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Yeah if I want to live in Idaho or some super rural town
Earning potential in IM lifestyle specialities
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Hospital medicine actually pays more here. Kaiser, SoCal. It’s quite saturated here so these are the only options for new grads. Maybe you mean allergists make more in rural towns? But then again, hospitalists can also make bank in rural towns.
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Thats one geographic location. Overall its widely known Allergists make more than hospitalists and work far less. If i had to be a hospitalist i would leave medicine
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are you an allergist? What’s your specialty?
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Looks like a PGY2 that has drank the allergy kool aid to the point of delusion.
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is 18-20 a resonable volume in rheuma? how much can one project to make on that volume? possible to break 400k?
There’s no free lunch out there that I’m aware of. I don’t know that it’s wise to choose between allergy, rheum, endo, etc based on what you perceive the compensation or market to be like right now. There’s a lot of complexities and things can change quick. a big cut in reimbursement for skin testing and shots for A/I, or infusions and ancillaries for rheum. I mean even if they legislated that oncologist could no longer directly profit off chemo or own infusion centers… a field could change dramatically. Private equity is always trying to creep in and figure out how they can monopolize and control the most lucrative aspects of every field in medicine.
I would choose a specialty based on what you like or maybe what you hate the least.
In terms of job market, I can only speak for A/I. One thing we don’t have is the option to go rural and increase our take. Rural communities just simply won’t support A/I. This is likely because a rural community can support an ENT or pulm and they will probably siphon off whatever would have otherwise went to allergy. It depends what you mean by semi rural. Smaller, less desirable cities with a population around 100-200k can support allergists but I don’t know that you make more. Your money would certainly go a longer way.
You can still succeed in opening up your own practice or gaining partnership with a small group. Probably the markets with the greatest potential are expanding suburbs full of young families. I don’t know much about the northeast but I imagine there’s less of this. The south and southwest are filled with this. Phoenix, Austin, Dallas, Las Vegas, Denver, etc are not land locked and seem to continually expand geographically. At the borders of those expansions are often booming new suburbs that are prime for really any field to open up shop, well particularly those that care for the younger and healthier. The Medicare population that feeds cards and other fields probs not buying up new builds 40min outside of Austin.
Every fellow I know got a job where they wanted. I heard of one when I was in residency who struggled but she was determined to be in San Diego and pretty sure she was wearing like a 3 karat diamond as a resident, so she was probably fine waiting.
I know plenty of allergists and I see the books at our large practice. The earning potential is plenty high. Most work 4 days. I can’t stress enough and I know I’m a broken record on this but I genuinely enjoy what I do every day. It’s really a great job. I wouldn’t choose any other field in IM but it’s not because of job market or compensation. If all you care about is money and job market, just be a hospitalist. Grind it out for a few years and gain relative financial freedom then you have one of the most portable and flexible jobs out there.
I would choose a specialty based on what you like or maybe what you hate the least.
In terms of job market, I can only speak for A/I. One thing we don’t have is the option to go rural and increase our take. Rural communities just simply won’t support A/I. This is likely because a rural community can support an ENT or pulm and they will probably siphon off whatever would have otherwise went to allergy. It depends what you mean by semi rural. Smaller, less desirable cities with a population around 100-200k can support allergists but I don’t know that you make more. Your money would certainly go a longer way.
You can still succeed in opening up your own practice or gaining partnership with a small group. Probably the markets with the greatest potential are expanding suburbs full of young families. I don’t know much about the northeast but I imagine there’s less of this. The south and southwest are filled with this. Phoenix, Austin, Dallas, Las Vegas, Denver, etc are not land locked and seem to continually expand geographically. At the borders of those expansions are often booming new suburbs that are prime for really any field to open up shop, well particularly those that care for the younger and healthier. The Medicare population that feeds cards and other fields probs not buying up new builds 40min outside of Austin.
Every fellow I know got a job where they wanted. I heard of one when I was in residency who struggled but she was determined to be in San Diego and pretty sure she was wearing like a 3 karat diamond as a resident, so she was probably fine waiting.
I know plenty of allergists and I see the books at our large practice. The earning potential is plenty high. Most work 4 days. I can’t stress enough and I know I’m a broken record on this but I genuinely enjoy what I do every day. It’s really a great job. I wouldn’t choose any other field in IM but it’s not because of job market or compensation. If all you care about is money and job market, just be a hospitalist. Grind it out for a few years and gain relative financial freedom then you have one of the most portable and flexible jobs out there.
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Why won't urban/suburban ENT/pulm siphon off patients from allergy?
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Not a lot of patients go on infusion tho anymore. A lot of patients get stable on po mtx. And a lot start complaining about 'allergy' on infusion, and then go to subq biologics. These po and subq biologics are decreasing the amount patients that are on infusion.
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These days, one would have to try really hard to get someone on infusions. It's basically only Medicare with supplement patients who can get Cimzia, Orencia, Actemra and Rituximab. Actemra profit margins are essentially nothing, and Rituximab is only 2x/year. It's just Orencia and Cimzia holding down the fort. Infusions aren't technically dead in the water, but it's close...
Inheriting infusions from retired docs is the only way for young rheumatologists to get a piece of that pie.
A/I i the golden ticket to a decent income for Peds-trained residents and a golden ticket to an easy life for the IM-trained. Might not get you a Ferrari, but that doesn't matter as much when you can cruise in at 9am, leave at 4:30, and have as close to a stress-free life as is possible in medicine. Must also be pretty idyllic to be dealing with patients so healthy that their biggest complaints for the day are itchy noses. No disrespect intended, I'm mostly joking. 😉
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Allergy is the move. Rheum is great as well. Both are happy/friendly groups of people which is a general maker of a great lifestyle in my opinion.
Endo doesn’t seem too bad either. Coming from IM, I got burnt out on diabetes and couldn’t possibly care less about joints. That’s how I ended up in allergy lol.
Endo doesn’t seem too bad either. Coming from IM, I got burnt out on diabetes and couldn’t possibly care less about joints. That’s how I ended up in allergy lol.
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I have a psychosomatic patient with dyspnea who likes to doctor shop. I put an end to all of the organic disease with full workup PFTs, bronchprovocation testing, exercise induced bronchoconstrictiontesting, CPET testing, CTC, echo, EKG stress test... sent to cardiology got CCTA and echo and holter - all unrevealing and normal.
sent for ENT to get vocal cord dysfunction evaluation - normal.
the patient went doctor shopping due to elevated IgE and dust mite allergy (though only some rhinorrhea issues)
the patient pestered the allergist to give allergy immunotherapy
then the patient had a psychosomatic reaction and "passed out" and claims she has allergic reaction to the immunotherapy
but she is not suing or causing trouble (so probably not malingering) and wants to press on
imagine that headache lol
sent for ENT to get vocal cord dysfunction evaluation - normal.
the patient went doctor shopping due to elevated IgE and dust mite allergy (though only some rhinorrhea issues)
the patient pestered the allergist to give allergy immunotherapy
then the patient had a psychosomatic reaction and "passed out" and claims she has allergic reaction to the immunotherapy
but she is not suing or causing trouble (so probably not malingering) and wants to press on
imagine that headache lol
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How are the offers you are seeing in what locale?
Some do, mostly ENT. Primary care in both adult and peds occasionally offer skin testing and sometimes shots. My understanding is that these practices are typically approached by larger corporations who sort of sell it as a service where the larger company sort of sets things up for them and the practice gets a piece of the revenue. It seems to be less common than it used to be. I've seen a few sort of get out of the game recently. There's a few reasons not to do it.
-Economy of scale. Skin testing and shots are margin dependent like anything else. If you're only dabbling, your return may not be worth the headache. Staffing is rough for everyone these days, so running lean and staying in your lane may be more profitable than biting off more than you can chew.
-Liability. Shots and drops carry risk. Testing, not so much. But then you have to interpret it correctly and are liable if you do it wrong. Wouldn't want to be the non-allergist who had a bad outcome from something outside their scope.
-Playing nice in the sandbox. Allergy, pulm, ENT, derm, and primary care all refer to each other. Allergy in a nice metro has a large portion of patients with PPO plans that self refer. Lots of patients that are on the younger side end up asking me for a PCP recommendation. You think we are sending patients to those folks who are poaching our specialty? I think both ENT and allergy do better when they work well together. I send you plenty of surgical cases and you send me allergy stuff. I'm also happy to deal with starting and maintaining patients on biologics for derm/ent/pulm. I have the built-in infrastructure to store biologics, administer them, and process the auths. There's not much money in this space either unless you're large enough to buy and bill.
Also, non-allergist providing immunotherapy tend to use much less potent serum than allergists. Probably because they don't want to be dealing with shot reactions and anaphylaxis like we do. You're simply not going to get efficacy out of it if you don't use high enough doses. I think patients catch on to this. In a metro/suburb area, patients have choices. Also, in the age of the internet, I think educated patients might pick up on the whole stepping out of their lane practice. I mean if you were gonna put you or your kid on shots, would you go to the allergist who specializes in it or to the PCP? If your pcp does testing, are they going to be able to have an in depth conversation on what the results actually mean for the patient? Probably similar to how we hear about family med doing colonoscopies and delivering babies in rural areas. Patients with choices would probably prefer GI and OB to be doing these things and they are readily accessible.
Level 4 NP e/m (maybe 5 depending on how long)
~500 worth of skin test
~2000 to mix the serum (that is billed out regardless of if she only did one shot)
~level 5 est e/m the day she had the shot reaction
It makes the somatic patients more palatable
"I'm so sorry this didn't work out for you. I appreciate the opportunity to help. Sorry for your suffering. Probably not safe for us to continue this route. Please just see that very kind, hard working pulmonologist in New York for further care."
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I gave got her an electronic peak flow linked to her phone app and asked her to constantly send me reports. if there was no drop in peak flow when she feels symptomatic, then there was no new bronchospasm issues.
this patient's issue is she has no real PCP. No way to chum it out with and have a nice talk about.
this patient is one of those "shop around for specialists only" patients.
yep an NYC specialty.
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What a mess. Have you considered a psych referral yet?
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to the patient, there is still some organic disease causing her dyspnea.
I even told her (nicely) that she had hyperventilation and elevated VE/VCO2 on her CPET in the resting phase that got better with exercise and was not accompanied by any increase in Vd/Vt.
Translation: there was inefficient ventilation present during the exercise test but no evidence of V/Q mismatch physiology. Hence there is hyperventilation / anxiety proven by the test. but the patient does not believe this and does not want to see psychiatry or psychology
Medicaid does not cover cognitive behavioral therapy. I mentioned how talking to a therapist can help. even using those apps.
the patient declined citing "it does not work and I swear there is something wrong with my body."
I used the good old "I believe that YOU believe that there is something wrong. That is good enough for me!"
anyway I did not have to bother with "empiric inhaler trials" because she has seen mutliple other pulmonologists all of whom did empiric inhaler trials. She has "allergies" (i.e. intolerances) to all of the SABAs, LABAs, LAMAs, ICS,
She read online about the IL5, IL4/13 biologics and wanted those. I said nope sorry insurance isn't ever covering those without actual asthma exacerbations. You could pay for it out of pocket if you wished.... lol that stopped that train in the station.
You're a better person than me. I have very little patience for that stuff. I'm a little more patient when real organic disease is combined with hysteria or anxiety. I try not to feed the fire and just focus on managing what I can. When it's purely anxiety, I try and give a thorough work up, maybe even some conservative attempts at therapy. When they show signs of that cluster B flavor, I won't tolerate it, I'm done.
Tangential but...It's a shame patients are so resistant to the idea of therapy or that when they do see psych, they just end up on a bunch of medications. I think we are making progress as a society but there are so many people that would benefit from improving mental health and dealing with the real root of problems. The taboo is still way too present. I see so many people that would benefit from personal, marital, and/or family counseling...many of them otherwise high functioning people that are on SSRIs, ADD meds, anxiety meds, etc.
Tangential but...It's a shame patients are so resistant to the idea of therapy or that when they do see psych, they just end up on a bunch of medications. I think we are making progress as a society but there are so many people that would benefit from improving mental health and dealing with the real root of problems. The taboo is still way too present. I see so many people that would benefit from personal, marital, and/or family counseling...many of them otherwise high functioning people that are on SSRIs, ADD meds, anxiety meds, etc.
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anyway ever since I instituted a "PCP or other doctor must provide a referral or no appointment policy" (hence a legit referral reason) the number of psychosomatics has plummeted. They yell and scream over the phone "BUT MAH INSURANCE DONT NEED PCP. I HAVE A RIGHT TO CHOOSE WHO I WANT TO SEE"
my staff replies "we are a private practice and not a concierge service for you and we have the right to institute our office policy. you are free to see NYU, New York Presbyterian, Montefiore, Northwell, Mt Sinai, so on so forth where "the customer is always right" and a nurse manager, bureaucrat or administrator (or a 3 in 1) will greet you at the door.
some of them go to google reviews and leave an angry 1 star saying "they wont let me be seen without PCP referral!" I report to google for not being a true review as the patient did not "receive services" and google eventually takes it down. a lot of new york city natives (i'll leave politics out of it but you can guess what I am getting at) are such "participation trophy" children.
my staff replies "we are a private practice and not a concierge service for you and we have the right to institute our office policy. you are free to see NYU, New York Presbyterian, Montefiore, Northwell, Mt Sinai, so on so forth where "the customer is always right" and a nurse manager, bureaucrat or administrator (or a 3 in 1) will greet you at the door.
some of them go to google reviews and leave an angry 1 star saying "they wont let me be seen without PCP referral!" I report to google for not being a true review as the patient did not "receive services" and google eventually takes it down. a lot of new york city natives (i'll leave politics out of it but you can guess what I am getting at) are such "participation trophy" children.
"Benign" heme includes sickle cell anemia management for pain crises and acute chest syndrome, stat consults for suspected TTP management, HIT consults in ICU patients who are concurrently at risk of clotting and bleeding, management of esoteric coagulability disorders, and putting together DVT histories largely on the basis of patient histories that are sometimes little better than coin-tosses. Pretty high-stakes.
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I'm glad I'm not the only one who feels this way about deciding on indefinite anticoagulation!
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Endos apparently making 400k-500k in pp in west coast recently. My guess would be it's mostly volume/clinic mil. But then I saw this job in Yuma Arizona for 500k for 16-18 patients a day only.
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Base many be there to attract for a couple of years but in order to reach base or beyond might become higher as time goes by, there may be something else too it.
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The "something else" is that it's Yuma.
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18 pts a day, if 3-4 news, and some CGM interpretations is easily 400-500k. Higher end if one is “aggressive” with billing. Lower end if not.
Don’t have to be in Yuma for those numbers. You can literally do this in most places outside of the top tier desirable metros.
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The only downside is that you have to be an endocrinologist 😂. But I’m sure that sentiment is shared by most for fields that aren’t their own.
If I were you in your shoes, I would do an allergy, endo, and rheum rotation then choose whatever you like best.
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That is quite impressive and sounds amazing haha but you are an exception to the rule. Your situation is not super common and I believe most people would agree with this
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Nah. That’s literally the going rate for rheum in a non metro area.
If you’re living in a place with <200k population and making less than 400k as rheum, then something’s wrong.
If you make <500k in a place with <100k population then something’s wrong.
In a major metro, 500k+ income would be an outlier. Most of those docs are running with legacy infusion patients and own their own practice.
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so you’re telling me if you’re doing rheum in a suburban town with a population less than 100K you should be making at least 500K? i mean if so thats pretty great. For instance, my family lives on the coast in the suburbs of southeast florida with a population of about 20K about 2 hours from the nearest biggest city which is 150K. I guess it doesnt always need to be some rural town in the middle of Idaho that pays the big bucks
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Well it really depends on the specifics of said suburban town.
When I say <100k population, I don’t mean a town that is a part of a greater metropolitan area. I mean literally it’s by itself and nothing until the next closest metro area. Laguna Beach being an hour of half to downtown LA doesn’t count.
I don’t know anything about SE Florida but isn’t most of it a part of a bigger metro area? Like Miami or Ft Lauderdale, West Palm Beach etc?
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regarding SE florida its all pretty suburban or rural unless youre like 30 mins to an hr outside palm beach, ft lauderdale or miami. Lots of small towns that are less than 30K population and at least 2-3 hrs from miami 2 hrs from ft laud or Palm Beach depends on exactly where. But yes i get your point with ur laguna analogy likely a ton of people that would want to practice there and im sure its saturated. How accurate is the doximity app salary map? seems artificially low for a lot of specialties
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Last I looked I thought it definitely underestimated non metro pay for rheum. With that said, the high incomes that occur in rural areas is due to higher patient volumes which means one has to put the work in. It’s not that hospitals or pp groups are just going to shell out 500k base with no strings attached in any of these places. And there are a lot of people out there who just want a “chill job” with doing the minimum possible. They bring down these averages quite a bit.
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18 patients a day, 5 days a week probably is 350-400k in my local environment.
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It is unlikely for even a mature endo to pull in 500k a year. 400k is pushing a lot of effort.
16-18 pts a day realistically is 300-325k a year. Which is respectable mind you.
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What’s your comp per wrvu?
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Not an Wrvu system.
But honestly this was a solid job. I was being offered 180-200 for full time in private practice. My rheum friends locally got 200-255l off the bat for 5 days a week.
Tbh the problem with Endo and Rheum is that amount of people looking to rip off new graduates off badly. I had an employer try to tell me that 25 patients a day for 280k was fair compensation.
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while an employed physician who uses an employer's / hospital's resources cannot be expected to take 100% of the billings, 25 patients a day for 280K is low ball
if we did napkin math and just used 99213 for easy numbers. 99213 pays about $107.46 per Medicare. With the 2% sequestration down to like $104 (varies by commercial insurances. this full amount may or may not be collected pending deductibles, copays, deadbeat patients)
but let's just use some easy numbers
25 patients of 99213 per day (im not going to get too complex and use hospital consult codes, new patients, RPM with dexcom etc...)
5 days a week
let's say 46 weeks a month (4 weeks vacation and the 10 federal holidays)
$100 * 25 * 5 * 46 = $575,000
moral of the story = if you want more money go private practice ASAP! this is the same for any specialty (that is not tied to a hospital like interventional radiology or cardiac surgery etc...)
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if we just do the math with wRVUs it doesn’t match up.
25 pts a day 5 days a week and 46 weeks a year, assuming mostly level 4s (with rare level 3 and level 5 that cancel out) is
25 x 1.92 x 5 x 46 = 11,040 wRVU.
typical compensation per wRVU is $50-53, so we’re looking at mid to high 500s.
This is for hospital employment set up. For private practice the numbers are very different and depends a lot on overhead expenses.
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My job cuts profits by making practice a bit more comfortable. Which I accept. We have a lot of staff.
But honestly for a first job I'm content.
I am frankly more offended by the garbage low ball offers I got from others.
