My Pay as an Intensivist - Then, now and to the future

[Trailmusings101]

When I came out of fellowship in 2009, I had a number of places vying for my services. I was interested in doing strictly critical care as an intensivist with no other specialty involvement.

I had several academic offers where salary was about $275-300k for essentially two weeks of service a month, and the other two weeks would be spent doing typical academic stuff - building the program clinically with various committee meetings and training sessions for residents and nurses, attempting to secure research funding, etc. I worked about 20 days a month - my 14 clinical days and roughly another 6 doing the clinical stuff. Of the 14 clinical days, I was 'in house' sleeping on call about half of them. Pay was $300k and about another 40k /yr in benefits. I felt like I was "doing well".

I also looked at community jobs where the salary seemed uncertain, and I was still enamored with "working in a Level 1" so I didn't seriously consider them (yet) though they were typically paying about 325k/yr for one week on/one week off (with nights anywhere from 3-7 per month). Many of these were with independent groups where I would some day be a partner in a small group.

After 5 years, and sick of the ever-increasing pressure to spend time writing bull**** grant proposals to try and secure as much money for the big department heads as possible (including a farcical exercise where I wanted 20k for a small study, but the "grants coordinator" instead forced me to apply for $150k from a particular agency because "that's what you do - you fluff up your app to justify needing the max"... I didn't get any funding on that one at all in the end) I looked for a community job.

This was much better. I was part of a small group as a non-partner, with plans to eventually join the partnership. I worked 12 days a month, roughly 12 hour days, where I was the primary intensivist of the day. I did multidisciplinary rounds, and I received productivity pay. I made about $375-400/hour depending on how busy we were in a given month. Then, our group got sold to a corporate company before I could become a partner.

My pay was immediately cut to $210/hr. No more productivity. Before, we ran the group pretty lean because we wanted to work hard and get paid for it. Now, it didn't matter how hard I worked (or how busy we were), corporate [you can fill in the blanks here -- ICC, Sound, whatever] got the glory.

I quit that job after 3 months. I travelled. I went back to my base specialty.

Now, as I survey the market, there aren't any jobs except cog-in-the-wheel, work-for-the-big-box groups. Anywhere from $145-$210 an hour (I'm on West coast now, but since leaving the East coast I've been looking all over except for cold rust belt and midwest towns). Oh, there are a few private groups hanging on, but they only offer part time work at nights (no mutli-disciplinary rounds, just fire fighting!) or weekends and holidays.

I am lucky. I have banked enough in my career that I pick and choose, and probably could survive and never work another ICU shift again.

But this is the direction of medicine. ICC, Sound, USACS, Envision, they're all the same. The have TAKEN OUR LIVELIHOOD AND OUR INCENTIVE TO WORK HARD, AND SIPHON OFF the DESIRE TO CREATE LONG-TERM SUSTAINABLE CULTURE IN THESE HOSPITALS AND COMMUNITIES.

Most job ads for intensivists are from ICC and Sound out there. Almost all are $140-160 an hour. No productivity. No support or coverage when the admin at your hospital gets fussy. You are only too-easily replaced, and they care not about your well being (despite the lip-service of the weekly "wellness" emails I get urging me to have a calming tea and meditate "for five minutes" at least once daily. The stock/ "ownership" programs for these companies are ridiculous. Do NOT get sucked into thinking "you are an owner"; you have no voting rights with these shares, and the return on investment is paltry compared to other investments.

Any of the ICC jobs in Florida in particular are poison and low end of the compensation spectrum despite no state taxes. Their postings in South Carolina are a mess, too, including Trident in Charleston where they've cycled through several director and intensivists. Their compensation is $140/hr. They don't even pay a director but for a few paltry admin dollars. They have a 28 bed unit and generate over $625/hr in net (not gross) charges. $140/hr to a physician and $80/hr to the nurse pracky. That should be $300 /hr to each of two physicians in a unit that size.

These companies are making so much money off the billing, working as fast as they can to fluff up the clinical coverage with cheap NPs and any doctor willing to work for $140 /hour despite the generation of probably 3-4x that in clinical revenue.

It sucks. This is the result, the reality, of physicians selling out other physicians.

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[CCM-MD]

Critical care has many issues and I share a pessimistic view of the future but right now every intensivist I personally know is making more than ever.

 

[Sushirolls]

The phenomena is what I refer to as the "Big Box" shops and rail against in Psychiatry. Similar experiences prompted me to embark in my own private practice.
I feel for you and understand. Best wishes in wherever you land.

 

[emergentmd]

You could essentially write the same and replace CC with EM 15 years ago.

When we were a private group, prob made about $300/hr if you included all the benefits/retirement. Alot of control over schedule, work flow, physician staffing decisions. We were left alone and if we wanted to run lean, we made more. If we overstaffed, we made less. But it was our decision and we reaped the benefits of either pay or easier workflow.

Once CMG, Take hold that profit and thus motivation to work hard starts to drop. Its life.

 

[POW16]

Why not go back to academia ? A lot of jobs out there with no/minimal research requirements.

 

[Nephro critical care]

How is it that CMG’s get hospital contracts when they could cut out the middle man and hire/contract with physicians directly and have more control over them ? Is it that CMGs give hospital administrators a cut for giving them the contract ?

 

[Vandalia]

How is it that CMG’s get hospital contracts when they could cut out the middle man and hire/contract with physicians directly and have more control over them ?

The key point is that they don't want control over them.

They want someone who will be a "black box" so that they don't have to deal with physician recruiting, management, staffing, etc.

It is essentially the same reason why they hire contractors to do the laundry, or security, or food services, or whatever else.

I will use my lawn as an example. I used to enjoy the riding lawnmower but age, arthritis, and prostate cancer mean that is no longer an (enjoyable) option. Now I could hire someone to do fertilizing, weed control, etc., and a kid to mow, and someone to do landscaping, and someone to do the weeding .... or I could pay the one local guy who said he would handle all of that. I pay about $100 a month premium, but it is worth it not to have to deal with 4 or 5 different people and all the conflicts.

That is basically how the CEO/COO/CMO view this stuff. They would rather sacrifice some income so that they don't have to think about staffing.

 

[psychbender]

With that logic, then why not just contact with private groups? Either way, they don't have to worry any the hiring/firing, and daily functions, so long as the work is done for the agreed upon price. Why the preference for corporate groups over private groups? I understand for HCA, since they own ICC, but why go with Sound, Team Health, etc, if there is a private group willing to take the contract (unless they are going with the corporate group for Hospitalist, EM, Radiology, and Critical Care coverage)?

The key point is that they don't want control over them.

They want someone who will be a "black box" so that they don't have to deal with physician recruiting, management, staffing, etc.

It is essentially the same reason why they hire contractors to do the laundry, or security, or food services, or whatever else.

I will use my lawn as an example. I used to enjoy the riding lawnmower but age, arthritis, and prostate cancer mean that is no longer an (enjoyable) option. Now I could hire someone to do fertilizing, weed control, etc., and a kid to mow, and someone to do landscaping, and someone to do the weeding .... or I could pay the one local guy who said he would handle all of that. I pay about $100 a month premium, but it is worth it not to have to deal with 4 or 5 different people and all the conflicts.

That is basically how the CEO/COO/CMO view this stuff. They would rather sacrifice some income so that they don't have to think about staffing.

 

[namethatsmell]

With that logic, then why not just contact with private groups? Either way, they don't have to worry any the hiring/firing, and daily functions, so long as the work is done for the agreed upon price. Why the preference for corporate groups over private groups? I understand for HCA, since they own ICC, but why go with Sound, Team Health, etc, if there is a private group willing to take the contract (unless they are going with the corporate group for Hospitalist, EM, Radiology, and Critical Care coverage)?

Speaking from the EM world where this is a massive problem...it's because these PE groups are more likely to proceed w/o a subsidy and they usually speak admin better and/or appear less threatening to admin than private groups.

 

[emergentmd]

Hospitals care only about maximizing $$$ and decrease headaches. No more, no less.

Scenario #1
You are a Hospital CEO with a private ER group for years but given need to increase profits, you tell the ER group that wait time stinks so they need to increase staffing and add a MLP in triage.

Private ER groups balk, saying we can't increase payroll/hours by 25% as income doesn't change.

Hospital CEO has the choice of giving the Er group a stipend to cover the costs or offer the contract to a CMG who will increase staffing without a stipend.

CMG is ok with either losing money or is better at billing to absorb the 25% staffing increase.

Scenario #2
Hospital CEO with private ER group for years need to improve metrics. Private ER group thinks they are doing a great job and do not care about all the crazy metrics. Private ER group, as all docs own it, balk at the metrics. Good luck threatening doctor owners with metrics, b/c most wont give a crap so metrics continue to stink.

Hospital CEO tells private group to do it or they will get a CMG. Eventually the HA of dealing with a bunch of doctor owners is too much, here comes the CMG.

Scenario #3
Everything else in a combo of #1/2. Hard to train a lapdog when SDG has bunch of doctor owners. Much easier to train a lapdog where docs are employees of CMG who can fire/hire at will keeping the CEO's hands clean

CEO's main job is increase profit, decrease issues, and keeping his hands clean of any blood. No CEO wants a SDG to revolt and have blood on his hands. Easier to let the CMG clean up the dead bodies and brush it under the rug.

 

[Vandalia]

With that logic, then why not just contact with private groups? Either way, they don't have to worry any the hiring/firing, and daily functions, so long as the work is done for the agreed upon price. Why the preference for corporate groups over private groups? I understand for HCA, since they own ICC, but why go with Sound, Team Health, etc, if there is a private group willing to take the contract (unless they are going with the corporate group for Hospitalist, EM, Radiology, and Critical Care coverage)?

Security.

They believe that with the national firms there is far less of a chance that they will be short of physicians. The national firm would be able to move physicians in to provide coverage and have the financial resources to pay for locums if needed.

So let's say they go with a local group. Then let's say that whoever that group picks to run things manages to aggravate all the other physicians and they leave on short notice. This practice - a couple of docs - also don't have the financial resources to staff for months with locums.

That is the primary reason. It all boils down to security. They feel more secure that they can guarantee physician coverage with a national firm over a small group of local physicians.

Does it work that way in practice? That is debatable. But that is what they believe.

 

[CCM-MD]

Just talked to a friend in the west who works for one of the mentioned staffing companies and gets 225/h + productivity and quality for days. More for night.

 

[grt398]

Just going to provide some additional perspective perhaps for current/future fellows since I've recently been on the job hunt as a graduating fellow. Geography matters a lot. I cannot emphasize that enough. I never looked at places like major NE/West coast cities (i.e. NYC/LA/Seattle etc) but I wouldn't be surprised if the pay in those type of "desirable" cities (depends how you define desireable) really did come out to even $130-160/hour (meaning straight hourly salary w/o calculating value of benefits), since I looked at locations that people might consider "second tier" and the pay was higher than that, but not by a huge margin. I'm IM-CCM and one of the corporate groups mentioned by the OP was paying $110/hr for hospitalists in similar areas when I finished residency, and they had no trouble recruiting people.

That said, as CCM-MD states above, it's still very possible to find full time positions paying $200-250/hour (again, straight salary or salary + RVU's, not including benefits), but in my admittedly limited experience, you're going to be living in locations that may or may not work for you depending on your life situation (family/hobbies etc). As someone who lived in the NYC/LA/Seattle type cities for years both before and during med school, I understand that many people wouldn't consider living in non-major urban areas, but the options are definitely out there if you're willing to live 1-2 hours from those areas. Obviously everyone has different views on what makes for a good QOL, and it's unfortunate the days of being able to pick almost any city in the country and get a well-compensated job are gone, but the option for higher compensation is still there. Also, if you're really flexible, I regularly get locums emails offering $250-350/hour right now so...that's an option for the right person as well.

 

[psychbender]

Coming from the anesthesia side, I've heard all of those arguments above, but they just don't end up being true. The management company ends up asking for a stipend, as they cannot maintain their profitability without one (since they have a bevy of shareholders and a ton of administrators to support). The shifting of personnel between locations is seen as a liability, as it's a never ending revolving door with no continuity. With the constant changeover, metrics, then suck. In every way, life would have been better had they simply worked with the private, local group. However, time after time, administrators fall for this bull****.

 

[bronx43]

Coming from the anesthesia side, I've heard all of those arguments above, but they just don't end up being true. The management company ends up asking for a stipend, as they cannot maintain their profitability without one (since they have a bevy of shareholders and a ton of administrators to support). The shifting of personnel between locations is seen as a liability, as it's a never ending revolving door with no continuity. With the constant changeover, metrics, then suck. In every way, life would have been better had they simply worked with the private, local group. However, time after time, administrators fall for this bull****.

I used to think administrators were some cabal of evil geniuses operating in the back room smoking a cigar and patting themselves on the back.

Now, after seeing them make idiotic blunder after idiotic blunder, I've come to realize that administrators are a cabal of evil dumb***es operating in the back room smoking a cigar and patting themselves on the back.

 

[turkeyjerky]

Coming from the anesthesia side, I've heard all of those arguments above, but they just don't end up being true. The management company ends up asking for a stipend, as they cannot maintain their profitability without one (since they have a bevy of shareholders and a ton of administrators to support). The shifting of personnel between locations is seen as a liability, as it's a never ending revolving door with no continuity. With the constant changeover, metrics, then suck. In every way, life would have been better had they simply worked with the private, local group. However, time after time, administrators fall for this bull****.

Can't tell which arguments you're referring to, those that the CMGs will use on hospital admin to get contracts, or the stuff people above are saying about the ultimate effects of the corporate practice of medicine? The former are obviously bull****, the situation with the latter is a little more nuanced, in which market inefficiencies can mask long term effects over a limited period of time (as happened in EM over the last decade).

I used to think administrators were some cabal of evil geniuses operating in the back room smoking a cigar and patting themselves on the back.

Now, after seeing them make idiotic blunder after idiotic blunder, I've come to realize that administrators are a cabal of evil dumb***es operating in the back room smoking a cigar and patting themselves on the back.

It's the Peter principle, except they somehow manage to keep getting promoted.

 

[robellis]

Critical care has many issues and I share a pessimistic view of the future but right now every intensivist I personally know is making more than ever.

So is the OP bull****ting or what

 

[Siggy]

Hospitals care only about maximizing $$$ and decrease headaches. No more, no less.

Scenario #1
You are a Hospital CEO with a private ER group for years but given need to increase profits, you tell the ER group that wait time stinks so they need to increase staffing and add a MLP in triage.

Private ER groups balk, saying we can't increase payroll/hours by 25% as income doesn't change.

Hospital CEO has the choice of giving the Er group a stipend to cover the costs or offer the contract to a CMG who will increase staffing without a stipend.

CMG is ok with either losing money or is better at billing to absorb the 25% staffing increase.

Scenario #2
Hospital CEO with private ER group for years need to improve metrics. Private ER group thinks they are doing a great job and do not care about all the crazy metrics. Private ER group, as all docs own it, balk at the metrics. Good luck threatening doctor owners with metrics, b/c most wont give a crap so metrics continue to stink.

Hospital CEO tells private group to do it or they will get a CMG. Eventually the HA of dealing with a bunch of doctor owners is too much, here comes the CMG.

Scenario #3
Everything else in a combo of #1/2. Hard to train a lapdog when SDG has bunch of doctor owners. Much easier to train a lapdog where docs are employees of CMG who can fire/hire at will keeping the CEO's hands clean

CEO's main job is increase profit, decrease issues, and keeping his hands clean of any blood. No CEO wants a SDG to revolt and have blood on his hands. Easier to let the CMG clean up the dead bodies and brush it under the rug.

The thing about metrics is that they have to be done regardless of whether it's a SDG or CMG. CMG doc doesn't do metrics, doc gets fired. SDG doc doesn't do metrics, SDG gets fired.

While some metrics are hard to meet, there are plenty of metrics that can be met without too much complaining. It was amazing at my fellowship how many people complained about doing transfer med recs (it's all of 5 clicks, no one cares if you just pencil whip it, as long as the numbers looked pretty... and you should be cutting down the unused meds/titrated off drips daily anyways), admission med recs (we want to act like a closed ICU, but don't want to put the work in. To be honest, I have no problem doing admit med recs because it keeps me in control on what is ordered anyways) or sepsis reassessments (hospital wide template, mark boxes. Almost every sepsis note was the same. Warm/dry, RRR, cap refil <2sec, yes I looked at vitals).

 

[CCM-MD]

So is the OP bull****ting or what

He might just be a glass half empty kinda guy. Can’t blame him, we’re all pretty burned right now. There are ****ty paying jobs out there but MGMA avg is >450k. Red hot locum market with the locum guy at my hospital getting $400/h and $600/h (1.5x regular rate holiday rate) for holidays.

Lots of problems in CCM and bleak future, but kinda hard to complain about compensation right now.

 

[CaliDent383]

He might just be a glass half empty kinda guy. Can’t blame him, we’re all pretty burned right now. There are ****ty paying jobs out there but MGMA avg is >450k. Red hot locum market with the locum guy at my hospital getting $400/h and $600/h (1.5x regular rate holiday rate) for holidays.

Lots of problems in CCM and bleak future, but kinda hard to complain about compensation right now.

What's the best way to find these locum jobs?

 

[CCM-MD]

What's the best way to find these locum jobs?

Don’t have to look very hard. I get lots of emails, don’t even know how they got my info.

Rates that get advertised are negotiable, so don’t just accept is initially offered. PM me and I’ll share the email if you want. Make hay while the sun shines cuz staffing companies, midlevels, and overtraining of intensivists is going to destroy the field eventually.

 

[Trailmusings101]

So is the OP bull****ting or what

Well, there's a bit of a disconnect here. I absolutely have seen relatively high paying, short-term jobs - I, too, have gotten locum emails for $300/hr. And it's true - they *are* negotiable, so I don't think it's a stretch that some people are commanding $400/hr and $600/hr over holiday weekends.

But that's not what I'm talking about.

I'm talking about sustainable, sink-your-teeth-into-a-career jobs, ones that you can be part of a hospital for several years minimum.

Those jobs have vanished.

 

[CCM-MD]

Well, there's a bit of a disconnect here. I absolutely have seen relatively high paying, short-term jobs - I, too, have gotten locum emails for $300/hr. And it's true - they *are* negotiable, so I don't think it's a stretch that some people are commanding $400/hr and $600/hr over holiday weekends.

But that's not what I'm talking about.

I'm talking about sustainable, sink-your-teeth-into-a-career jobs, ones that you can be part of a hospital for several years minimum.

Those jobs have vanished.

Nah, they’re out there. Theres also a disconnect between your numbers and MGMA numbers. Even if we believe your below the mean numbers, that just means there are even higher paying jobs out there that keep the mean where it is. Btw that mgma value has gone up each year I’ve worked and most employers use that as a reference. You also missed the anecdote I provided against your anecdotes, of my buddy working for a staffing company in the western region, who makes significantly more than the numbers you quoted.

 

[chocomorsel]

Critical care has many issues and I share a pessimistic view of the future but right now every intensivist I personally know is making more than ever.

I hear you. And I interviewed with ICC and their base pay for the places I saw was about $200 an hour. In the city it was $180. I make way more than that now, but it's not with a large company. I lucked out actually.

 

[chocomorsel]

Don’t have to look very hard. I get lots of emails, don’t even know how they got my info.

View attachment 346647

Rates that get advertised are negotiable, so don’t just accept is initially offered. PM me and I’ll share the email if you want. Make hay while the sun shines cuz staffing companies, midlevels, and overtraining of intensivists is going to destroy the field eventually.

That's some good money right there. I need me a Kansas license. That is easy money. Eight patients? Are you serious?

 

[spacegun]

Anyone know what the Texas market looks like in the suburbs of major cities (eg places like the Woodlands for Houston or Plano for Dallas)? Thanks!

 

[CCM-MD]

Anyone know what the Texas market looks like in the suburbs of major cities (eg places like the Woodlands for Houston or Plano for Dallas)? Thanks!

The Houston and Dallas areas are dominated by HCA (Envision) or academics. In general, staffing companies + desirable areas = compensation probably sucks.

 

[deleted941485]

The Houston and Dallas areas are dominated by HCA (Envision) or academics. In general, staffing companies + desirable areas = compensation probably sucks.

Literally every desirable area forget it…you’ll work harder and make less. You won’t even be able to enjoy any of the cultural benefits of living in or near a city because you’re literally just working to live.

The suburbs were a nice kind of best of both worlds that worked for many docs but even these areas suck now.

Unless you are a surg subspecialist like neurosurg or something you’re either looking at living in the sticks to make good money or a very very long commute from a desirable place.

 

[CCM-MD]

Literally every desirable area forget it…you’ll work harder and make less. You won’t even be able to enjoy any of the cultural benefits of living in or near a city because you’re literally just working to live.

The suburbs were a nice kind of best of both worlds that worked for many docs but even these areas suck now.

Unless you are a surg subspecialist like neurosurg or something you’re either looking at living in the sticks to make good money or a very very long commute from a desirable place.

All while everyone talks about a “physician shortage”. Breaking news: it doesn’t exist. It’s a distribution problem, nobody wants to work in BFE and will gladly take massive pay cuts to work in more desirable areas.

 

[robellis]

Literally every desirable area forget it…you’ll work harder and make less. You won’t even be able to enjoy any of the cultural benefits of living in or near a city because you’re literally just working to live.

The suburbs were a nice kind of best of both worlds that worked for many docs but even these areas suck now.

Unless you are a surg subspecialist like neurosurg or something you’re either looking at living in the sticks to make good money or a very very long commute from a desirable place.

It depends what you consider good money?

 

[grt398]

Anyone know what the Texas market looks like in the suburbs of major cities (eg places like the Woodlands for Houston or Plano for Dallas)? Thanks!

Things may have changed from earlier this year when I spoke to someone who works multiple sites for Envision, but at that time (Spring 2021) they were paying ~$200/hr for Dallas area (straight hourly salary, no RVU component, not sure how many patients per day b/c I wasn't actively looking and didn't ask), not sure what it was outside of Dallas but I would guess a bit higher.

 

[ellinopedo182]

I don't know about the other guys but I get paid pretty well. I started off first year out (2018) at $3k/shift and now my lowest paying spot is $3400/shift which I'm letting go of.

I am getting paid on average closer to $4200-$4500 now for strictly ICU work, and $5200-5500 for combined ICU and Pulm consults at another hospital.

Another hospital is paying me $11.5k per day ($4000 ICU, $3000 pulm, $4500 night ICU) but I'm on at night and I can go to the hotel, sleep and come back if needed. I do pulm, ICU and night ICU admits. This setup is rare and most hospitals will use APNs instead at night. I am not sure how sustainable it is for them, but currently it seems like they are ok with it.

There's still money to be made and there's more demand then ever for critical care physicians imo. I am also very straight forward with locums agency's, if they aren't offering at least $4000/shift and with room to negotiate I won't waste their time. Most locums agencies get paid between $400-450/hr by the hospital and finder fees, so when they say they can't do better, it's usually a lie. If it's close to home, make sure you ask for more money (hourly) if they aren't reimbursing hotel/air fare/car rental, etc.

I'm not sure why anyone would want to work salaried. As a 1099, I can put massive amount of my income in my retirement SEP-IRA or a pension 401k. You also can make your own schedule and take weeks off at a time for vacation, etc. Best of all, if more people worked 1099, the average reimbursement would increase and administration wouldn't feel as confident giving low reimbursement rates ($200-250/hr) to intensivists.

As far as Texas, I start next month at a new location in San Antonio working for $4200/shift.

 

[chocomorsel]

All while everyone talks about a “physician shortage”. Breaking news: it doesn’t exist. It’s a distribution problem, nobody wants to work in BFE and will gladly take massive pay cuts to work in more desirable areas.

So true. I am from Houston and work in the Valley. Only live here because of family and assisting with my parents. If I could move completely I would. I hate big cities and am making much more working in a very high need area with a much more humble and appreciative patient population.

 

[chocomorsel]

I don't know about the other guys but I get paid pretty well. I started off first year out (2018) at $3k/shift and now my lowest paying spot is $3400/shift which I'm letting go of.

I am getting paid on average closer to $4200-$4500 now for strictly ICU work, and $5200-5500 for combined ICU and Pulm consults at another hospital.

Another hospital is paying me $11.5k per day ($4000 ICU, $3000 pulm, $4500 night ICU) but I'm on at night and I can go to the hotel, sleep and come back if needed. I do pulm, ICU and night ICU admits. This setup is rare and most hospitals will use APNs instead at night. I am not sure how sustainable it is for them, but currently it seems like they are ok with it.

There's still money to be made and there's more demand then ever for critical care physicians imo. I am also very straight forward with locums agency's, if they aren't offering at least $4000/shift and with room to negotiate I won't waste their time. Most locums agencies get paid between $400-450/hr by the hospital and finder fees, so when they say they can't do better, it's usually a lie. If it's close to home, make sure you ask for more money (hourly) if they aren't reimbursing hotel/air fare/car rental, etc.

I'm not sure why anyone would want to work salaried. As a 1099, I can put massive amount of my income in my retirement SEP-IRA or a pension 401k. You also can make your own schedule and take weeks off at a time for vacation, etc. Best of all, if more people worked 1099, the average reimbursement would increase and administration wouldn't feel as confident giving low reimbursement rates ($200-250/hr) to intensivists.

As far as Texas, I start next month at a new location in San Antonio working for $4200/shift.

Strictly locums? Just 12 hour shifts or with nightcall? And both pulmonary and ICU?
I only do straight CCM.

 

[grt398]

So maybe a question for people who have been out of fellowship at least 2-3 years...do you feel like there is a benefit to taking a full time position initially vs starting off locums these days? Or do you think it doesn't matter? B/c the pay difference is pretty big when you're talking numbers like $4k/shift.

Part of my rationale for taking a permanent position was that it might be helpful as a new attending to have a year or two to get settled into being a fully independent physician out of fellowship. I know multiple faculty from both residency and fellowship who do quite a bit of locums now, but no one who started off doing it immediately after fellowship.

 

[ellinopedo182]

Strictly locums? Just 12 hour shifts or with nightcall? And both pulmonary and ICU?
I only do straight CCM.

I do both. One is a locum other is a group that only does 1099. The group negotiates straight with the hospitals we help at, about 6 of them. Some are ICU only, others include pulm consults, others include night call from home or hotel with APN coverage.

 

[ellinopedo182]

So maybe a question for people who have been out of fellowship at least 2-3 years...do you feel like there is a benefit to taking a full time position initially vs starting off locums these days? Or do you think it doesn't matter? B/c the pay difference is pretty big when you're talking numbers like $4k/shift.

Part of my rationale for taking a permanent position was that it might be helpful as a new attending to have a year or two to get settled into being a fully independent physician out of fellowship. I know multiple faculty from both residency and fellowship who do quite a bit of locums now, but no one who started off doing it immediately after fellowship.

I did a perm position for a year. It was salaried. But as soon as I started, I felt I had less control of my schedule, I was being scheduled more nights without getting paid more. They were also wanting more involvement in administrative committees. Even though it was closer to home, I had to leave.

One position makes me complete eLearning. I tried leaving that hospital, so they offered me pay me hourly rate whenever I do eLearning from home. You can't do that at salaried positions.

The money difference is great, but you need to be on top of your expenses, and your own benefits (deductions apply) and taxes. Plus, with a SEP-IRA I get to put about $57k tax free for retirement or if you are an LLC even more with a pension 401k.

 

[tartesos]

I don't know about the other guys but I get paid pretty well. I started off first year out (2018) at $3k/shift and now my lowest paying spot is $3400/shift which I'm letting go of.

I am getting paid on average closer to $4200-$4500 now for strictly ICU work, and $5200-5500 for combined ICU and Pulm consults at another hospital.

Another hospital is paying me $11.5k per day ($4000 ICU, $3000 pulm, $4500 night ICU) but I'm on at night and I can go to the hotel, sleep and come back if needed. I do pulm, ICU and night ICU admits. This setup is rare and most hospitals will use APNs instead at night. I am not sure how sustainable it is for them, but currently it seems like they are ok with it.

There's still money to be made and there's more demand then ever for critical care physicians imo. I am also very straight forward with locums agency's, if they aren't offering at least $4000/shift and with room to negotiate I won't waste their time. Most locums agencies get paid between $400-450/hr by the hospital and finder fees, so when they say they can't do better, it's usually a lie. If it's close to home, make sure you ask for more money (hourly) if they aren't reimbursing hotel/air fare/car rental, etc.

I'm not sure why anyone would want to work salaried. As a 1099, I can put massive amount of my income in my retirement SEP-IRA or a pension 401k. You also can make your own schedule and take weeks off at a time for vacation, etc. Best of all, if more people worked 1099, the average reimbursement would increase and administration wouldn't feel as confident giving low reimbursement rates ($200-250/hr) to intensivists.

As far as Texas, I start next month at a new location in San Antonio working for $4200/shift.

My man!. That’s how it’s done.
Locum agencies will always try to low ball you and will drop you in a heartbeat if they find someone that can do it cheaper.
Don’t sell yourself cheap.

 

[bronx43]

All while everyone talks about a “physician shortage”. Breaking news: it doesn’t exist. It’s a distribution problem, nobody wants to work in BFE and will gladly take massive pay cuts to work in more desirable areas.

This is certainly true. However, for most "desirable" metropolitan areas with >2M population, physician income has already hit the lower threshold for what can sustain a reasonable QOL. In my mid-size Midwestern city, many of the academic jobs and even some private jobs aren't paying enough for a single non-surgical physician family to buy a modest house in a "nice" neighborhood with a good school district. This is especially true given student loans and the rapidly escalating prices of gas, food, utilities, etc.
Back in the pre-covid days, when physicians took a pay cut to live in a "desirable city," it basically meant giving up some luxuries of life. Instead of a Lexus, you drive an old Toyota. Instead of a 4000 sqft house, you get a 3000 sqft house. Today, you simply get priced out of a house. Period. No physician is going to tolerate living in the "bad" part of town or not sending their kids to the best public school the city has to offer.

I anticipate that we will be seeing more and more physicians take BFE or semi-BFE jobs in the upcoming years. Another option is to commute, which is a better option for some.

 

[ellinopedo182]

This is certainly true. However, for most "desirable" metropolitan areas with >2M population, physician income has already hit the lower threshold for what can sustain a reasonable QOL. In my mid-size Midwestern city, many of the academic jobs and even some private jobs aren't paying enough for a single non-surgical physician family to buy a modest house in a "nice" neighborhood with a good school district. This is especially true given student loans and the rapidly escalating prices of gas, food, utilities, etc.
Back in the pre-covid days, when physicians took a pay cut to live in a "desirable city," it basically meant giving up some luxuries of life. Instead of a Lexus, you drive an old Toyota. Instead of a 4000 sqft house, you get a 3000 sqft house. Today, you simply get priced out of a house. Period. No physician is going to tolerate living in the "bad" part of town or not sending their kids to the best public school the city has to offer.

I anticipate that we will be seeing more and more physicians take BFE or semi-BFE jobs in the upcoming years. Another option is to commute, which is a better option for some.

This is true. In Chicago and even the burbs, I have had hospital recruiters offer salaries close to $2280-2500/shift. Hospitalists can make about $1800-2200/shift now a days and more a little farther out. I didn't see it as advantageous for me to try to take a pay cut to work/live in the city. So I took jobs 1.5-2.5 hours away, and work there 10-12 days a month and make double what I'd make in the city/burbs. I still have my nice house in the Chicago burbs, my exotic + other cars in my garage, trips to Europe every few months and putting away a lot of money towards my retirement. And a lot of deductions for tax purposes. On the days off, I'm opening up a bar/restaurant and a dealership importing unique older cars that are in demand here from Europe (bmw, land rovers, etc). I worked at some point as a salaried intensivist in Chicago and realized I wasn't happy, felt tired all the time, and felt as if I was just an employee rather than get the respect for all my schooling and post graduate training. It's still a work in progress for me though, including negotiating skills and not being a pushover.

Bottom line, I'd rather work less days in BFE and make double and work 4-5 less days a month then be employeed and feel to be part of a system that uses us and disposes us whenever we become too expensive for them and watch my years pass away.

Some people are stuck in the routine, have families, obligations and need to be closer, and that's fine. But if you don't have those obligations, it's easiest to get the big money now doing 1099 than when you're older and have a family. I'm 37, so I'd like a few more years of this type of work and be able to have some passive income sources set for me so I can work even less in the future and not have to worry anymore about being burned out in a broken healthcare system.

 

[turkeyjerky]

I’m getting real EM circa-2017 vibes from this thread…

 

[Ccm1215]

This is true. In Chicago and even the burbs, I have had hospital recruiters offer salaries close to $2280-2500/shift. Hospitalists can make about $1800-2200/shift now a days and more a little farther out. I didn't see it as advantageous for me to try to take a pay cut to work/live in the city. So I took jobs 1.5-2.5 hours away, and work there 10-12 days a month and make double what I'd make in the city/burbs. I still have my nice house in the Chicago burbs, my exotic + other cars in my garage, trips to Europe every few months and putting away a lot of money towards my retirement. And a lot of deductions for tax purposes. On the days off, I'm opening up a bar/restaurant and a dealership importing unique older cars that are in demand here from Europe (bmw, land rovers, etc). I worked at some point as a salaried intensivist in Chicago and realized I wasn't happy, felt tired all the time, and felt as if I was just an employee rather than get the respect for all my schooling and post graduate training. It's still a work in progress for me though, including negotiating skills and not being a pushover.

Bottom line, I'd rather work less days in BFE and make double and work 4-5 less days a month then be employeed and feel to be part of a system that uses us and disposes us whenever we become too expensive for them and watch my years pass away.

Some people are stuck in the routine, have families, obligations and need to be closer, and that's fine. But if you don't have those obligations, it's easiest to get the big money now doing 1099 than when you're older and have a family. I'm 37, so I'd like a few more years of this type of work and be able to have some passive income sources set for me so I can work even less in the future and not have to worry anymore about being burned out in a broken healthcare system.

How do you go about getting locums gigs? Do you rely on a few locum companies and pick n choose or get in touch with hospitals directly?

 

[ellinopedo182]

How do you go about getting locums gigs? Do you rely on a few locum companies and pick n choose or get in touch with hospitals directly?

Pick and chose occasionally locum agencies and am pretty upfront with them with what others are paying. I won't accept at this time anything lower than $4200 / ICU shift (unless it's Cali than I demand more due to taxes and expenses).

Otherwise, the group I work for only does 1099 at hospitals that we have contracts with. Some of the hospitals have perm docs there already and we cover the rest of the days, other hospitals we are their full time providers but still get paid 1099. I got lucky I guess in finding my group (through word of mouth) but it's still a work in progress.

At my group, we have been doing pulm+ccm but it looks like we are changing our compensation structure to get paid separately for both specialties each day were are working rather than use us for both pulm and cc. I feel like hospitals have been getting away with hiring pulm cc physicians, and paying a flat fee to do both ICU and pulmonary consults in a package deal. And now with covid, as a pulmonologist I get consulted more frequently.

 

[Drägerman]

I’m getting real EM circa-2017 vibes from this thread…

In what way? Some factors are similar (increased PE, hot locums) but I feel like there are factors that were essential to the ER crash that make it less likely (less room for mid level expansion due to patient sickness, no drop in patient volumes with pandemic)

 

[turkeyjerky]

In what way? Some factors are similar (increased PE, hot locums) but I feel like there are factors that were essential to the ER crash that make it less likely (less room for mid level expansion due to patient sickness, no drop in patient volumes with pandemic)

Just similiar vibes, all I'm saying. I agree with you, I think CCM is far less susceptible to midlevel expansion and general ratf^cking than EM. I don't know enough about the general market forces to comment on whether or not it's susceptible to a crash. Just that in 2017 there was a mix of people talking about difficulty finding good jobs at the same time I was driving 1 hr out of chigago making 4-5k a shift w/ semi-regularity...

 

[Trailmusings101]

This is certainly true. However, for most "desirable" metropolitan areas with >2M population, physician income has already hit the lower threshold for what can sustain a reasonable QOL. In my mid-size Midwestern city, many of the academic jobs and even some private jobs aren't paying enough for a single non-surgical physician family to buy a modest house in a "nice" neighborhood with a good school district. This is especially true given student loans and the rapidly escalating prices of gas, food, utilities, etc.
Back in the pre-covid days, when physicians took a pay cut to live in a "desirable city," it basically meant giving up some luxuries of life. Instead of a Lexus, you drive an old Toyota. Instead of a 4000 sqft house, you get a 3000 sqft house. Today, you simply get priced out of a house. Period. No physician is going to tolerate living in the "bad" part of town or not sending their kids to the best public school the city has to offer.

I anticipate that we will be seeing more and more physicians take BFE or semi-BFE jobs in the upcoming years. Another option is to commute, which is a better option for some.

I think everyone on this thread has valid points. I've seen lots of places offering $4k/shift and more, but only in Texas and the Midwest and some other outlier rural areas. But these are almost exclusively mercenary positions - locum status, or the provider who is merely on the schedule sucking up some dollars while they attempt to build a program. Not a long lasting commitment to pay you at that rate for the long term to allow you to move your family there, buy a home and put down roots.

The broader point I was trying to make is that the "career intensivist" positions are dead, at least in 1) what most people would consider desirable locales and 2) at a salary level that affords a standard of living that I personally think befits people who spend as much time as we do training.

And the reason is a combination of the big box groups bringing in their templated critical care programs that reduce the job to serial 12-hour shift work stints, all the while skimming huge productivity off the top, and the old guard who are holding on to the day shifts/rounding and just offering nights and holidays and weekends to firefighters.

 

[Trailmusings101]

Just similiar vibes, all I'm saying. I agree with you, I think CCM is far less susceptible to midlevel expansion and general ratf^cking than EM. I don't know enough about the general market forces to comment on whether or not it's susceptible to a crash. Just that in 2017 there was a mix of people talking about difficulty finding good jobs at the same time I was driving 1 hr out of chigago making 4-5k a shift w/ semi-regularity...

Prime Healthcare came into one of the Level II trauma centers in Los Angeles. There was a functional independent group there when they took over, a true intensivist program with anesthesia, ER, and pulmonary providers. They had already gone through the transition from old pulmonary guard to putting in a real ICU program.

Prime immediately fired the group, put NPs as the primary providers in the unit, and hired a series of locum/part-time ICU folk to come in and 'run the list' with the NPs every day for $200/hr. The NPs call anesthesia for their airways, over utilize IR for line placement, and call the ER to come and help out on codes. The "ICU docs" are there from 11am-2pm, get paid for 8hours, and simply walk through the unit. No real rounding; To me, that's ****ty care for patients, an erosion of the standard of ICU, and highly risky for those docs who are taking the $1600 for 3 hours of work (and phone consult during the other 5 hours).

 

[Siggy]

Prime Healthcare came into one of the Level II trauma centers in Los Angeles. There was a functional independent group there when they took over, a true intensivist program with anesthesia, ER, and pulmonary providers. They had already gone through the transition from old pulmonary guard to putting in a real ICU program.

Prime immediately fired the group, put NPs as the primary providers in the unit, and hired a series of locum/part-time ICU folk to come in and 'run the list' with the NPs every day for $200/hr. The NPs call anesthesia for their airways, over utilize IR for line placement, and call the ER to come and help out on codes. The "ICU docs" are there from 11am-2pm, get paid for 8hours, and simply walk through the unit. No real rounding; To me, that's ****ty care for patients, an erosion of the standard of ICU, and highly risky for those docs who are taking the $1600 for 3 hours of work (and phone consult during the other 5 hours).

I mean... with Prime what do you expect. During med school I rotated through one of their Inland Empire area hospitals and the FM program director and CMO (note, apparently he is no longer the CMO) bragged about how often he'd been investigated for Medicare fraud and claimed that he was always cleared.

 

[chocomorsel]

Prime Healthcare came into one of the Level II trauma centers in Los Angeles. There was a functional independent group there when they took over, a true intensivist program with anesthesia, ER, and pulmonary providers. They had already gone through the transition from old pulmonary guard to putting in a real ICU program.

Prime immediately fired the group, put NPs as the primary providers in the unit, and hired a series of locum/part-time ICU folk to come in and 'run the list' with the NPs every day for $200/hr. The NPs call anesthesia for their airways, over utilize IR for line placement, and call the ER to come and help out on codes. The "ICU docs" are there from 11am-2pm, get paid for 8hours, and simply walk through the unit. No real rounding; To me, that's ****ty care for patients, an erosion of the standard of ICU, and highly risky for those docs who are taking the $1600 for 3 hours of work (and phone consult during the other 5 hours).

Would please stop calling physicians "providers?" Stop drinking that KoolAid. Do you see how you are calling docs and midlevels "providers?"
We are Doctors and Physicians. Please pick one. Don't assist them in muddying the waters.

 

[deleted941485]

I mean... with Prime what do you expect. During med school I rotated through one of their Inland Empire area hospitals and the FM program director and CMO (note, apparently he is no longer the CMO) bragged about how often he'd been investigated for Medicare fraud and claimed that he was always cleared.

Prime HC is a terrible player. Working with them at this point is either out of desperation or a criminal record. If your hospital is prime it’s probably on the verge or closing.