Malignant heme career questions

[MifflinDunder]

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[randomhemoncpd]

1. Yes
2. Lots of opportunities to generate RVU since there’s both clinic and a lot more rounding than med onc. Whether you get paid per RVU (eat what you kill) or not matters a lot since it’s easy to scale up volume if you’re efficient.
3. BMT year strongly helps but isn’t absolutely mandatory — not all malignant heme jobs these days involve BMT.

There are a lot of types of malignant heme careers as well as different centers. Some places you’ll be a jack of all trades including allo, CAR-T, leukemia, lymphoma, myeloma whereas others you’ll be in one disease type or treatment modality (i.e. all BMT or all leukemia but not both). There are opportunities to make a lot of money (north of a million) in the right setup, but there are also abusive academic positions that will ride you for close to 10k RVU and give you 300k to show for it.

 

[WanderingBlast]

Maybe others have different opinions but if interested in BMT, you do not need to do a BMT fellowship IF you are able to get adequate exposure to BMT in-house during your heme-onc fellowship. I did not do a BMT year and instead used my 3rd year of fellowship to focus on BMT and CAR-T experiences. I interviewed at a few academic centers besides my own institution and got multiple offers and never felt that not having a separate BMT fellowship was held against me. It can be tough to put yourself and/or your family through a second fellowship. Most SCT and cell therapy is constant on the job learning with the majority of the current experts in the field not having done fellowship and doing just fine figuring things out as they go.

Benign heme is very often a path to more work for not more RVUs. Many benign heme issues unfortunately generate less high-complexity/risk billing and therefore less RVUs. BMT generates a lot of RVUs but caution and take randomhemeoncpd’s words to heart: you may or may not see them reflected in your salary depending on your setup, especially at academic institutions.

 

[gutonc]

Maybe others have different opinions but if interested in BMT, you do not need to do a BMT fellowship IF you are able to get adequate exposure to BMT in-house during your heme-onc fellowship. I did not do a BMT year and instead used my 3rd year of fellowship to focus on BMT and CAR-T experiences. I interviewed at a few academic centers besides my own institution and got multiple offers and never felt that not having a separate BMT fellowship was held against me. It can be tough to put yourself and/or your family through a second fellowship. Most SCT and cell therapy is constant on the job learning with the majority of the current experts in the field not having done fellowship and doing just fine figuring things out as they go.

Benign heme is very often a path to more work for not more RVUs. Many benign heme issues unfortunately generate less high-complexity/risk billing and therefore less RVUs. BMT generates a lot of RVUs but caution and take randomhemeoncpd’s words to heart: you may or may not see them reflected in your salary depending on your setup, especially at academic institutions.

To speak to the bolded, for benign heme (in the outpatient setting), you can easily generate 6 99213+G2211 an hour with these cases. 8 hours of that a day is 75-80 wRVU with very little actual work involved. That's actually more wRVU than you would generate from 3 99215+G2211 in an hour, and for that you'd actually have to put in a lot of work. And seeing 3 of those disasters an hour all day every day would be (at least for me) soul crushing.

The problem with complex cases is that they're complex. So they take more time. And the ceiling on what you get compensated for that is far too low. If the CPT codes went up to 99217 or 99218 and you were getting 4.5 or 5 wRVU for each of those complex cases then it would make more sense to do that.

As the system is currently structured, I could sit back and see nothing but 4 or 5 benign heme patients an hour all week (which I easily could because every PCP within a 100 mile radius of me sends every single abnormal CBC they see for my "input"), could finish clinic with all of my notes done by 4:45p and pull in nearly 7 figures working 3 days a week.

(Note that all of this is for the outpatient setting only)

 

[randomhemoncpd]

To speak to the bolded, for benign heme (in the outpatient setting), you can easily generate 6 99213+G2211 an hour with these cases. 8 hours of that a day is 75-80 wRVU with very little actual work involved. That's actually more wRVU than you would generate from 3 99215+G2211 in an hour, and for that you'd actually have to put in a lot of work. And seeing 3 of those disasters an hour all day every day would be (at least for me) soul crushing.

The problem with complex cases is that they're complex. So they take more time. And the ceiling on what you get compensated for that is far too low. If the CPT codes went up to 99217 or 99218 and you were getting 4.5 or 5 wRVU for each of those complex cases then it would make more sense to do that.

As the system is currently structured, I could sit back and see nothing but 4 or 5 benign heme patients an hour all week (which I easily could because every PCP within a 100 mile radius of me sends every single abnormal CBC they see for my "input"), could finish clinic with all of my notes done by 4:45p and pull in nearly 7 figures working 3 days a week.

(Note that all of this is for the outpatient setting only)

It's not all doom and gloom! Most of the malignant 99215 cases are very straightforward - the R-CHOP's, ven/azas, etc of the world are easy, and the weekly / biweekly allo follow-ups by and large don't take that much time either and those visits really rack up quickly. Post auto / CAR-T follow-up is even easier although they don't come nearly as often. One of my colleagues sees 30+ in clinic, almost all pre / post-allo, and his outcomes are absolutely spectacular (and he by and large leaves on time). 4 99215 + G2211 in an hour is very doable without being crushing; of course, there is often that 1 patient that is struggling that takes more time, but if they're that symptomatic they simply need to get admitted and stabilized, so that's practically speaking not that hard either.

 

[HemOncCheng]

Maybe others have different opinions but if interested in BMT, you do not need to do a BMT fellowship IF you are able to get adequate exposure to BMT in-house during your heme-onc fellowship. I did not do a BMT year and instead used my 3rd year of fellowship to focus on BMT and CAR-T experiences. I interviewed at a few academic centers besides my own institution and got multiple offers and never felt that not having a separate BMT fellowship was held against me. It can be tough to put yourself and/or your family through a second fellowship. Most SCT and cell therapy is constant on the job learning with the majority of the current experts in the field not having done fellowship and doing just fine figuring things out as they go.

Benign heme is very often a path to more work for not more RVUs. Many benign heme issues unfortunately generate less high-complexity/risk billing and therefore less RVUs. BMT generates a lot of RVUs but caution and take randomhemeoncpd’s words to heart: you may or may not see them reflected in your salary depending on your setup, especially at academic institutions.

I second that, it is certainly possible without BMT sub-fellowship. One of the fellows in my program who graduated last year did that, and went on to an west coast academic center (although not the big/famous ones)

 

[randomhemoncpd]

I second that, it is certainly possible without BMT sub-fellowship. One of the fellows in my program who graduated last year did that, and went on to an west coast academic center (although not the big/famous ones)

Definitely possible to get an in-house BMT job without an extra year depending on how you structure your fellowship. However, to get an external BMT job at a top academic center is hard without an extra year unless you're from a top fellowship. Not saying that's the way it should be, but that seems to be the reality. BMT fellowships remain relatively non-competitive.

 

[CatFactorial]

This makes sense. 4 years of fellowship to get a hospitalist base salary (what our malignant heme/BMT docs start at) might be a worse investment than nephro/ID. You'll never recover financially from the years lost.

Private BMT groups can be quite lucrative once you make partner. There’s also a lot of BMT/pharma overlap, so industry could be an option down the road. Plus, CAR-T and other IECTs are booming, with volumes increasing and likely expanding into other areas like solid tumors and autoimmune diseases (e.g., rheum).

 

[whoknows2012]

1st-year fellow and looking for info on Malignant Heme as a career, as I find it much less draining than being fully outpatient 5 days a week.

I know the pay will start at the same base as hospitalists and not 400-500k base, you'll have more inpatient time, and a higher call burden vs the solid onc folks.

1) Are most jobs still in academic centers?
2) What determines how you can add on RVUs in this setting? Is it by covering benign heme and/or BMT?
3) Besides doing an extra BMT year, what can I do in the next 2.5 years to set myself up better for an inpatient heavy career?

1) yes but more options exist in hybrid and even rarely private groups
2) lots of options. Could see more patients, get more administrative roles or do more research for rvu buy backs. Can choose to do only inpatient or more inpatient than others. In my experience while many malignant hematologists enjoy inpatient work, if they at the same time have to have an active clinic it becomes very difficult to do both.
2a) when signing a contract make sure there’s a stipulation for incentive/bonus if the institution offers it. 20 patients with average wRVU or 2.5 (2.4 for level iii 3.5 for consults and admits, 2.15 for discharge >30 mins) is 50 wRVU per day. Do the math…
3) do not get stuck doing an extra bmt year if you can avoid it. If you decide for 100% certainty you want to pursue a career in BMT spend as many elective months 3rd year doing that + leukemia.

You are correct base pay for these jobs is relatively poor (250-300 for academics) but if there is incentive offered it can quickly make more sense financially

As an inpatient leukemia doc for >5 yrs I have lots of experience navigating if any further questions…