Earning potential in IM lifestyle specialities

[Legend of Link]

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Is it hard to find outpatient only private practice pulm+/-sleep jobs?

 

[NewYorkDoctors]

unclear. i am fully solo independent. i can do as much or as little as i want. my PCCM colleagues in the hospital love to see my inpatients as they can "bill for private" and i dont bother seeing inpatients. ill do my own bronchs if needed though. its like a PCP/hospitalist set up.

but usually the employed jobs usually want the PCCM doctor to work critical care also.

but analogously , I know plenty of general cardiologists and GI who are fully independent who put off all inpatient requirements

before the EMR, one "had to be with the patient inpatient to know what happened." That's not really the case these days with EMR

 

[Legend of Link]

unclear. i am fully solo independent. i can do as much or as little as i want. my PCCM colleagues in the hospital love to see my inpatients as they can "bill for private" and i dont bother seeing inpatients. ill do my own bronchs if needed though. its like a PCP/hospitalist set up.

but usually the employed jobs usually want the PCCM doctor to work critical care also.

but analogously , I know plenty of general cardiologists and GI who are fully independent who put off all inpatient requirements

before the EMR, one "had to be with the patient inpatient to know what happened." That's not really the case these days with EMR

Being solo private, has volume ever been an issue? Especially when you first started. I like outpatient pulm but not the acuity of crit care. Planning to settle in west coast after residency/fellowship, not sure if the market there too saturated to start a solo private practice and if anyone would hire a outpatient pulm only doctor.

 

[NewYorkDoctors]

Being solo private, has volume ever been an issue? Especially when you first started. I like outpatient pulm but not the acuity of crit care. Planning to settle in west coast after residency/fellowship, not sure if the market there too saturated to start a solo private practice and if anyone would hire a outpatient pulm only doctor.

this is variable as is this case for any "small business"

I happen to be part of an independent practice association in NYC that does not have many pulmonologists. so all the internists and cardiologists (among others) refer to me in this local area. The local thoracic surgeons even part of the big hospital systems like to send patients to me for the CPET I do for them.

Moreover, I made a website and social media. Even patients who do not see PCPs in this IPA check me up on google or the website and find I can schedule to see me faster. I tend to "do PFTs on the same day." Nothing gets in the way of doing this. It's just I suspect sometimes staff issues or union issues with the hospital RTs prevent that from being done same day.

99203-modifier 25 plus 94060 + 97426 + 94729 can pay the full PFT and office visit same day. I go over the result almost treating PFTS like a point of care test. Then move the workup along swiftly.

Evveryone will always need pulmonology in the community (primarily for chronic cough and nonspecific dyspnea...)

as with any private practice, one needs the 3 As to be successful

Availability, accessibility, and affability.

The benefit for outpatinet pulmonary if you buy your own office, machines, etc is no prior authorizations are required for most outpatient pulmonary procedures.

Home sleep study needs a PA but usually insurances can approve it the next day... the perfect day in which the patinet brings it back on that date...

Non sleep medicine physicians like pulmonary only can buy and bill for home sleep studies. Just cant do a Type 1 or 2 sleep study (the in lab versions) . get them onto AutoCPAP right away. if not working then send to split night study to figure out BiPAP need or something else.
the patients love it more this way

Something like general cardiology needs to run PA for everything so many of my general cardiology colleagues do a first viist and 12 lead. then wait to PA for the TTE, holter, US carotid... then PA for nuclear later.. it takes time and therapeutic inertia may have patients lose interest and may lead to a lot of lost to followups and inefficiencies.

 

[Angler]

as with any private practice, one needs the 3 As to be successful

Availability, accessibility, and affability.

The 2 other classic A's which are less important are affordability and ability. Sad to say, but ability is the least important A.

 

[NewYorkDoctors]

The 2 other classic A's which are less important are affordability and ability. Sad to say, but ability is the least important

Right. Not everyone who hangs a shingle is an academician. I do not fancy myself an academic doctor (as I do no original research) despite my clinical faculty "title." But I do have enough self pride to check Uptodate all the time and "do the full workup no matter how hard and tedious explaining it all is and coordinating it all is"

I do notice a "lot of shortcuts are taken" in private practice. there is no quality control out there other than perhaps google / social media reviews. but even then that is just reviewing the patient experience and not medical acumen.

my justification for running so many procedures in office is they are usually coming for dyspnea so I figure guidelines say I can do PFT and CPET off the bat. This may help reduce unnecessary nuclear stress tests and CT chests.

affordability - that's an insurance issue. if someone has financial hardship, then i have looked the other way about copays.
while I am not allowed to do that, my staff makes an honest effort to collet and send bills. but am I really going to tell the SSc related PAH patient nope you cant see me you're not paying copays and let him worsen and die? or the IPF patient who needs to get BI Cares charity for Ofev?
i just dont send a billing debt agency (as I have no time for that either)
fortunately i see a lot of low income patients in NYC (i'm in the lower SES part of town. but NY Managed Medicaid is literally the same as cadillac insurance lol. zero deductibles, zero copays, bill at will, very easy prior auths.) and the money issue really has not been that big of a deal fortunately.


but im doing my part to always check the formularies (not hard just google it to see what is lower tier - there is a Med coverage phone app - or have my staff call the pharmacy to confirm) and never prescribe name brand stuff unless I know its really needed and I get the PA first (something like Nucala or Fasenra no other way around for those)

 

[Angler]

if someone has financial hardship, then i have looked the other way about copays.
while I am not allowed to do that, my staff makes an honest effort to collet and send bills. but am I really going to tell the SSc related PAH patient nope you cant see me you're not paying copays and let him worsen and die? or the IPF patient who needs to get BI Cares charity for Ofev?
i just dont send a billing debt agency (as I have no time for that either)

Yeah, when i was in PP early in my career, I got nervous whenever I would write off medicare copays. We were always told to be careful of HCFA (now it's CMS) audits; I don't know how often they did this, but if they caught you regularly not collecting copays, you'd be in deep doodoo. Of course, way back then, I had a number of FFS patients which I just collected full price and gave them a superbill.

 

[anaphyrelaxed]

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%

Would like to chime in and put a plug for Allergy/Immunology as others have already stated and stress how important it is to set yourself up for A/I (and any specialty for that matter) by going to the best residency you can.

A/I is easily the best IM lifestyle specialty and actually more competitive than people tend to think.

Allergy’s competitiveness is reflected in this year’s NRMP match data:

GI - 65.5% (57.3% US MD, 99.7% filled)
Cards - 66.8% (51.8% US MD, 99.7%)
A/I - 72.0% (67.3% US MD, 99.4% filled)
H/O - 77.5% (54.9% US MD, 99.3% filled)
Rheum - 77.9% (42.9% US MD, 98.9% filled)
Pulm/Crit - 78.9% (45.5 US MD, 98.5% filled)
Endo - 90.6% (31.1% US MD, 92.3% filled)
Palli - 91.2% (63.7% US MD, 83.1% filled)
Sleep - 91.5% (40.4% US MD, 88.3% filled)
Nephro - 93.9% (25.5% US MD, 65.8% filled)
Geri - 96.0% (40.6% US MD, 44.5% filled)
ID - 96.7% (54.5% US MD, 67.3% filled)

Allergy is the third most competitive specialty in IM right behind GI and Cards (although IM + peds apply and there’s no way to differentiate between the match rate for IM or peds only) and has the highest percentage of US MD’s matching into the specialty.

People are realizing it’s a sweet gig for the money you make and amount you work. It’s not as “sexy” as GI or cards but I highly recommend that IM residents consider this field.

 

[Deecee2DO]

Would like to chime in and put a plug for Allergy/Immunology as others have already stated and stress how important it is to set yourself up for A/I (and any specialty for that matter) by going to the best residency you can.

A/I is easily the best IM lifestyle specialty and actually more competitive than people tend to think.

Allergy’s competitiveness is reflected in this year’s NRMP match data:

GI - 65.5% (57.3% US MD, 99.7% filled)
Cards - 66.8% (51.8% US MD, 99.7%)
A/I - 72.0% (67.3% US MD, 99.4% filled)
H/O - 77.5% (54.9% US MD, 99.3% filled)
Rheum - 77.9% (42.9% US MD, 98.9% filled)
Pulm/Crit - 78.9% (45.5 US MD, 98.5% filled)
Endo - 90.6% (31.1% US MD, 92.3% filled)
Palli - 91.2% (63.7% US MD, 83.1% filled)
Sleep - 91.5% (40.4% US MD, 88.3% filled)
Nephro - 93.9% (25.5% US MD, 65.8% filled)
Geri - 96.0% (40.6% US MD, 44.5% filled)
ID - 96.7% (54.5% US MD, 67.3% filled)

Allergy is the third most competitive specialty in IM right behind GI and Cards (although IM + peds apply and there’s no way to differentiate between the match rate for IM or peds only) and has the highest percentage of US MD’s matching into the specialty.

People are realizing it’s a sweet gig for the money you make and amount you work. It’s not as “sexy” as GI or cards but I highly recommend that IM residents consider this field.

Great post. Would like to echo sure youre more likely to be making 600K-800K+ as a cardiologist or GI but youre working more. Not many subspecialties in IM aside from A/I where you can pretty confidently know that youll work under 40 hrs per week and clear 400K+ once youre established in a private practice either as partner or working independently in pvt practice. Its quite an attractive gig only caveat is having to do IM or peds residency which is no walk in the park. A/I is the lifestyle IM subspecialty where you get lifestyle AND good income unlike the others (endo etc) where you really only get lifestyle

 

[hotsaws]

It really is a great specialty. There's even more than the lifestyle and earning potential, which are no doubt strong points. It's also an enjoyable and fulfilling day to day job. I try to point this out when I have med students rotate with me. We get rhintis, asthma, cough, rashes/hives, etc. every day and the vast majority of them improve dramatically after we start managing it. Sometimes it's hard to see that value as a student or even a resident. It's a very rewarding field. I'm not sure but I don't think alot of IM/peds based outpatient fields see the same amount of daily "wins." I could be wrong though because so much of my exposure to other fields is based on the helllish landscape of large teaching hospital based care.

I also believe we are about to see a massive improvement in the way we are able to treat food allergy over the next couple years. I think this will add to our field in a huge way. Pharma/industry is continuing to allocate resources and make big strides in many of the common things we treat. Just in the last couple years, I have seen multiple new drugs and new indications for existing drugs that expand our arsenal.

The point above about competitiveness is important. The field is MD heavy and within that pool of applicants every year are a lot of very competitive people. Most allergists I've met are quite happy about their choice. I don't know any that would have chosen another field in IM...maybe a few that would have done derm or something surgical (those ENTs have a good gig).

 

[Deecee2DO]

It really is a great specialty. There's even more than the lifestyle and earning potential, which are no doubt strong points. It's also an enjoyable and fulfilling day to day job. I try to point this out when I have med students rotate with me. We get rhintis, asthma, cough, rashes/hives, etc. every day and the vast majority of them improve dramatically after we start managing it. Sometimes it's hard to see that value as a student or even a resident. It's a very rewarding field. I'm not sure but I don't think alot of IM/peds based outpatient fields see the same amount of daily "wins." I could be wrong though because so much of my exposure to other fields is based on the helllish landscape of large teaching hospital based care.

I also believe we are about to see a massive improvement in the way we are able to treat food allergy over the next couple years. I think this will add to our field in a huge way. Pharma/industry is continuing to allocate resources and make big strides in many of the common things we treat. Just in the last couple years, I have seen multiple new drugs and new indications for existing drugs that expand our arsenal.

The point above about competitiveness is important. The field is MD heavy and within that pool of applicants every year are a lot of very competitive people. Most allergists I've met are quite happy about their choice. I don't know any that would have chosen another field in IM...maybe a few that would have done derm or something surgical (those ENTs have a good gig).

Amen @hotsaws

 

[Legend of Link]

It really is a great specialty. There's even more than the lifestyle and earning potential, which are no doubt strong points. It's also an enjoyable and fulfilling day to day job. I try to point this out when I have med students rotate with me. We get rhintis, asthma, cough, rashes/hives, etc. every day and the vast majority of them improve dramatically after we start managing it. Sometimes it's hard to see that value as a student or even a resident. It's a very rewarding field. I'm not sure but I don't think alot of IM/peds based outpatient fields see the same amount of daily "wins." I could be wrong though because so much of my exposure to other fields is based on the helllish landscape of large teaching hospital based care.

I also believe we are about to see a massive improvement in the way we are able to treat food allergy over the next couple years. I think this will add to our field in a huge way. Pharma/industry is continuing to allocate resources and make big strides in many of the common things we treat. Just in the last couple years, I have seen multiple new drugs and new indications for existing drugs that expand our arsenal.

The point above about competitiveness is important. The field is MD heavy and within that pool of applicants every year are a lot of very competitive people. Most allergists I've met are quite happy about their choice. I don't know any that would have chosen another field in IM...maybe a few that would have done derm or something surgical (those ENTs have a good gig).

Did you have trouble finding job in the locale you wanted? How's the volume of patients available? Do you think you have volume available if you for some reason decide to work more?
Allergy honestly sounds like a good gig. I don't mind making 400k in a job as chill as allergy and honestly I think diagnosing cause of and treating rhinitis and allergies is very satisfactory. I'm just scared of job market or not having enough volume if I want to work more

 

[NewYorkDoctors]

Pulmonary minus critical care +/- sleep is a chill job also
you can never go to the hospital again if you did not want to. (though will still need to do bronchs sometimes but mostly thoracic handles the cancers for you)
all respiratory emergencies go to MICU anyway.

these jobs are not easy to get in established practices as the old guys and gals get them

 

[NewYorkDoctors]

It really is a great specialty. There's even more than the lifestyle and earning potential, which are no doubt strong points. It's also an enjoyable and fulfilling day to day job. I try to point this out when I have med students rotate with me. We get rhintis, asthma, cough, rashes/hives, etc. every day and the vast majority of them improve dramatically after we start managing it. Sometimes it's hard to see that value as a student or even a resident. It's a very rewarding field. I'm not sure but I don't think alot of IM/peds based outpatient fields see the same amount of daily "wins." I could be wrong though because so much of my exposure to other fields is based on the helllish landscape of large teaching hospital based care.

I also believe we are about to see a massive improvement in the way we are able to treat food allergy over the next couple years. I think this will add to our field in a huge way. Pharma/industry is continuing to allocate resources and make big strides in many of the common things we treat. Just in the last couple years, I have seen multiple new drugs and new indications for existing drugs that expand our arsenal.

The point above about competitiveness is important. The field is MD heavy and within that pool of applicants every year are a lot of very competitive people. Most allergists I've met are quite happy about their choice. I don't know any that would have chosen another field in IM...maybe a few that would have done derm or something surgical (those ENTs have a good gig).

question to the allergists in general (not just asking hotsaws)

what agree of pulmonary function testing do you do for your asthma patients?

the local allergists I work with do basic spirometry and bronchodilator response with a basic spirometer for 94060

It does not seem like many do FENO (which mays peanuts honestly and there are better tests for atopy available to the allergist anyway)

But nothing seems to prohibit the allergist from doing a full PFT (barring the usual requirement of a respiratory therapist and buying the more expensive setup).

just curious. the local allergists send me to me for full PFT testing

 

[chessknt]

question to the allergists in general (not just asking hotsaws)

what agree of pulmonary function testing do you do for your asthma patients?

the local allergists I work with do basic spirometry and bronchodilator response with a basic spirometer for 94060

It does not seem like many do FENO (which mays peanuts honestly and there are better tests for atopy available to the allergist anyway)

But nothing seems to prohibit the allergist from doing a full PFT (barring the usual requirement of a respiratory therapist and buying the more expensive setup).

just curious. the local allergists send me to me for full PFT testing

Allergists in my area do full PFTs and when volume and diffusion are low they refer them to me after farming the lucrative procedure. Its pretty fkn stupid honestly. Imagine if I did skin prick testing with no ability to react to it but wanted to get the most lucrative procedure on the tab before referring out?

 

[NewYorkDoctors]

Allergists in my area do full PFTs and when volume and diffusion are low they refer them to me after farming the lucrative procedure. Its pretty fkn stupid honestly. Imagine if I did skin prick testing with no ability to react to it but wanted to get the most lucrative procedure on the tab before referring out?

I have a slot in my scheduled called “talking only .” Any new patient who already had full work up done I relegate to this time slot . Make lemonade out of lemons . It’s usually at the very end of the day.

My office policy is “nothing is scheduled unless I find records from local emrs or pcp sends me all relevant findings .” Don’t like it patient ? Well you’re not gonna like it even more When I do a sh it consult because I went to hands empty .

 

[The kitchen sink]

Allergists in my area do full PFTs and when volume and diffusion are low they refer them to me after farming the lucrative procedure. Its pretty fkn stupid honestly. Imagine if I did skin prick testing with no ability to react to it but wanted to get the most lucrative procedure on the tab before referring out?

Aren’t there pulm offices that offer allergy skin testing though as well?

How much does it reimburse anyway?

 

[NewYorkDoctors]

Aren’t there pulm offices that offer allergy skin testing though as well?

How much does it reimburse anyway?

depends how many skin pricks are done
each one is billed 95004 for like $5 each or payment or something. allergist can correct me otherwise.

There are third part companies that do this testing. The mobile testing companies could run this in an office.

As I do not do the allergen immunotherapy shots, I see little utility it doing this in a pulm office that the IgE RAST panel can't get similar info with

yes I am aware of the difference between Type 1 hypersensitivity vs Type 4, yes I know skin testing is more sensitive, yes yes yes

but I also know i do not want to be asking patients to hold their beta blockers in case epinephrine is needed or have to deal with possible anaphylaxis.

ultimately what would I do with that information? give more impetus to start the patient on a biologic for asthma I suppose.

 

[hotsaws]

We just do spirometry in our offices. We offer FeNO and do it occasionally. Each allergist practices a little differently. We have patient sign an ABN saying that they will be on the hook for 30 dollars if their insurance does not reimburse for it. I personally use FeNO in cases where spirometry is normal but I have symptoms like chronic cough. It can help drive empiric therapy. Sometimes I will try FeNO in young patients who can't quite get the spiro technique. Also, helpful in cases like obstruction that isn't reversible. Overall, it adds a little to the diagnostic picture but it isn't lucrative.

I do post-bronchodilators as needed and not routine. Any new patient with obstruction or similar findings on spiro is probably getting a post.

We don't have the infrastructure for full PFTs. I send these to pulm. Yall can have it and then determine the workup after. If I have some restrictive physiology and I am actually concerned about primary lung disease, I will often order the HRCT for the patient so they can get that ball rolling while trying to get scheduled with pulm.

Even if someone has done the PFTs and then refers to you after, can't you justify repeating if the person wasn't pulmonary? If I get some of these BS non-allergist doing skin testing (which is often just run by an MA or 3rd party), I repeat the skin testing if I think the patient is going to go on shots and insurance reimburses. I'm not mixing a serum for a patient based on someone else's test. There's too much subjectivity in skin testing to trust an outside source unless it's another allergist, in my (defensive) opinion.

 

[NewYorkDoctors]

We just do spirometry in our offices. We offer FeNO and do it occasionally. Each allergist practices a little differently. We have patient sign an ABN saying that they will be on the hook for 30 dollars if their insurance does not reimburse for it. I personally use FeNO in cases where spirometry is normal but I have symptoms like chronic cough. It can help drive empiric therapy. Sometimes I will try FeNO in young patients who can't quite get the spiro technique. Also, helpful in cases like obstruction that isn't reversible. Overall, it adds a little to the diagnostic picture but it isn't lucrative.

I do post-bronchodilators as needed and not routine. Any new patient with obstruction or similar findings on spiro is probably getting a post.

We don't have the infrastructure for full PFTs. I send these to pulm. Yall can have it and then determine the workup after. If I have some restrictive physiology and I am actually concerned about primary lung disease, I will often order the HRCT for the patient so they can get that ball rolling while trying to get scheduled with pulm.

Even if someone has done the PFTs and then refers to you after, can't you justify repeating if the person wasn't pulmonary? If I get some of these BS non-allergist doing skin testing (which is often just run by an MA or 3rd party), I repeat the skin testing if I think the patient is going to go on shots and insurance reimburses. I'm not mixing a serum for a patient based on someone else's test. There's too much subjectivity in skin testing to trust an outside source unless it's another allergist, in my (defensive) opinion.

there is no limit on PFT testing persay like there is no prior auth obviously.
but why subject patients to more copay / deductibles?
even if a patient has medi/medi pay nothing, I would still feel bad just "squeezing a PFT out of a patient" unless there was a good clinical reason to do so.
(general cardiologist who nuc's a patient once a year to squeeze out money is not something I strive to do)

lucky for me when I get someone from the outside who had prior PFts, my justification often becomes (that was done with N2 washout. we are going to do body plethysmography cool?) patient : sure looks fancy

 

[NewYorkDoctors]

there are those “portable full pft systems “ that use the helium dilution method for lung volumes (the dlco step is basically helium dilution ) and can be done quickly and fairly easily

An RT is not even needed for this machine it’s so easy to use . Hardly more difficulty than a basic spiro .

Nothing stops an allergist from looking into this and billing for full pft

When they come to me I’ll just use my fancy shcmancy vyntus body for a plethysmographic lung volume

Mannitol is also far easier to admister and perform than methacholine . The aridol name brand comes with a DPI kit to inhale the mannitol capsules . It also tastes sweet (sugar alcohol after all) when inhaling . Takes far less time than nebulizing the methacholine and no “mixing And diluting methacholine “ is required .

Regardless insurances tend to not pay me for the mannitol meds itself so it’s a money loser procedure - hence I wold only do it as a means of “getting to to the bottom of an equivocal case “ and I tend to pair it with cpet in the same day to ensure adequate revenue

 

[hotsaws]

I guess it would depend on how much the reimbursement difference is between doing full PFTs and doing spiro (with or without BD). Then, of course, the difference between the cost of buying and maintaining equipment, training staff, and how much time it adds to workflow. I've never looked into it but I think its quite uncommon in the allergy community. Makes me think the juice isn't worth the squeeze for us but I could be wrong. My volume of spiro in a given day is decent but I'm not sure I would just funnel all those patients into full PFTs. Whereas I'm sure at a pulm office, just about every new patient you see is probably getting PFTs (or you could certainly justify it based on how much you wanna bill...kind of like a cardiologist can probably justify an echo for just about everyone they see). I'm sure most new patients with a respiratory component to their complaint could warrant PFTs. I routinely get spiro on my asthma and cough follow ups but I probably wouldn't get full PFTs unless I was really trying to milk it.

 

[NewYorkDoctors]

Right to be fair for asthma the spiro component has all one really needs with fev1 and peak flow . Though except for a younger patient whose only issue is asthma (th2 or non) , most patients I see tend to have multiple issues going on such as obesity restriction , asthma copd overlap , etc .

For my “textbook “ asthma patients I tend to give them a peak flow meter and just go by that on follow ups as ask as the asthma action plan. I got one of those MIR . I tend not to “just do spiro “ on the full PFT machine becuase that’s not a good use of the mouthpieces and RT time . I also have a MIR spirometer and don’t want to compare measurements made on different machines even if the same reference ranges were used to prevent any errors with technique .

There is that patient who has asthma (intermittent , possibly non TH2 ) who has normal spiro and negative bronchodilator response who reports improvement with bronchodilator use but who has hyperinflation on cxr and lung volumes (as well as the textbook elevated dlco ) whom I would trend full PFTs on if symptoms of dyspnea persisted to see whether it is due to persistence hyperinflation or if that improved and other etiologies should be investigated . I would likely do a bronchoprovacation and cpet on that patient

anyway the original point of my comment was wondering how many “non textbook asthma “ patients do the allergists see for dyspnea ? Or becuase these patients come for atopic issues then by selection bias alone most dyspnea in this population is going to be th2 asthma ?

 

[dozitgetchahi]

Great post. Would like to echo sure youre more likely to be making 600K-800K+ as a cardiologist or GI but youre working more. Not many subspecialties in IM aside from A/I where you can pretty confidently know that youll work under 40 hrs per week and clear 400K+ once youre established in a private practice either as partner or working independently in pvt practice. Its quite an attractive gig only caveat is having to do IM or peds residency which is no walk in the park. A/I is the lifestyle IM subspecialty where you get lifestyle AND good income unlike the others (endo etc) where you really only get lifestyle

As I’ve said elsewhere here before…

I’m rheum, I work 4.5 days a week, zero call zero rounds and I made $540k as a partner in a PP last year.

Ask me anything.

 

[NewYorkDoctors]

As I’ve said elsewhere here before…

I’m rheum, I work 4.5 days a week, zero call zero rounds and I made $540k as a partner in a PP last year.

Ask me anything.

what do you do when PCPs send you an ANA 1:80 and patient is freaking out? lol.

i would imagine a full joint exam, holding in your frustration at PCP or midlevel for doing this, get some joint imaging, and explaining how ANA is sensitive but not specific and how 5% of normal population can have 1:160 titers?

at least when im dealing with sub 6mm low risk no follow up Fleischner nodules, I have an option of "labeling it high risk" and doing it one more year later once and getting a PFT out of it. im unsure what the rheums get other than headaches?

 

[dozitgetchahi]

what do you do when PCPs send you an ANA 1:80 and patient is freaking out? lol.

i would imagine a full joint exam, holding in your frustration at PCP or midlevel for doing this, get some joint imaging, and explaining how ANA is sensitive but not specific and how 5% of normal population can have 1:160 titers?

at least when im dealing with sub 6mm low risk no follow up Fleischner nodules, I have an option of "labeling it high risk" and doing it one more year later once and getting a PFT out of it. im unsure what the rheums get other than headaches?

Sorting through the +ANA consults can indeed be somewhat painful at times lol. In my experience, often these people also have fibro, OA etc and the PCPs are ordering the ANA to try to sneak it through the filters.

I basically do what you describe. When I worked in AL, one nearby practice declined all ANA referrals unless they were >1:360, which is an interesting approach.

Also, wrt billing and ancillaries, I can usually bill a fair amount of labs to a +ANA workup…ENA panel, RF, CBC/CMP/ESR/CRP, C3/C4 and urinalysis. And maybe more labs if other symptoms are present. Potentially some joint imaging if joint symptoms are present. Which isn’t half bad as ancillaries go. And we do all of these in-house. And sometimes people have a bit of back pain as well, and I might be able to get PT started or a lumbar MRI etc, both of which we do in house also - and these are the real money makers as far as ancillaries go (especially PT).

 

[The kitchen sink]

As I’ve said elsewhere here before…

I’m rheum, I work 4.5 days a week, zero call zero rounds and I made $540k as a partner in a PP last year.

Ask me anything.

Not even practice call? Patient phone calls after hours ? Portal messages? However miniscule it may be be

 

[dozitgetchahi]

Not even practice call? Patient phone calls after hours ? Portal messages? However miniscule it may be be

I can be called with urgent lab results, or (very occasionally) an emergent patient issue. In practice this occurs once every 1-2 months or so, and usually is a nothing burger.

 

[Drrrrrr. Celty]

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…

I think there's a reason why a lot of Endos don't do high productivity like primary cares despite the fact that they could easily do it. It's easy to get burnt out from our patients and also because it's hard to unteach yourself that you need to be incredibly meticulous with patient charts, notes, numbers.
I think we as endocrinologists really go out of our way to make our own lives harder half the time because we think we're doing right by our patients.

 

[Drrrrrr. Celty]

I can be called with urgent lab results, or (very occasionally) an emergent patient issue. In practice this occurs once every 1-2 months or so, and usually is a nothing burger.

I think you're the boss man/madam.

 

[hotsaws]

Right to be fair for asthma the spiro component has all one really needs with fev1 and peak flow . Though except for a younger patient whose only issue is asthma (th2 or non) , most patients I see tend to have multiple issues going on such as obesity restriction , asthma copd overlap , etc .

For my “textbook “ asthma patients I tend to give them a peak flow meter and just go by that on follow ups as ask as the asthma action plan. I got one of those MIR . I tend not to “just do spiro “ on the full PFT machine becuase that’s not a good use of the mouthpieces and RT time . I also have a MIR spirometer and don’t want to compare measurements made on different machines even if the same reference ranges were used to prevent any errors with technique .

There is that patient who has asthma (intermittent , possibly non TH2 ) who has normal spiro and negative bronchodilator response who reports improvement with bronchodilator use but who has hyperinflation on cxr and lung volumes (as well as the textbook elevated dlco ) whom I would trend full PFTs on if symptoms of dyspnea persisted to see whether it is due to persistence hyperinflation or if that improved and other etiologies should be investigated . I would likely do a bronchoprovacation and cpet on that patient

anyway the original point of my comment was wondering how many “non textbook asthma “ patients do the allergists see for dyspnea ? Or becuase these patients come for atopic issues then by selection bias alone most dyspnea in this population is going to be th2 asthma ?

I see a fair amount of non textbook asthma, mostly as chronic cough or VCD. Sometimes I get some weird non specific dyspnea or hypoxia that's been labeled asthma by someone else and referred over to me. Sometimes these are cardiac or primary pulmonary issues that need to be seen (and sometimes quite quickly) by cards or pulm. Sometimes they just need to see psych and speech therapy. I typically manage chronic cough and VCD without involving pulm unless I really think I need them. We have a treadmill and can do exercise challenges or bronchoprovication but it's rarely necessary as it's usually sufficient to just empirically treat and see how they do.

 

[NewYorkDoctors]

I think there's a reason why a lot of Endos don't do high productivity like primary cares despite the fact that they could easily do it. It's easy to get burnt out from our patients and also because it's hard to unteach yourself that you need to be incredibly meticulous with patient charts, notes, numbers.
I think we as endocrinologists really go out of our way to make our own lives harder half the time because we think we're doing right by our patients.

Agreed
I would argue any sub specialist worth a lick would do this becuase unlike primary care , the subspecialize does on it have anyone else to refer to if it’s part of said subspecialists field

 

[Drrrrrr. Celty]

Agreed
I would argue any sub specialist worth a lick would do this becuase unlike primary care , the subspecialize does on it have anyone else to refer to if it’s part of said subspecialists field

I've progressively been going out of my way to "stay in my lane". I probably order less than half the amount of CBCs, CMPs, etc that I ordered last year. I mention that I see the patient has diabetes, but will defer manage to PCP unless otherwise requested / discuss medication compliance and proper technique but no more.

I also see myself progressively as time goes on doing more frequent and shorter visits for when active/new multiproblem patients are sent to me. Otherwise I don't have the time to discuss every problem.

 

[NewYorkDoctors]

I've progressively been going out of my way to "stay in my lane". I probably order less than half the amount of CBCs, CMPs, etc that I ordered last year. I mention that I see the patient has diabetes, but will defer manage to PCP unless otherwise requested / discuss medication compliance and proper technique but no more.

I also see myself progressively as time goes on doing more frequent and shorter visits for when active/new multiproblem patients are sent to me. Otherwise I don't have the time to discuss every problem.

of course

I mean what would the endocrine do any differently for a noncompliant ,metabolic syndrome Type 2 patient that the PCP couldn't do?

I surmise
1) actually spend time trying to education the patient on meds that a non-academic PCP does not have time (or want to) spend time with
2) having diabetes educator / nursing educator on hand
3) dealing with DEXCOM measurements?
4) rule out type 1 overlap / LADA etc?
5) assess cushing's, hemochromatosis, and other secondary DM?

Ultimately noncompliant patients gonna noncompliant.

 

[The kitchen sink]

As I’ve said elsewhere here before…

I’m rheum, I work 4.5 days a week, zero call zero rounds and I made $540k as a partner in a PP last year.

Ask me anything.

What locality / region do you practice in?

 

[ICmyFuture]

I've been making north of 400 as an Endo for a few years now. Hospital employed/ wrvu based. 4 days a week , get home around 5 pm one day and 4 pm the other 3 days. No call. It's definitely feasible in Endo to make more but I get why a lot of my colleagues make less/ see less patients. I don't mind seeing 19-24 patients a day though. I've thought about PP route as can likely take home more but just don't want to deal with all the other non medical stuff. I like having all my time off.

 

[dozitgetchahi]

What locality / region do you practice in?

Semi rural Midwest.

 

[Legend of Link]

I've been making north of 400 as an Endo for a few years now. Hospital employed/ wrvu based. 4 days a week , get home around 5 pm one day and 4 pm the other 3 days. No call. It's definitely feasible in Endo to make more but I get why a lot of my colleagues make less/ see less patients. I don't mind seeing 19-24 patients a day though. I've thought about PP route as can likely take home more but just don't want to deal with all the other non medical stuff. I like having all my time off.

that's a good gig. what part of the country? Do you have trouble going through 19-24 patients a day? do you think you can ramp up in future if you wanted to (volume avaibility, capibility of seeing more patients)?

 

[ICmyFuture]

that's a good gig. what part of the country? Do you have trouble going through 19-24 patients a day? do you think you can ramp up in future if you wanted to (volume avaibility, capibility of seeing more patients)?

Colorado. Seeing that many patients is not that hard. Most of the notes are pre-written, which allows me to actually talk with patients. Some patients take 3 mins, some 30 but it always evens out through out the day. I have yet to run behind and finish my last note as the last patient is walking out. The most I will see is around 25, not sure I would want to do more due to inbox stuff. I guess I could work 5 days a week and make 100-110k more but then I wouldn't be able to golf and ski on Friday 😉. I love what I do but you have to have balance in your life or you will burn out.

 

[Legend of Link]

Colorado. Seeing that many patients is not that hard. Most of the notes are pre-written, which allows me to actually talk with patients. Some patients take 3 mins, some 30 but it always evens out through out the day. I have yet to run behind and finish my last note as the last patient is walking out. The most I will see is around 25, not sure I would want to do more due to inbox stuff. I guess I could work 5 days a week and make 100-110k more but then I wouldn't be able to golf and ski on Friday 😉. I love what I do but you have to have balance in your life or you will burn out.

Were offers like these pretty typical when you were applying? Thinking mostly in west or east coast. Does inbox management take up a lot of your time day to day? For the notes, do you pre-write them the night before clinic?

 

[TexasMed22]

Were offers like these pretty typical when you were applying? Thinking mostly in west or east coast. Does inbox management take up a lot of your time day to day? For the notes, do you pre-write them the night before clinic?

MGMA average for endo is 289k. If someone is making substantially more than the average and says it's easy, you need to ask yourself, why aren't all the other docs doing that?

 

[bronx43]

MGMA average for endo is 289k. If someone is making substantially more than the average and says it's easy, you need to ask yourself, why aren't all the other docs doing that?

Demographics of the specialty. This is true in rheumatology as well. A lot of the rheum workforce are women who are married to high earning spouses, and have lower incentive to crank out 20-25 pts a day 4-5 days a week.

 

[CCM-MD]

MGMA average for endo is 289k. If someone is making substantially more than the average and says it's easy, you need to ask yourself, why aren't all the other docs doing that?

💯
Keep this in mind for every crazy number you see on this website.

 

[ICmyFuture]

This is why I don't like stating my income on these threads because I come off like every other poster who seems to make so much more than the average. Like how every hospitalist says they make 500 plus etc. It's the sdn effect I guess. I truly believe that most endos do not care about making all this money. I went into this speciality fully aware of the compensation and still so happy I did it. I say easy in that I have 34 contact hours and spend an extra 4 hours ( some time before clinic and an hour sometime between fri-sun) a week working on inbox. With commute that's only 40 hours a week for what I make. I never would have thought I would do this coming out of fellowship. I have a good setup, support staff. I also only do about 20% diabetes, and block a lot of bs referrals . I still say you need to do what you love ( I would do the same thing for 1/2 of what I make).

 

[NewYorkDoctors]

This is why I don't like stating my income on these threads because I come off like every other poster who seems to make so much more than the average. Like how every hospitalist says they make 500 plus etc. It's the sdn effect I guess. I truly believe that most endos do not care about making all this money. I went into this speciality fully aware of the compensation and still so happy I did it. I say easy in that I have 34 contact hours and spend an extra 4 hours ( some time before clinic and an hour sometime between fri-sun) a week working on inbox. With commute that's only 40 hours a week for what I make. I never would have thought I would do this coming out of fellowship. I have a good setup, support staff. I also only do about 20% diabetes, and block a lot of bs referrals . I still say you need to do what you love ( I would do the same thing for 1/2 of what I make).

agreed and appreciated

I work 80-90 hours like a resident / fellow still but i rake in much more. but that's not a flex to say "i'm better" far from it.
it just highlights that each doctor should decide what he/she wants to do.
less work less total revenue but better home life/personal life?
or grind pedal to the metal and squeeze every bit of juice out of this golden goose while we still can?

no right answer. one decides for oneself.


fortunately int he current EMR era i can do most of the paperwork at home with my kids nearby

i cannot imagine this would be feasible in a pre-EMR era.

 

[dozitgetchahi]

MGMA average for endo is 289k. If someone is making substantially more than the average and says it's easy, you need to ask yourself, why aren't all the other docs doing that?

1) MGMA numbers tend to be artificially low. MGMA sells its data primarily to hospital systems that have a vested interest in keeping salaries low. I’ve never been asked to fill out a salary survey, and I make well over MGMA medians in rheumatology.

2) Supply and demand based on locale. Doctors tend to oversaturate urban areas, and thus urban docs’ pay is lower on account of this excessive supply. Most doctors hang out in urban areas => urban docs pay is lower => the numbers reflect primarily what urban doctors make.

3) The “mommy track” effect in some specialties, as described above.

 

[NewYorkDoctors]

1) MGMA numbers tend to be artificially low. MGMA sells its data primarily to hospital systems that have a vested interest in keeping salaries low. I’ve never been asked to fill out a salary survey, and I make well over MGMA medians in rheumatology.

2) Supply and demand based on locale. Doctors tend to oversaturate urban areas, and thus urban docs’ pay is lower on account of this excessive supply. Most doctors hang out in urban areas => urban docs pay is lower => the numbers reflect primarily what urban doctors make.

3) The “mommy track” effect in some specialties, as described above.

yep.

just do some basic math and you know how much revenue a private practice doctor can pull in

99213 = $100 give or take which insurance, deductible, coinsurance/copay (if secondary medicaid or a Medicare supplement secondary then that coinsurance gets paid to you anyway

no procedures just basic math

PCP mill 30 patients a day X $100 = $3000 revenue
let's go a bit extreme now

5 days a week x 48 weeks a month (maybe four weeks off only like in residency)

30 * 1000 * 5 * 48 = $720,000

yes this is what PP 99213 mill PCPs make in the big urban areas.

unless you need to be tied to a hospital (for academics, for super specialized procedural specialties, or to get a nice 7 on 7 off job) you want to go private ASAP

 

[CCM-MD]

yep.

just do some basic math and you know how much revenue a private practice doctor can pull in

99213 = $100 give or take which insurance, deductible, coinsurance/copay (if secondary medicaid or a Medicare supplement secondary then that coinsurance gets paid to you anyway

no procedures just basic math

PCP mill 30 patients a day X $100 = $3000 revenue
let's go a bit extreme now

5 days a week x 48 weeks a month (maybe four weeks off only like in residency)

30 * 1000 * 5 * 48 = $720,000

yes this is what PP 99213 mill PCPs make in the big urban areas.

unless you need to be tied to a hospital (for academics, for super specialized procedural specialties, or to get a nice 7 on 7 off job) you want to go private ASAP

What about overhead?

 

[NewYorkDoctors]

What about overhead?

Well it’s just revenue . Still gottta pay the staff of course. But that overheard is unlikely to drop the physicians take home pay too far down unless one is hiring excessively . In Practice some of these 99213 mills see far higher numbers of patients. It’s just a thought exercise . Sure beats the 150K starting academic pcp salary in nyc .

 

[bronx43]

Well it’s just revenue . Still gottta pay the staff of course. But that overheard is unlikely to drop the physicians take home pay too far down unless one is hiring excessively . In Practice some of these 99213 mills see far higher numbers of patients. It’s just a thought exercise . Sure beats the 150K starting academic pcp salary in nyc .

Most clinic overhead I’ve seen (including my old physician owned group) is 50-60%. How low do you think staffing/overhead can get before you negatively impact operations?

I’ve played around with the idea of opening up own shop with very low overhead, but am concerned about being too lean.