Finishing up 3rd year as a neurosurgery attending, ask me anything

[NeuroJHB]

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Pre-M1 MD/PhD student interested in neurosurgery. Any suggestions for how to position myself well?

 

[mmmcdowe]

Pre-M1 MD/PhD student interested in neurosurgery. Any suggestions for how to position myself well?

Well, I think the biggest thing is to show interest first and to identify whether or not there is a neurosurgery affiliated or run lab that would potentially meet your PhD objectives. For example, if you have a MD, PhD epilepsy surgeon who studies language and that's what you want to do your PhD in that would be optimal in terms of both building a relationship with neurosurgeons and also developing practical research skills.

 

[mmmcdowe]

Now coming up on almost two years as an attending in pediatric neurosurgery. AMA.

 

[Cognovi]

You previously stated that many of your consults as a resident were along the lines of being asked to interpret a radiology read. What do you hope (neuro)radiologists could say more clearly so you could avoid such consults?

Now that you're an attending, do you have a go-to trusted neuroradiologist for second opinions about weird studies (or weird first reads)?

 

[mmmcdowe]

Well to be fair, a lot of it is more the consulting service wanting me interpret what the radiologists mean by what they say rather than asking the radiologist.

For their part, being reasonable with hedging is appreciated. For example, there is no such thing as a borderline Chiari. It is either a Chiari or it isn't. So instead of saying borderline Chiari, say cerebellar ectopia that does not meet criteria for Chiari Malformation.

Yes, I have several radiologists that I work with for different imaging types (skullbase/pituitary, spine, etc).

 

[Rachapkis]

Are you finding that you enjoy your career more as you are becoming more knowledgable and accomplished at neurosurgery? Is attending > resident > medical student?

 

[operaman]

Looking back, anything specifically you wish you’d negotiated for back when you applied? Clinic support, scribes, etc?

How much control do you have over your non-call schedule? Do you decide your own clinic hours, number of patients, etc?

 

[mmmcdowe]

Are you finding that you enjoy your career more as you are becoming more knowledgable and accomplished at neurosurgery? Is attending > resident > medical student?

I enjoyed the whole process and each has had their own joys and frustrations, but it's hard to argue that my life isn't better in terms of finances, freedom, and free time now. I would do it all again if I could go back but I wouldn't do it again for fun now

 

[mmmcdowe]

Looking back, anything specifically you wish you’d negotiated for back when you applied? Clinic support, scribes, etc?

How much control do you have over your non-call schedule? Do you decide your own clinic hours, number of patients, etc?

I wish I had argued for block time rather than the communal time my group shares. It ends up with a lot of weird case orders.

I have substantial control of my schedule, but surprisingly getting busier is harder than staying at the same volume. Despite verbal support actually getting new clinics, etc up and running is a very lengthy undertaking. It took me more than a year to set up my first clinic remote to the main hospital.

 

[mmmcdowe]

Bump. Got board certified, got promoted to associated professor at a different institution, seriously considered leaving academics despite success in it, now two kids in. AMA

 

[karaya]

Here's a personal question since you mentioned kids. What were you actually looking for in a partner? Did you approach dating methodically? Or did you just meet someone who was funny and hot and it clicked right away? I feel a lot of pressure to find someone and start a family, but it ain't happening anytime soon and I'm starting to feel weird. There seems to be a soft taboo around dating classmates, but those are the only people I see and know (preclinical here).

 

[mmmcdowe]

Here's a personal question since you mentioned kids. What were you actually looking for in a partner? Did you approach dating methodically? Or did you just meet someone who was funny and hot and it clicked right away? I feel a lot of pressure to find someone and start a family, but it ain't happening anytime soon and I'm starting to feel weird. There seems to be a soft taboo around dating classmates, but those are the only people I see and know (preclinical here).

Well truthfully I had a series of deeply unhealthy relationships in medical school and early residency due to a propensity towards serial monogamy with the first person I connected with even if there were red flags. After one particularly chaotic relationship, I took some time to work on myself and work on saying no and putting my needs first instead of feeling guilty about not being satisfied. Went on a ton of first dates and had a few overlapping casual dating situations that didn't go anywhere. I pushed myself to stay single for at least a year unless I truly felt like it checked all the boxes and held myself accountable for breaking it off directly and respectfully when it wasn't a match after a date or dates. When I met my wife it was love at first sight, which was something I had given up on in my 30s. We met via dating app, which was my go to due to trying to avoid dating within my hospital system. No real method except I guess a practice makes perfect mentality. I also stopped talking to my social circle about casual dating. No more locker room talk, etc.

 

[Kierkegaard's Bud]

Bump. Got board certified, got promoted to associated professor at a different institution, seriously considered leaving academics despite success in it, now two kids in. AMA

Do you think the stability of academics is overrated given the larger forces at work in the current times? I'm finishing medical school right now and I used to think the benefits of academics really shine later in your career when you dont have to work as much (or more flexible), or at least that what my mentor advised me on. Thoughts?

 

[mmmcdowe]

Do you think the stability of academics is overrated given the larger forces at work in the current times? I'm finishing medical school right now and I used to think the benefits of academics really shine later in your career when you dont have to work as much (or more flexible), or at least that what my mentor advised me on. Thoughts?

I would not say that academic jobs are necessarily more stable. Tenure even if you get it does not protect your clinical salary, only your academic one. This tends to be a very small fraction of your income as a surgeon. Further, there is a growing trend towards one-year contracts in academics, which in many regards is much less stable. Dan than buying into a partnership. There are so many ways to earn income as a surgeon. I would not base your life. Ann, a future belief that you will work less. Who knows what the state of education will be then, but currently there is a rapid decrease in work hours, which at some point is going to result in greater work hours for faculty. I get paid my monthly academic salary by taking 10 days of locums a month. Some of these jobs are shockingly low volume. For example, I have done about a month's worth of coverage for one specific hospital and have done a total of one emergent procedure. There have been whole weekends where I've received no consults and just hung out with my family at a local hotel or resort. Plus you have to factor in all of the non-clinical stuff that you often will get involved in as an academic Neurosurgeon. Hour for hour I think hospital owns and Private practice are going to out compete academics at all stages. Conversely, you can pretty much grind in any type of practice. It is more specific to the location and competition then type of practice.

 

[Cognovi]

How long did it take to get to associate professor and what are the general criteria for promotion at your place?

 

[mmmcdowe]

Well that is somewhat complicated. In general, it is much easier to get promoted when you move to a new job. So in full disclosure that is what happened for me. I am finishing my third year of post fellowship practice and I would say I am probably 2 to 5 years ahead of the average for that promotion because I moved. That being said The exact criteria for promotion are program specific. At my prior institution the expectation was to have a minimum of 30 or so publications after graduation and evidence of local and national academic activity or other contributions. You also had to solicit support from 10 individuals of the rank you were applying to or higher that could not be from your own institution, primarily. It then went to a university advisory board dedicated to academic promotions for approval. It is like a year-long process and I was invited to apply but to be fair I suspect that was partially because they knew I was looking at other positions and they were trying to keep me. One thing that has really shocked me about academics is how much people love titles and how often those titles come with no additional compensation or resources. Granted professorial status does come with a very small pay boost, but all of the other fancy titles are essentially just something to put in your signature in a lot of cases, unless you specifically negotiate that they come with certain resources such as a coordinator this is why I think it is important not to be super impressed by all of these clinics for specific diseases. I ran what was called a comprehensive pediatric neurovascular clinic of excellence. It just consisted of me in my neuroendovascular partner seeing patients on a specific day together. We didn't have a special coordinator or anything. It was just two people doing their normal clinic with a few hours of overlap. I often have to prevent myself from rolling my eyes when patients will tell me about ascher neurosurgeons that they got opinions from who have blah blah blah clinic. It is absolutely good to have a group of physicians with expertise on a specific topic, but the multidisciplinary clinic of the old days has now become a marketing scheme which I don't love. In the end, when you are talking about surgeons and patient outcomes, 95% of that comes down to the specific surgeons.

 

[MilesDavisTheDoctor]

im going into ortho but im curious to hear your thoughts on private practice vs. employed vs academics as a surgeon.

 

[mmmcdowe]

im going into ortho but im curious to hear your thoughts on private practice vs. employed vs academics as a surgeon.

Without a doubt going into private practice should be the default for most surgeons. Both hospital-based practice and especially academics take away a lot of economic power, but just as importantly, they tend to take away a lot of ability to make decisions that have a lot of effect on your quality of life, such as hiring and salary of employees. Hospital employed physicians however may have access to a little bit more resources to do more complex work depending on the situation and relationship that a given private practice has with a hospital. The primary reason to go into academics is if there is something that you can truly not do outside of it. This definitely does not include research as a whole, though it probably does include basic science unless you were very far along in your career. Frankly, I have found academic bureaucracy to be a significant hurdle rather then help when it comes to my research which is primarily device development, so I wouldn't say that you can't do research outside of academics, but your scope is going to be much more limited. The primary reason I stayed in the academics after residency and continue to stay in academics is two fold. First, I really do love teaching medical students and residents and that is going to be in general. Pretty hard to do in true private practice. Second, as a pediatric neurosurgeon, the vast majority of jobs are at academic affiliated children's hospitals, simply due to the rarity of the field. There are far less pediatric neurosurgeons than NFL players, so you can imagine that significantly limits the migration potential one has. They do exist however.

 

[phantasmo]

I think the future of neurological treatment is going to rely heavily on bio-informatics to determine appropriate individual treatment. As far as neurosurgery goes, I think we are going to continue to invest heavily in technology to improve our surgical performance.

10 years later.

how true is this and can you give a lay of the land.

how much innovation is there, and how are nsgy attendings getting involved? and is it more on the academic side where they get involved or pp or both. how does it work.

thanks

 

[phantasmo]

Certainly I can see it losing some of its pizaz but I have always enjoyed manual tasks like model building so ultimately I am not too worried because every case is unique no mater how simple. For me at least I also tend to be invigorated by teaching so I hope that by being involved in teaching I can remain engaged.

Im not halfway done yet its a 7 year program 😉 but no I dont feel burnt out and other than wishing I had been wiser in my personal life with relationships I have no regrets.

can you give insight into how your personal relationships have gone since if you're ok discussing (ill keep reading the thread as well to see if it comes up but just before I forget)

and how personal relationships of your fellow residents/peers have gone.

i remember you saying something during m4 didn't work out. was that because of the stress of sub-I's / etc? or just random life stuff

my impression is that this specialty is a life killer. and therefore a relationship killer. at least until done with residency between age 35-40 (so life is over xD).

am I wrong. thanks.

Im happy to discuss it openly. I was in a long distance relationship for five years in medical school. My significant other and eventual fiance lived in Mexico City so I saw her maybe 4 times a year during breaks and 3 day weekends. I spent a fair amount of my year off there working long distance as well. My focus on med school slowly eroded my availability and willingness to spend time communicating by phone and daily skype sessions and she eventually found someone to replace the emotional unavailabilty.

It was a tough time and it all broke during subis and the match process so it definitly had an impact on my focus at that point. Multiple failed relationships with bitter ends has taught me that I may be trying to hard to subscribe to traditional values of what a good life entails. A wife teo kids and a white picket fence may not be mandatory for my own happiness.

juh oh that answers the previous question

 

[phantasmo]

Well truthfully I had a series of deeply unhealthy relationships in medical school and early residency due to a propensity towards serial monogamy with the first person I connected with even if there were red flags. After one particularly chaotic relationship, I took some time to work on myself and work on saying no and putting my needs first instead of feeling guilty about not being satisfied. Went on a ton of first dates and had a few overlapping casual dating situations that didn't go anywhere. I pushed myself to stay single for at least a year unless I truly felt like it checked all the boxes and held myself accountable for breaking it off directly and respectfully when it wasn't a match after a date or dates. When I met my wife it was love at first sight, which was something I had given up on in my 30s. We met via dating app, which was my go to due to trying to avoid dating within my hospital system. No real method except I guess a practice makes perfect mentality. I also stopped talking to my social circle about casual dating. No more locker room talk, etc.

if i may ask. was she in a similarly high paying career. and how does she navigate you having to work so much?

also could you describe what an average day looks like for you, a busy day, and an average week? thanks

 

[phantasmo]

You have time for what you choose to have time for. I certainly could have made more time but the reality is I have been publishing and otherwise strengthening my career.

the rat race never ends huh. not ideal.

 

[mmmcdowe]

10 years later.

how true is this and can you give a lay of the land.

how much innovation is there, and how are nsgy attendings getting involved? and is it more on the academic side where they get involved or pp or both. how does it work.

thanks

As predicted bioinformatics continues to grow. Machine learning making headway towards clinical practice. More and more surgeons getting involved in medical startups as the perception of industry thaws combined with increasing barriers to investments in other areas (restrictions on owning a stake in hospitals, same day surgery centers, etc). I've seen a mixture of both pp and academic surgeons involved and have several patients and fingers in startups as an academic. Lots of accelerators and innovation institutes looking to get good ideas commercialized. Requires a lot of education as a business model is a wildly different area of knowledge and learning. I plan on getting a MBA at some point.

 

[mmmcdowe]

can you give insight into how your personal relationships have gone since if you're ok discussing (ill keep reading the thread as well to see if it comes up but just before I forget)

and how personal relationships of your fellow residents/peers have gone.

i remember you saying something during m4 didn't work out. was that because of the stress of sub-I's / etc? or just random life stuff

my impression is that this specialty is a life killer. and therefore a relationship killer. at least until done with residency between age 35-40 (so life is over xD).

am I wrong. thanks.



juh oh that answers the previous question

Fwiw over the years I took a hard look at myself, accepted responsibility for my own failings in the relationships, and made a commitment towards more healthy communication with partners. I came to a point where I realized a lot of the issue was me choosing to prioritize my career over the relationships so I made the commitment to stay out of relationships until I found someone I would be willing to sacrifice some of my career ambitions for. I eventually did and I kept the commitment and I'm now married with two kids and in a nonchaotic relationship. I'm not doing poorly academically by any means but I know for a fact that my life would have been different if I hadn't made deliberate choices for the good of the family rather than my own ambition. Specifically, I turned down a position that I would have otherwise 100 percent jumped on if academic credentials and success had remained the main priority. I don't disagree with my past self however. Forcing oneself into a specific path because it's what society thinks is best, be it the white picket fence track or the academic superstar track, is not a healthy way to live. You have to be honest with yourself about what you truly want out of life.

 

[mmmcdowe]

if i may ask. was she in a similarly high paying career. and how does she navigate you having to work so much?

also could you describe what an average day looks like for you, a busy day, and an average week? thanks

She was a dentist. Making better money than me as a resident but not as much as me as an attending (to be fair, she also only worked 2 to 3 days a week). Earlier in our marriage we lived close to her family so she was able to just go over and spend time with them. Now we live about 3 hours away so still doable but can't really be done spontaneously with two young kids. So, for example, I was on call for memorial day weekend and she just packed up and went to her parents for a week. She no longer works and takes care of the kids full time. It can be tough for her at times especially if I get caught up with a late in the day add on. Ultimately a lot of it is just a phase of life thing. Our youngest still wakes up a couple times at night to be fed and the majority of that falls on her. Once we are done having kids and they're all in school it will be different. Much of it is also personal choice. We have the resources to afford any degree of childcare we want, especially if she went back to work, but she prefers to do it herself.

My day starts around 5. Currently that consists of feeding the baby but historically I would go for a run or do a couple hours of computer work. Rounds at 7 with the residents then clinic, meetings, or operating until around 5 to 6. If I don't have anything scheduled I catch up on research stuff and emails. Except when I'm on call I'm usually home around 6 and will cook dinner, help with putting the kids to bed, etc. If that goes quickly I might get another hour or two of computer work time and then bed ideally by 10 to 1030.

 

[mmmcdowe]

the rat race never ends huh. not ideal.

View attachment 404015

I have come to the realization that being productive is the key to a long life. I don't subscribe to the retire early concept. Just strive to be able to afford to do something you enjoy

 

[phantasmo]

I have come to the realization that being productive is the key to a long life. I don't subscribe to the retire early concept. Just strive to be able to afford to do something you enjoy

true and fair

as long as you love what you do. which you seem to which is great to see

 

[phantasmo]

As predicted bioinformatics continues to grow. Machine learning making headway towards clinical practice. More and more surgeons getting involved in medical startups as the perception of industry thaws combined with increasing barriers to investments in other areas (restrictions on owning a stake in hospitals, same day surgery centers, etc). I've seen a mixture of both pp and academic surgeons involved and have several patients and fingers in startups as an academic. Lots of accelerators and innovation institutes looking to get good ideas commercialized. Requires a lot of education as a business model is a wildly different area of knowledge and learning. I plan on getting a MBA at some point.

this is good insight.

going to ask a question from another nsgy thread I had. you seem like the guy to ask at least on sdn.

basically, is nsgy a good specialty to go to for startup/innovation/jumping into things that scale wealth.

I don't want my end all be all in medicine to be treating X patient at a time for Y dollars and tied to number of hours worked. what would be the difference in choosing nsgy + innovation/startups vs derm (bc of all the free time and still high base salary) + startups/innovation. is there any advantage to doing that startup stuff through the nsgy route? lmk if my question reads poorly can reword it.

how are nsgy people balancing their actual 55-60 hrs of work a week with startups if they are doing both? from your day to day, it seems like you're basically working 5/6am or so to 6 pm

also how does nsgy salary tie to academics vs pp.

 

[mmmcdowe]

this is good insight.

going to ask a question from another nsgy thread I had. you seem like the guy to ask at least on sdn.

basically, is nsgy a good specialty to go to for startup/innovation/jumping into things that scale wealth.

I don't want my end all be all in medicine to be treating X patient at a time for Y dollars and tied to number of hours worked. what would be the difference in choosing nsgy + innovation/startups vs derm (bc of all the free time and still high base salary) + startups/innovation. is there any advantage to doing that startup stuff through the nsgy route? lmk if my question reads poorly can reword it.

how are nsgy people balancing their actual 55-60 hrs of work a week with startups if they are doing both? from your day to day, it seems like you're basically working 5/6am or so to 6 pm

also how does nsgy salary tie to academics vs pp.

The short answer is yes because there is a lot of innovation and interest in innovation, but the long answer is that the skills you will develop in any specialty will be of limited use in what you are proposing. Finding a good business proposition is possible in all specialties, but the real question is where are you going to get the experience and knowledge to actually commercialize it, which is at least one full time job. I want to make sure that we cover a very common misconception, that the person with the idea gets the lion share of company equity. This is quite the opposite to reality. The people who get the most equity are the ones leveraging time and risk. A passive inventor might get a token 1% equity, but the people putting in the time and giving up a job in order to work on the project are the ones who get the majority because they are taking the majority of the risk. Case in point, Elon Musk did not come up with Tesla (wasn't one of the original co-founders), but he invested the money and time to see it through at significant risk. I try to bridge the divide by being a mostly passive inventor but trying to spin off as many projects with as many people as possible in order to maximize my chance of one being successful. The people who actually take it across the finish line have such a different skill set that it borders on a different language.

If your interest is equal between derm and neurosurgery you should do derm IMO. The extra years of training will slow your entry into the commercial sector if that is ultimately your goal. You should look into getting a MD/MBA or going to a residency that will let you do an infolded MBA.

Academic salary essentially across the board is going to be lower that private practice, but if innovation is your goal you will have a much wider availability of easy to access funds and collaborators to generate IP. At some point, however, you have to give up a scarcity mindset once you are in medicine. You'll be making a solid middle to upper middle class income in residency and will be, minimum, at the top 10% of W2 earners as attending. There is a thing as enough. You won't become a billionaire as a physician but if you spend and invest mindfully you will never want for anything. I recommend reading the millionaire next door and Dave Ramsey total money makeover if you will have debt upon graduation from medical school. If not (or when you are near the end of residency) I recommend reading the White Coat Investor and I Will Teach You to Be Rich.

 

[operaman]

I’ll add a quick thought on the startups/IP in academics in particular. Don’t forget that all institutions have some kind of policy regarding how IP is disclosed and future revenues shared. The numbers and nuances of policies can vary quite a bit as well. I think the 1% rule is not far off unless you’re the one truly driving everything and leveraging time and risk with IP that isn’t bound by your IP sharing policies.

I’ve done a tiny bit of this and so far not terribly lucrative as a passive IP generator. Too often things stall while waiting for others to do things, or the institution opts to support it but doesn’t quite do enough to move the ball forward. And of course, the more people you involve so that the project actually goes somewhere, the more any future take is diluted.

I know another guy who was able to get around his institutional IP rules by developing a new patented device for a completely unrelated field, so he was able to successfully argue that it was wholly unrelated to his work for the institution. Of course he leveraged countless hours and lots of money but ultimately was able to build a small company and sell it off for a tidy sum to a big fish.

Personally I’ve found that the value of my time clinically is worth so much more than if I spend it on anything else. I could spend my saturdays working on startups and most likely not have a ton of money to show for it after 10 years, or I could add a Saturday clinic and generate an extra 150-200k a year guaranteed with quite a chunk of change after 10 years. Not insane money, probably more than I’d get in startup world.

As it is, I don’t even remotely spend what I earn now so I’m not sure what I’d do with the extra money and I’d rather have my weekends free. If you want to do IP work, pick something that allows you adequate free time to move things forward.

 

[phantasmo]

I try to bridge the divide by being a mostly passive inventor but trying to spin off as many projects with as many people as possible in order to maximize my chance of one being successful. The people who actually take it across the finish line have such a different skill set that it borders on a different language.

if I may ask how this is working out?

The people who actually take it across the finish line have such a different skill set that it borders on a different language.

if I may ask if being nsgy helps here (vs a derm/rads or some non-layman's prestige specialty) does your advising/them saying they have an nsgy as a board member or whatever help you get in on ventures? or is it just that you have pure capital.

If your interest is equal between derm and neurosurgery you should do derm IMO. The extra years of training will slow your entry into the commercial sector if that is ultimately your goal. You should look into getting a MD/MBA or going to a residency that will let you do an infolded MBA.

wise comment. truthfully my interest is way more in nsgy, my only gripe is the work life balance (but the work is way more interesting to me!). derm work is very boring, but the 4 days a week for 450k is hard to beat when my main goal is to get rich and have enough time to spend with family and friends (with second goal of having work fulfillment).

i just don't know how to come to terms with 7 years of 80-100 hrs a week until like age 33, and then attending life also similarly being some 50-60 hrs a week. just seems idk - not smart i guess? really confused as to why people are going into it with these conditions (the work looks interesting asf, but it legit steals life away from you no?). could use guidance here.

If your interest is equal between derm and neurosurgery you should do derm IMO. The extra years of training will slow your entry into the commercial sector if that is ultimately your goal. You should look into getting a MD/MBA or going to a residency that will let you do an infolded MBA.

how much does prestige of MBA matter here? is any of the m7 or whatever fine? the infolded MBA residencies are pretty top tier academic which for nsgy is ultra hard to get no?

Academic salary essentially across the board is going to be lower that private practice, but if innovation is your goal you will have a much wider availability of easy to access funds and collaborators to generate IP. At some point, however, you have to give up a scarcity mindset once you are in medicine. You'll be making a solid middle to upper middle class income in residency and will be, minimum, at the top 10% of W2 earners as attending. There is a thing as enough. You won't become a billionaire as a physician but if you spend and invest mindfully you will never want for anything. I recommend reading the millionaire next door and Dave Ramsey total money makeover if you will have debt upon graduation from medical school. If not (or when you are near the end of residency) I recommend reading the White Coat Investor and I Will Teach You to Be Rich.

thanks. will read the latter. thankfully no debt from med school, got lucky/blessed with some scholarship thing.

will read white coat investor.



what are your thoughts on finance/biotech? like shkreli style. i assume it's too much domain knowledge for someone pursuing nsgy to learn seriously? same with what you said about being "the guy" that's making the startups I assume? im connected to 1 guy like this and he'd let me invest unlimited capital. we're very close and have 20 years of history with each other. so maybe that solves the issue of not being "the guy"?

 

[phantasmo]

Personally I’ve found that the value of my time clinically is worth so much more than if I spend it on anything else. I could spend my saturdays working on startups and most likely not have a ton of money to show for it after 10 years, or I could add a Saturday clinic and generate an extra 150-200k a year guaranteed with quite a chunk of change after 10 years. Not insane money, probably more than I’d get in startup world.

how. can you expound. i agree though, at some point it is important we all recognize that we're not "the guy" that's developing insane startups. that's why we're in medicine xD. i guess that is your point? that unless top .0001% of startup people it's already not worth?

If you want to do IP work, pick something that allows you adequate free time to move things forward.

could you expound on this? maybe some examples, having trouble visualizing what you mean.

thanks to you as well operaman you have great comments.

 

[operaman]

how. can you expound. i agree though, at some point it is important we all recognize that we're not "the guy" that's developing insane startups. that's why we're in medicine xD. i guess that is your point? that unless top .0001% of startup people it's already not worth?


could you expound on this? maybe some examples, having trouble visualizing what you mean.

thanks to you as well operaman you have great comments.

At heart, it’s that any side hustle or start up will also require a great deal of time. Whether it’s doing the real estate thing or side hustle thing or start up thing, it does take quite a bit of time if you’re going to be successful. Then I compare likely ROI from the side hustles and whatnot versus what I could make spending that extra time working clinically and saving/investing conservatively.

So in my example, if I add a Saturday clinic each week, that’s roughly 200-250k in additional income depending on how busy I want it to be and how well it runs. That gets taxed of course, but assuming I save and invest that money I’m looking at around $2m in ten years. Thats a fairly high bar to meet with a similar time commitment from other endeavors. If I spend a lot of time developing some kind of IP that gets bought for $50-100m - very rare event - and I get about 1% of that after everyone else gets their cut, then I’m roughly where I’d have from doing the sure thing of working more at my already high hourly rate. But then I realize I can’t spend what I make already so why bust my tail for more? So then I use my precious time to do other things I love to do.

The idea of picking a field with time for IP work just means that it takes significant time investment to move an idea along into something that pays you money. Countless steps depending on what you’re doing - search for prior art, design, prototyping, patenting, marketing, countless meetings with potential colleagues with whatever skill sets you lack, etc. The people I know who are good at this spend a lot of time on it and often have multiple ideas in the pipeline at any given time. So if you’re going to do that, it’s a lot easier to do so as a dermatologist working 9-2 4 days a week rather than a Neurosurgeon working from 6a-7p plus add ons and call and the rest of it. Not that it can’t be done, but it’s going to be harder.

 

[phantasmo]

At heart, it’s that any side hustle or start up will also require a great deal of time. Whether it’s doing the real estate thing or side hustle thing or start up thing, it does take quite a bit of time if you’re going to be successful. Then I compare likely ROI from the side hustles and whatnot versus what I could make spending that extra time working clinically and saving/investing conservatively.

So in my example, if I add a Saturday clinic each week, that’s roughly 200-250k in additional income depending on how busy I want it to be and how well it runs. That gets taxed of course, but assuming I save and invest that money I’m looking at around $2m in ten years. Thats a fairly high bar to meet with a similar time commitment from other endeavors. If I spend a lot of time developing some kind of IP that gets bought for $50-100m - very rare event - and I get about 1% of that after everyone else gets their cut, then I’m roughly where I’d have from doing the sure thing of working more at my already high hourly rate. But then I realize I can’t spend what I make already so why bust my tail for more? So then I use my precious time to do other things I love to do.

The idea of picking a field with time for IP work just means that it takes significant time investment to move an idea along into something that pays you money. Countless steps depending on what you’re doing - search for prior art, design, prototyping, patenting, marketing, countless meetings with potential colleagues with whatever skill sets you lack, etc. The people I know who are good at this spend a lot of time on it and often have multiple ideas in the pipeline at any given time. So if you’re going to do that, it’s a lot easier to do so as a dermatologist working 9-2 4 days a week rather than a Neurosurgeon working from 6a-7p plus add ons and call and the rest of it. Not that it can’t be done, but it’s going to be harder.

agree. i would not personally meddle with IP/hardware/product type stuff but I see what you mean. software way easier (and real estate but that would take a ton of time like you said).

didn't know derm is 9a-2pm. are they working 5 hours a day @ 4 days a week and making 400k? that's like 20 hours of work for a **** ton of money no? combined with residency being chill and only 4 years.

thanks

 

[hopefulraddaddypls]

if I may ask how this is working out?



if I may ask if being nsgy helps here (vs a derm/rads or some non-layman's prestige specialty) does your advising/them saying they have an nsgy as a board member or whatever help you get in on ventures? or is it just that you have pure capital.



wise comment. truthfully my interest is way more in nsgy, my only gripe is the work life balance (but the work is way more interesting to me!). derm work is very boring, but the 4 days a week for 450k is hard to beat when my main goal is to get rich and have enough time to spend with family and friends (with second goal of having work fulfillment).

i just don't know how to come to terms with 7 years of 80-100 hrs a week until like age 33, and then attending life also similarly being some 50-60 hrs a week. just seems idk - not smart i guess? really confused as to why people are going into it with these conditions (the work looks interesting asf, but it legit steals life away from you no?). could use guidance here.



how much does prestige of MBA matter here? is any of the m7 or whatever fine? the infolded MBA residencies are pretty top tier academic which for nsgy is ultra hard to get no?



thanks. will read the latter. thankfully no debt from med school, got lucky/blessed with some scholarship thing.

will read white coat investor.



what are your thoughts on finance/biotech? like shkreli style. i assume it's too much domain knowledge for someone pursuing nsgy to learn seriously? same with what you said about being "the guy" that's making the startups I assume? im connected to 1 guy like this and he'd let me invest unlimited capital. we're very close and have 20 years of history with each other. so maybe that solves the issue of not being "the guy"?

No one cares about prestige of a specialty in the real world. Michael Burry dropped out of pathology to start a hedge fund and he's likely richer than any physician

 

[operaman]

agree. i would not personally meddle with IP/hardware/product type stuff but I see what you mean. software way easier (and real estate but that would take a ton of time like you said).

didn't know derm is 9a-2pm. are they working 5 hours a day @ 4 days a week and making 400k? that's like 20 hours of work for a **** ton of money no? combined with residency being chill and only 4 years.

thanks

Yeah they do quite well. There’s a reason it’s so competitive.

It comes down to how many billable procedures you can do along with your office visits in those 5 hours. Derm can do a lot of quick procedures in an office visit, so with a well oiled practice you can do a ton of volume in those hours. I’m ENT and I usually work 8-1 most days and I can see 30-35 patients in that time frame, each with procedures beyond their regular visit code. Good derm practices can do more volume than that easily.

It’s something that gets under emphasized and something I always bring up with students: your quality of life will depend heavily on your skills. If you can see a full day worth of patients in half a day, you can have a much better life than someone who can’t. Ditto for OR skills - good surgeons go home earlier and get called in less often.

I think the side hustle thing is worthwhile if you enjoy it and are particularly good at it. Also works if you have a partner who’s into it and can do some of the legwork such as with real estate. I’ve dabbled in some IP stuff just for fun but never with any thought I’d get any money out of it. More just for my own interest in developing an idea and working with other people to see where it might go. If it ever does I’m probably looking to rake in a few dozen dollars at best!

 

[hopefulraddaddypls]

Yeah they do quite well. There’s a reason it’s so competitive.

It comes down to how many billable procedures you can do along with your office visits in those 5 hours. Derm can do a lot of quick procedures in an office visit, so with a well oiled practice you can do a ton of volume in those hours. I’m ENT and I usually work 8-1 most days and I can see 30-35 patients in that time frame, each with procedures beyond their regular visit code. Good derm practices can do more volume than that easily.

It’s something that gets under emphasized and something I always bring up with students: your quality of life will depend heavily on your skills. If you can see a full day worth of patients in half a day, you can have a much better life than someone who can’t. Ditto for OR skills - good surgeons go home earlier and get called in less often.

I think the side hustle thing is worthwhile if you enjoy it and are particularly good at it. Also works if you have a partner who’s into it and can do some of the legwork such as with real estate. I’ve dabbled in some IP stuff just for fun but never with any thought I’d get any money out of it. More just for my own interest in developing an idea and working with other people to see where it might go. If it ever does I’m probably looking to rake in a few dozen dollars at best!

Dang how much does a visit per pt generate then?

 

[phantasmo]

Dang how much does a visit per pt generate then?

uh oh people are waking up xD

 

[phantasmo]

Yeah they do quite well. There’s a reason it’s so competitive.

It comes down to how many billable procedures you can do along with your office visits in those 5 hours. Derm can do a lot of quick procedures in an office visit, so with a well oiled practice you can do a ton of volume in those hours. I’m ENT and I usually work 8-1 most days and I can see 30-35 patients in that time frame, each with procedures beyond their regular visit code. Good derm practices can do more volume than that easily.

It’s something that gets under emphasized and something I always bring up with students: your quality of life will depend heavily on your skills. If you can see a full day worth of patients in half a day, you can have a much better life than someone who can’t. Ditto for OR skills - good surgeons go home earlier and get called in less often.

I think the side hustle thing is worthwhile if you enjoy it and are particularly good at it. Also works if you have a partner who’s into it and can do some of the legwork such as with real estate. I’ve dabbled in some IP stuff just for fun but never with any thought I’d get any money out of it. More just for my own interest in developing an idea and working with other people to see where it might go. If it ever does I’m probably looking to rake in a few dozen dollars at best!

is there anything similar to this in nsg or nah? didn't know ent could do that good of a lifestyle.

it seems to me that the "best" lifestyle for nsgy is pp 50-60 hrs a week with very light call since many people to pass it around. is that true or is there a way to be like "part time" by mid stage career (age 40-45 or something)

 

[phantasmo]

I think the side hustle thing is worthwhile if you enjoy it and are particularly good at it. Also works if you have a partner who’s into it and can do some of the legwork such as with real estate. I’ve dabbled in some IP stuff just for fun but never with any thought I’d get any money out of it. More just for my own interest in developing an idea and working with other people to see where it might go. If it ever does I’m probably looking to rake in a few dozen dollars at best!

agree. to me it's way more interesting. infinite ways to learn and not "stuck" on the same subject for 15 years or whatever like would be done with nsgy (7 year residency + early career years)

 

[operaman]

Dang how much does a visit per pt generate then?

Depends on what’s done. I’m paid based on wRVU so that’s how I think. For me, it’s usually 4-12 wRVU per visit with most being on the lower end of that spectrum. Not sure about derm but similar - ability to stack lots of procedures into a single encounter.

 

[operaman]

is there anything similar to this in nsg or nah? didn't know ent could do that good of a lifestyle.

it seems to me that the "best" lifestyle for nsgy is pp 50-60 hrs a week with very light call since many people to pass it around. is that true or is there a way to be like "part time" by mid stage career (age 40-45 or something)

Yeah I’ve got a bit of a unicorn job but most of my colleagues have nice setups. I could work more and make more; I just don’t want to.

Nsg, from what I can tell, doesn’t have a way to generate much revenue in clinic, but their OR procedures are quite well reimbursed and stackable in many instances. Since they only make money in the OR, they’re more subject to the scheduling issues and less predicable nature of the OR. Plus they often have a large inpatient service as well whereas I just finished my full OR day a few minutes ago and everyone went home so nobody to round on tomorrow for me (that’s the norm). Long cases, lots of demand, need to be in the OR to make money, and call - these are drive the Nsg lifestyle issues. Many people are able to combat them and make a nice life though.

Part time is always possible but you’ll have to make sacrifices in terms of money, location, and other things. That tends to be harder mid career due to family and other entanglements.

But nobody will ever touch the dermatologists for lifestyle and money combo. I wish I liked skin enough to have done it! But I’m pretty darn happy with how things worked out.

 

[phantasmo]

Yeah I’ve got a bit of a unicorn job but most of my colleagues have nice setups. I could work more and make more; I just don’t want to.

Nsg, from what I can tell, doesn’t have a way to generate much revenue in clinic, but their OR procedures are quite well reimbursed and stackable in many instances. Since they only make money in the OR, they’re more subject to the scheduling issues and less predicable nature of the OR. Plus they often have a large inpatient service as well whereas I just finished my full OR day a few minutes ago and everyone went home so nobody to round on tomorrow for me (that’s the norm). Long cases, lots of demand, need to be in the OR to make money, and call - these are drive the Nsg lifestyle issues. Many people are able to combat them and make a nice life though.

Part time is always possible but you’ll have to make sacrifices in terms of money, location, and other things. That tends to be harder mid career due to family and other entanglements.

But nobody will ever touch the dermatologists for lifestyle and money combo. I wish I liked skin enough to have done it! But I’m pretty darn happy with how things worked out.

thanks good insight

 

[mmmcdowe]

if I may ask how this is working out?

It is a long process. One just did its second round of fundraising at a 9M valuation, two others are being investigated for licensing, 2 died for co-founders at each others throats, one is in bureaucratic limbo preventing them from accessing their 500K SBIR grant, and another 3-4 died on the drawing table due to either prior IP claims or lack of demonstrable market.

if I may ask if being nsgy helps here (vs a derm/rads or some non-layman's prestige specialty) does your advising/them saying they have an nsgy as a board member or whatever help you get in on ventures? or is it just that you have pure capital.

Being connected builds new connections but it isn't specialty specific. I have a steady stream of contacts with other entrepreneurs. Sometimes we just help each other, sometimes it builds new partnerships.

wise comment. truthfully my interest is way more in nsgy, my only gripe is the work life balance (but the work is way more interesting to me!). derm work is very boring, but the 4 days a week for 450k is hard to beat when my main goal is to get rich and have enough time to spend with family and friends (with second goal of having work fulfillment).

i just don't know how to come to terms with 7 years of 80-100 hrs a week until like age 33, and then attending life also similarly being some 50-60 hrs a week. just seems idk - not smart i guess? really confused as to why people are going into it with these conditions (the work looks interesting asf, but it legit steals life away from you no?). could use guidance here.

God can be found at the center of the spinal cord. I love what I do every day and I contribute meaningfully to others. Society is impressed by me and my family is proud of me and I will have a financially secure job unless the whole world collapses. Even then people would probably seek me out with bread and cheese.

Just by your comments it sounds like neither specialty may be right for you. If you are smart enough to be a specialist MD then you probably have what it takes to be very successful in the business world. No doubt you can work just as many hours out there but your potential for scalable wealth will be much higher.

how much does prestige of MBA matter here? is any of the m7 or whatever fine? the infolded MBA residencies are pretty top tier academic which for nsgy is ultra hard to get no?

If you are just using to it to help bridge the knowledge gap then it is reasonable to do it locally, especially if your university will pay for it. If you are planning to go full entrepreneur then the connections from a top MBA are worth it. There are a lot of executive MBAs (Wharton and I think Harvard come to mind) that allow you to continue to work full time and cram the work into a few weekends a semester. I'm not convinced it is as good as doing the full MBA, even if you did it part time locally, but that's probably the route I will eventually go unless my department picks up the tab for me to do it locally.

thanks. will read the latter. thankfully no debt from med school, got lucky/blessed with some scholarship thing.

will read white coat investor.



what are your thoughts on finance/biotech? like shkreli style. i assume it's too much domain knowledge for someone pursuing nsgy to learn seriously? same with what you said about being "the guy" that's making the startups I assume? im connected to 1 guy like this and he'd let me invest unlimited capital. we're very close and have 20 years of history with each other. so maybe that solves the issue of not being "the guy"?

I don't know what that is. Investing capital is good but unless it is a LOT of capital you are still not going to end up with a big chunk of the pie. Even then, you would need to potentially invest at at least some subsequent fundraising cycles to avoid being diluted to really maximize your potentially payoff. Don't get me wrong, you can definitely invest some dollars and 10x your money 7 years later with a successful exit, but realistically you aren't going to turn $500 in to 5M. Most of the investments I deal in start at 50K lots minimum. 25K if you bring something to the table like connections. That might buy you a starting percentage ranging from a 0.5% to 2% stake if you get in pre-seed or seed. So, in the example of my startup above, investing 50K now at this valuation would only yield you 0.5%. Let's say they catch a bigger fishes eye in another year and a half and exit at 20M. You would be getting a solid ROI even with long term capital gains tax, but you aren't buying a vacation home. Sure it would be awesome for it to go on to be a company worth a few billion, but those are few and far between.

 

[phantasmo]

thanks for the detailed responses. this is great

Being connected builds new connections but it isn't specialty specific. I have a steady stream of contacts with other entrepreneurs. Sometimes we just help each other, sometimes it builds new partnerships.

gotcha so those connections are specialty independent you think? what type of work do the MD's do (as advisors/consultant or whatever it is) and how does being nsgy specifically help?

God can be found at the center of the spinal cord.

very cool genuinely.

If you are smart enough to be a specialist MD then you probably have what it takes to be very successful in the business world. No doubt you can work just as many hours out there but your potential for scalable wealth will be much higher.

sure but doing what? worked this hard to get into med school would at least like to cash in on it lol. having a 500k a year job for little work (derm) or a 1.5m a year job that is really cool and respected and interesting (i like the work) (nsgy) seems sick no? then start a second life at age 35 or so after residency and scale?

There are a lot of executive MBAs (Wharton and I think Harvard come to mind) that allow you to continue to work full time and cram the work into a few weekends a semester. I'm not convinced it is as good as doing the full MBA, even if you did it part time locally, but that's probably the route I will eventually go unless my department picks up the tab for me to do it locally.

good insight. will find an mba forum to learn more.

I deal in start at 50K lots minimum. 25K if you bring something to the table like connections. That might buy you a starting percentage ranging from a 0.5% to 2% stake if you get in pre-seed or seed. So, in the example of my startup above, investing 50K now at this valuation would only yield you 0.5%. Let's say they catch a bigger fishes eye in another year and a half and exit at 20M.

even this scenario, if you get 1% equity its like 200k (so 4x). that is a bad deal for waiting like 8 years or whatever lol. juh oh. i see what you and operaman mean.

basically have to decide whether start own thing or just make money in medicine? or if starting something like pp within medicine.


what are your thoughts on where pp will be in 10 years. i only just started reading wci and so learning about how private prac is becoming close to impossible to do. speak from the viewpoint if you could of a resident with capital (so not in debt, but let's say 3-5m nw and then their 500k salary)

 

[phantasmo]

No one cares about prestige of a specialty in the real world. Michael Burry dropped out of pathology to start a hedge fund and he's likely richer than any physician

my king

 

[slowthai]

But nobody will ever touch the dermatologists for lifestyle and money combo. I wish I liked skin enough to have done it! But I’m pretty darn happy with how things worked out.

PP OMFS though. And breast rads. These two are unbeatable.

 

[phantasmo]

PP OMFS though. And breast rads. These two are unbeatable.

pay + lifestyle or just lifestyle?

is there a site that shows pay per hour for specialties (and actually accurate, not just user reported with sample size of like 5)?

 

[slowthai]

pay + lifestyle or just lifestyle?

Just like derm, pay and lifestyle.