Earning potential in IM lifestyle specialities

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How likely can one break north of 400k in the following 3 subspecialties of IM: endocrine, rheumatology, allergy/immunology, sports medicine?
That's given an employed position or private practice with no partnership opportunities. Location: West coast preferably.
Hours worked: 4-4.5 days a week, 8 hour days.

I like being in the clinic more than being in the hospital.
Don't mind being a PCP either, it's satisfying work, but very hard work having to deal with charting and inbox and every single little problem in the patient all the time.
I was set on doing heme/onc for the earning potential and clinic life but I realized even tho they get paid more, they actually work hard for that money.
So while money is not everything, coming from a poor background, I know not having enough money is everything. I am looking for an IM subspecialty that has good earning potential and has a good life where you are not too stressed/ overworked for the amount of money you make.
No hate please..I'm just too stressed and tired from residency and the rat race of matching at a competitive fellowship at this point... I want a normal life after I graduate and make enough to live comfortably and help my parents and brother out financially.

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a senior in endo made 430k last year seeing 20-24pts /day x4.5 days in rural east area
 
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How likely can one break north of 400k in the following 3 subspecialties of IM: endocrine, rheumatology, allergy/immunology, sports medicine?
That's given an employed position or private practice with no partnership opportunities. Location: West coast preferably.
Hours worked: 4-4.5 days a week, 8 hour days.

I like being in the clinic more than being in the hospital.
Don't mind being a PCP either, it's satisfying work, but very hard work having to deal with charting and inbox and every single little problem in the patient all the time.
I was set on doing heme/onc for the earning potential and clinic life but I realized even tho they get paid more, they actually work hard for that money.
So while money is not everything, coming from a poor background, I know not having enough money is everything. I am looking for an IM subspecialty that has good earning potential and has a good life where you are not too stressed/ overworked for the amount of money you make.
No hate please..I'm just too stressed and tired from residency and the rat race of matching at a competitive fellowship at this point... I want a normal life after I graduate and make enough to live comfortably and help my parents and brother out financially.
Everyone works hard for that money.

You can easily break 400k in rheumatology, though I cannot speak for the West Coast since I'm in the Midwest. I've posted numerous times in the past regarding rheumatology in desirable areas, and how you're essentially better off as a PCP in those places.
I would only consider rheumatology if you're ok living in a non-desirable location, or don't mind seeing garbage referrals. With that said, I don't know that seeing garbage referrals as an employed doc is necessarily as safe as it once was. I've seen hospitals that canceled the contracts of their whole rheumatology department due to the fact that a clinic full of +ANA, joint pain, fatigue is not profitable. A lot of those patients are on Medicaid, and there's not a whole lot of ancillary revenue that can be generated a la additional lab testing, imaging or infusions.

Endocrine has insanely high demand due to the severe shortage in most areas - even in alot of "desirable" locations. Getting patients is not a problem, and if you're on RVU model, you can do high volume and make bank. In my quadrant of the state, there are only a handful of endos, and the wait is like 6-9 months. Compare that to the local pain doc or ortho, where you can get in within 1-2 weeks (maybe less). I've literally placed referrals to orthopedics before, and the patient already had an appointment before they even left my office.
 
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you will have to see high volume in endocrine to break $400k...and live in fairly undesirable places...big cities like Boston, NYC, DC, ATL, are going to pay less, even on a productivity model.

IM subspecialty wise, you will need to go more procedural based to make that amount with less work.
 
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How likely can one break north of 400k in the following 3 subspecialties of IM: endocrine, rheumatology, allergy/immunology, sports medicine?
That's given an employed position or private practice with no partnership opportunities. Location: West coast preferably.
Hours worked: 4-4.5 days a week, 8 hour days.

I like being in the clinic more than being in the hospital.
Don't mind being a PCP either, it's satisfying work, but very hard work having to deal with charting and inbox and every single little problem in the patient all the time.
I was set on doing heme/onc for the earning potential and clinic life but I realized even tho they get paid more, they actually work hard for that money.
So while money is not everything, coming from a poor background, I know not having enough money is everything. I am looking for an IM subspecialty that has good earning potential and has a good life where you are not too stressed/ overworked for the amount of money you make.
No hate please..I'm just too stressed and tired from residency and the rat race of matching at a competitive fellowship at this point... I want a normal life after I graduate and make enough to live comfortably and help my parents and brother out financially.
Spouse is allergist 32 clinical hours a week. She recently chose a 3 day a week schedule. No thursday or fridays, weekends, hospital consults, calls, overnights, holidays.

She clearing 400K this year, when including her productivity bonus
Hospital system employed. Midwest
 
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Spouse is allergist 32 clinical hours a week. She recently chose a 3 day a week schedule. No thursday or fridays, weekends, hospital consults, calls, overnights, holidays.

She clearing 400K this year, when including her productivity bonus
Hospital system employed. Midwest
Is that 11 hours a day? 400k for 32 hours is pretty good
 
Spouse is allergist 32 clinical hours a week. She recently chose a 3 day a week schedule. No thursday or fridays, weekends, hospital consults, calls, overnights, holidays.

She clearing 400K this year, when including her productivity bonus
Hospital system employed. Midwest
That's such a sweet deal. Is it fairly common to get job offers like that in allergy?
 
That's such a sweet deal. Is it fairly common to get job offers like that in allergy?
For hospital system employment this is not common. For productivity bonus her $/wrvu is way way higher than surrounding areas (like 40% more) but i will not be surprised if they lower it in the future to favor a greater base salary in attempt to save on compensation costs
 
How easy/amenable is endocrine to doing super high volume (25-30+pts a day)? Can the visits be short and efficient? I imagine rheum is not as able because of the thorough history and physical exam required to do quality work.

I ask because it seems like volume is really the key. From a strictly lifestyle/compensation POV, a fellowship over being PCP would only be worthwhile if it makes achieving high volume easier with less headaches and BS than primary care. Most IM fellowships just seem like more work for the increased pay and prestige. Do you think Endo is worthwhile from this standpoint?
I was wondering the same. Endo prly would be easier than rheumatology to bust out a lot of volume since a lot of it is lab and number driven. Rheumatology you need a hood extensive history and physical. Appreciate any input @rokshana
 
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How easy/amenable is endocrine to doing super high volume (25-30+pts a day)? Can the visits be short and efficient? I imagine rheum is not as able because of the thorough history and physical exam required to do quality work.

I ask because it seems like volume is really the key. From a strictly lifestyle/compensation POV, a fellowship over being PCP would only be worthwhile if it makes achieving high volume easier with less headaches and BS than primary care. Most IM fellowships just seem like more work for the increased pay and prestige. Do you think Endo is worthwhile from this standpoint?
Also I wonder how much chart review you have to do in rheumatology for new patients. And if it's kind of on autopilot once you figure one patient out and their ideal treatment. Appreciate any input @bronx43
 
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How easy/amenable is endocrine to doing super high volume (25-30+pts a day)? Can the visits be short and efficient? I imagine rheum is not as able because of the thorough history and physical exam required to do quality work.

I ask because it seems like volume is really the key. From a strictly lifestyle/compensation POV, a fellowship over being PCP would only be worthwhile if it makes achieving high volume easier with less headaches and BS than primary care. Most IM fellowships just seem like more work for the increased pay and prestige. Do you think Endo is worthwhile from this standpoint?
Then also it makes me wonder why rheumatology on average makes more than endocrinology. Is it most endocrinology decide work in academia and/or part time?
 
How easy/amenable is endocrine to doing super high volume (25-30+pts a day)? Can the visits be short and efficient? I imagine rheum is not as able because of the thorough history and physical exam required to do quality work.

I ask because it seems like volume is really the key. From a strictly lifestyle/compensation POV, a fellowship over being PCP would only be worthwhile if it makes achieving high volume easier with less headaches and BS than primary care. Most IM fellowships just seem like more work for the increased pay and prestige. Do you think Endo is worthwhile from this standpoint?
You can easily tailor your rheum clinic to be mostly MSK, which requires essentially no chart review and only a focused H&P. Even if you see more complex cases, you'll fill up within 2-3 years, and you will know everything about those patients without even looking at your EMR. A lot of those visits are just a "check up" and take very little time/effort.
In the big cities, however, you'll have tons of psychosomatic patients that takes a long time, all of which is spent listening to incessant complaining. Sitting through one of those visits is like getting your molars pulled without anesthesia.

You can definitely do a high volume endo practice, but the trick is to get a lot of DM and not a lot of needy thyroid patients that suck up all your time.
 
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I was wondering the same. Endo prly would be easier than rheumatology to bust out a lot of volume since a lot of it is lab and number driven. Rheumatology you need a hood extensive history and physical. Appreciate any input @rokshana
Endocrine is very time consuming and the standard is 40/20…and many, me included do a 60/30.
And generally I have found that patients are referred to endocrine with little in the way of work up done so I spend a significant amount of time trying to figure out why the pt is being referred in the first place and spend more time discussing with the pt why they dont actually have an endocrine problem.
Diabetes pts take a lot of education and re education…the straightforward diabetes pt can be managed by their pcp so the ones that end up seeing endocrine are either complex or difficult to manage.
 
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You can easily tailor your rheum clinic to be mostly MSK, which requires essentially no chart review and only a focused H&P. Even if you see more complex cases, you'll fill up within 2-3 years, and you will know everything about those patients without even looking at your EMR. A lot of those visits are just a "check up" and take very little time/effort.
In the big cities, however, you'll have tons of psychosomatic patients that takes a long time, all of which is spent listening to incessant complaining. Sitting through one of those visits is like getting your molars pulled without anesthesia.

You can definitely do a high volume endo practice, but the trick is to get a lot of DM and not a lot of needy thyroid patients that suck up all your time.
You have a misunderstanding of the pt that sucks up the most time… diabetes pts are by far the greatest time suck… give me a graves Pt any day over the diabetes pt… the graves pt is easy to explain and treat and they take their medication consistently… otherwise that thyroid is coming out ( or ablated) … and then even easier to treat.
It’s the “it must be my thyroid” pt , that doesn’t actually have a thyroid issue that is the pain… but they are only a pain for one visit…because they go back to their pcp.
 
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How easy/amenable is endocrine to doing super high volume (25-30+pts a day)? Can the visits be short and efficient? I imagine rheum is not as able because of the thorough history and physical exam required to do quality work.

I ask because it seems like volume is really the key. From a strictly lifestyle/compensation POV, a fellowship over being PCP would only be worthwhile if it makes achieving high volume easier with less headaches and BS than primary care. Most IM fellowships just seem like more work for the increased pay and prestige. Do you think Endo is worthwhile from this standpoint?
So super high volume would be 30-45 pts a day… some do that … though whether appropriate care is given is debatable.
25-30 pts would be a high volume and some do that… but the typical endocrine prolly sees 18-22 pt a day.
 
You have a misunderstanding of the pt that sucks up the most time… diabetes pts are by far the greatest time suck… give me a graves Pt any day over the diabetes pt… the graves pt is easy to explain and treat and they take their medication consistently… otherwise that thyroid is coming out ( or ablated) … and then even easier to treat.
It’s the “it must be my thyroid” pt , that doesn’t actually have a thyroid issue that is the pain… but they are only a pain for one visit…because they go back to their pcp.
one patient had a "full workup" by other physicians. I was seeing the patient for asthma. the patient kept asking me about chest pain. cardiac workup negative. I do a full "chest workup" (besides just the pulmonary items also the "chest" workup such as looking for thoracic radiculopathy, reviewing history about shingles, doing a neuropathy labwork up, etc... all negative.

I try to reassure patient

one of the patient's labs is a high Anti TPO Ab but euthymic otherwise.

this patient downloaded some pubmed articles about how Anti TPO Ab can cause chronic whole body pain.
there seem to be some low quality evidence behind all of that on a quick search...

she went to three surgeons to ask for a thyroidectomy. naturally, she was turned down by all (appropriately so)
she went to three endos who turned her away (appropriately so)

i just made my money (appropriately so for her chest pain and dyspnea complaints) and provide some side reassurance.

i let her email me (and I response at midnight and let the patient know "hey get a hint now") and this "long term reassurance" seems to have calmed the patient down somewhat.... i think... at least she never bothers me now for her asthma follow up
 
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So super high volume would be 30-45 pts a day… some do that … though whether appropriate care is given is debatable.
25-30 pts would be a high volume and some do that… but the typical endocrine prolly sees 18-22 pt a day.

I feel like you're going to sacrifice a lot of patient quality metrics with 30 pts a day. Even if 1/2 your patients that day are A1cs of 6.5, TSHs of 1s, you're going to need to at least validate some of their recent ****, family things, etc.

I'm on the job market right now for Endo and a lot of entry is 250k after productivity in good areas. Not bad. Not great. But also quality of life. At 400k I don't think you're a lifestyle profession anymore. You're honestly pushing into quality of life then.

Also I don't understand why people are so quick to forget that you're always able to add an extra hustle into things. Like if you're doing your 32-36 hours of work a week in 4 days. You can always throw in an extra day of something extra and make some side money.
 
Also I don't understand why people are so quick to forget that you're always able to add an extra hustle into things. Like if you're doing your 32-36 hours of work a week in 4 days. You can always throw in an extra day of something extra and make some side money.

Like what? What would pay better on an hourly basis than putting our degree to use?
 
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That's such a sweet deal. Is it fairly common to get job offers like that in allergy?
very common yes in pvt practice. Aside from Hemeonc pvt practice Allergy definitely makes the most of all the lifestyle specialties for the amount of time spent working. You can definitely make 400K+ without sacrificing lifestyle. Most partners make 400-500K+ and its not abnormal to become partner after 2-3 years in practice. Of course geographic location and practice model determines how much youre making but that goes with any specialty
 
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Spouse is allergist 32 clinical hours a week. She recently chose a 3 day a week schedule. No thursday or fridays, weekends, hospital consults, calls, overnights, holidays.

She clearing 400K this year, when including her productivity bonus
Hospital system employed. Midwest

This is awesome, esp since it's one of the chillest gigs in medicine. Good for her!
 
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This is awesome, esp since it's one of the chillest gigs in medicine. Good for her!
Yeah allergy in private practice is a pretty amazing gig if you like predominantly outpatient subspecialty medicine its the best bang for your buck of these types when it comes to salary and lifestyle (not including heme-onc which probably wins)
 
Yeah allergy in private practice is a pretty amazing gig if you like predominantly outpatient subspecialty medicine its the best bang for your buck of these types when it comes to salary and lifestyle (not including heme-onc which probably wins)

It beats Heme/Onc hands down. H/O entails never-ending labs coming in after-hours, near-emergencies, perennially-changing SOC, notes that take forever to write... Not a lifestyle specialty.
 
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Pretty DO-unfriendly overall though, right?
No its not DO unfriendly but the kicker is most allergy programs are at big academic centers so coming from a community IM or peds program can make it more challenging than being a DO at an academic program. However, coming from a community program does not in any way shape or form preclude you from matching Allergy. I would suggest DOs who want to match Allergy prepare an app in med school that will be competitive enough for an academic program in peds or IM to maximize chances of matching. Allergy is middle competitiveness of all the subspecialties-in order of competitiveness I would say:
1. GI
2. Cards
3. H/O
4. PCCM
5. Allergy
6. Rheum
7. ID
8. Endo
9. Nephro

Regardless, the match rate for Allergy is actually quite high at around 80%
 
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That’s good to hear. What would be the most viable method to match Allergy through a community IM program? Feels like it would take a lot of luck if there’s no A/I fellowship in-house.
Your ticket to be confident in matching Allergy coming from a community program will be research. I would highly suggest that if said community program doesnt have an allergy program in-house (which they likely dont since community Allergy programs arent super common) to apply to the Chrysalis Project (AAAAI) or Spark program (ACAAI). These programs are specifically for individuals with poor access to Allergy mentors or residents without in-house fellowships. Submitting abstracts and presenting a poster at the annual conferences will boost your app as well. Im not saying you need 10+ pubs to match allergy but 1-2 pubs and attending a conference or two will be super helpful. If you have any specific questions you can always PM me
 
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I think from an IM perspective it is important to mention that allergy is the only IM-based specialty that also sees peds. I found that really strange in the community but peds and IM trained allergists see all ages which, as far as I can tell, is not done by any other IM subspec.
 
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I think from an IM perspective it is important to mention that allergy is the only IM-based specialty that also sees peds. I found that really strange in the community but peds and IM trained allergists see all ages which, as far as I can tell, is not done by any other IM subspec.
Sleep medicine . Ped pulmonologists who get sleep trained inevitably see adult osa . Adult sleep medicine inevitably see young kids for osa due to a lack of peds sleep medicine in many places . Not to mention seeing narcolepsy and those kind of things that may also present in kids

Then again sleep is not a pure IM subspecialty
 
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I think from an IM perspective it is important to mention that allergy is the only IM-based specialty that also sees peds. I found that really strange in the community but peds and IM trained allergists see all ages which, as far as I can tell, is not done by any other IM subspec.
this is true however if your IM trained you can only see adults if you choose and peds u can choose to only see kids. its whatever you prefer. If youre a partner at a pvt practice many times youll be seeing both
 
Match rates alone don't completely characterize competitiveness. It will be quite difficult to match into A/I from a community program and even more so if you're a DO. The first question would be why you're at a community program to begin with. Most likely it's because you weren't competitive coming out of med school. If that's the case, chances would be very poor. If there's some exception, like you were actually a very competitive student but you stayed at a community program for personal reasons or something like that...sure, that changes things. Unlike other fellowships, there are not many DOs in allergy (even less IMGs). All of the things that matter for residency (step scores, where you trained, AOA, research, etc.) also matter for fellowship. Research in residency can certainly give you a leg up but that's hard enough to accomplish at a large academic residency, probably way more so in a community program. Networking is your best bet. If you can get yourself known by a local fellowship program and some of the faculty, you may be able to build a relationship with them that is strong enough to make them take you vs an outside applicant. I'm not trying to be a Debbie downer but want to keep it real. There is a fair amount of self selection with a/i applicants and the pool is relatively competitive. Perhaps my own bias comes into play based on being and allergist and where I trained.
 
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Nearly all A/I docs in the community see kids and adults. It would be hard to develop and maintain a practice otherwise. There may be some skewing in referral base but most docs are probably seeing a good mix of both. At large academic centers, it is common for peds and adult allergy to separate and see a focused age range. At certain places that are sort of community-academic hybrids (ie Mayo), you may also have focused age cutoffs. In general, any doc working in the community can expect to see a range of ages.
 
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How likely can one break north of 400k in the following 3 subspecialties of IM: endocrine, rheumatology, allergy/immunology, sports medicine?
That's given an employed position or private practice with no partnership opportunities. Location: West coast preferably.
Hours worked: 4-4.5 days a week, 8 hour days.

I like being in the clinic more than being in the hospital.
Don't mind being a PCP either, it's satisfying work, but very hard work having to deal with charting and inbox and every single little problem in the patient all the time.
I was set on doing heme/onc for the earning potential and clinic life but I realized even tho they get paid more, they actually work hard for that money.
So while money is not everything, coming from a poor background, I know not having enough money is everything. I am looking for an IM subspecialty that has good earning potential and has a good life where you are not too stressed/ overworked for the amount of money you make.
No hate please..I'm just too stressed and tired from residency and the rat race of matching at a competitive fellowship at this point... I want a normal life after I graduate and make enough to live comfortably and help my parents and brother out financially.
I'm Onc and I don't work all that hard for north of 400K. At least not compared to how hard some of the other folks here in endo, rheum, etc have to work for that amount.

Bottom line, choose something you're interested in, you're going to be doing it for a long time. I love Oncology and TBH, had no idea how it paid compared to other IM specialties when I chose it. I wouldn't do endo or rheum for the same amount of work/money I do right now, but I've done Onc for less and been pretty happy with it.
 
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I think from an IM perspective it is important to mention that allergy is the only IM-based specialty that also sees peds. I found that really strange in the community but peds and IM trained allergists see all ages which, as far as I can tell, is not done by any other IM subspec.
Rheumatology does as well since they have both IM and peds trained fellows.
 
Rheumatology does as well since they have both IM and peds trained fellows.
I always thought Peds Rheum and Adult Rheum were separate fellowships and a brief google shows them listed separately on ERAS (unlike A/I which is not separated).

I think A/I is the only one I can think of that allows you to do Peds or IM and then see both… unless you count that time Peds tried to make me see a pregnant 13 year old with Asthma because they claimed she was “an emancipated minor” and therefore belonged to IM(?).

Edit: it looks like Palliative care may also allow you to see both?
 
I always thought Peds Rheum and Adult Rheum were separate fellowships and a brief google shows them listed separately on ERAS (unlike A/I which is not separated).

I think A/I is the only one I can think of that allows you to do Peds or IM and then see both… unless you count that time Peds tried to make me see a pregnant 13 year old with Asthma because they claimed she was “an emancipated minor” and therefore belonged to IM(?).

Edit: it looks like Palliative care may also allow you to see both?
I know in a couple of IM rheum fellowship, adult fellow sees limited number of peds, particularly in institutions that have no peds rheum fellowship.

In less populated areas, because there are so little ped rheum, adult rheum can manage peds patients, if they feel comfortable
 
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It beats Heme/Onc hands down. H/O entails never-ending labs coming in after-hours, near-emergencies, perennially-changing SOC, notes that take forever to write... Not a lifestyle specialty.
Second this. Have seriously considered switching to Endocrine for this reason.
 
Second this. Have seriously considered switching to Endocrine for this reason.
Endocrine here…lol… you won’t be happy with the next level inbox, notes that take forever, the “critical “ glucose that gets called at 5a , and the bags of hair…we don’t have a lot of emergencies… but do have the worried well that thinks checking their hormones is gonna fix their life…
 
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Endocrine here…lol… you won’t be happy with the next level inbox, notes that take forever, the “critical “ glucose that gets called at 5a , and the bags of hair…we don’t have a lot of emergencies… but do have the worried well that thinks checking their hormones is gonna fix their life…
…bags of hair?
 
I can tell you that outside of academia I have literally no hospital access to rheum, A/I, endocrine or sleep. So I imagine all of these are lifestyle specialties for the sole reason that they can peace out of hospital practice.
 
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Well, in A/I, most of us never go to hospitals, the inbox burden is minimal (comparatively speaking)...and there are no bags of hair. One time, in residency continuity clinic, a patient brought me an old pill bottle with old picked scabs in it. It ties with one of the most disturbing things I've seen in medicine, right up there with a neglected wound filled with maggots.
 
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someone brought me a piece of mold from his air conditioning. i sent it off as an "other" sample and it was penicillium species. does not mean that's in his lungs though though that patient is going for bronchoscopy so I shall see shortly enough
 
People do get fixated on molds. I think its a combo of the internet and the idea that, mold = bad, in relationship to foods expiring and stuff like that. I tell patients that they are breathing, eating, touching, and basically living in mold all day. Even the whole "black mold" thing is probably way overblown.
 
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I will also say pure outpatient pulmonology +/- sleep can be considered a lifestyle specialty.
most employed jobs put the critical care in there though
but if one can go private practice, then one can eliminate critical care entirely (or go academics and when you are older skip the critical care)

mainly office based and hospital management is usually rather straightforward.
no night time emergencies usually (because that goes to MICU anyway)
outside of an academic center with CF or transplant patients, there is no overnight emergencies.
 
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I will also say pure outpatient pulmonology +/- sleep can be considered a lifestyle specialty.
most employed jobs put the critical care in there though
but if one can go private practice, then one can eliminate critical care entirely (or go academics and when you are older skip the critical care)

mainly office based and hospital management is usually rather straightforward.
no night time emergencies usually (because that goes to MICU anyway)
outside of an academic center with CF or transplant patients, there is no overnight emergencies.
Whats income like for this type of gig (purely pvt practice outpatient pulm +/- sleep no CC)?
 
Whats income like for this type of gig (purely pvt practice outpatient pulm +/- sleep no CC)?
well let's just say my office does aobut 8-16 PFTs with 2-4 CPETs per day on average (i have two RTs)
plus the office visit codes

on average a PFT pays $150 and a CPET pays $200 in my neck of the woods.
the office visits vary depending on insurance but can range from $30 to $200 depending on commercial insurance quick follow up to complex new patient 99205.

one can do the math over a year.

the nice thing is no prior authorization is needed for these office procedures
 
well let's just say my office does aobut 8-16 PFTs with 2-4 CPETs per day on average (i have two RTs)
plus the office visit codes

on average a PFT pays $150 and a CPET pays $200 in my neck of the woods.
the office visits vary depending on insurance but can range from $30 to $200 depending on commercial insurance quick follow up to complex new patient 99205.

one can do the math over a year.

the nice thing is no prior authorization is needed for these office procedures
Not sure what any of that means but sounds like you pull ~400-500K+. Why more people dont do OP Pulm only is beyond me
 
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