc is making the most from this setup but does PCP office not bill for vaccines? Does Rheum/GI/Derm not bill for their infusions? Does your hospital not bill for saline and levophed?

 

[bronx43]

I mean I agree that Onc is making the most from this setup but does PCP office not bill for vaccines? Does Rheum/GI/Derm not bill for their infusions? Does your hospital not bill for saline and levophed?

I think the argument presented here is against the buy and bill model as a whole. It’s simply a loophole in the system where a pharmacy dispensing a medication is not bought and billed by the physician but an infusion is. A hospital billing for saline or levophed is one thing, but paying the doc that orders it based on the volume of orders is totally different.

As a rheumatologist I actually don’t think buy and bill should be allowed since it really adds a layer of… let’s just call it unnecessary financial incentives that often isn’t ideal for the patient.

 

[chessknt]

I mean I agree that Onc is making the most from this setup but does PCP office not bill for vaccines? Does Rheum/GI/Derm not bill for their infusions? Does your hospital not bill for saline and levophed?

The hospital does not bill for saline or levophed (it does for cash patients but they are otherwise reimbursed by DRGs so they dont make extra money for doing extra stuff). And yes other specialties get a small taste of the oncology infusion setup but that is like saying that Oncology gets to bill for bone marrow biopsies so it makes sense that interventional cardiologists get to be paid 1k/hr doing caths and tavrs. Not really apples to apples.

 

[VA Hopeful Dr]

I mean I agree that Onc is making the most from this setup but does PCP office not bill for vaccines? Does Rheum/GI/Derm not bill for their infusions? Does your hospital not bill for saline and levophed?

Us PCPs basically break even at best on vaccines.

 

[gutonc]

I think the argument presented here is against the buy and bill model as a whole. It’s simply a loophole in the system where a pharmacy dispensing a medication is not bought and billed by the physician but an infusion is. A hospital billing for saline or levophed is one thing, but paying the doc that orders it based on the volume of orders is totally different.

As a rheumatologist I actually don’t think buy and bill should be allowed since it really adds a layer of… let’s just call it unnecessary financial incentives that often isn’t ideal for the patient.

I am in an employed onc practice and although the hospital does "buy and bill", I am compensated the same for a 99215 getting a drug that costs $100K/month and one not getting any treatment. But the hospital clearly makes a f***ton more from patient A than patient B. As a result, my productivity-based compensation/RVU (above my base guarantee) is higher than it would be if I were an endocrinologist. And a lot of that is market forces.

In a true PP model, it's absolutely an area rife with potential for abuse and I'm not a fan of it in general.

 

[Mehena]

This exactly.

Not sure the argument ‘exactly’ has merits. We just threw “case complexity” out of the window. Perhaps we are underestimated the power of CMS. Despite its gargantuan bureaucracy, CMS was credited for uncovering the most sophisticated medical frauds, price gouging and over billings. Take the case of Therano’s for example, even the bean-counters were dumbfounded. If this was true and so obvious, the cost cutting Samurai of CMS would’ve landed on Oncology limbs long ago.

 

[CCM-MD]

Not sure the argument ‘exactly’ has merits. We just threw “case complexity” out of the window. Perhaps we are underestimated the power of CMS. Despite its gargantuan bureaucracy, CMS was credited for uncovering the most sophisticated medical frauds, price gouging and over billings. Take the case of Therano’s for example, even the bean-counters were dumbfounded. If this was true and so obvious, the cost cutting Samurai of CMS would’ve landed on Oncology limbs long ago.

Do you know how oncologists bill and generate 99% of their wRVUs? I’ll answer for you: E&M codes, which account for complexity. Now tell me how case complexity accounts for why heme/onc makes $150k more annually for similar amount of wRVUs generated as rheumatology?

 

[bronx43]

Not sure the argument ‘exactly’ has merits. We just threw “case complexity” out of the window. Perhaps we are underestimated the power of CMS. Despite its gargantuan bureaucracy, CMS was credited for uncovering the most sophisticated medical frauds, price gouging and over billings. Take the case of Therano’s for example, even the bean-counters were dumbfounded. If this was true and so obvious, the cost cutting Samurai of CMS would’ve landed on Oncology limbs long ago.

Complexity is already accounted for by CMS. Not sure what your point is here...

 

[bronx43]

I am in an employed onc practice and although the hospital does "buy and bill", I am compensated the same for a 99215 getting a drug that costs $100K/month and one not getting any treatment. But the hospital clearly makes a f***ton more from patient A than patient B. As a result, my productivity-based compensation/RVU (above my base guarantee) is higher than it would be if I were an endocrinologist. And a lot of that is market forces.

In a true PP model, it's absolutely an area rife with potential for abuse and I'm not a fan of it in general.

I mean, the bolded part is what the discussion is about. The only market force at play here is the buying and billing that goes on for high priced chemo and immunotherapy. Endo has a bigger shortage nationwide than heme onc, yet no one offers them more than $60/wRVU - for reasons that you stated. The hospital simply doesn't make enough from endocrinology ancillaries than they do for heme onc.

Call it what you want, but it's more or less "soft" kickback. With that said, I would argue the entire hospital employment model is various degrees of soft kickback since the wRVU compensation is higher than the clinical billing that all of us can generate minus overhead.

 

[Osteoth]

The $/wRVU being significantly higher for heme/onc in comparison to other outpatient specialties is due to the referrals/imaging/chemo... and that feels a lot like "kickback" if one is employed by a hospital. Idk how it is justified that a specialist using the billing same codes, working the same hours, and generating the same RVUs gets paid almost double. I see that coming under scrutiny.

Colonoscopy reimbursement isn't that much higher than bronchoscopy, its the volume. Alternative colon cancer screening tools are the threat to GI but I'm sure they will be just fine.

Adenoma detection rate is between 30-50% so even if people prep to get a CT colonography half will need a colonoscopy and will have to prep again which they hate. Especially considering we’re doing 45 for age now colon volume is sitting pretty for now.

 

[Clarus]

I do appreciate this discussion. I was just considering the pros/cons of each since I'm very early into my career and wanted to get a better understanding of each of the fellowships available in Internal Medicine. Just want to start off on the right foot and shoot towards that goal.

 

[aafisahar]

Adenoma detection rate is between 30-50% so even if people prep to get a CT colonography half will need a colonoscopy and will have to prep again which they hate. Especially considering we’re doing 45 for age now colon volume is sitting pretty for now.

CT Colo is dumb because you still have to prep and get your ass inflated. It's 90% of a colonoscopy but without any of the benefits.

 

[Osteoth]

CT Colo is dumb because you still have to prep and get your ass inflated. It's 90% of a colonoscopy but without any of the benefits.

Agreed. I would worry more about colon compensation going down. Jealous of cardio they have procedures + imaging + critical care + more robust clinic experience to bank on.

 

[CCM-MD]

Adenoma detection rate is between 30-50% so even if people prep to get a CT colonography half will need a colonoscopy and will have to prep again which they hate. Especially considering we’re doing 45 for age now colon volume is sitting pretty for now.

CT is not what’s going to get them. It’s the stool DNA testing.

 

[bronx43]

M

CT is not what’s going to get them. It’s the stool DNA testing.

Hasn’t FIT been out for several years now? Doesn’t seem to have affected scope volume too much, though I certainly can’t say for sure.

 

[Osteoth]

CT is not what’s going to get them. It’s the stool DNA testing.

30-50% of people still need a scope.

 

[HemeOncHopeful19]

I do appreciate this discussion. I was just considering the pros/cons of each since I'm very early into my career and wanted to get a better understanding of each of the fellowships available in Internal Medicine. Just want to start off on the right foot and shoot towards that goal.

Sorry this thread sort of took a different direction.

I agree that traditionally if all you care about is “lifestyle” then Endo/Rheum are typically banker hours and may not even involve hospital call depending on the setup but primary care can probably be similar if you enjoy PCP work.

If you find some other field particularly interesting I think you can make a good lifestyle work if you are willing to take lower pay in exchange for having fellows take call for you.

 

[rokshana]

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

 

[bronx43]

30-50% of people still need a scope.

But that means 50-70% don’t.

I guess one can argue that more people are willing to do a stool test so it would potentially capture a bigger market. However, the system already pushes colon CA screening extremely aggressively. Not many people in this country make it past 50 without having a fiber optic scope up their butt.

 

[Kaustikos]

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

Because they're too busy having fun doing stuff outside and counting money.

 

[sloh]

Because they're too busy having fun doing stuff outside and counting money.

Not sure about the “counting money” part.

 

[Prehealth1011]

Is Allergy counting more money than endo/rheum? MGMA shows they're ahead of both but not a lot of info on the specialty here

 

[CCM-MD]

Is Allergy counting more money than endo/rheum? MGMA shows they're ahead of both but not a lot of info on the specialty here

MGMA is higher for allergy by a little bit. Not sure exactly why. It is a small field though and I have heard it is harder to get a job. Important to take that into account if one is geographically restricted.

 

[HemeOncHopeful19]

MGMA is higher for allergy by a little bit. Not sure exactly why. It is a small field though and I have heard it is harder to get a job. Important to take that into account if one is geographically restricted.

Allergy $hots, I think

 

[Kaustikos]

Not sure about the “counting money” part.

They may not be rich as hell, but relative to the hours they work...they're making a decent amount.
But I'm no Allergist.

 

[rokshana]

Because they're too busy having fun doing stuff outside and counting money.

You know I’m endocrine, right?

 

[Kaustikos]

You know I’m endocrine, right?

Well, in my defense, I didn't see anything that screamed Endocrine. And sarcasm is hard to see on the internet.

Also, I'm surprised because I figured you'd be having too much fun 😉🤣🤣

 

[rokshana]

Well, in my defense, I didn't see anything that screamed Endocrine. And sarcasm is hard to see on the internet.

Also, I'm surprised because I figured you'd be having too much fun 😉🤣🤣

Lol… then you haven’t paid attention… it’s fairly well know here that I’m an endocrinologist

 

[Kaustikos]

Lol… then you haven’t paid attention… it’s fairly well know here that I’m an endocrinologist

Definitely true. I have been absent from these forums for about 5 years and just recently came back. So...yeah

 

[aafisahar]

Depends. ID can have a nice lifestyle depending on the region.

Inpatient ID is probably the worst job in medicine. Sure outpatient may be better, but that's crushed by the time you have to do inpatient and dealing with all the bull**** pushed on you (osteo, endocarditis, routine infection consults, setting up OPAT). Miss me with that ****.

 

[Kaustikos]

Inpatient ID is probably the worst job in medicine. Sure outpatient may be better, but that's crushed by the time you have to do inpatient and dealing with all the bull**** pushed on you (osteo, endocarditis, routine infection consults, setting up OPAT). Miss me with that ****.

Meh, to each their own. I like it. The bull**** can be annoying and how some hospitalist are board certified and consult me for certain things. But, overall, the good definitely outweighs the bad. And outpatient? Boo!

Also worst? Have you seen the Nephrology threads here?

 

[aafisahar]

Meh, to each their own. I like it. The bull**** can be annoying and how some hospitalist are board certified and consult me for certain things. But, overall, the good definitely outweighs the bad. And outpatient? Boo!

Also worst? Have you seen the Nephrology threads here?

OH shoot, nephrology is the actual worst lol forgot about that.

 

[rokshana]

OH shoot, nephrology is the actual worst lol forgot about that.

Though it seems EM is going in that direction as well.