Maximum compensation pathway offered during first three years as attending?

[sallyhasanidea]

Hey everyone,

I had a quick question regarding job prospects as a first-year private practice subspecialty internal medicine attending. I understand that compensation depends on many factors, including but not limited to, partnership, location, volume, compensation model, days/week, etc, but I’m curious what your opinions on the pathways that will lead to the highest possible salary after training. Is cardiology or GI more lucrative, keeping into consideration saturation concerns such as oversupply of interventionalists in cardiology after training, please support your answer with anecdotal evidence of salaries you have seen for first year attending salary.

The reason I ask is because I will have a hefty student loan debt burden at the completion of my training. My spouse and I will have a combined debt burden of $1.1 Million upon completion of fellowship training. Yes I have made financial mistakes in the past when I was a student (expensive undergrad, expensive masters, expensive medical school, for both spouse and myself). Spouse going into pediatrics and wants to do subspecialty training so I am expecting realistically 150k after tax for their income. Location does not matter, days/week does not matter, and honestly satisfaction with my work environment does not matter as this would be a temporary position as I work to build a sizable nest egg and pay off debt. My goal would to work as hard as possible, even if that includes 120 hr weeks in order to pay off our debt. Eventually, I would transition to a work environment and location that I desired, but this would be at least several years down the line. How can I maximize my income in internal medicine?

Thanks for any insight,
Sally

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[sylvanthus]

 

[wamcp]

Hey everyone,

I had a quick question regarding job prospects as a first-year private practice subspecialty internal medicine attending. I understand that compensation depends on many factors, including but not limited to, partnership, location, volume, compensation model, days/week, etc, but I’m curious what your opinions on the pathways that will lead to the highest possible salary after training. Is cardiology or GI more lucrative, keeping into consideration saturation concerns such as oversupply of interventionalists in cardiology after training, please support your answer with anecdotal evidence of salaries you have seen for first year attending salary.

The reason I ask is because I will have a hefty student loan debt burden at the completion of my training. My spouse and I will have a combined debt burden of $1.1 Million upon completion of fellowship training. Yes I have made financial mistakes in the past when I was a student (expensive undergrad, expensive masters, expensive medical school, for both spouse and myself). Spouse going into pediatrics and wants to do subspecialty training so I am expecting realistically 150k after tax for their income. Location does not matter, days/week does not matter, and honestly satisfaction with my work environment does not matter as this would be a temporary position as I work to build a sizable nest egg and pay off debt. My goal would to work as hard as possible, even if that includes 120 hr weeks in order to pay off our debt. Eventually, I would transition to a work environment and location that I desired, but this would be at least several years down the line. How can I maximize my income in internal medicine?

Thanks for any insight,
Sally

So..how far along are you? MS1? PGY1?

if a med student the future is less certain and the risk increases that drastic changes like gov reimbursement cuts, market oversupply due to private equity shenanigans will completely change the outlook.

for example, see emergency medicine. Literally 3 years ago they could get >$500/hr locums....today? No jobs exist and income falling everywhere. Or look at radonc. Path. Rads several years ago (rebounded since).

So, if you choose for example GI or cards the possibility is there that by the time you exit training you get the short end of the stick

 

[aafisahar]

Your SO shouldn't be doing pediatrics with that much loan burden. That's the harsh truth.

Secondly, GI vs cardiology is a dumb dichotomy. They are vastly different fields. You should be looking at what you want to do for 30-40 years instead. Cardiology and GI pay similarly, GI has a higher ceiling.

Honestly, if you did a nocturnist job right out of residency then picked up day shifts or more nights, you could probably make GI or cardiology money right out of residency. I would rather drink bleach, but if you want to maximize income, that'd be one of the best ways.

 

[rokshana]

Hey everyone,

I had a quick question regarding job prospects as a first-year private practice subspecialty internal medicine attending. I understand that compensation depends on many factors, including but not limited to, partnership, location, volume, compensation model, days/week, etc, but I’m curious what your opinions on the pathways that will lead to the highest possible salary after training. Is cardiology or GI more lucrative, keeping into consideration saturation concerns such as oversupply of interventionalists in cardiology after training, please support your answer with anecdotal evidence of salaries you have seen for first year attending salary.

The reason I ask is because I will have a hefty student loan debt burden at the completion of my training. My spouse and I will have a combined debt burden of $1.1 Million upon completion of fellowship training. Yes I have made financial mistakes in the past when I was a student (expensive undergrad, expensive masters, expensive medical school, for both spouse and myself). Spouse going into pediatrics and wants to do subspecialty training so I am expecting realistically 150k after tax for their income. Location does not matter, days/week does not matter, and honestly satisfaction with my work environment does not matter as this would be a temporary position as I work to build a sizable nest egg and pay off debt. My goal would to work as hard as possible, even if that includes 120 hr weeks in order to pay off our debt. Eventually, I would transition to a work environment and location that I desired, but this would be at least several years down the line. How can I maximize my income in internal medicine?

Thanks for any insight,
Sally

So your spouse is not going to anything about their debt and you are going to try to be superwoman and take care of both? Really?
Working 120 h /wk is not sustainable even on the short term.

live like you are residents, not med students, for the next 5-7 years and put the rest to paying off loans... get jobs in places that pay the most... I know there are peds hospitalist positions that pay in the 200s... middle of nowhere places in the Midwest are the best places to look.

remember fellowship keeps you in a lower training income for 3 years... yes cards or gi currently have the potential to make bigger money, but if you are looking to get money early, go find a nocturnist position and then take on extra shifts.

are you budgeting appropriately now? What can you put towards paying things off now? Or are you accumulating debt as we speak?

 

[bobow98]

oh boy here we go again.

inb4lock

 

[Chemist0157]

You'd probably be better off just doing hospital medicine/nocturnist rather than sink time and lost income into a fellowship. It takes time to build up a practice or work through a partner pathway after fellowship. With hospital medicine, you just sign up for more shifts. This is not true if you actually want to do a certain subspecialty. Being a cardiologist 20 years from now won't mean much to you if your priority is getting paid a lot and fast now.

Keep living expenses low.

Go wherever the high pay is on the interview trail. It's not going to be any of these unicorn jobs around here. It's going to be seeing a lot of patients in a less desirable area.

 

[chessknt]

Are these private or government loans? Where are you in the process? This is a scenario where I would recommend you go all-in on PSLF assuming you havent ****ed it up already by going in to forbearance and that is a scenario that favors prolonging training.

 

[Osteoth]

You'd probably be better off just doing hospital medicine/nocturnist rather than sink time and lost income into a fellowship. It takes time to build up a practice or work through a partner pathway after fellowship. With hospital medicine, you just sign up for more shifts. This is not true if you actually want to do a certain subspecialty. Being a cardiologist 20 years from now won't mean much to you if your priority is getting paid a lot and fast now.

Keep living expenses low.

Go wherever the high pay is on the interview trail. It's not going to be any of these unicorn jobs around here. It's going to be seeing a lot of patients in a less desirable area.

This is the way.

If you do 2x FTE nocturnist in BFA you can probably clear >500k gross. How long you can keep that up is anyone’s guess.

 

[chessknt]

This is the way.

If you do 2x FTE nocturnist in BFA you can probably clear >500k gross. How long you can keep that up is anyone’s guess.

At that debt level each of them could instead do 3+2-3 years of PSLF payments as trainees then pay off an additional 10-20% as attendings under PAYE over the next 4-5 years in a qualifying position (could be hospital employees at a nonprofit) and get the other 60-80% forgiven. It requires faith that the program wont be disemboweled but at the same time allows them to pursue their career interests and not work at a pace that precludes sanity/time with family.

They can continue to live like residents in the interim and put their earnings toward retirement/home downpayment instead of the student loan supermassive black hole

 

[InternistDO]

It seems like doing whatever you actually enjoy and aiming for PSLF or some other loan repayment would be a vastly superior option as opposed to trying to aggressively pay down that much debt rapidly. As someone else pointed out, if your spouse does a fellowship they'll be 6 years into a potential PSLF payoff, which means just 4 years as an academic or nonprofit attending. You can either do general medicine the whole time and save aggressively, or do whatever fellowship you end up liking and do academics/underserved stuff for 4-5 years after.

Working 80-120 hours a week as an attending when your spouse is (more wisely, I'd argue) focusing on their interests is a recipe for burnout and marital strife.

 

[cards67]

Best bet is probably hospitalist in some undesirable area and picking up extra shifts. Years back I remember hearing about a nocturnist gig, 250K, 1 on 2 off, in a major city. Certainly opportunity out there. A GI friend out of training got offers in 400-500k range in good areas without breaking a sweat. Cards the highest I've heard is 500k for gen cards, 750k for IC, but less desirable, not awful, areas. But that's all 3-4yrs more pgy training and salary. The dollars will eventually catch up to those extra few years of hospitalist pay, but could take a little bit. Limiting factor may be your spouses job options. Pediatric subspecialist may not be able to just practice anywhere.

 

[sallyhasanidea]

Your SO shouldn't be doing pediatrics with that much loan burden. That's the harsh truth.

Secondly, GI vs cardiology is a dumb dichotomy. They are vastly different fields. You should be looking at what you want to do for 30-40 years instead. Cardiology and GI pay similarly, GI has a higher ceiling.

Honestly, if you did a nocturnist job right out of residency then picked up day shifts or more nights, you could probably make GI or cardiology money right out of residency. I would rather drink bleach, but if you want to maximize income, that'd be one of the best ways.

Could you please expand on how GI has a higher ceiling than cardiology and what it takes to get to that ceiling? I am MS3 btw.

 

[Splenda88]

This is the way.

If you do 2x FTE nocturnist in BFA you can probably clear >500k gross. How long you can keep that up is anyone’s guess.

Where one of my friends just signed a nocturnist contract, 19.8 shifts/month with get him 500k/yr. You really don't need 2x FTE nocturnist to make 450-500k/yr.

a co-resident signed 1 week on and 3 weeks off hospitalist contract for ~160k/yr with benefits (not a 1099 gig). Average census 16-18.

There are a few good gigs out there, but you gotta be lucky to find them.

 

[VA Hopeful Dr]

Where one of my friends just signed a nocturnist contract, 19.8 shifts/month with get him 500k/yr. You really don't need 2x FTE nocturnist to make 450-500k/yr.

a co-resident signed 1 week on and 3 weeks off hospitalist contract for ~160k/yr with benefits (not a 1099 gig). Average census 16-18.

There are a few good gigs out there, but you gotta be lucky to find them.

20 nocturnist shifts/month isn't a good gig to my reckoning.

 

[Splenda88]

20 nocturnist shifts/month isn't a good gig to my reckoning.

Yeah, was telling the poster you don't need 2 FTE nocturnist to make 500k/yr.

 

[CCM-MD]

Where one of my friends just signed a nocturnist contract, 19.8 shifts/month with get him 500k/yr. You really don't need 2x FTE nocturnist to make 450-500k/yr.

a co-resident signed 1 week on and 3 weeks off hospitalist contract for ~160k/yr with benefits (not a 1099 gig). Average census 16-18.

There are a few good gigs out there, but you gotta be lucky to find them.

There are unicorn gigs out there for every specialty. GI unicorn gigs pay 1mil. Key: don’t base career choices on anecdotal unicorn gigs that you hear about on SDN.

 

[gutonc]

Yeah, was telling the poster you don't need 2 FTE nocturnist to make 500k/yr.

20 night shifts a month IS a 2x FTE job.

 

[Splenda88]

20 night shifts a month IS a 2x FTE job.

Not in the 'hospitalist world'

 

[Splenda88]

What do you guys/gals think about that hospitalist employment model?

1st year salary is guaranteed (~230k), then you will get 55% of collection.

@VA Hopeful Dr @gutonc

 

[gutonc]

Not in the 'hospitalist world'

In the nocturnist world it is. A good nocturnist job should be 10-12 shifts a month.

 

[Splenda88]

In the nocturnist world it is. A good nocturnist job should be 10-12 shifts a month.

I have been in the job market for 5 months right now and I only saw one job that offers that kind of setting. It is not common.

 

[sallyhasanidea]

There are unicorn gigs out there for every specialty. GI unicorn gigs pay 1mil. Key: don’t base career choices on anecdotal unicorn gigs that you hear about on SDN.

So which will be more lucrative GI or cardiology?

 

[CCM-MD]

So which will be more lucrative GI or cardiology?

That’s the wrong question. Wrong questions get wrong answers.

 

[Splenda88]

So which will be more lucrative GI or cardiology?

Interventional card

 

[SeldingerTechneek]

So which will be more lucrative GI or cardiology?

Not medicine

 

[sallyhasanidea]

Not medicine

I'm in too deep bro

 

[chessknt]

What do you guys/gals think about that hospitalist employment model?

1st year salary is guaranteed (~230k), then you will get 55% of collection.

@VA Hopeful Dr @gutonc

Depends on payor mix but that is an abusive cut. An inpatient group should have minimal overhead and be getting a stipend for coverage. Stiffing you for the non payments while keeping half your take and the stipend is bull****

 

[Osteoth]

Interventional card

Or high volume GI endoscopist where clinic and inpatients are done by PA/NP

 

[Splenda88]

Are these 12h shifts?

yeah

 

[sallyhasanidea]

Or high volume GI endoscopist where clinic and inpatients are done by PA/NP

Where can you find gigs like these? Are they readily available?

 

[aafisahar]

Not medicine

Ha, that's a joke. Medicine offers the best guaranteed path to 6 figures. None of the graduating fellows (all 32-34) are signing for less than 400k. Not hard to make 100k in fellowship moonlighting either.

Not medicine is boomer talk back when you could get a job at the factory in 1985 paying 36 bucks an hour and invest in Disney at 2.10 and buy a 4 bed 2 br in the bay area for 100k.

 

[Osteoth]

Where can you find gigs like these? Are they readily available?

Jobs after training is all about market, connections and luck. The best jobs don’t advertise because they don’t have to, but there are plenty of jobs out there paying >$500k.

A CPA came to talk to my program the other day and said something interesting, “for every hospitalist or PCP making >$400k there’s a GI doc making >$800k”.

I’ve personally seen 1-2 year partner track jobs paying $600k plus non partner then $1m plus after partner.

 

[VA Hopeful Dr]

Depends on payor mix but that is an abusive cut. An inpatient group should have minimal overhead and be getting a stipend for coverage. Stiffing you for the non payments while keeping half your take and the stipend is bull****

If you have a good payer mix, 55% of collections COULD be lucrative but I'd have my concerns about it.

 

[Splenda88]

If you have a good payer mix, 55% of collections COULD be lucrative but I'd have my concerns about it.

You think I should negotiate for 60%. This job is in the prime location that I want to be at. However, the issue is that I have another offer for 330k/year guaranteed with no incentive but location is not ideal.

I wish I had only one offer so I would not have to think any other offers. This process is crazy!

 

[chessknt]

You think I should negotiate for 60%. This job is in the prime location that I want to be at. However, the issue is that I have another offer for 330k/year guaranteed with no incentive but location is not ideal.

I wish I had only one offer so I would not have to think any other offers. This process is crazy!

You want a guaranteed daily stipend. What if your census is low or all the patients are uninsured? Then you’re working for free. I’d also ask to see what collections have been like for other Hospitalists under this system in the past 2 years so you have an idea pre and post pandemic.

even better would be to negotiate stipend + 80% and be 1099 so you are in charge of your own benefits and Medmal and they can take a more appropriate sized bite without the obfuscating lie that it pays for your benefits.

 

[VA Hopeful Dr]

You want a guaranteed daily stipend. What if your census is low or all the patients are uninsured? Then you’re working for free. I’d also ask to see what collections have been like for other Hospitalists under this system in the past 2 years so you have an idea pre and post pandemic.

even better would be to negotiate stipend + 80% and be 1099 so you are in charge of your own benefits and Medmal and they can take a more appropriate sized bite without the obfuscating lie that it pays for your benefits.

I'd agree - salary plus RVU bonus of some kind.

 

[tantacles]

Best bet is probably hospitalist in some undesirable area and picking up extra shifts. Years back I remember hearing about a nocturnist gig, 250K, 1 on 2 off, in a major city. Certainly opportunity out there. A GI friend out of training got offers in 400-500k range in good areas without breaking a sweat. Cards the highest I've heard is 500k for gen cards, 750k for IC, but less desirable, not awful, areas. But that's all 3-4yrs more pgy training and salary. The dollars will eventually catch up to those extra few years of hospitalist pay, but could take a little bit. Limiting factor may be your spouses job options. Pediatric subspecialist may not be able to just practice anywhere.

This is essentially my job down to the exact number of shifts. 120 shifts per year. I take a ton of extra work (though plan to scale back very soon), but yes, a good nocturnist job should look is exactly like this.

 

[Splenda88]

This is essentially my job down to the exact number of shifts. 120 shifts per year. I take a ton of extra work (though plan to scale back very soon), but yes, a good nocturnist job should look is exactly like this.

Spent 5 months looking a job like that with no luck. One of my co-residents was able to find one that is somewhat close (3 days on, 1 day off, 3 days on and 7 days off and repeat). From what that co-resident said, salary potential is 280-290k.

 

[tantacles]

Spent 5 months looking a job like that with no luck. One of my co-residents was able to find one that is somewhat close (3 days on, 1 day off, 3 days on and 7 days off and repeat). From what that co-resident said, salary potential is 280-290k.

So 13 shifts per month for $40,000 more per year? Not bad.

 

[Splenda88]

So 13 shifts per month for $40,000 more per year? Not bad.

He was reluctant to take the job. I told him it is a good job. That day off in between can make a HUGE difference in term of burnout.

 

[tantacles]

He was reluctant to take the job. I told him it is a good job. That day off in between can make a HUGE difference in term of burnout.

Yeah, that format is not bad at all. I think if I were him though I'd try to negotiate for 1 fewer shift every two weeks for $20000 less per year assuming they're paying about $1800/shift.

 

[wamcp]

Yeah, that format is not bad at all. I think if I were him though I'd try to negotiate for 1 fewer shift every two weeks for $20000 less per year assuming they're paying about $1800/shift.

In 2019 there was a closed ICU, major city suburb, nocturnist job that i found and interviewed at for 13 shifts per month full time. Base salary 280K plus RVU, but actual pay the nocturnists were getting was 450k.

Why did I not take it? Simple, you got paid well because you were working your butt off every second. 20 admissions a night was “normal”. Crosscover pages every couple minutes (you covered six hours of it, the other nocturnist took the other half of the night).

I figured if I wanted to get paid 240/hr seeing 1.6 patients per hour I could have just gone into EM (although EM today has no jobs, lol) Which is not what I would be happy doing (burnout)

 

[sloh]

In 2019 there was a closed ICU, major city suburb, nocturnist job that i found and interviewed at for 13 shifts per month full time. Base salary 280K plus RVU, but actual pay the nocturnists were getting was 450k.

Why did I not take it? Simple, you got paid well because you were working your butt off every second. 20 admissions a night was “normal”. Crosscover pages every couple minutes (you covered six hours of it, the other nocturnist took the other half of the night).

I figured if I wanted to get paid 240/hr seeing 1.6 patients per hour I could have just gone into EM (although EM today has no jobs, lol) Which is not what I would be happy doing (burnout)

Considering just how efficient you are (easily probably >90 percentile among all hospitalists) based off your prior posts, people should take this to heart

 

[Splenda88]

I almost had a good noctunirst job but the interview did not go well, and they said they chose another candidate.
Salary was 280k plus 20% incentive. Ncturnist always got > 90% of that 20% (confirmed). 100k student loa repayment for 3 yrs. The state will give you another 100k for 4 yrs. Average admission 14-16 for 2 docs and 1 NP/PA. Was mad at myself that I did not get the job.

 

[tylerb1800]

You think I should negotiate for 60%. This job is in the prime location that I want to be at. However, the issue is that I have another offer for 330k/year guaranteed with no incentive but location is not ideal.

I wish I had only one offer so I would not have to think any other offers. This process is crazy!

I would ask for a payor breakdown as well as what each insurance reimburses based on the hospital contracts. If you see self-pay patients, you will likely not get paid to see them as you will only be paid if the hospital collects. If the hospital writes off their bill, then you worked for free

 

[rokshana]

Where one of my friends just signed a nocturnist contract, 19.8 shifts/month with get him 500k/yr. You really don't need 2x FTE nocturnist to make 450-500k/yr.

a co-resident signed 1 week on and 3 weeks off hospitalist contract for ~160k/yr with benefits (not a 1099 gig). Average census 16-18.

There are a few good gigs out there, but you gotta be lucky to find them.

Ummm... 19 shifts/month as a nocturnist is pretty much 2 FTE...

 

[rokshana]

Not in the 'hospitalist world'

In the nocturnist world it is

 

[Splenda88]

In the nocturnist world it is

No it's not... 90+% of nocturnist jobs out there are 7 days on/off. I have spent 5 months looking for 10-12 nights/month nocturnist job with no luck.

 

[CCM-MD]

Our nocturnists do week on/off. Definitely not 10/month.