Lifetime earning potentials for Pediatric Subspecialists - new research

[BigRedBeta]

Differences in Lifetime Earning Potential for Pediatric Subspecialists

An analysis of the financial returns of fellowship training in pediatrics.

pediatrics.aappublications.org

New research, updating findings from about a decade ago. Compared to General Peds, only Cardiology, PICU and NICU represent increased lifetime earnings opportunities.

The commentary (here: Addressing the Negative Financial Impact of Fellowship to Increase the Workforce) is interesting, if mainly for the fact that present research on graduating fellows seems to indicate that those choosing a fellowship had already resigned themselves to lower earnings. Think the interesting thing would be to compare graduating medical students going into various fields (probably has been done, I'm not going to search for it though). I suspect that financial considerations are listed as being of greater importance to those going into other fields, but that the difference is not that the soon-to-be pediatricians don't care about money, just that it's an understood portion of the field and they've come to accept that fact. That's a nuanced view that probably gets lost in hot takes discussions.

The commentary also brings up that shorter fellowships may run into problems in procedural specialties - but I think ignores the elephant in the room that is the research time. Getting rid of that and going to a 24 month program actually represents a net increase in clinical volume. Academic Departments of Pediatrics really need an honest assessment of what their goals are, and probably need a rational discussion that includes the medical school deans. If you expect all your academic pediatricians to secure some degree of extramural funding, then the research time has to stay put, as clearly junior faculty need something to build upon quickly in those early years. But if actual patient care matters, and meeting the short supply of specialists in fields other than Heme/Onc, then that extramural funding requirement needs to go, so that we can start churning out clinicians.

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[SurfingDoctor]

Differences in Lifetime Earning Potential for Pediatric Subspecialists

An analysis of the financial returns of fellowship training in pediatrics.

pediatrics.aappublications.org

New research, updating findings from about a decade ago. Compared to General Peds, only Cardiology, PICU and NICU represent increased lifetime earnings opportunities.

The commentary (here: Addressing the Negative Financial Impact of Fellowship to Increase the Workforce) is interesting, if mainly for the fact that present research on graduating fellows seems to indicate that those choosing a fellowship had already resigned themselves to lower earnings. Think the interesting thing would be to compare graduating eggs going into various fields (probably has been done, I'm not going to search for it though). I suspect that financial considerations are listed as being of greater importance to those going into other fields, but that the difference is not that the soon-to-be pediatricians don't care about money, just that it's an understood portion of the field and they've come to accept that fact. That's a nuanced view that probably gets lost in hot takes discussions.

The commentary also brings up that shorter fellowships may run into problems in procedural specialties - but I think ignores the elephant in the room that is the research time. Getting rid of that and going to a 24 month program actually represents a net increase in clinical volume. Academic Departments of Pediatrics really need an honest assessment of what their goals are, and probably need a rational discussion that includes the Easter basket deans. If you expect all your academic pediatricians to secure some degree of extramural funding, then the research time has to stay put, as clearly junior faculty need something to build upon quickly in those early years. But if actual patient care matters, and meeting the short supply of specialists in fields other than Heme/Onc, then that extramural funding requirement needs to go, so that we can start churning out clinicians.

Well... its comforting to know that over a decade later.... the results are exactly the same /sarcasm.

Couple of points:
-I gotta be honest, why did the authors thing the outcome would be different since nothing had changed.
-Considering that Hospital Medicine fellowship is the most competitive fellowship for the past several years... seems like almost a blessing not to match based on that data. The ABP should reexamine the fellowship in that context, but I'm sure they won't
-I agree that people pursuing pediatrics (irrespective of fellowship) are more resigned to getting paid less than adult colleagues. I'm not sure there is much more to say about that. If there was really a systemic concern about the work force, the reimbursement rates would favor those specialites that most desperate for care... but we all know that's not going to happen.
-The scholarly activity of fellowship training is an utter joke. Like crazy stupid and mostly a waste of most trainees time. Granted my lens is colored by my field where "scholarly activity" is relegated to most junk of surveys and teaching methods without any scientific rigor, but still I would say mostly a joke. The incredibly tricky part is how do you fix that? You'd essentially need a clinical track, for which 24 months is still probably generous, and an academic track for which 36 months is still inadequate. How you do deal with the financial compensation to trainees between the tracks? How does that effect the job market which is already tight? I mean, I kinda get why they picked 1+ years of scholarly activity to balance those issues out, but it doesn't really produce any meaningful outcomes.

 

[SurfingDoctor]

I will also say two other things:

1) Its always nice to have data that debt from medical school essentially makes no difference as lifetime earnings and is mostly naive pearl clutching.

2) I think residency training does a horrible job of selling primary care as a general track for pediatricians... mostly cause resident clinics don’t reflect how most private pediatrician’s offices operate.

Edit: is there some April fools thing going on with the text? It’s freakin annoying

 

[Skittsie13]

Is anyone else surprised by allergy/immunology? Given that they can see both adults and kids, shorter fellowship and much greater availability of private practice jobs, I would have expected it to be much more towards the NICU/PICU/cardiology side of things.

 

[blue.jay]

My spouse is the star resident in her program. She is liked by all her faculty members, program leadership and subspecialty faculty. She has decided to do general peds though she likes inpatient care or PICU. She is more than qualified to he a hospitalist and we both think the 2 yr hospitalist fellowship is a scam. I told her it's worth the stress and time to do NICU but she finds PICU more interesting and NICU has more repetitive. Due to limited job market for PICU she decided to be an outpatient pediatrician.

If pediatric board decreases fellowship length I think they can attract more medical students to their speciality. 6 yrs of GME to earn less than a general pediatrician in peds Nephro,Pulm,ID,endo is ridiculous. When adult Nephro, ID, Endo ca be 2 yr fellowship there is no reason why peds fellowship can't be done well in 2 yrs.

 

[SurfingDoctor]

Is anyone else surprised by allergy/immunology? Given that they can see both adults and kids, shorter fellowship and much greater availability of private practice jobs, I would have expected it to be much more towards the NICU/PICU/cardiology side of things.

Do they do a lot of invasive procedures? I actually don't know, but the increase in the number of invasive procedures, the higher the billing and reimbursement. I would imagine them to break even closer to general pediatrics though.

 

[blue.jay]

Do they do a lot of invasive procedures? I actually don't know, but the increase in the number of invasive procedures, the higher the billing and reimbursement. I would imagine them to break even closer to general pediatrics though.

Private practice allergy can make good money. Basically by easily seeing 30-40 pts a day. Allergy visits are quicker plus reimbursements from allergy shots and ease of private practice. Problem with peds subspecialties compared to IM is relatively fewer number of sick kids compared to older adults. For that reason most ped subspecialty jobs are limited to academic children's hospitals.

 

[SurfingDoctor]

Private practice allergy can make good money. Basically by easily seeing 30-40 pts a day. Allergy visits are quicker plus reimbursements from allergy shots and ease of private practice. Problem with peds subspecialties compared to IM is relatively fewer number of sick kids compared to older adults. For that reason most ped subspecialty jobs are limited to academic children's hospitals.

Yeah, except as mentioned A/I sees pediatrics and adults, even from a pediatrics background. But I do believe that allergy shots make good money from the point that they are quick, easy outpatient procedures... like Botox

 

[holaho]

I’m skeptical of this paper because it used MGMA data for general pediatrics (mix of private and academics) and AAMC Faculty Salary Data for the subspecialties (all academics). This is where the difference is stark because it is common knowledge you’re paid significantly less in academics no matter what specialty.

 

[blue.jay]

I’m skeptical of this paper because it used MGMA data for general pediatrics (mix of private and academics) and AAMC Faculty Salary Data for the subspecialties (all academics). This is where the difference is stark because it is common knowledge you’re paid significantly less in academics no matter what specialty.

Except neonatology, I thought every other subspeciality is predominantly employed by a children's hospital

 

[holaho]

AI I would argue is predominantly private practice. This is why the data doesn’t make sense to me in terms of AI. It’s comparing apples to oranges in terms of comparing two different salary databases. I know for a fact private practice AI pays way better than private practice pediatrics.

 

[BigRedBeta]

I’m skeptical of this paper because it used MGMA data for general pediatrics (mix of private and academics) and AAMC Faculty Salary Data for the subspecialties (all academics). This is where the difference is stark because it is common knowledge you’re paid significantly less in academics no matter what specialty.

Except neonatology, I thought every other subspeciality is predominantly employed by a children's hospital

@holaho
I think this is where you get into choices on methodology and can make arguments on what is and isn't appropriate to include.

MGMA data is appropriate for Gen Peds as most people going this route will be PP

The question becomes then what about the other fields. Neonatology certainly has a much higher ratio of PP positions than any other field, but do you include PP and further exacerbate an already noticeable difference? You've proven that academic Neo is already more lucrative.

How do you try to compare apples to apples when 98% of pediatric nephrologists are academic but only 70% (that's a random guess) of neonatologists are?

Private practice in any field pays more. I just got contacted by a recruiter for a PP PICU in a trendy location that only manages a miniscule 6 beds and is paying 375k/yr. I'm in a large PP PICU and make more than double what most academic PICU physicians make. But on the flip side, what's the service time requirement? I have 26 weeks of service that's just shift work. This small PICU wants 26 weeks a year but the weeks are 24/7 coverage. Is it reasonable to compare my salary to an academicians' salary when they only have 14 weeks of service and protected research time? If 90%+ of all the PICU jobs are academic then is there really any utility in adding in the PP jobs that have very different set ups? If your PP peds neuro who does no inpatient weeks, is that a reasonably equivalent position to compare to the academic neurologist?

In the end, if you are putting together a study such as this, you have to make decisions on how to craft it and these sorts of questions get asked. I think given that most fields make sense to use the AAMC data, it's a justifiable decision to use them even for fields like A/I or Neo where there are large PP numbers of jobs. Is it the most accurate method from a pure income level discussion? No, but it controls for a number of other variables that could be relevant.

 

[blue.jay]

@holaho
I think this is where you get into choices on methodology and can make arguments on what is and isn't appropriate to include.

MGMA data is appropriate for Gen Peds as most people going this route will be PP

The question becomes then what about the other fields. Neonatology certainly has a much higher ratio of PP positions than any other field, but do you include PP and further exacerbate an already noticeable difference? You've proven that academic Neo is already more lucrative.

How do you try to compare apples to apples when 98% of pediatric nephrologists are academic but only 70% (that's a random guess) of neonatologists are?

Private practice in any field pays more. I just got contacted by a recruiter for a PP PICU in a trendy location that only manages a miniscule 6 beds and is paying 375k/yr. I'm in a large PP PICU and make more than double what most academic PICU physicians make. But on the flip side, what's the service time requirement? I have 26 weeks of service that's just shift work. This small PICU wants 26 weeks a year but the weeks are 24/7 coverage. Is it reasonable to compare my salary to an academicians' salary when they only have 14 weeks of service and protected research time? If 90%+ of all the PICU jobs are academic then is there really any utility in adding in the PP jobs that have very different set ups? If your PP peds neuro who does no inpatient weeks, is that a reasonably equivalent position to compare to the academic neurologist?

In the end, if you are putting together a study such as this, you have to make decisions on how to craft it and these sorts of questions get asked. I think given that most fields make sense to use the AAMC data, it's a justifiable decision to use them even for fields like A/I or Neo where there are large PP numbers of jobs. Is it the most accurate method from a pure income level discussion? No, but it controls for a number of other variables that could be relevant.

Is it true that PICU job market is saturated ? What % of graduating fellows will get PP job with salary like this ?

 

[PTPoeny]

Is it true that PICU job market is saturated ? What % of graduating fellows will get PP job with salary like this ?

Many of the 6 bed units are "PICU" by hospital designation but ship out anything more complex than bronchiolitis or DKA -at least all the ones that recruiters contacted me about were like this. These aren't jobs that most PICU grads want and these aren't jobs that you can work at for any length of time and go back to a real PICU without also doing locums.

 

[SurfingDoctor]

@holaho
I think this is where you get into choices on methodology and can make arguments on what is and isn't appropriate to include.

MGMA data is appropriate for Gen Peds as most people going this route will be PP

The question becomes then what about the other fields. Neonatology certainly has a much higher ratio of PP positions than any other field, but do you include PP and further exacerbate an already noticeable difference? You've proven that academic Neo is already more lucrative.

How do you try to compare apples to apples when 98% of pediatric nephrologists are academic but only 70% (that's a random guess) of neonatologists are?

Private practice in any field pays more. I just got contacted by a recruiter for a PP PICU in a trendy location that only manages a miniscule 6 beds and is paying 375k/yr. I'm in a large PP PICU and make more than double what most academic PICU physicians make. But on the flip side, what's the service time requirement? I have 26 weeks of service that's just shift work. This small PICU wants 26 weeks a year but the weeks are 24/7 coverage. Is it reasonable to compare my salary to an academicians' salary when they only have 14 weeks of service and protected research time? If 90%+ of all the PICU jobs are academic then is there really any utility in adding in the PP jobs that have very different set ups? If your PP peds neuro who does no inpatient weeks, is that a reasonably equivalent position to compare to the academic neurologist?

In the end, if you are putting together a study such as this, you have to make decisions on how to craft it and these sorts of questions get asked. I think given that most fields make sense to use the AAMC data, it's a justifiable decision to use them even for fields like A/I or Neo where there are large PP numbers of jobs. Is it the most accurate method from a pure income level discussion? No, but it controls for a number of other variables that could be relevant.

When can I start?!

Academic is a hodge podge though. I only have 90 12 hour shifts/year... whatever that equates to, but I often go in on the weekends, or have early/late hours for experiments. Granted... most of my colleagues don't though. If anything, I'm a lot more eat what I kill from a research standpoint than any of my colleagues where it is more a hobby. But I'm in the minority.

There is something to be said for lifestyle/salary trade offs which is impossible to put a dollar amount on though.

 

[SurfingDoctor]

Is it true that PICU job market is saturated ? What % of graduating fellows will get PP job with salary like this ?

In the past, it's been about 50/50 for academic/PP. But the academic jobs are drying up. I would only assume the PP are similar. It's not like you can just make a PICU. You need a federal "Certificate of Need" to have a hospital and the associated ancillary support and most intensivists should be able to manage 10 to 15 critical care patients comfortably. Considering PICU by nature is a field of rare disease... there's just not that much need.

I know we've had a couple of more recent grads struggle to find jobs. Granted, they were IMGs with visa issues, but even the US grads didn't have much to choose from (if at all). Our division chief gets lots of cold calls and emails asking to interview for a position... that doesn't exist.

Many other specialities aren't dependent on hospitals though. I've known quite a few PP endocrinologists and infectious disease doctors.

 

[blue.jay]

In the past, it's been about 50/50 for academic/PP. But the academic jobs are drying up. I would only assume the PP are similar. It's not like you can just make a PICU. You need a federal "Certificate of Need" to have a hospital and the associated ancillary support.

I know we've had a couple of more recent grads struggle to find jobs. Granted, they were IMGs with visa issues, but even the US grads didn't have much to choose from (if at all). Our division chief gets lots of cold calls and emails asking to interview for a position... that doesn't exist.

I read somewhere that PICU jobs are cyclical. Some years they have tons of openings and few years like you said some grads have a tough time finding a position. I am not sure how bad the situation is, like RadOnc/EM/Path where one has to be geographically flexible to get a job.

 

[SurfingDoctor]

I read somewhere that PICU jobs are cyclical. Some years they have tons of openings and few years like you said some grads have a tough time finding a position. I am not sure how bad the situation is, like RadOnc/EM/Path where one has to be geographically flexible to get a job.

I don't know about the cyclical nature. There are years where we are hiring and years where we are not, mostly in the cardiac intensivist care group. They are slightly more a hot commodity because hospital systems like anything that support ORs, especially CT ORs because they are large revenue generators. But about half the physicians that have left our group since I joined about 8 years ago have left from burnout. Seems more random to be than anything else.

 

[Bernardo_11]

My specialty was not even counted in their damn list. That can't be good. lol

Nardo

 

[blue.jay]

My specialty was not even counted in their damn list. That can't be good. lol

Nardo

DBP? Child abuse?

 

[Bernardo_11]

DBP? Child abuse?

DBP

 

[BigRedBeta]

When can I start?!

Academic is a hodge podge though. I only have 90 12 hour shifts/year... whatever that equates to, but I often go in on the weekends, or have early/late hours for experiments. Granted... most of my colleagues don't though. If anything, I'm a lot more eat what I kill from a research standpoint than any of my colleagues where it is more a hobby. But I'm in the minority.

There is something to be said for lifestyle/salary trade offs which is impossible to put a dollar amount on though.

Send me a PM if you want and I'll forward you the email. I'm sure there is a referral bonus in there for me. It's not a bad little hospital, I interviewed there about 6 years ago coming out of fellowship when they were just starting up their unit, was just nowhere near the right fit for me at that point. At this point, not the right fit for me because of kids, time commitment, and it would be a significant drop in salary that would not outweigh the geographic arbitrage.

 

[BigRedBeta]

Is it true that PICU job market is saturated ? What % of graduating fellows will get PP job with salary like this ?

Graduating fellows? Get my salary? or the one I listed?

I've had to put in sweat equity in my group to reach my current salary and I'm in a very unique situation in which we're PP, but still have an extremely large ICU and our annual admissions are easily top quartile nationwide. Volume matters for sustainability.

Most other PP jobs probably max out in units with no more than 12 beds, which limits income potential. The other question is what sort of subspecialty support is there. If you're having to transfer out all you status epilepticus patients because you don't have neuro coverage, then that is limiting. If any cancer patient is stabilize and ship, even if just a fever and neutropenia/sepsis, that's limiting. Nevermind TBI/trauma/ruptured appy's, if there's no surgeons willing to take kids to the OR, then youre left taking asthmatics, bronchiolitis, DKA, and ingestions. It's not amenable to a sustainable income without significant hospital investment in the unit. Some PP groups augment their base by serving as pediatric hospitalists as well so that they can garner that income stream.

The PP gig I mentioned from the recruiter, having seen that location up close, I know is part of a strategy by a major hospital corporation to augment their patient retention from the OB and NICU investments they've made. There is an academic center in town, but the geography puts it far from the continued growth of the metro, so this corporation sees it as an easy sell - come to us, forget the 45 minute trip in traffic to see those other guys. They've set up a Peds ED, they are recruiting other pediatric subspecialists, but those subspecialists also want ICU support, so it has to grow in fits and starts. But since they've grown their L&D market share and care for a lot of NICU babies, they want to keep those families in house so to speak. They were committed long term to see that through and so are subsidizing the salaries of certain fields so that they can keep building.

However, anytime you're dependent on subsidies, there's a chance that the rug can get pulled out from under you. This just recently happened at Children's Mercy in Kansas City, where the ICU group there was in a hybrid model that was PP from a monetary sense but with academic appointments tacked on. The PICU docs were a small section of a much larger Anesthesia group in Kansas City, and it's not unusual for hospitals to subsidize anesthesia contracts when volumes at various hospitals don't yield enough revenue to recruit those positions. As you might imagine Pediatric Anesthesia probably also need subsidies. The hospital board decided they were paying too much for that contract and so as a cost cutting measure notified with a 6 month lead time that they would not renew at current terms and began putting out ads to recruit replacements. The PICU group with lower salaries to recruit to was less dependent on the subsidies but got taken along for the ride as well and were in danger of losing their jobs. The contract was renegotiated and all is well, but was scary moments there for a while.

 

[SurfingDoctor]

Send me a PM if you want and I'll forward you the email. I'm sure there is a referral bonus in there for me. It's not a bad little hospital, I interviewed there about 6 years ago coming out of fellowship when they were just starting up their unit, was just nowhere near the right fit for me at that point. At this point, not the right fit for me because of kids, time commitment, and it would be a significant drop in salary that would not outweigh the geographic arbitrage.

Thanks for the offer, but it was more in jest. I like research and I’d never be able to do it in PP.

 

[mvenus929]

If pediatric board decreases fellowship length I think they can attract more medical students to their speciality. 6 yrs of GME to earn less than a general pediatrician in peds Nephro,Pulm,ID,endo is ridiculous.

This is a little bit of a double edged sword. We say there is a need for more of these specialties, but when I went to find a job, most of the jobs had dried up. One that I went through the interview process for decided on another candidate and another took the job off the market. My other option was basically starting a private practice from scratch, which didn't sound terribly appealing to me since I have a niche interest in my field.

My co-fellow still hasn't signed a contract yet. One of my friends in PEM is worried that the hospital he signed with won't honor his contract because they had to shut down another hospital. I realize that these are probably specific to COVID depression, but what's to say something else won't happen in 5-10 years to the wave of med students we are currently working on recruiting into our specialty?