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I'm having a really difficult time deciding whether I want to pursue ophtho or psychiatry. I find both really interesting and could use some help. A friend pointed out to me, and it is also what I've seen on this forum, that ophtho attendings early in their careers make ~200-250, which seems to be in the range of psych (241k according to the most recent MG MA). Lifestyle and compensation is something I'm considering to differentiate, and it seems surprisingly (to me at least) that psych is compensated in the similar range with a more relaxed lifestyle.
 

docdoc2012

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One is a surgical field requiring technical skills, the other you will never have to use your hands. They are completely different fields. Do you want to operate? Do you want to do microsurgical procedures?
 
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Iladelphia

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Yah not your typical “Ophtho vs ENT”
Question. I’ll echo what the first responder said - completely different fields. If you don’t picture yourself enjoying at least one day/week of surgery - go with psych
 
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I've read in other forums where psych can reach up to 400k in pay. For ophth, except in large over saturated locations, that's probably closer to the average (not counting academics). Also, the skies the limit with ophth. Literally you can have opportunities to make $200k or a seven figure income
 

Fascia Lata

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Just because the two fields are very different does not mean you cannot like or enjoy both. Tough question. The typical pros/cons answers to these types of questions may not be very helpful here. I second what Iladelphia wrote above. If the surgery part is not something you must do to feel good about yourself (yes, some people enjoy slicing up certain organs in living humans), then go with psych.
 
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linevasel

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I'm having a really difficult time deciding whether I want to pursue ophtho or psychiatry. I find both really interesting and could use some help. A friend pointed out to me, and it is also what I've seen on this forum, that ophtho attendings early in their careers make ~200-250, which seems to be in the range of psych (241k according to the most recent MG MA). Lifestyle and compensation is something I'm considering to differentiate, and it seems surprisingly (to me at least) that psych is compensated in the similar range with a more relaxed lifestyle.
Houston,

What year are you in med school?

I liked Psych a lot. I even thought about Psych+IM. The neurobiology of pscyh disorders can be fascinating to no end. Having said that, there are some people who are really passionate about the process of discover and the underlying science of their fields. Others really take to the "care" aspect (procedures/surgeries/etc) of their field. Some appreciate the flexibility. As interesting as retina is to me, there were probably other organ systems that I found more intriguing from a scientific discovery standpoint (please no hating from the visual science researchers.... I know we have yet to fully appreciate the mysteries of vision). The advice I kept receiving from trainees /staff further along in medicine was to carefully examine the personality, lifestyles, interests and day-to-day tasks of the attendings in the fields of my interest. As interesting as it was learning about the inhibitory roles of parvalbumin neurons in the hippocampus as a ms3, it was clear to me that my psych attendings on the wards did not spend much time thinking about the neural pathways for the diseases they treated. The same way, you can be a good retina specialist and save sight without spending much time thinking about the retinogeniculate pathway or the intricacies of the blood-retinal barrier.

But I was fortunate to train at a place with multiple retina-uveitis specialist who loved to think about visually threatening diseases and their systemic presentations. They also knew how to turn it off and become master technicians working with unflappable confidence to repair the most delicate of tissues. Its a gross oversimplification, but this duality appealed to me. In short, do you really want the challenges (and rewards) of psych practice as an attending. the intellectual life of a Psych attending is likely very different than the intellectual life of an ms3 rotating through a psych ward. Ask your attendings if they can share the most frustrating parts of their days with you. You want to hear the mundane and the profane. Then ask yourself if thats what you want for your adult professional life. Then ask someone in ophtho. I dare say you'll find those answers to be worlds apart.

Lastly money. I applaud Ophtho as a field. We have done a really good job letting the world think we make 200-400 for the better part of our working lives. I have no idea what psychiatrists make coming out. $240 sounds reasonable. Ask yourself what your psych attendings are making 4 and 10 years out in inpatient and outpatient settings. No one from ophtho should be making 200k four years out. That is just atrocious. In fact I am getting anxiety just thinking about those low numbers. So long as you are flexible in where you live (this requires a modicum of flexibility, its not like you have to move to alaska...) I would say 350 is the lowest, and i mean lowest you should be making 4 years out for the field as a whole. If your retina, you should at least be pulling 450K, 4 years out.

So In summary. The giddy butterfly experience of ms3 rotations is a starting point for most people. But You do really want to get a sense of what its like as an attending.
 

dantt

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If the surgery part is not something you must do to feel good about yourself (yes, some people enjoy slicing up certain organs in living humans), then go with psych.
Many surgeons very much enjoy slicing and dicing. Ophthalmologists are notorious for wanting to slice up very specific organs (corneas, lenses, vitreous, etc). If you like both, consider ophthalmology. Plenty of psych in ophthalmology. As noted above, if you dont like slicing, best not to do a surgical specialty.
 

ophthodude1001

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apples and oranges. Psych is an interesting field and I believe that there is a lot of potential for research and improvement in the next 40-50 years. Typically it was one of the least competitive specialties, but now there's been a huge surge in competition. It is now moderately competitive (maybe because the mental health of America is declining?? ... social media etc... this is for another conversation).

Ophtho is completely different. Almost everything is based on evidence that you see on your examination. This is one of the HUGE reasons why I chose ophtho. It is very objective, vs. psychiatry is very subjective. This has been discussed in multiple threads before, but the starting salaries for ophtho are notoriously misleading. Echoing @RetinaDude that sky is the limit with ophtho salaries.
 
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Hi everyone! Thanks for taking the time to respond.

I'll start off by saying that I actually disliked ENT, and even other surgical specialties for that matter. Ophtho is really the only type of surgery I found rewarding and enjoy microsurgery, especially how the surgeries were relatively shorter than those of other surgical fields. I find the field more interesting than psych, but I guess one of the main concerns I was having about ophtho was the future of the field and lifestyle aspects. Does one have to be associated with a private practice to have flexibility, ie hours worked/etc? Or Is this available in a hospital or academic setting?
 

docdoc2012

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The field has a strong future. The boomer generation is just now starting to hit the cataract market. Outside of major metros ophthos are always in demand.
Ophtho has multiple types of setups. The most jarring thing about ophtho is thst there is a huge discrepancy between employed/academic jobs and private jobs in terms of salary
- private practice owner track: more investment, more responsibility, but more control and financial rewards, i would say low end of avg 450k as an owner with a decent lifestyle and not super high volume,
- academics: intellectual stimulation, access to complex cases and latest tech, research, being in the know, but also huge overheads, admin blockades for things. Salary is based on how community based your job is...can be anywhere from 200k - 450k and above depending on where you practice, rank etc.
- PE employed: basically you are paid by volume. Pay is better than academics, but not as good as a well run private. You have no control, are told how to practice but no admin hassles, usually huge noncompetes.
- kaiser/VA type jobs: controlled hours, controlled volume, lower pay. I believe kaiser physicians reach around 350k-400k midcareer. VA attendings are at about 250 -350k, but can retire after 20 years or service (correct me on the number if wrong) govt benefits.
- hospital employed: similar to VA or kaiser. Pay varies based on how much they need you or how rural. Can be anywhere from 250k-500k avg with bonuses based on specialties.

The above numbers are avgs. Obviously there are a lot of people making a lot more. Regardless of the situation you wont need to get some crazy unique job to make atleast as much or very often a lot more than psyche with a good lifestyle
 
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ace_inhibitor111

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The field has a strong future. The boomer generation is just now starting to hit the cataract market. Outside of major metros ophthos are always in demand.
Ophtho has multiple types of setups. The most jarring thing about ophtho is thst there is a huge discrepancy between employed/academic jobs and private jobs in terms of salary
- private practice owner track: more investment, more responsibility, but more control and financial rewards, i would say low end of avg 450k as an owner with a decent lifestyle and not super high volume,
- academics: intellectual stimulation, access to complex cases and latest tech, research, being in the know, but also huge overheads, admin blockades for things. Salary is based on how community based your job is...can be anywhere from 200k - 450k and above depending on where you practice, rank etc.
- PE employed: basically you are paid by volume. Pay is better than academics, but not as good as a well run private. You have no control, are told how to practice but no admin hassles, usually huge noncompetes.
- kaiser/VA type jobs: controlled hours, controlled volume, lower pay. I believe kaiser physicians reach around 350k-400k midcareer. VA attendings are at about 250 -350k, but can retire after 20 years or service (correct me on the number if wrong) govt benefits.
- hospital employed: similar to VA or kaiser. Pay varies based on how much they need you or how rural. Can be anywhere from 250k-500k avg with bonuses based on specialties.

The above numbers are avgs. Obviously there are a lot of people making a lot more. Regardless of the situation you wont need to get some crazy unique job to make atleast as much or very often a lot more than psyche with a good lifestyle
From what I understand there is a buy-in involved for the very high salaries. So to become partner in a private practice you might make 250k over your first three years, followed by a 400k buy-in to become partner over 5 years in exchange for a 450k salary. What it amounts to is an “actual” salary of ~250-300k for the first 8 years of working. The crazy high salaries like 800k income might require a 1,000,000 buy-in etc. More details are here:

 

liquidshadow22

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Psych here. I agree with everyone above, this decision should primarily be based on your desire to cut.

Psychiatry is not a bad field. The patients are definitely interesting and IMO we have one of the least stressful jobs in medicine. Lowest liability in terms of malpractice. Employed jobs can get you 300k without any call. Big money in psych is private practice cash, where if you're good, you can earn $500 an hour or more. 30 hrs per week *$500 = 15k per week =720k per year with little overhead. This would certainly take a few years to build up, but the demand is there.

Anything nonsurgical gets very tedious IMO because you simply spend most of your day documenting, writing scripts etc. It gets old after a while. I don't hate it, but it's not like I'm itching to see every patient in an outpatient clinic.

Procedures are nice because they keep you in the moment and there is a sense of accomplishment that comes with it. Personally, I would do ophtho if I had the choice today. Surgery is a skill that takes a long time to master and perfect; there's always things to improve on and you provide a tangible benefit to mankind. Results in psychiatry are seen but it's usually very slow and improvements ebb and flow. Also NPs are a threat in psych, where as that will never be an issue for a ophtho.

Go with ophtho, if you don't like it after pgy2 just find a psych program to switch into as a pgy 2. There are many openings
 
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dantt

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From what I understand there is a buy-in involved for the very high salaries. So to become partner in a private practice you might make 250k over your first three years, followed by a 400k buy-in to become partner over 5 years in exchange for a 450k salary. What it amounts to is an “actual” salary of ~250-300k for the first 8 years of working. The crazy high salaries like 800k income might require a 1,000,000 buy-in etc. More details are here:

The numbers don't make sense to me. Why would one pay 400k to make 450k salary when one could make close to 400k employed without much difficulty. By that calculation itll take about 10 years to make back your money.
 

hello lady!

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From what I understand there is a buy-in involved for the very high salaries. So to become partner in a private practice you might make 250k over your first three years, followed by a 400k buy-in to become partner over 5 years in exchange for a 450k salary. What it amounts to is an “actual” salary of ~250-300k for the first 8 years of working. The crazy high salaries like 800k income might require a 1,000,000 buy-in etc. More details are here:

The numbers don't make sense to me. Why would one pay 400k to make 450k salary when one could make close to 400k employed without much difficulty. By that calculation itll take about 10 years to make back your money.

It's not that you're blindly paying $400k like its a country-club membership fee. You're buying real assets (like real estate, ASC, portion of the business). After 10 years you will have an extra $400k (not even taking into account the asset's appreciation) in wealth that you've accumulated. It's analogous to renting vs buying your home - at the end of 30 years you'll own your home and you can do whatever you want with it. When you retire you'll sell the assets back at a much higher value.

The other thing is that when you own your business you want your take home salary to be as low as possible. You run everything you can (legally) through the company to avoid paying taxes. So that $450,000 partner salary doesn't mention all of the written off items that count as "overhead" (like your car and gas etc).
 
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dantt

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It's not that you're blindly paying $400k like its a country-club membership fee. You're buying real assets (like real estate, ASC, portion of the business). After 10 years you will have an extra $400k (not even taking into account the asset's appreciation) in wealth that you've accumulated. It's analogous to renting vs buying your home - at the end of 30 years you'll own your home and you can do whatever you want with it. When you retire you'll sell the assets back at a much higher value.

The other thing is that when you own your business you want your take home salary to be as low as possible. You run everything you can (legally) through the company to avoid paying taxes. So that $450,000 partner salary doesn't mention all of the written off items that count as "overhead" (like your car and gas etc).
Not to poo poo practice ownership but again, the numbers don't make sense to me. The first question is why is a practice worth $400k only throwing off essentially $50k in profit annually? That means you're buying your portion of the practice 8X EBITDA which is extremely high, PE type of valuation. Where is all the money going? If there is no more excess money, why not? You can't just write off your car for your practice. There are very specific rules regulating this. Practices are also not necessarily appreciating assets.
 

hello lady!

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Not to poo poo practice ownership but again, the numbers don't make sense to me. The first question is why is a practice worth $400k only throwing off essentially $50k in profit annually? That means you're buying your portion of the practice 8X EBITDA which is extremely high, PE type of valuation. Where is all the money going? If there is no more excess money, why not? You can't just write off your car for your practice. There are very specific rules regulating this. Practices are also not necessarily appreciating assets.
I think you're overly simplifying the calculations.

First, if you're an associate making $400k, you're probably pulling in at least $1.2 million. Probably closer to $1.5 realistically.

In the practice valuation, there are usually three major pieces (and there's obviously some variance between practices).

1. Real estate - this will be a huge chunk of your buy in. The price here usually is determined by appraisals, comps, etc - just like buying a home.

2. The medical/ASC/Optical/etc - this is more of a fuzzy number. Some practices choose to do an EBITA multiple (usually between 2 to 4) and maybe the value of the equipment minus depreciation and debts. Typically # active charts don't have a value when it comes to buy in. Everything is negotiable though.

3. Goodwill - this is a "thank you" money to be added on top of the top two. Many practices don't charge this, some may ask for $100,000 premium or may put it in as a percentage. The hope is that you'd recover this from the next person who buys into the practice but it's kind of Ponzi scheme-ish - unless you're buying in the middle of LA I wouldn't go somewhere that requires this.

If your buy in is only the first two, then any money that you "lose" towards it actually are building your wealth. An associate who is pulling a take home pay of $400k is really going to be generating enough money for a $650-750k paycheck as a partner. Yes, a chunk of this will be so you can pay your bills, like a $5,000 per month practice loan note, but when the buyout is complete you now own a piece of commercial medical real estate and a portion of the medical practice - these are assets which you're writing off as worthless.

When it's time to pay yourself as a partner you want as little going through payroll taxes. You have to pay state/federal income tax, social security tax, Medicare tax, etc. So you'll run your car through the company, your cell phone bills, work trips, hotel stays, meals, computers, all sorts of things to pay with pre-tax dollars. You'll be maxing out every tax-advantaged account you can find. Your accountant will help you.

If you can't find the value in the ownership piece then just be employed. Nothing wrong with that, it's just financially such a huge advantage to be a business owner.
 
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I'm with you on the Goodwill part in that I'd walk away from any offer that expected me to pay it. My current practice did not ask me to pay Goodwill. When we eventually look for another partner, I'd feel like a schmuck asking the new guy/gal to pay me goodwill. It's BS in today's world
 

dantt

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I think you're overly simplifying the calculations.

First, if you're an associate making $400k, you're probably pulling in at least $1.2 million. Probably closer to $1.5 realistically.

In the practice valuation, there are usually three major pieces (and there's obviously some variance between practices).

1. Real estate - this will be a huge chunk of your buy in. The price here usually is determined by appraisals, comps, etc - just like buying a home.

2. The medical/ASC/Optical/etc - this is more of a fuzzy number. Some practices choose to do an EBITA multiple (usually between 2 to 4) and maybe the value of the equipment minus depreciation and debts. Typically # active charts don't have a value when it comes to buy in. Everything is negotiable though.

3. Goodwill - this is a "thank you" money to be added on top of the top two. Many practices don't charge this, some may ask for $100,000 premium or may put it in as a percentage. The hope is that you'd recover this from the next person who buys into the practice but it's kind of Ponzi scheme-ish - unless you're buying in the middle of LA I wouldn't go somewhere that requires this.

If your buy in is only the first two, then any money that you "lose" towards it actually are building your wealth. An associate who is pulling a take home pay of $400k is really going to be generating enough money for a $650-750k paycheck as a partner. Yes, a chunk of this will be so you can pay your bills, like a $5,000 per month practice loan note, but when the buyout is complete you now own a piece of commercial medical real estate and a portion of the medical practice - these are assets which you're writing off as worthless.

When it's time to pay yourself as a partner you want as little going through payroll taxes. You have to pay state/federal income tax, social security tax, Medicare tax, etc. So you'll run your car through the company, your cell phone bills, work trips, hotel stays, meals, computers, all sorts of things to pay with pre-tax dollars. You'll be maxing out every tax-advantaged account you can find. Your accountant will help you.

If you can't find the value in the ownership piece then just be employed. Nothing wrong with that, it's just financially such a huge advantage to be a business owner.
So are many people actually paying $400k buy in to end up with a take home of $450k? Many young docs don't know this but most buy ins are structured such that the real estate, ASC, optical, are an additional buy-in on top of the medical practice if it is even offered. The basic buy in very often does not include any hard assets. Not such a good deal anymore, is it?
 

MstaKing10

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Only reason to buy in is if there will be a huge increase in salary. Goodwill, real estate etc don’t mean a whole let when you decided to retire. Very few practices that I know of will buy out the retiring partner for a huge amount. In fact, this is part of what is driving older docs to pursue PE buyouts. Obviously being partner carries other perks in terms of decision making and so on, but the most critical competent is income
 

percyeye

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Only reason to buy in is if there will be a huge increase in salary. Goodwill, real estate etc don’t mean a whole let when you decided to retire. Very few practices that I know of will buy out the retiring partner for a huge amount. In fact, this is part of what is driving older docs to pursue PE buyouts. Obviously being partner carries other perks in terms of decision making and so on, but the most critical competent is income
Way more reasons to be an owner than just salary. Ownership in real estate is a huge deal over the long term in terms of tax advantages, equity, and income. The autonomy and decision making alone is worth being the owner vs associate. Someone being an owner vs associate in a good practice is 10x more valuable in a decent practice. I have no idea why they don't teach this anymore but I'd refuse to work anywhere without ownership possibility. Medicine in general is losing control over the entire profession because they are giving up control to hospitals and investment bankers (PE).
 

docdoc2012

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Just being able to go from a w-2 to a 1099 as an owner seems extremely worth it. However my understanding is that many larger practices now pay out clinical earnings as w-2
 
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One person I spoke to said That In being a partner/becoming owner, you’re looking for the long term potential of practice. He made it sound like the long term goal is to sell the practice (to another buyer or PE) which I know can’t be the case for most right?

I definitely would love to learn more about the business side of owning.
 

dantt

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Just being able to go from a w-2 to a 1099 as an owner seems extremely worth it. However my understanding is that many larger practices now pay out clinical earnings as w-2
I have heard of this as well. What is the rationale of structuring the practice in this way such that the previously passive income investments such as real estate and asc that were paid as dividend are now paid out as w2 income at the highest marginal tax bracket? Not only do you pay at the highest tax bracket, you lose the ability to max out your 401k to the 54k combined contribution and have to pay fica taxes on the full amount.
 

MstaKing10

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Way more reasons to be an owner than just salary. Ownership in real estate is a huge deal over the long term in terms of tax advantages, equity, and income. The autonomy and decision making alone is worth being the owner vs associate. Someone being an owner vs associate in a good practice is 10x more valuable in a decent practice. I have no idea why they don't teach this anymore but I'd refuse to work anywhere without ownership possibility. Medicine in general is losing control over the entire profession because they are giving up control to hospitals and investment bankers (PE).
All great but if I’m not going to get paid extra to take on the risk as owner keep me as employee. Rather take the extra money and invest in some other asset. Btw I’m partner and receive K1 income etc so well aware of the advantages. But if my income won’t reflect that increased risk and responsibility it’s not worth it to me
 
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