Casting a wide net

[petomed]

What should I be looking for in residency programs if my goals after residency are:

1) maximal flexibility (walk away from a bad employer, locum work, telehealth, etc.)
2) maximal hourly rate
3) minimal required weekly work hours

Basically I'd like the option to work as little or as much as is needed. Only a 2nd year medical student here but I see the lay of the corporate medicine land that awaits me. Torn between FM and IM as I'm unsure which one will be best for moving between running down 50k in a year while chasing 300k+ the following year.

I know good salary jobs are out there. But I'm not going to hang my training hat on finding one.

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[VA Hopeful Dr]

Generally speaking it doesn't matter what residency you go to.

FM gives you more options after training for the most part.

 

[cabinbuilder]

IM is the stepping stone for specialist fellowships
FM gives you the flexibility to practice the way you want. You can make as much or as little as you want. Depends on your personal motivation.

 

[Lee Ik-jun MD]

I think the first question should be, what is it that you don't like , and then ask the questions you're asking.. when you do your clerkship, you will understand what I mean.

 

[petomed]

I appreciate all the replies.

Is anyone willing to elaborate on the 'make as much as you want' concept? To me, it's all about the hourly rate. If you pull $100/hr and work 2,000 hr/yr (~40 hrs/wk), you gross 200k. Double your hours, double your pay to 400k, but that would mean working on the order of 80 hr/wk. Not many FM's are going to voluntarily work sustained 80 hr weeks after residency (I know I won't), so this method of 'work as much as you want' is capped at around 80 hr/wk. Conversely, if you can pull $200/hr and work that same baseline 2,000 hr/yr, you're already pulling 400k and you've put in a low of ~40 hr/wk. Up the number of hr/wk to 80 again and now you're at 800k for the year...

So to me, it's really all about the hourly rate you can pull. Efficiency, incentives, bonuses, etc--that's all fluff and isn't guaranteed so I can't shoot from the hip about it.

Feel free to correct me on any of the above and mind you, the numbers I presented are only rough cuts to expound upon the difference between working lots of hours vs. working strategic hours.

It was also brought up to use clinical rotations to help answer the question regarding work-life balance. Absolutely will be doing that, however I can definitely cross off the surgeries (not up for the residency length / rigor) and most IM specialties (would feel pigeon-holed into 'doing the same 20-30 things all the time'). That assessment is certain to change as time goes on however that's where I'm at with what I know now.

As you can see, to me choosing the right direction depends most heavily on 1, 2, 3 from the original post.

I'm not chasing the money if that's what this thread seems to be trending toward. I actually gave up a prior career that would've netted me more money and work-life balance than medicine ever will. I'm just trying to understand how to be paid well for what I love spending my time doing until I'm too old and feeble to do it anymore.

Anyone willing to chime in on whether FM vs. IM is going to get me what I'm after?

 

[sloh]

Efficiency, incentives, bonuses, etc--that's all fluff and isn't guaranteed so I can't shoot from the hip about it.

Those aren’t all fluff and they separate the docs who make 500k+ and the rest within the same specialty.

 

[petomed]

Those aren’t all fluff and they separate the docs who make 500k+ and the rest within the same specialty.

Are you able to elaborate on what this looks like within FM?

 

[Make Or Break]

Locum Hospitalist can make you 200+/hr. Work as much or as little as you want in some areas. Partner with multiple locum firms and you will always have work. Look into Team Health Special Ops if you want 200+/hr and guaranteed number of shifts every month.

Also look into doing emergency, it’s not hard to find places paying 200+/hr and willing to hire FM.

 

[VA Hopeful Dr]

Are you able to elaborate on what this looks like within FM?

Prior to this year, year end quality bonuses accounted for approximately 10 to 15% of my total pay for the year.

This year's contract shifts that closer to about 25 to 30%. I have fewer RVUs this year compared to last year and I'm on track to make 10-15% more than last year because I focus heavily on meeting all of the quality measures.

 

[Sardonix]

Stop seeing this as an FM vs IM money problem and a what you wanna do to make money problem.

FM = only consider if you can see yourself doing OB and pediatrics, tends to focus more on clinic and outpatient procedures
IM = More chances to specialize (which is more work but more money), focus on adults, focus on hospital work

Both FM and IM can make great money in clinic. This all depends on how much you want to work (changes with family and other life priorities) and how efficient you are (easier said than done). So lets break things down into the three points you addressed:

1) maximal flexibility (walk away from a bad employer, locum work, telehealth, etc.)
2) maximal hourly rate
3) minimal required weekly work hours

1. Have you considered that having an clinic patient panel will make this difficult? You need to build the panel, curate it to your career goals, and take the time to grow it to grow your income. That can be hard to walk into/walk away from and crappy administrators know it. Locum work is absolutely the most flexible. To be a good locum you need to be confident in what you know and working in uncertain settings. In that regard, the would look for a residency where you learn the most and are exposed to best learning opportunities you believe will be relevant to your career goals... which should be your goal for any residency program anyway.

2. Stop seeing how hard you work as "hours spent" or "money per hour" and more along the lines of RVUs. RVU = number of patients seen and the rate that you bill them based on complexity, orders, procedures etc.

3. See number two. The more RVUs you work fast = efficiency = fewer hours worked for more money

 

[cabinbuilder]

I appreciate all the replies.

Is anyone willing to elaborate on the 'make as much as you want' concept? To me, it's all about the hourly rate. If you pull $100/hr and work 2,000 hr/yr (~40 hrs/wk), you gross 200k. Double your hours, double your pay to 400k, but that would mean working on the order of 80 hr/wk. Not many FM's are going to voluntarily work sustained 80 hr weeks after residency (I know I won't), so this method of 'work as much as you want' is capped at around 80 hr/wk. Conversely, if you can pull $200/hr and work that same baseline 2,000 hr/yr, you're already pulling 400k and you've put in a low of ~40 hr/wk. Up the number of hr/wk to 80 again and now you're at 800k for the year...

So to me, it's really all about the hourly rate you can pull. Efficiency, incentives, bonuses, etc--that's all fluff and isn't guaranteed so I can't shoot from the hip about it.

Feel free to correct me on any of the above and mind you, the numbers I presented are only rough cuts to expound upon the difference between working lots of hours vs. working strategic hours.

It was also brought up to use clinical rotations to help answer the question regarding work-life balance. Absolutely will be doing that, however I can definitely cross off the surgeries (not up for the residency length / rigor) and most IM specialties (would feel pigeon-holed into 'doing the same 20-30 things all the time'). That assessment is certain to change as time goes on however that's where I'm at with what I know now.

As you can see, to me choosing the right direction depends most heavily on 1, 2, 3 from the original post.

I'm not chasing the money if that's what this thread seems to be trending toward. I actually gave up a prior career that would've netted me more money and work-life balance than medicine ever will. I'm just trying to understand how to be paid well for what I love spending my time doing until I'm too old and feeble to do it anymore.

Anyone willing to chime in on whether FM vs. IM is going to get me what I'm after?

You are assuming that we are all just working an hourly rate. This is not the case. My contract is a salary base, + hourly for extra shifts + RVU bonuses + quality incentives + I get paid for NP's on my licenses. I get bonuses every quarter so to say that is no guaranteed may not be the case. So it's not just working my hours, it's having a smarter contract and seeing a lot of patients during the days that you do work so the number's and the $$ multiplies quickly.

 

[petomed]

Really helpful information everyone, I appreciate the replies! Learning a lot here.

Stop seeing this as an FM vs IM money problem and a what you wanna do to make money problem.

FM = only consider if you can see yourself doing OB and pediatrics, tends to focus more on clinic and outpatient procedures
IM = More chances to specialize (which is more work but more money), focus on adults, focus on hospital work

Both FM and IM can make great money in clinic. This all depends on how much you want to work (changes with family and other life priorities) and how efficient you are (easier said than done). So lets break things down into the three points you addressed:


1. Have you considered that having an clinic patient panel will make this difficult? You need to build the panel, curate it to your career goals, and take the time to grow it to grow your income. That can be hard to walk into/walk away from and crappy administrators know it. Locum work is absolutely the most flexible. To be a good locum you need to be confident in what you know and working in uncertain settings. In that regard, the would look for a residency where you learn the most and are exposed to best learning opportunities you believe will be relevant to your career goals... which should be your goal for any residency program anyway.

2. Stop seeing how hard you work as "hours spent" or "money per hour" and more along the lines of RVUs. RVU = number of patients seen and the rate that you bill them based on complexity, orders, procedures etc.

3. See number two. The more RVUs you work fast = efficiency = fewer hours worked for more money

Pretty cursory but I really only saw things from the available jobs point of view. Nearly every search I perform yields 30% more FM jobs than IM. To me, this translates to more flexibility. But as you said, IM opens substantially more fellowship doors. It's definitely not all about the money. I did that before medicine and well, here I am on career #2.

I'll keep with the 1, 2, 3 format:

1. I don't really have an interest in building a clinic panel, nor can I say I'm interested in the 'cradle to grave' concept of FM. What I like about FM is diversity in the patient panel. Definite yes to kids and OB because it'll keep my wheels turning to keep up with. Not a definite yes to following the kiddo from 0-90, relationship-wise. Just isn't my thing. To that end, I'm more interested in getting good/efficient so that I can travel and plug any hell hole as a locum. I know very little at this point but that might not mean practicing too much in an outpatient clinic setting because as you said, such a setting may be more about being there long-term and growing the practice. Definitely agree though, I want the residency that fosters the greatest growth of skills, as should anyone. This is especially true for my goals.

2. Yeah look, if RVUs are the currency, then lets make it easy and replace anywhere I have $ with RVU. The immediate question I have there is--do all employers reimburse an RVU at the same rate? RVUs sound like a nice intermediate that incorporates efficiency and I can certainly understand the incentive for both sides (doc vs. employer).

3. Again, I'm not interested in an indefinite contract that requires me to work X number of hours each week. I'd be much happier with several shorter contracts so that I can re-up on increasingly favorable terms as I learn more about good contracts.

You are assuming that we are all just working an hourly rate. This is not the case. My contract is a salary base, + hourly for extra shifts + RVU bonuses + quality incentives + I get paid for NP's on my licenses. I get bonuses every quarter so to say that is no guaranteed may not be the case. So it's not just working my hours, it's having a smarter contract and seeing a lot of patients during the days that you do work so the number's and the $$ multiplies quickly.

At the end of the day, everyone does work an hourly rate. Your contract makes that hourly rate highly variable. For me, that's alright provided it's a good contract, much the same as it likely is for you. However, the problem occurs when the contract doesn't favor the employee. This is the point of having the smarter contract you referenced. I'm trying to figure out how to set myself up for acquiring that smarter contract.

 

[Sardonix]

Really helpful information everyone, I appreciate the replies! Learning a lot here.


Pretty cursory but I really only saw things from the available jobs point of view. Nearly every search I perform yields 30% more FM jobs than IM. To me, this translates to more flexibility. But as you said, IM opens substantially more fellowship doors. It's definitely not all about the money. I did that before medicine and well, here I am on career #2.

I'll keep with the 1, 2, 3 format:

1. I don't really have an interest in building a clinic panel, nor can I say I'm interested in the 'cradle to grave' concept of FM. What I like about FM is diversity in the patient panel. Definite yes to kids and OB because it'll keep my wheels turning to keep up with. Not a definite yes to following the kiddo from 0-90, relationship-wise. Just isn't my thing. To that end, I'm more interested in getting good/efficient so that I can travel and plug any hell hole as a locum. I know very little at this point but that might not mean practicing too much in an outpatient clinic setting because as you said, such a setting may be more about being there long-term and growing the practice. Definitely agree though, I want the residency that fosters the greatest growth of skills, as should anyone. This is especially true for my goals.

2. Yeah look, if RVUs are the currency, then lets make it easy and replace anywhere I have $ with RVU. The immediate question I have there is--do all employers reimburse an RVU at the same rate? RVUs sound like a nice intermediate that incorporates efficiency and I can certainly understand the incentive for both sides (doc vs. employer).

3. Again, I'm not interested in an indefinite contract that requires me to work X number of hours each week. I'd be much happier with several shorter contracts so that I can re-up on increasingly favorable terms as I learn more about good contracts.

At the end of the day, everyone does work an hourly rate. Your contract makes that hourly rate highly variable. For me, that's alright provided it's a good contract, much the same as it likely is for you. However, the problem occurs when the contract doesn't favor the employee. This is the point of having the smarter contract you referenced. I'm trying to figure out how to set myself up for acquiring that smarter contract.

1. If you wanna see full spectrum care but don't want patient panel, why not do EM then? Pretty sure their locums get paid at a higher rate as well, though an FM doc could potentially make just as much depending on where you work and what you're doing.

2. To answer your question, no, sadly. Different companies compensate RVUs differently. There are various posts on this FM forum of different contracts and their related RVU compensation agreements. This is where complexity kicks in. Some contracts are salary. Some are productivity (aka "keep what you catch" aka the more RVUs you bring in, the more money you make). Many FM contracts start out with a guaranteed salary of ____ for x1-2 years before they switch to production. RVUs are really where number and efficiency minded physicians can EARN. For example, is it worth your time and money in a clinic to dedicate a day to doing vasectomies? What about IUDs? What about straight medical encounters billed at a 99214 rate. A faculty broke this down for us in residency and the answer is not what you would expect unless you know exactly what procedure pays what.

2a. Side note, but brief history of RVU is the reason primary care gets ****'d in modern medicine payment structures. I forget how many physicians are currently on the AMA's Comittee right now, but primary care is far in the minority. As a result the specialists practically break their hands patting each other on the back in agreement that the procedures and work they do needs to receive the majority of funding vs the lowly time wasted by a PCP coordinating their patient's care. It is likely why America's physicians are so reactive/procedure heavy compared to the rest of the world. It simply pays far more to do certain procedures and acute care than complex preventative/primary care.

3. Again-again, I don't know why you keep mentioning hours then.

4.

At the end of the day, everyone does work an hourly rate. Your contract makes that hourly rate highly variable. For me, that's alright provided it's a good contract, much the same as it likely is for you. However, the problem occurs when the contract doesn't favor the employee. This is the point of having the smarter contract you referenced. I'm trying to figure out how to set myself up for acquiring that smarter contract.

Not to respond for Cabinbuilder, but they are perhaps the end-all-be-all resource for LOCUMs work. Even though you are technically correct that, yes, after all the numbers and cake and ice cream, everyone is paid an hourly wage. But it is really not that simple and it's like comparing an RN's hourly wage to a CEO's... it likely won't be very comparable overall not that relevant when there are so many factors and compensation metrics involved.

This "Smarter" contract you are referencing does not really involve discussion of hours beyond how much time you are expected to be in the room physically interacting with patients. It involves location, patient population, RVU compensation, supporting staff, number and quality of colleagues, how good your training was and how much you are confident handling on your own, what procedures you are interested/competent in, benefits, retirement, productivity bonuses etc. If you are truly interested in just LOCUM work I think Cabinbuilder is probably your best resource here.

 

[petomed]

why not do EM then?

Honestly, I think you might be on to something here. I've only ever heard that EM is the meat grinder and the most recent match data certainly supports that idea. But it seems I'm trying to piece together a big EM roundabout. Might have to really look into this again.

Appreciate the rest of your post!

 

[sloh]

RVUs are really where number and efficiency minded physicians can EARN. For example, is it worth your time and money in a clinic to dedicate a day to doing vasectomies? What about IUDs? What about straight medical encounters billed at a 99214 rate. A faculty broke this down for us in residency and the answer is not what you would expect unless you know exactly what procedure pays what.

I feel like this is not emphasized enough to residents. Residents and attendings are also not inclined to want to think about these things and just want to clock in and clock out. But this is what often separates the top 10-20% income physicians from the others in the same specialty.

 

[Sardonix]

I feel like this is not emphasized enough to residents. Residents and attendings are also not inclined to want to think about these things and just want to clock in and clock out. But this is what often separates the top 10-20% income physicians from the others in the same specialty.

This is where residency clinic and private practice don't match up and having a young, effiency/billing driven attending in touch with reality of practice and patient care is invaluable.

 

[cabinbuilder]

Not to respond for Cabinbuilder, but they are perhaps the end-all-be-all resource for LOCUMs work. Even though you are technically correct that, yes, after all the numbers and cake and ice cream, everyone is paid an hourly wage. But it is really not that simple and it's like comparing an RN's hourly wage to a CEO's... it likely won't be very comparable overall not that relevant when there are so many factors and compensation metrics involved.

This "Smarter" contract you are referencing does not really involve discussion of hours beyond how much time you are expected to be in the room physically interacting with patients. It involves location, patient population, RVU compensation, supporting staff, number and quality of colleagues, how good your training was and how much you are confident handling on your own, what procedures you are interested/competent in, benefits, retirement, productivity bonuses etc. If you are truly interested in just LOCUM work I think Cabinbuilder is probably your best resource here.

Been out of the locums scene for about 8 yrs now but I still have a lot of connections. I don't think petomed was really getting my point on the contract differences. When I worked strictly locums at a true hourly rate, I pulled in about 180K a year. I now actually work less days a month but still see a ton of patients and have a salary + hourly + RVU contract and make 550-600K /yr plus now have retirement which is a huge difference than just working hourly.