Career in Geriatrics?

[ericdamiansean]

How bright is a future in geriatrics? Other than the expanding geriatric population and a definite need for geriatricians, how much can one earn?

From http://www.allied-physicians.com/salary_surveys/physician-salaries.htm,
the max an internist earns is about $238000.

Just thinking about it because my interest has always been in geriatrics, but the other subspecialties in internal med ie. hem/onco, gastro, interventional cardiology etc seem to be doing so much better (even allergy/immuno?! ). Not sure how much the nett income for those other specialties like interventional cardio would be after insurance, I'm sure it is probably more than that of a geriatrician, but the difference is still going to be pretty huge right?

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[AmoryBlaine]

Interventional cards is far above geri in pay. But then again, interventional is far above alot of specialties.

They are two different worlds, I doubt your ultimate decision will come down to money.

 

[deleted87716]

Currently, cognitive specialties like internal medicine (including geriatrics) are reimbursed less than those that focus heavily on procedures. There are signs that this is changing, however, so don't pick a specialty based on the reimbursement policies of today. You really shouldn't be picking a specialty based on income anyway, as you're setting yourself up for disappointment. Pick a specialty based on what you want to spend the rest of your life actually doing every day. Geriatrics and interventional cardiology are worlds apart, as another poster mentioned.

 

[ericdamiansean]

They are two different worlds, I doubt your ultimate decision will come down to money.

But I guess with that said, pay does affect to a certain extent what you would like to do, with loans to pay off etc?

There are signs that this is changing, however, so don't pick a specialty based on the reimbursement policies of today.

Elaboration?

 

[deleted87716]

Elaboration?

CMS (Medicare) increased reimbursement for some of the ambulatory RVUs this year, at the expense of some of the procedural codes. I suspect this is the beginning of a trend.

http://www.acponline.org/journals/news/sep06/washington.htm

 

[momo7430]

I too am a budding Internist... Geriatrician in the making, so I share your passion for that population.
My view is that #1-because of what we're doing we will always have debt. And #2- as most people do... we are almost always going to outlive our means, you know- house, cars, family.... SO you may as well do what will make you feel good when you go to bed at night.

Good luck!
Mo

 

[Dr JPH]

As a geriatrician you wont be hurting for business. In fact, you may be too busy to spend any money that you DO make!

Ultimately you need to decide if you want to do procedures or not...that will determine if you are going to be happy as a geriatrician vs other specialties.

 

[ericdamiansean]

Thanks guys

 

[PCAndrew]

Several things should be noted. #1) geriatricians (and geriatic psychiatrists) are the happiest physicians according to a recent study in the Annals. #2) geriatricians are trained to provide not one, but TWO of the very few services that have been proven to lower total lifetime health care costs: Advanced Directives and Hospice referrals. I think vaccines and smoking cessation might also be on the list, but providing those services has not been well compensated, so maybe the future is not so bright after all. #3) as our department chair says, "no one is doing geriatrics, and everyone needs geriatricians, so if you do [geriatrics], you can go anywhere, do anything, be anyone." #4) The hospital I'm at now runs a very lucrative geriatrics consult service; geriatrician hospitalists, at least, do well. #5) As Medicare is set up now, with 5 levels of out-patient acuity billing, geriatricians can typically at least bill a 3 if not a 4 or a 5 on every visit. In patient (out of 3 levels) they always bill a 3. Get used to writing longer notes. Where most internists see altered mental status and CHF, a geriatrician sees CHF, gait disturbance, depression, delirium, early dementia, incontinence, and malnutrition. And there's some money in the system for that type of thouroughness.

 

[MattD]

I don't know a ton about the field, but my clinical medicine preceptor is a VA geriatrician, and seems very happy and satisfied with his work/life. Don't know how much he makes. FWIW

 

[EBI831]

From http://www.allied-physicians.com/salary_surveys/physician-salaries.htm,
the max an internist earns is about $238000.

i wanna find this internist who makes 238000. it's not my mother. she'll prob want his/her position. but chances are its a lucky person in private practice or an unfortunate who lives in new york/LA or some equally expensive place where it evens out.

 

[Northerner]

How bright is a future in geriatrics?

 

[Law2Doc]

How bright is a future in geriatrics? Other than the expanding geriatric population and a definite need for geriatricians, how much can one earn?

Be very skeptical of the "max" of any salary survey -- it often tends to be some anomoly, and rarely is going to be someone of recent vintage. The max is the salary you will not be getting. As others have suggested geriatrics is not going to have a short supply of patients, but don't expect supply and demand to drive income. You will be working for reimbursements/medicare, and so you don't get to set your own fees. Choose your specialty based on what you like to do, not what you'd like to earn. FWIW, all non-peds/OB fields will encompass some degree of geriatrics in the coming years, as the baby boomer generation is getting up there, living longer, and outnumbering the rest of us as patients big time.

 

[PCAndrew]

$238,000 represents the 90%ile if I remember right, it's high, but it's not an anomoly. Internists making that kind of money now-a-days are typically hospitalists.

And OB/Gyns do quite a bit of geriatrics, neoplastic disorders increase in incidence with increasing age. They stop delivering babies and start removing cancers around 45 years old.

 

[Law2Doc]

And OB/Gyns do quite a bit of geriatrics, neoplastic disorders increase in incidence with increasing age. They stop delivering babies and start removing cancers around 45 years old.

Yeah, that's why I left the Gyn part out of my post.

For people coming right out of residency these days, the max on the Allied list is not very realistic or attainable. By anomaly I wanted to suggest the OP not get his/her hopes up - that is simply not a normal salary. If you look at other threads where that allied list has been posted (especially in pre-allo), you will come across a dozen or so people actually expecting to attain million dollar salaries when they become spine surgeons, and already counting all their mansions and bentleys.

 

[dilated]

Currently, cognitive specialties like internal medicine (including geriatrics) are reimbursed less than those that focus heavily on procedures. There are signs that this is changing, however, so don't pick a specialty based on the reimbursement policies of today.

The real reason I don't think this can change much is just the size of the cognitive specialties. There are, what, 20 times more internists and FPs than cardiologists? 50 times more than derms? So you have to take 50 dollars from every derm to give 1 to FP/IM. The size of the pie is never increasing, but the sheer number of "cognitives" makes it hard to substantially increase their reimbursement without halving the salary of others (which would start an intramedicine jihad).

 

[deleted87716]

The size of the pie is never increasing, the sheer number of "cognitives" makes it hard to substantially increase their reimbursement without halving the salary of others (which would start an intramedicine jihad).

"Budget neutrality" seems to be the buzzword nowadays, but it's unrealistic to think that we're going to be able to keep Medicare expenditures static indefinitely.

 

[dilated]

"Budget neutrality" seems to be the buzzword nowadays, but it's unrealistic to think that we're going to be able to keep Medicare expenditures static indefinitely.

True, but I think hoping for substantial increases to the physician pay portion of Medicare expenditures is probably wishful thinking. Rate of inflation would be a pleasant surprise.

That's really a big part of why procedural specialties make more: they're constantly coming up with new developments that force the billing system to change and provide a legitimate reassessment of how much something is worth, and often Medicare is trying to negotiate them down (from when something is overpaid due to a technology shift like current radiology imaging). The cognitives, on the other hand, the 30 minute exam hasn't changed since the dawn of time so it's very easy to just leave it untouched and hard to fight for why it suddenly needs increased now.

 

[deleted87716]

The cognitives, on the other hand, the 30 minute exam hasn't changed since the dawn of time so it's very easy to just leave it untouched and hard to fight for why it suddenly needs increased now.

Sorry, I'm going to have to throw a flag on that play.

Today's ambulatory patients are incredibly more complex than those of thirty years ago. Back then, we didn't even have a fraction of the therapeutics, tests, or even knowledge of disease processes that we have today. As people live longer with chronic medical conditions, it's only getting more complicated.

Incidentally, fifteen-minute visits are the norm, not thirty.

 

[dilated]

Sorry, I'm going to have to throw a flag on that play.

Today's ambulatory patients are incredibly more complex than those of thirty years ago. Back then, we didn't even have a fraction of the therapeutics, tests, or even knowledge of disease processes that we have today. As people live longer with chronic medical conditions, it's only getting more complicated.

Incidentally, fifteen-minute visits are the norm, not thirty.

There's different billing codes for different levels of exam though, right? I vaguely remember talking about this when I was on one of our community preceptor things. It was something like there's 1 code for a 15 minute repeat visit and another one for a longer initial H&P.

And yeah, I'm not saying it's not more complicated than it used to be. But incremental increases in complication do not force Medicare to reevaluate reimbursement, whereas a new procedure or a change in the efficacy of a procedure -- laparascopic procedures or suddenly increasing the number of radiological studies you can do/day -- demand that Medicare change things. Having average patients that are on 5 medications instead of 2 (etc., etc.) takes more work but is much more easily ignored when reimbursement changes are done.

 

[NonTradMed]

Currently, cognitive specialties like internal medicine (including geriatrics) are reimbursed less than those that focus heavily on procedures. There are signs that this is changing, however, so don't pick a specialty based on the reimbursement policies of today. You really shouldn't be picking a specialty based on income anyway, as you're setting yourself up for disappointment.

So true. My parents work with doctors and so I've noticed changes in trends in terms of physician salary and specialties. Anesthesia used to be really easy to match into, so easy that a lot of foreign docs end up getting those spots b/c US docs don't want them. Why was that? I'm not exactly sure, but from what I overheard, the perception was that gas docs would be soon out of work, and their income was declining because of changes in technology. as a result, no one wanted to go into it. Now look at it. It's a lifestyle specialty and the income from gasdocs is pretty impressive. Changes in technology, public policy, public demand....they will all change a doctor's lifestyle and income. Choosing a specialty based on what is 'hot' now may not guarantee that will be hot tomorrow. I think the best idea is to choose something you know you can stick with 'through thick and thin'. God, it's almost like marriage.

For people coming right out of residency these days, the max on the Allied list is not very realistic or attainable. By anomaly I wanted to suggest the OP not get his/her hopes up - that is simply not a normal salary. If you look at other threads where that allied list has been posted (especially in pre-allo), you will come across a dozen or so people actually expecting to attain million dollar salaries when they become spine surgeons, and already counting all their mansions and bentleys.

You know, you keep on mentioning that there are people like that on preallo, but from what I've seen, most people, especially long term posters, do NOT see medicine that way.

In fact, there's a few quite vocal people who see the exact opposite: that medicine is in its last legs, ready to collapse and make us all slave-paupers for Big Brother Government.

For every post about a preallo kid who thinks he'll break his first million by 35, there's about a dozen post that says that doctors will be on the welfare line by the time they get to graduation. It's a sad state of affairs when Panda Bear ends up defending medicine.

 

[Doctor Bagel]

It's a sad state of affairs when Panda Bear ends up defending medicine.

Sad indeed. I agree with your perception regarding sdn. Most people here seem to be more negative about future earnings than positive. However, I think a lot of people are reasonably excited about the prospect of earning an income that places them in the top 5% of incomes in the US.

About geriatrics, I think I'd hate it, but if you like it, great. You're never going to be short of work. You probably won't be one of the highest salaried physicians, but you'll be able to accomplish any reasonable financial goals that a person could set. Also, as mentioned above, it's rated as a very high satisfaction specialty. My aunt did FM and hated it for lots of bad reasons, imo -- she's very moralistic, and it interfered with her practice. Anyway, she did a geriatrics fellowship and now apparently loves her work.

 

[deleted87716]

There's different billing codes for different levels of exam though, right? I vaguely remember talking about this when I was on one of our community preceptor things. It was something like there's 1 code for a 15 minute repeat visit and another one for a longer initial H&P.

Coding for ambulatory visits is generally based on complexity and medical decision-making (my typical office visit is a 99214), but you can bill based on time if more than 50% of that time is spent counseling the patient. It's complicated, frankly. The issue most docs have isn't so much with coding requirements (which are onerous, but most of us have gotten used to them), but the actual reimbursement itself.

But incremental increases in complication do not force Medicare to reevaluate reimbursement

Well, they should. Reimbursement is based on "Relative Value Units" (RVUs), which (in theory) reflect the actual work involved as well as the cost of the service or procedure. As outpatient medicine becomes more complicated, RVUs and reimbursement should increase commensurately.

Having average patients that are on 5 medications instead of 2 (etc., etc.) takes more work but is much more easily ignored when reimbursement changes are done.

Sure, but that's the problem, isn't it? I think we're in agreement on that.

 

[Law2Doc]

You know, you keep on mentioning that there are people like that on preallo, but from what I've seen, most people, especially long term posters, do NOT see medicine that way.

In fact, there's a few quite vocal people who see the exact opposite: that medicine is in its last legs, ready to collapse and make us all slave-paupers for Big Brother Government.

For every post about a preallo kid who thinks he'll break his first million by 35, there's about a dozen post that says that doctors will be on the welfare line by the time they get to graduation. It's a sad state of affairs when Panda Bear ends up defending medicine.

This wave of pessimism is actually a relatively new trend on SDN - and probably a healthy one, driven by a handful of rampantly prolific SDN posters (mostly med students, and Panda). Better to be pleasantly surprised by reality than shocked by it. But if you do a search of terms like Bentley, mansion, millionaire etc, you are not going to find a shortage of unreaslistic premeds. I've not actually seen any welfare line type posts, but lots on SDN seem to have a lack of ability to see between extremes, so I don't doubt it.

 

[Critical Mass]

This wave of pessimism is actually a relatively new trend on SDN - and probably a healthy one, driven by a handful of rampantly prolific SDN posters (mostly med students, and Panda)

Guilty. I think that my perception is based on my own personal experience in the healthcare field as well as considerable dissatisfaction as a patient with respect to wait times, billing, health insurance premiums, etc. Of course it didn't help that the three docs that I got LOR's from berated my decision to go into medicine. Then I look at my school's match list from 2003 which had 22 people go into family medicine. This year, it's down to 11; and I am in a red state that really needs primary care docs.

With rising tuition, people are easily freaked out. Nobody wants to get raked over the coals for 7-10 years and not get recompense for it. Unfortunately for many of my colleagues, that recompense is in the form of money. I really don't care as long as I can cover my educational debt, but I don't want to do a specialty where malpractice handcuffs my ability to do certain procedures that were once commonplace for the specialty.

I've never been interested in geriatrics because senior citizens frighten me. I think that it will definitely be an important specialty in the future, but it's not for me.

 

[naegleria brain]

first, the people who respond to those surveys: i think the ones making it big are the ones too busy to care about such surverys. the max doesn't reflect the actual max

second, i don't know a single specialty where i can't find a doctor making seven figures

third, the vast majority of doctors are making six figures. i don't know any who make less.

the only difference is how much you're willing to work and where youre willing to go.

geriatrics, in my prediction, will see a slight increase provided we don't go universal due to the aging baby boomers, which you'll be taking care of out of residency. however, the higher paying specialties (usu procedure oriented) will do much better given that old people get sick.

salaries vary greatly. certain fields always do consistently well, but you can't predict the best field out there and try to get in. pretty much all fields of medicine will illustrate that you won't be on welfare, you won't be broke, you can have a bmw and a nice house, and you can have three to four kids and comfortably put them through college. you may not own your own jet, but you won't be pathologically scraping through newspapers for coupons either.

so unless your soul is centered around money due to paranoia of debt (then why are you going through med school?) or growing up poor (more understandable), might as well do something you really like.

as dr. cox said, he became a doctor for chicks, money, power, and chicks. what's your impetus? the most important thing you can do is figure that out, and go from there. the only poor doctors i know are from multiple divorces. so dont get divorced, or get a prenup, and youre good

 

[Law2Doc]

first, the people who respond to those surveys: i think the ones making it big are the ones too busy to care about such surverys. the max doesn't reflect the actual max

Actually, speaking as a prior career professional who used to get surveyed all the time, those of us who returned such salary surveys tended to only do so if we were proud of our income, thus the max was pretty close to right, but the average was always skewed high. I assume it works the same in medicine.

 

[Critical Mass]

Again, I have no expectation that today's salary level for doctors will remain where it is over the next decade.

 

[McDoctor]

Several things should be noted. #1) geriatricians (and geriatic psychiatrists) are the happiest physicians according to a recent study in the Annals. #2) geriatricians are trained to provide not one, but TWO of the very few services that have been proven to lower total lifetime health care costs: Advanced Directives and Hospice referrals. I think vaccines and smoking cessation might also be on the list, but providing those services has not been well compensated, so maybe the future is not so bright after all. #3) as our department chair says, "no one is doing geriatrics, and everyone needs geriatricians, so if you do [geriatrics], you can go anywhere, do anything, be anyone." #4) The hospital I'm at now runs a very lucrative geriatrics consult service; geriatrician hospitalists, at least, do well. #5) As Medicare is set up now, with 5 levels of out-patient acuity billing, geriatricians can typically at least bill a 3 if not a 4 or a 5 on every visit. In patient (out of 3 levels) they always bill a 3. Get used to writing longer notes. Where most internists see altered mental status and CHF, a geriatrician sees CHF, gait disturbance, depression, delirium, early dementia, incontinence, and malnutrition. And there's some money in the system for that type of thouroughness.

I disagree with number #3). FP's and internists are doing geriatrics all over the place. Most hospitals only want someone who is going to adhere to protocols and formulary preferences and ultimately get patients out of the hospital quickly and at a total cost less than the DRG reimbursement. Most hospitals don't want someone who is able to "think outside the box".

I think geriatrics can be very lucrative if you are working purely within extended care facilities, since essentially you have no overhead. (Though you would have to wrestle this market away from already established docs in your geographic area). And that extra year probably does add some to your income by increasing the complexity of your visits allowing you to bill more. But ultimately, I don't think that extra year is really worth it unless you want to get into academia in some capacity.

Extended care facilities are already hard wired to ensure advance directives and smoking cessation and any other cost saving concept you can think of is addressed. These places are essentially mills that take care of the elderly, but only within a rigid business model that ensures a profit. I get frustrated in these places as a family doc. I'm sure the frustration is exponentially worse for a specialty trained geriatric specialist who finds him/herself constrained by the limitations of the system.

I would say do a geriatrics fellowship because you enjoy it, are passionate about it, and want to teach students, interns, and residents in some capacity. Don't do it for this notion that just because there are alot of old people around, it must be financially lucrative or in high demand from hospitals. That just is not the case.

 

[McDoctor]

Sorry, I'm going to have to throw a flag on that play.

Today's ambulatory patients are incredibly more complex than those of thirty years ago. Back then, we didn't even have a fraction of the therapeutics, tests, or even knowledge of disease processes that we have today. As people live longer with chronic medical conditions, it's only getting more complicated.

In the same respect, medical information is so much more widely available to the general public than it was thirty years ago. It used to be that going to medical school gave you an exclusivity of access to medical information. Medical texts and journals were not widely available to the public. Nowadays, practically all the sources of information I use are available to pretty much anyone who is capable of comprehending the material. A highly motivated and well educated patient can probably figure out which blood pressure medication he should be started on based on JNC-7 guidelines, or which anti-lipidemic has the best outcome studies.

On the other hand, if you need your gallbladder out, then you still definitely need to see a surgeon. So I think the procedure oriented specialists will always have an edge in salary over cognitive specialties.

 

[NonTradMed]

The demand for doctors will always be there, more so for geriatrics. The question will be, will there be doctors to fill the demand? Health care cost is raising for a number of reasons and doctors are feeling the pinch. As a result, more docs are entering fields which are more lucrative and not seeing shortages. I anticipate that if more doctors are fleeing the primary care specialities, something will have to give. In my state, where ~30% of graduates did primary care last year, the state is giving anyone full tuition waiver if you plan on doing primary care in an underserved area for something like five years. Not a bad gig, but most students figure they can hedge their bets and get into something more lucrative (as shown by the matchlist). I think stuff like this will become more common as doctors find ways to avoid the high debt in return for lower paying gigs.

The problem is that med schools are filled with ambitious students, although we all pay lip service to serve the underserved, most are in it in part because they are ambitious and want to do something that will impress society. So yes, prestige and money is an unspoken reason to do medicine at my school. And primary care, especially with a predominately medicare population such as geriatrics will not see a huge boost in numbers, even though the demand will increase in the next 10 years.

 

[deleted87716]

A highly motivated and well educated patient can probably figure out which blood pressure medication he should be started on based on JNC-7 guidelines, or which anti-lipidemic has the best outcome studies.

I've yet to see either, and a lot of my patients are NASA engineers (actual rocket scientists.)

Information does not equal knowledge.

 

[naegleria brain]

Agreed. even though people can find out this sort of information, they still rely on their doctor. In a recent survey on where people get information regarding their drugs, number 1 is still their doctor. number 2 is internet, i believe, and number 3 is pharmacists.
sidenote: that's a slap in the face to pharmacists

 

[montessori2md]

Re: geriatrics >50%+ of hospitalized pts are geriatric pts. I would guess numbers are similar for office visits (peds excluded of course). So like 'em or not, I think you'll be seeing them.

Re: Patients knowing what meds to take.....okay, this reminds of a Really old post over in the EM forum about things learned from pts ----lots of stories about errr....streetwise and not so streetwise pts and their babies' mamas....also can tell you from my time volunteering that a lot of pts just want their doc to tell them what to do, as long as whatever the doc says doesn't involve any invasive procedure or limits to their diet : )

I'd like to see medicare billing accordingly for "cognitive" specialists communicating to the pts to explain to them what the other specialists want to do, and coordinating the 5 different opinions (from renal, cardio, ortho, etc) the poor pt is trying to sort out.

I also think there's some hope for FP and IM because of profits earned for their practices b/c of NP and PA staff. If you get 15% (or whatever) for "supervising" them, doesn't that help your bottom line?