Lifestyle specialty question? Primary care versus something competitive?

[dizzybanister]

Hello! I've been mulling this over for a long time now and wanted to get some input. I just started M3 at a T20 USMD. I always thought I would do a specialty with more flexibility (IM, FM) so I could do residency in an urban area and I've always loved preventative healthcare/checkups, but now I'm considering derm or optho simply because I'm loving all the rotations and also like clinic a lot, and recently have been weighing the attending lifestyle more--to have time to build a family, hobbies outside of medicine, etc. I currently have 4 poster presentations (3 1st author), 4 papers in the works (none 1st author), 1 case report, and less than 2 years left to continue doing research. Is it feasible to build a strong application for derm/optho, or is it also feasible to enjoy a decent lifestyle as primary care in a major city? I've heard conflicting things about primary care paying enough to offset cost of living in major metro areas, but I've also heard that many metro areas are wanting for more PCPs. A simple Google search for PCP jobs shows comfortable salaries (for me at least, ~$200+).

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[operaman]

If you really like the day to day aspect of derm and Ophtho, I’d seriously consider going for it. Much higher salary potential with fewer hours in both cases. But the key is whether you actually enjoy the work.

Hard to predict the details of future jobs. The old rule was to consider salary, location, and lifestyle. A good job will give you 2/3.

 

[Angus Avagadro]

I used to counsel students and residents to consider where you want to live and how you want to live. Do you have to live on the west coast where the COL is very high and there are lots of specialists holding done compensation? Do you want a 5,000 sq ft home and income? You might want to live in the Midwest. Regardless, work and life balance is tricky. It will be up to you to sort it out.

 

[voxveritatisetlucis]

At T20 anything is possible for any student aside from things like step failures, suspensions etc especially now that Step is pass fail. so I would just go for it

 

[eyeeye_captain]

I’d echo the advice above. You have the chance at any option if you like something clinically. Of those, ophtho is a slightly different beast. You really should like the OR as you’ll most likely be doing 1+ day a week. There are also a decent number of procedures in general ophthalmology. Some sub specialties like mine are doing procedures on 50-75% of patients, so that would have to be in your wheelhouse.

 

[collegestud2013]

Hello! I've been mulling this over for a long time now and wanted to get some input. I just started M3 at a T20 USMD. I always thought I would do a specialty with more flexibility (IM, FM) so I could do residency in an urban area and I've always loved preventative healthcare/checkups, but now I'm considering derm or optho simply because I'm loving all the rotations and also like clinic a lot, and recently have been weighing the attending lifestyle more--to have time to build a family, hobbies outside of medicine, etc. I currently have 4 poster presentations (3 1st author), 4 papers in the works (none 1st author), 1 case report, and less than 2 years left to continue doing research. Is it feasible to build a strong application for derm/optho, or is it also feasible to enjoy a decent lifestyle as primary care in a major city? I've heard conflicting things about primary care paying enough to offset cost of living in major metro areas, but I've also heard that many metro areas are wanting for more PCPs. A simple Google search for PCP jobs shows comfortable salaries (for me at least, ~$200+).

$200k is very low for physician compensation in 2023 with inflation through the roof ,especially if you have large amounts of loans and are going to be the primary income provider for a family. However, a PCP with decent patient load should be able to pull in at least low $300k nowadays. However burnout is high among PCPs, a lot of it due to high patient volumes you need to see and the multitude of tasks that have to be done as the patient's PCP (eg paperwork and administrative burden tends to be high for PCP than specialists). However, PCPs are much more needed across the board (while derm and optho are pretty saturated in the big cities at this point).

Derm and optho do have higher compensation but the difference between them and PCP is smaller than it looks once you consider the longer training time and high tax brackets physicians are in. Insurance reimbursements for optho have also declined significantly so pay is not that good anymore for many new grads, unless you're into selling cash based elective procedures (Eg Lasik). Matching into to derm/optho is also very uncertain, and unless your school offers enough dedicated research time already, you'll usually need take a research year off to get specialty-specific research done (and even then there's still no guarantee of matching). And without a Step 2 score it's also not known yet whether you'll be competitive.

 

[eyeeye_captain]

$200k is very low for physician compensation in 2023 with inflation through the roof ,especially if you have large amounts of loans and are going to be the primary income provider for a family. However, a PCP with decent patient load should be able to pull in at least low $300k nowadays. However burnout is high among PCPs, a lot of it due to high patient volumes you need to see and the multitude of tasks that have to be done as the patient's PCP (eg paperwork and administrative burden tends to be high for PCP than specialists). However, PCPs are much more needed across the board (while derm and optho are pretty saturated in the big cities at this point).

Derm and optho do have higher compensation but the difference between them and PCP is smaller than it looks once you consider the longer training time and high tax brackets physicians are in. Insurance reimbursements for optho have also declined significantly so pay is not that good anymore for many new grads, unless you're into selling cash based elective procedures (Eg Lasik). Matching into to derm/optho is also very uncertain, and unless your school offers enough dedicated research time already, you'll usually need take a research year off to get specialty-specific research done (and even then there's still no guarantee of matching). And without a Step 2 score it's also not known yet whether you'll be competitive.

Yes and no.

Agree:
- PCPs can make >$300k, but that's about the ceiling on average
- Burnout is high and scutwork is still rampant in primary care
- Higher salaries lead to higher taxes
- Ophtho has had cuts recently, as have most other fields outside of primary care
- Hard to count your chickens with competitive specialties before they hatch

Disagree:
- The extra single year of training to potentially double+ your income is not a bad return on investment.
- The higher taxes lead to you losing around 4-5% of income once you cross the border beyond PCP money. It's not good, but not terrible.
- The ophtho job market is pretty good, and most make around the ceiling for PCPs. You'll take a hit in big cities but jobs are there.
- The LASIK market is a little tough to break into. Most ophthalmologists getting cash pay dollars get it from premium intraocular lenses in cataract surgery or cosmetic facial things like Botox.
- Most people don't wind up doing a research year in ophtho, though some do to be more competitive. Can't speak to derm, which is traditionally more competitive.

Bottom line: Do what floats your boat clinically, and, more importantly, life-wise.

 

[RangerBob]

You're in a great position to be in.

Figure out what you'll enjoy doing the most, and consider what will you still enjoy doing when everything is very routine--which it will be for any specialty. For me it wasn't so much the science of the medical specialty but the day-to-day/office environment type stuff. I liked working with a lot of people in an interdisciplinary team. I preferred inpatient. I didn't want to work with kids under any circumstance unless all I did was well-child checks and only saw kids who would never get sick, so that wasn't going to happen. And I like elderly patients and veterans. So I chose PM&R with plans to do VA inpatient or SCI rehab. I ended up doing community inpatient rehab after our son was born and we wanted to be near family (no option for VA near them).

Whatever specialty you're in, you'll make plenty. $400k isn't going to make you any happier than $200k if you enjoy the $200k job more. With that said, if you like the specialties equally, then clearly go for the one that pays $400k and/or has a better lifestyle.

 

[Gilakend]

FWIW, during my med school rotations I thought the PCPs had some of the worst lifestyles of any specialty. If I was only considering lifestyle I would put ophtho and derm way above PCP.

 

[dizzybanister]

FWIW, during my med school rotations I thought the PCPs had some of the worst lifestyles of any specialty. If I was only considering lifestyle I would put ophtho and derm way above PCP.

What makes you say that PCPs had the worst lifestyle?

 

[Gilakend]

What makes you say that PCPs had the worst lifestyle?

We'd usually work 7:30 - 5:00 and then at the end of the day the PCP would go home and finish notes.

 

[VA Hopeful Dr]

We'd usually work 7:30 - 5:00 and then at the end of the day the PCP would go home and finish notes.

Yeah that's not the norm.

I get to work just before 8. I rarely leave later than 4:20 or so. I take a 90 minute lunch.

I will do about 15 minutes of work at home in the morning, but if I was willing to work more during my lunch I could skip that entirely.

 

[operaman]

Yeah that's not the norm.

I get to work just before 8. I rarely leave later than 4:20 or so. I take a 90 minute lunch.

I will do about 15 minutes of work at home in the morning, but if I was willing to work more during my lunch I could skip that entirely.

I feel like medical students don’t get much exposure to what true community primary care looks like. An academic ivory tower pcp clinic is vastly different from a quiet suburban practice. My friends who do it describe very similar hours to yours.

 

[VA Hopeful Dr]

I feel like medical students don’t get much exposure to what true community primary care looks like. An academic ivory tower pcp clinic is vastly different from a quiet suburban practice. My friends who do it describe very similar hours to yours.

My school produces a decent number of FPs, especially for a USMD school. Big reason is that 2 weeks of our FM rotation are spent with community preceptors. I got there at 8, saw patients who just loved their doctor and were very pleasant to see, out by around 430. Made FM seem like a pretty good gig.

 

[djiboutiman]

Something else, is Derm/Ophtho tend to have quick appointments/see a ton of patients per day. Whereas IM/FM tend to have longer appointments/see fewer patients per day. I worked at a Derm clinic before medical school and ~50 patients/day was pretty common. Out on FM rotations, most days averaged around 15-20 patients.

 

[Ho0v-man]

My school produces a decent number of FPs, especially for a USMD school. Big reason is that 2 weeks of our FM rotation are spent with community preceptors. I got there at 8, saw patients who just loved their doctor and were very pleasant to see, out by around 430. Made FM seem like a pretty good gig.

I think this is a big reason a lot at my school switched to FM. We had 3 required FM rotations and 2 had to be rural. You ended up being very familiar with outpatient FM and saw your preceptors take long lunches and leave by 4:30pm everyday except on their Friday half days.

Yeah other specialties sure other specialties make more. But their clinics usually see more patients per day and they burn through it so they can get back to the hospital and grind even harder there.

I’ve always felt like the higher paying specialties train much longer and work harder/longer hours than primary care…except derm.

 

[VA Hopeful Dr]

I think this is a big reason a lot at my school switched to FM. We had 3 required FM rotations and 2 had to be rural. You ended up being very familiar with outpatient FM and saw your preceptors take long lunches and leave by 4:30pm everyday except on their Friday half days.

Yeah other specialties sure other specialties make more. But their clinics usually see more patients per day and they burn through it so they can get back to the hospital and grind even harder there.

I’ve always felt like the higher paying specialties train much longer and work harder/longer hours than primary care…except derm.

Derm pays their dues in med school. And from my understanding, while their residency doesn't have crazy hours, they do way more reading than the rest of us generally speaking.

 

[Dr. Anonymouss]

Something else, is Derm/Ophtho tend to have quick appointments/see a ton of patients per day. Whereas IM/FM tend to have longer appointments/see fewer patients per day. I worked at a Derm clinic before medical school and ~50 patients/day was pretty common. Out on FM rotations, most days averaged around 15-20 patients.

I’d way rather have 50 brief appointments than 15 appointments that last 30-45 minutes each. I guess that’s why there is a specialty for everyone!

 

[VA Hopeful Dr]

I’d way rather have 50 brief appointments than 15 appointments that last 30-45 minutes each. I guess that’s why there is a specialty for everyone!

I haven't had an appointment last more than 20 minutes in years.