financial impact of pulm/ccm vs hospitalist

[manofmen]

Hello all,

I'm a hospitalist in NYC interested in a career in global health (med-ed, humanitarian work) and have been considering a pulm/ccm fellowship based on these goals, but more recently, with some more consideration of finances. In brief, I've realized I've been naively idealistic about money and combining my goals of living a comfortable life in CA (buying a mid-sized home in LA/Bay Area, etc) while also giving up income to work in South Asia one day. I think pulm/ccm might be a sustainable career in a way that hospital medicine (currently first year as hospitalist at my residency institution) will not be, and perhaps in my 'off time' allow me to explore my non-clinical interests/hobbies in a way that cards/GI may not be able to.

I was wondering if people here could briefly speak to the ways in which pulm/ccm is a better financial option than hospital medicine? I currently make 180k full time in NYC as an academic hospitalist before moonlighting (total ~200-220k), and am looking to move to CA and practice medicine there for much of my career. Do you know/have a sense of the starting and mid-career pulm/ccm salaries in SF/LA based on your or your colleagues' experience? I was curious about both the 7 on/off models and the hybrid ICU/clinic models and the pay differentials, esp ones that involve a 'week off' and have the option of pulm consults and clinic.

I hate to be crassly asking about money but I've regrettably realized at this stage in my life (I'm 32) that my generation's world will be a lot more complicated with regard to living a decent life in an expensive state and doing meaningful global health work. I'm asking this question because I actually enjoyed my time in the ICU, am fairly analytical/math minded and for that reason might enjoy pulmonology as well.

Thank you so much for your thoughts.

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[Splenda88]

Wow. I am a hospitalist. That is an extremely low salary. Is hospitalist salary that bad in these big cities (NY, LA etc...)?

 

[chessknt]

Don't ask this question on SDN and expect realistic answers. MGMA median is usually a third of what numbers get posted here where 90th percentile income is the starting point.

There was a thread on this exact topic in IM recently--the consensus was that thanks to guaranteed 10% annual returns in the stock market and hospitalist pay of 350/hr hospitalist will win against every medical subspecialty and most sutgical subspecialties. In conclusion, be a hospitalist and start cashing the 6 figure monthly checks from home by 2 pm during your 10 days or work a month.

 

[CCM-MD]

Not this again. See recent IM section thread.

 

[aafisahar]

the simple answer that no one wants to hear is that you can't have it all. you can't have a 90th percentile job in a coastal city and also have enough time off to do month long jaunts in indonesia or wherever it is you want to go.

job
money
location

Choose two.

 

[manofmen]

There was a thread on this exact topic in IM recently--the consensus was that thanks to guaranteed 10% annual returns in the stock market and hospitalist pay of 350/hr hospitalist will win against every medical subspecialty and most sutgical subspecialties. In conclusion, be a hospitalist and start cashing the 6 figure monthly checks from home by 2 pm during your 10 days or work a month.

Are you referring to the MGMA median for hospitalists and pulm/ccm?

One of the reasons I started this thread was because I thought that previous conversation dovetailed into unnecessary comparisons and unrealistic expectations for how much a hospitalist makes-I make 180k in a large city and certainly feel to reach the 350k median for pulm/ccm would come with quite a bit of extra work that hospitalists have to do, and may not be feasible long term for many such as myself. I was curious what the CA market looked like as I plan out my future goals.

 

[manofmen]

Not this again. See recent IM section thread.

I wasn't sure how much the rate for pulm/ccm would be in CA and I couldn't find that addressed in the recent IM thread. I also thought the hospitalists were not making fair comparisons with pulm/ccm given the 90th percentile for pulm/ccm would likely be making quite a bit more than the 350-400k hospitalists. Thank you for your helpful comments on that thread. I too worry about midlevel creep.

 

[manofmen]

the simple answer that no one wants to hear is that you can't have it all. you can't have a 90th percentile job in a coastal city and also have enough time off to do month long jaunts in indonesia or wherever it is you want to go.

job
money
location

Choose two.

Picking location (SF/LA) and money! As the stones sing, 'you can't always get what you want...'

 

[chessknt]

Are you referring to the MGMA median for hospitalists and pulm/ccm?

One of the reasons I started this thread was because I thought that previous conversation dovetailed into unnecessary comparisons and unrealistic expectations for how much a hospitalist makes-I make 180k in a large city and certainly feel to reach the 350k median for pulm/ccm would come with quite a bit of extra work that hospitalists have to do, and may not be feasible long term for many such as myself. I was curious what the CA market looked like as I plan out my future goals.

If you're working in LA/SF I'm not sure the opportunity coat makes sense. Pccm in LA might be in the 300s while hospitalists are in the low 200s, I know some outlying places in northern California have advertised 600+ as pccm but it is an hour plus away from SF still with 7+ figure home values.

 

[sloh]

I live in SoCal. Agree it’s not worth the the opportunity cost unless you make over 400k minimum.

 

[manofmen]

I live in SoCal. Agree it’s not worth the the opportunity cost unless you make over 400k minimum.

Can you speak to what the average rates are in LA or SF?

 

[Student3322]

Can you speak to what the average rates are in LA or SF?

Kaiser around SF was offering ~380k when I asked around, academics was ~200k

 

[spacegun]

For $ you'll probably find more intra-specialty variability (IM vs. IM, pccm vs. pccm) than inter-specialty (IM vs. pccm).

Plus $ depends on so many variables. Base $, RVU % until make partner, how long to partner, expected schedule (what mix of ICU, inpatient pulm, clinic), what are nights like (e.g. in-house?), what's call like (e.g. home?), procedures, any mid-levels to help, payer mix, PTO, 401k match, non-competes, etc.

Generally speaking, probably not worth doing fellowship if money/FIRE is primary concern. White Coat Investor has some posts on the topic of whether or not to do fellowship. For example:

Should I Do a Medical Fellowship? | White Coat Investor

Does it make financial sense for you to do a fellowship? Maybe not. But don't let that dissuade you. Here's what to consider about a medical fellowship.

www.whitecoatinvestor.com

 

[manofmen]

For $ you'll probably find more intra-specialty variability (IM vs. IM, pccm vs. pccm) than inter-specialty (IM vs. pccm).

Plus $ depends on so many variables. Base $, RVU % until make partner, how long to partner, expected schedule (what mix of ICU, inpatient pulm, clinic), what are nights like (e.g. in-house?), what's call like (e.g. home?), procedures, any mid-levels to help, payer mix, PTO, 401k match, non-competes, etc.

Generally speaking, probably not worth doing fellowship if money/FIRE is primary concern. White Coat Investor has some posts on the topic of whether or not to do fellowship. For example:

Should I Do a Medical Fellowship? | White Coat Investor

Does it make financial sense for you to do a fellowship? Maybe not. But don't let that dissuade you. Here's what to consider about a medical fellowship.

www.whitecoatinvestor.com

Ah thank you for this, and your point is well taken. In reading that post it seemed as if on average, pulm/ccm, cards and GI were medicine fields where the net benefit may be worth it in the long-term. I think money and the longevity of the career is the primary concern. I enjoy IM for now but am sensing potential future burnout in a way that I don't think I would with the flexibility of pulm/cccm; if the averages in California stay around 350k in a big city (70-100k more than a daytime hospitalist in a big CA city), or perhaps my goals change and I leave a bigger city for a smaller market, it sounds like I'd be ok for the near future (albeit not considering NP creep and future of AI in medicine) doing fellowship.

 

[Splenda88]

@CCM-MD

What's the $/RVU range for CCM and what is the national average number of RVUs?

 

[CCM-MD]

@CCM-MD

What's the $/RVU range for CCM and what is the national average number of RVUs?

Off the MGMA 2020 for CC/Intensivist
$448k mean
Mean wRVU 4877
$114/wRVU

 

[Splenda88]

Off the MGMA 2020 for CC/Intensivist
$448k mean
Mean wRVU 4877
$114/wRVU

a CCM doc was telling me his base pay is 425k plus RVUs. Does that mean he makes ~1 mil per year?

 

[CCM-MD]

a CCM doc was telling me his base pay is 425k plus RVUs. Does that mean he makes ~1 mil per year?

Unlikely

 

[psychbender]

a CCM doc was telling me his base pay is 425k plus RVUs. Does that mean he makes ~1 mil per year?

No, the $/RVU and RVU average represents the billing and collections for the professional fees generated by the intensivist, going to whatever entity employees the physician. A hospital paying out base plus RVU bonus will try to get the total pay to be close to the amount they receive from billing. So, 4877 average RVUs at $114/ unit yields $555,978. If the hospital paid $425k base, and $20/ RVU, they'd end up paying the intensivist $522,540. Benefits likely cost another $50-75k, so the hospital is subsidizing the intensivist income at that level from money collected from other sources. That $20/ unit was pulled out of my ass, all of us here at my shop are paid per shift, so I don't know how that rate maps onto people that are actually paid via this base + production model.

 

[CCM-MD]

Benefits are not included in the MGMA number, it’s based on total cash compensation - so 401k, CME money etc is included but not health insurance etc. There are so many compensation models out there. My previous job was 420k base plus $40/wRVU over 5000. We worked days only and ran a high census so we generated quite a lot of wRVUs (9000 range) and the bonus check ended up being pretty fat. Where I am now, base comp is much higher and the $/wRVU number is also much higher, but the wRVU bonus I end up seeing is minimal. Adding in nights complicates the calculation as well since most of the RVUs are generated during the day.

No, the $/RVU and RVU average represents the billing and collections for the professional fees generated by the intensivist, going to whatever entity employees the physician. A hospital paying out base plus RVU bonus will try to get the total pay to be close to the amount they receive from billing. So, 4877 average RVUs at $114/ unit yields $555,978. If the hospital paid $425k base, and $20/ RVU, they'd end up paying the intensivist $522,540. Benefits likely cost another $50-75k, so the hospital is subsidizing the intensivist income at that level from money collected from other sources. That $20/ unit was pulled out of my ass, all of us here at my shop are paid per shift, so I don't know how that rate maps onto people that are actually paid via this base + production model.

 

[SurfingDoctor]

At a 0.5 FTE, I generate 6000+ wRVUs and get no bonus and a much lower salary.

Damn, pediatric ICU is a rip off. I mean, I wouldn’t change it cause I love my job… but damn. They needs to make an electric Lada.