Maximum compensation pathway offered during first three years as attending?

[yakattack16]

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If we're talking academic medical centers, I agree. You're paid in pristige, and for some godforsaken reason some folks are willing to take a 100k+ haircut just to have some fancy emblem on their patagucci. But for most nocturnist that could care less, nobody should ever be making under 300k. I firmly believe no nocturnist should be getting out of bed for less than $150/hr. Heck, for years they've been paying midlevels $100 an hour at my shop just to do some crosscoverage The going rate is now widely around $175, my per diem job recently raised their rates to $220 due to burn out and short staffing (and still, very few are picking up extra shifts), and my primary job now regularly offers $250. Both places in the northeast, I can see the skyline from both hospitals. It doesn't take that many shifts a month to add up to 300k and thats before any bonuses. No nocturnist I know/work with makes less, average is close to 350-400k, and 500k quite achievable. It's not a bad time to be a hospitalist.

Is that closed ICU, no codes/procedures/rapids? How many admits? Because where I am, nocturnist is paid 275k for 7/7 with the above perks and about 8-10 admits.

 

[CCM-MD]

Is that closed ICU, no codes/procedures/rapids? How many admits? Because where I am, nocturnist is paid 275k for 7/7 with the above perks and about 8-10 admits.

Our hospitalists/nocturnists don’t get compensated like their counterparts on SDN either.

 

[Nocturnist]

Is that closed ICU, no codes/procedures/rapids? How many admits? Because where I am, nocturnist is paid 275k for 7/7 with the above perks and about 8-10 admits.

Closed ICU, no procedures. Rapids and codes responsibility rotated through nocturnists.

275k for 180 12-hour shifts a year is $127/hr. Last I checked thats not far from what they're paying in academia in the northeast, why anybody would take that outside of academia is beyond me...

 

[yakattack16]

Closed ICU, no procedures. Rapids and codes responsibility rotated through nocturnists.

275k for 180 12-hour shifts a year is $127/hr. Last I checked thats not far from what they're paying in academia in the northeast, why anybody would take that outside of academia is beyond me...

Am academia in NE lol. Nocturnist contracted for 160 shifts.

 

[ortnakas]

Closed ICU, no procedures. Rapids and codes responsibility rotated through nocturnists.

275k for 180 12-hour shifts a year is $127/hr. Last I checked thats not far from what they're paying in academia in the northeast, why anybody would take that outside of academia is beyond me...

Pure curiosity since everywhere seems a little different- if you don’t normally do procedures, but you do do rapids/codes, whose responsibility is the airway? (Just wondering from a logistic perspective- I have no idea what nocturnists make or should make)

 

[Nocturnist]

Pure curiosity since everywhere seems a little different- if you don’t normally do procedures, but you do do rapids/codes, whose responsibility is the airway? (Just wondering from a logistic perspective- I have no idea what nocturnists make or should make)

Most rapid responses are low level ones that don't involve airway management, but the for the few that do- anesthesia or intensivist are in house 24/7 to manage the airway, while I'll typically continue to run the code if I got there first.

 

[Splenda88]

Our hospitalists/nocturnists don’t get compensated like their counterparts on SDN either.

Maybe they have a cushy job, rounding on 10-12 patients, or admitting 5-7 patients at night. I would be ok making 260k/yr rounding on 10-12 patients, or ~300k/yr admitting 5-7 patients at night.

 

[Nocturnist]

Am academia in NE lol. Nocturnist contracted for 160 shifts.

Sorry, not sure I understood what you were trying to say? Anyway, nocturnist pay at academic hospitals in my area is 240-270k a year, typically for 7 on/off. This is at least a 100k a year less than any similar non-academic job.

I meet quite a few of these full time academic nocturnists the nights they moonlight at my per diem gig. They're usually very transparent about their pay. Many of them will work an extra 2-3 nights a month to also bring their income comfortably into the 300s.

 

[CCM-MD]

Maybe they have a cushy job, rounding on 10-12 patients, or admitting 5-7 patients at night. I would be ok making 260k/yr rounding on 10-12 patients, or ~300k/yr admitting 5-7 patients at night.

Don’t know how many admits but they cover more than 40 ICU beds, rapids and codes at night. I guess they have residents so it’s sort of academic but not really.

My comment was more to highlight the general theme of highly compensated hospitalists on SDN.

 

[Splenda88]

Don’t know how many admits but they cover more than 40 ICU beds, rapids and codes at night. I guess they have residents so it’s sort of academic but not really.

My comment was more to highlight the general theme of highly compensated hospitalists on SDN.

I guess we can call that SDN bias.

In all honesty, I was not expecting to make > 300k/yr when entering the job market. People here weren't that open to talk about salary. My gig is not a perfect one, but I think I can make ~400k/yr for 2-3 yrs without burning myself out...

 

[Splenda88]

Sorry, not sure I understood what you were trying to say? Anyway, nocturnist pay at academic hospitals in my area is 240-270k a year, typically for 7 on/off. This is at least a 100k a year less than any similar non-academic job.

I meet quite a few of these full time academic nocturnists the nights they moonlight at my per diem gig. They're usually very transparent about their pay. Many of them will work an extra 2-3 nights a month to also bring their income comfortably into the 300s.

Academia where I did residency pay hospitalist 210k, but these people are rounding on 12 patients. I had 11 patients the other day and I was done by 11 am.

If you are paying me 210k/yr in a major city to round on 12 patients and leave, of course I would take a job like that in a heartbeat.

 

[Nocturnist]

Don’t know how many admits but they cover more than 40 ICU beds, rapids and codes at night. I guess they have residents so it’s sort of academic but not really.

My comment was more to highlight the general theme of highly compensated hospitalists on SDN.

I don't disagree there's a selection bias on SDN. I probably wouldn't be online sharing my salary if somebody else was making twice for the same work. On the other hand, I've got a dozen highly compensated nocturnist colleagues who've never heard of SDN and probably never will.

Honestly, it wasn't until I discovered SDN it struck me there was anything rare or unique about my job or pay. There's no secret hand shake at the interview, and we've been constantly recruiting. Yes, its at the higher end of compensation locally, but there are at least 3-4 other hospitals within a 25 mile radius that pay similarly. The only aspect I'm baffled by is just why folks continue saying yes to lower paying gigs (especially outrageously low ones in academia)

 

[osprey099]

I think whatever you decide to do, STAY AWAY from academia if you want to make money.

Hospitalist/nocturnist is a good gig. I'm currently a first year heme-onc fellow who almost decided to do Hospitalist. I'm NE based and in my area, 7 on 7 off Hospitalists make anywhere from 240-300k depending on how far away from major city you are (in the city vs 1-hr drive away).

The biggest oncology private practice in my area (part of USA oncology) starts at 250k until you become partner in 4-5 years, and all the partners easily clear 800k. The hospital-based onc groups in my area start 300k and can go up to 450-600k in 2-3 years.

This is all anecdotal evidence from upper year fellows who've signed in the past few months. The Hospitalist info is anecdotal evidence from my former co-residents.

In contrast, academic Hospitalist at my large academic residency program starts at 180k. My heme-onc fellowship PD (who honestly works his tail off) is making 220k. This is public data available online.

TLDR: DONT GO INTO ACADEMICS!

 

[ChordaEpiphany]

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

OP, I don't think you're in as bad a spot as you think (or some of these comments are making out). You don't have to work 120 hours/week or make $1M/year in GI/cards to get out from under this debt. Your spouse is not completely irresponsible for choosing peds. While you have incredible debt, you are in a dual physician income household. If you choose a decent-paying subspecialty and manage to clear $400K, you should be able to live quite comfortably in most US cities while paying off the debt over 10-20 years.

I have been refining a Matlab script for calculating personal finances for quite a few years now, so now it's pretty trivial for me to work through various scenarios. So far this script has held up to reality for my own finances as well as some other people I shared this with. I made some assumptions and calculated just about where you could potentially be in a few scenarios, and the script auto-populates the following. Disclaimer: I'm just a guy with a hobby, and I'm definitely not maximizing your tax efficiency or optimizing loan payments or running through different compensation regimens or even considering your preferred investment strategies, all of which can alter this dramatically. I'm just demonstrating on an approximate basis how this could go down and what, generally, you need to do to stay above water. This also assumes medicine is not raked over the coals by PE or government regulation.

Assumptions:
-US federal + Colorado taxes (these are the most "average" state income taxes, so I used these when making the calculator)
-6% interest on investments after inflation (so this includes principle on a mortgage/real estate appreciation or average S&P 500 gains)
-4% interest on loans (I assume you will refinance to private loans and not participate in loan forgiveness)

I ran a few scenarios based on what you've said. This assumes you both graduate at the same time.

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Scenario #1: Save responsibly and live your life
Jobs you/spouse prefer, medium loan payment aggressiveness, reasonable savings strategy, upper middle class lifestyle
Inputs:
-Combined pre-tax income = $200K + $400K = $600K
-Yearly amount paid towards loans = $100K
-Savings rate (includes retirement, real estate, etc...) = 40% of post-tax/post-loan payment income

Outcomes:
-Years to pay debt: 16
-Yearly allowable expenditure while paying debt: $180K ($240K after debt is paid)
-Net worth after 10 years of attending salary: +$1.0M
-Net worth after 20 years of attending salary: +$4.7M --> Can retire here and maintain lifestyle
-Net worth after 30 years of attending salary: +$10.5M

Scenario #2: Aggressive high earner/superwoman
High intensity/earning job, high loan payment aggressiveness, aggressive savings strategy, upper/upper-middle class lifestyle
Inputs:
-Combined pre-tax income = $200K + $600K = $800K
-Yearly amount paid towards loans = $150K
-Savings rate (includes retirement, real estate, etc...) = 40% of post-tax/post-loan payment income

Outcomes:
-Years to pay debt: 10
-Yearly allowable expenditure while paying debt: $230K ($325K afterwards)
-Net worth after 10 years of attending salary: +$2.1M
-Net worth after 20 years of attending salary: +$6.6M --> Can retire here and maintain lifestyle
-Net worth after 30 years of attending salary: +$13.7M --> Congrats on being the 1%

Scenario #3: Spendthrift
Jobs you/spouse prefer, low loan payment aggressiveness, poor savings strategy, closing in on upper class lifestyle
Inputs:
-Combined pre-tax income = $200K + $400K = $600K
-Yearly amount paid towards loans = $70K
-Savings rate (includes retirement, real estate, etc...) = 15% of post-tax/post-loan payment income

Outcomes:
-Years to pay debt: 27 (this would have to be negotiated with the lender)
-Yearly allowable expenditure while paying debt: $285K ($345K afterwards)
-Net worth after 10 years of attending salary: +$660K
-Net worth after 20 years of attending salary: +$1.8M
-Net worth after 30 years of attending salary: +$4.0M --> Can retire here, but must downgrade lifestyle

Scenario #4: Responsible Academic Dreamers
Low income jobs in academics, medium loan payment aggressiveness, reasonable savings strategy, middle class lifestyle (upper middle later in life)
Inputs:
-Combined pre-tax income = $170K + $250K = $420K
-Yearly amount paid towards loans = $100K
-Savings rate (includes retirement, real estate, etc...) = 30% of post-tax/post-loan payment income

Outcomes:
-Years to pay debt: 16
-Yearly allowable expenditure while paying debt: $130K ($200K afterwards)
-Net worth after 10 years of attending salary: +$170K
-Net worth after 20 years of attending salary: +$2.2M
-Net worth after 30 years of attending salary: +$5.1M --> Can retire here and maintain lifestyle

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The takeaway from the above is pretty simple: avoid SF/NYC, save aggressively, refinance your loans, and pay them off before you plan to retire and you'll be fine. You don't need a seven figure household income to deal with this debt, and it's probably not worth tailoring your career towards attaining one of those jobs if it will impact your long-term happiness. As long as you save ~40% of your post-tax, post-loan payment income and pay on the order of $100K toward the loans each year, pretty much any non-academic path will see you both retiring comfortably in your 50s debt free (or working towards flashy levels of wealth in your 60s).