Endocrine fellowship to owning a practice

[ARhospitalist]

Not much endocrinology talk in here but wanted to see if anyone had thoughts on my plan.

I am currently an academic hospitalist for the past 5 years. I am getting tired of the schedule and not having continuity with my patients.. Considering going back to endocrinology fellowship to have the outpatient gig but not primary care (don't think I could handle what primary care has become).

My overall thought would be to own a private practice, possibly concierge/direct pay set up, several years after fellowship.

Is this possible in endocrine? Can you go out on your own and actually make money without the backing of a big hospital or corporation. I currently have great benefits, vacation, job security etc.. So doing something like this would make me nervous. But I really can't imagine being required to see patients every 15 minutes with all the other requirements in outpatient med.

Thanks for any help

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[rokshana]

Not much endocrinology talk in here but wanted to see if anyone had thoughts on my plan.

I am currently an academic hospitalist for the past 5 years. I am getting tired of the schedule and not having continuity with my patients.. Considering going back to endocrinology fellowship to have the outpatient gig but not primary care (don't think I could handle what primary care has become).

My overall thought would be to own a private practice, possibly concierge/direct pay set up, several years after fellowship.

Is this possible in endocrine? Can you go out on your own and actually make money without the backing of a big hospital or corporation. I currently have great benefits, vacation, job security etc.. So doing something like this would make me nervous. But I really can't imagine being required to see patients every 15 minutes with all the other requirements in outpatient med.

Thanks for any help

possible, but PP is not easy and high volume is basically the way you are going to become solvent...and it may take a few years before there is profit. And you need to be fairly business savvy...something most physicians are not...

for example, i recently helped a local PP endocrinologist when the employed physician he had working for him left the practice...it was eye opening to say the least...he sees new in 30 min, eat 10-15...he will easily see 25-30 pt a day...while for a PC, this is probably no big deal, the standard in endo is 40/20 or 30/30 (the established ones take <30 so that time can be used with the new pts that > 30....plus he takes call at 2 local hospitals...frankly i don't know how he does it.

small group or multi specialty group have be more feasible in this day and age.

 

[IM2GI]

Is this possible in endocrine? Can you go out on your own and actually make money without the backing of a big hospital or corporation. I currently have great benefits, vacation, job security etc.. So doing something like this would make me nervous. But I really can't imagine being required to see patients every 15 minutes with all the other requirements in outpatient med.

Thanks for any help

Sounds like an awful plan.

You have to get into and go through an endocrinology fellowship after being in practice for 6-7 years depending on when you get in. Right off the bat, many people forget how much it sucks being a trainee making 60k.

So lets assume you pull that off, match into a decent fellowship, take the personal/financial/family hit of being a trainee for another 2-3 years. Even then, I think you would be insane in the 2019 climate where every group is trying to merge/get bigger to try to hang up a shingle as a subspecialist. Who is going to refer you patients? Most primary care groups are being bought up and likely then refer to whatever endocrine providers are within that system.

Rest assured that smarter/more business savvy endocrinologists have been in your area for a long time.

The bottom line for me is that your window for something like this closed decades ago. It is just too high risk for limited upside. Bundled payments and ever declining reimbursements are the future. After overhead, insurance, etc, you are just not going to make any money trying to do this by yourself and are accepting a huge amount of financial liability. "cash pay" "concierge medicine" sounds great, but you know what? Super rich people who will/can afford such luxuries are not looking for the 40 year old brand new grad.

Now is the time to be content with the skills and specialty you have chosen. Do not risk your financial future and retirement nor put yourself/your family through this. If you don't like your hospitalist job find a new, not a new field. If you are hellbent on concierge medicine, a primary care clinic is at least somewhat more sane, although again I wouldn't recommend it.

 

[ARhospitalist]

possible, but PP is not easy and high volume is basically the way you are going to become solvent...and it may take a few years before there is profit. And you need to be fairly business savvy...something most physicians are not...

for example, i recently helped a local PP endocrinologist when the employed physician he had working for him left the practice...it was eye opening to say the least...he sees new in 30 min, eat 10-15...he will easily see 25-30 pt a day...while for a PC, this is probably no big deal, the standard in endo is 40/20 or 30/30 (the established ones take <30 so that time can be used with the new pts that > 30....plus he takes call at 2 local hospitals...frankly i don't know how he does it.

small group or multi specialty group have be more feasible in this day and age.

Thanks for the reply. How is the job market overall for larger groups or even hospital owned groups? And what is your daily patient numbers run?
I feel like alternant models for endocrine practice, especially diabetes care, are going to be popular in the not distant future. And the ability to innovate and be independent is one of the things that I would want to do. Even if it means being under a larger group.

To IM2GI, thanks for your advice as well. I certainly know the financial implications of this and I always thought I may go back to fellowship when I finished residency. But loans are paid off, large nest egg saved up for this transition. And definitely would only do a two year fellowship.
I just in no way see myself as a hospitalist, working evenings/nights and feeling like a well payed resident, in 10-15 years... now do I think I want to be seeing outpatients 5 days per week? not really.

The medicine world is sometimes so inflexible that I feel like getting to what I want for my career will be tough. But may. not be impossible by taking risks.

 

[rokshana]

Thanks for the reply. How is the job market overall for larger groups or even hospital owned groups? And what is your daily patient numbers run?
I feel like alternant models for endocrine practice, especially diabetes care, are going to be popular in the not distant future. And the ability to innovate and be independent is one of the things that I would want to do. Even if it means being under a larger group.

To IM2GI, thanks for your advice as well. I certainly know the financial implications of this and I always thought I may go back to fellowship when I finished residency. But loans are paid off, large nest egg saved up for this transition. And definitely would only do a two year fellowship.
I just in no way see myself as a hospitalist, working evenings/nights and feeling like a well payed resident, in 10-15 years... now do I think I want to be seeing outpatients 5 days per week? not really.

The medicine world is sometimes so inflexible that I feel like getting to what I want for my career will be tough. But may. not be impossible by taking risks.

Not sure why you think so since endocrinology is low revenue generating and relies on the ability to have a balance from higher revenue generating specialties...to start solo in this day and age means a lot of work to be profitable...if you dont see yourself seeing pts 5 days a week as outpt, the PP endo is not going to be for you if you are also looking to make decent money.

There is a great deal of flexibility in medicine, but something had to give...want money? you have to work a lot or live on the middle of nowhere...want free time? You give up money...you have to decide what is important and what you are willing to compromise on...

But please, don’t go into endocrinology because you think it’s not that much work...it is and people who choose endo do so because they like the field not money.

 

[ARhospitalist]

Sorry if my post came across about talking about lifestyle and trying not to find something that is "not that much work". I really enjoy endocrine problems in the hospital and enjoyed the long term nature of diabetes care in residency. The inflexible nature I am taking about is the way a clinic must run to make money or the way the hospital must run because that is the way it is done. Not the lifestyle/money flexibility. I actually have more flexibility in my schedule as a hospitalist than I ever imagined possible. And I imagine working in endocrine will be more, not less work than I perform in my hospitalist job now.

It is just in residency, I could do a lot of patient care through email and phone messages (because my salary did not matter if I saw you in clinic or not). But what I worry about is my ability to practice the way I want to and the way I think patients would want. For example, why do we have diabetes patients come in every 3 months (or even more frequently). Why don't we have tele-visits or ongoing care through messaging. My experience, as a patient and from talking with endocrine physicians, is that this is hard to do because of payment structures from insurance.

I am trying to get a sense of whether anyone practices differently. Is there any innovation in the endocrine outpatient world? Do patients desire this or am I just out in left field with my ideas.

 

[IM2GI]

Sorry if my post came across about talking about lifestyle and trying not to find something that is "not that much work". I really enjoy endocrine problems in the hospital and enjoyed the long term nature of diabetes care in residency. The inflexible nature I am taking about is the way a clinic must run to make money or the way the hospital must run because that is the way it is done. Not the lifestyle/money flexibility. I actually have more flexibility in my schedule as a hospitalist than I ever imagined possible. And I imagine working in endocrine will be more, not less work than I perform in my hospitalist job now.

It is just in residency, I could do a lot of patient care through email and phone messages (because my salary did not matter if I saw you in clinic or not). But what I worry about is my ability to practice the way I want to and the way I think patients would want. For example, why do we have diabetes patients come in every 3 months (or even more frequently). Why don't we have tele-visits or ongoing care through messaging. My experience, as a patient and from talking with endocrine physicians, is that this is hard to do because of payment structures from insurance.

I am trying to get a sense of whether anyone practices differently. Is there any innovation in the endocrine outpatient world? Do patients desire this or am I just out in left field with my ideas.

Effect of telemedicine on glycated hemoglobin in diabetes: a systematic review and meta-analysis of randomized trials. - PubMed - NCBI

Search PubMed for telemedicine + Diabetes and there are many, many articles.

There is no question that once Apple figures out how to integrate blood glucose monitoring into an Apple Watch that there will be significant disruption to the industry. IMO, that disruption will not come from the solo practitioner managing his/her own patients, but large companies with armies of PAs/NPs/pharmacists managing 10s of thousands of patient's blood sugar. You are correct in that coming in every 2-3 months with your log book is antiquated, the question is are you the guy that is going to change the industry?

There are already companies out there on the monitoring side, I suspect there will be management as well.

Remote Patient Monitoring - Glooko

Your heart seems to be in the right place, I just think this is a losing proposition from a business perspective. Your model is not as innovative as you may think it is. If you want to practice endocrinology that's great. Join an established private group that will let you explore this model within the confines of an established practice.

 

[rokshana]

Sorry if my post came across about talking about lifestyle and trying not to find something that is "not that much work". I really enjoy endocrine problems in the hospital and enjoyed the long term nature of diabetes care in residency. The inflexible nature I am taking about is the way a clinic must run to make money or the way the hospital must run because that is the way it is done. Not the lifestyle/money flexibility. I actually have more flexibility in my schedule as a hospitalist than I ever imagined possible. And I imagine working in endocrine will be more, not less work than I perform in my hospitalist job now.

It is just in residency, I could do a lot of patient care through email and phone messages (because my salary did not matter if I saw you in clinic or not). But what I worry about is my ability to practice the way I want to and the way I think patients would want. For example, why do we have diabetes patients come in every 3 months (or even more frequently). Why don't we have tele-visits or ongoing care through messaging. My experience, as a patient and from talking with endocrine physicians, is that this is hard to do because of payment structures from insurance.

I am trying to get a sense of whether anyone practices differently. Is there any innovation in the endocrine outpatient world? Do patients desire this or am I just out in left field with my ideas.

If you are interested in diabetes care primarily, there are groups out there that do telemedicine ...

 

[Raryn]

Thanks for the reply. How is the job market overall for larger groups or even hospital owned groups? And what is your daily patient numbers run?

I can speak to this some. The job market in Endocrine is generally excellent, but heavily regional when it comes to pay. I know fellows who graduated this year who got jobs in most of the large markets in the US, and everyone found groups that were recruiting.

A typical job is 4-5 days/week of clinic with the typical expectation of eventually seeing 20 patients per day. Right now I have a job where I work 4.5 days/week (I alternate 4 and 5) with a template that has 18 spots (it's not full yet) and I have 30 days (6 weeks) of PTO (combined vacation/CME/sick leave) per year. My final template has 18 slots/day (though it hasn't filled up yet) - this is fairly typical for an employed position where you end up making around average pay (low 200s your first year with an earning potential in the median, ~$250k range). That pay will be less in big cities (ex: NYC) where more people want to live, even less in academia. Will be more in more rural areas (could be a lot more). But regardless, there's very few unemployed endocrinologists.

I will leave you with one post card I got a couple months ago for an extreme (I've gotten similar job posting information before):

 

[bronx43]

Endo job market is great - possibly one of the best within IM specialties. My group is trying to hire an additional 1-2 endos and it's been nearly impossible. Other specialties like cardiology is dime a dozen.

 

[rokshana]

I can speak to this some. The job market in Endocrine is generally excellent, but heavily regional when it comes to pay. I know fellows who graduated this year who got jobs in most of the large markets in the US, and everyone found groups that were recruiting.

A typical job is 4-5 days/week of clinic with the typical expectation of eventually seeing 20 patients per day. Right now I have a job where I work 4.5 days/week (I alternate 4 and 5) with a template that has 18 spots (it's not full yet) and I have 30 days (6 weeks) of PTO (combined vacation/CME/sick leave) per year. My final template has 18 slots/day (though it hasn't filled up yet) - this is fairly typical for an employed position where you end up making around average pay (low 200s your first year with an earning potential in the median, ~$250k range). That pay will be less in big cities (ex: NYC) where more people want to live, even less in academia. Will be more in more rural areas (could be a lot more). But regardless, there's very few unemployed endocrinologists.

I will leave you with one post card I got a couple months ago for an extreme (I've gotten similar job posting information before):

View attachment 248983

I can’t even imagine how crazy that schedule will be for that lone endo in the middle of no where...even with 46 days off...

 

[Raryn]

I can’t even imagine how crazy that schedule will be for that lone endo in the middle of no where...even with 46 days off...

With a 4 day workweek and 46 days off, that's 3 months of vacation. Sounds like you'd need it.

 

[ARhospitalist]

I can speak to this some. The job market in Endocrine is generally excellent, but heavily regional when it comes to pay. I know fellows who graduated this year who got jobs in most of the large markets in the US, and everyone found groups that were recruiting.

Thanks for the great information. And thanks to everyone else for the advice and help.

Raryn, when you have a full schedule, do you feel like you still get everything done at work. Notes, following up labs etc. I like that all my notes and stuff are done while in the hospital with my job now. But I am also very efficient and do not take long to write/dragon dictate an H/P or progress note. So I am expecting that I could do a clinic note in even less time. I am happy to work after hours for call or answering my patients questions. Just don't know about sitting at a computer all evening typing notes, which seems to be a common complaint in primary care.

 

[Raryn]

Thanks for the great information. And thanks to everyone else for the advice and help.

Raryn, when you have a full schedule, do you feel like you still get everything done at work. Notes, following up labs etc. I like that all my notes and stuff are done while in the hospital with my job now. But I am also very efficient and do not take long to write/dragon dictate an H/P or progress note. So I am expecting that I could do a clinic note in even less time. I am happy to work after hours for call or answering my patients questions. Just don't know about sitting at a computer all evening typing notes, which seems to be a common complaint in primary care.

I don't but I could if I didn't spend 2/3 of my downtime in my workday surfing SDN and Reddit.

 

[rokshana]

Thanks for the great information. And thanks to everyone else for the advice and help.

Raryn, when you have a full schedule, do you feel like you still get everything done at work. Notes, following up labs etc. I like that all my notes and stuff are done while in the hospital with my job now. But I am also very efficient and do not take long to write/dragon dictate an H/P or progress note. So I am expecting that I could do a clinic note in even less time. I am happy to work after hours for call or answering my patients questions. Just don't know about sitting at a computer all evening typing notes, which seems to be a common complaint in primary care.

Realize that a hospitalist inpt is very different that a endocrine (or any subspecialist note) in that there are more details in the note since you are having to answer a question for the referring doctor...and many times there are a number of issues that have to addressed...my clinic consultation note does take longer than my hospitalist H&P. Most endocrinologist I know stay and hour or so after clinic ends to get work wrapped up. If you want to switch to endo, do so because you like the work not because you think it will be easier than being a hospitalist...I still do both and while nocturnist work is generally easier , it’s not as overall interesting to me and if I have a choice , I’ll pick the endo job over the hospitalist job, even if the hospitalist job is easier.

I’m getting the sense you think the grass is greener ...it’s not, just different.