Purely from a financial perspective, how much more money do pulm/crit attendings roughly make than hospitalists?

[Sarcoid_Sorcerer]

Hello! Internal medicine PGY-2 here!

I’m trying to decide if I want to apply to pulm/crit fellowships in a few months from now, or if I would prefer to be a hospitalist instead. I’m considering all aspects of this decision, one of which is the financial incentives of both jobs. Of course this decision is not based solely on money, I would never do something like that, but I just don’t know very much about this topic and I’d like to know more.

Like, all else being equal, roughly how much more would an intensivist earn than a hospitalist in a year? Let’s assume that they both work in a major US city and not somewhere rural.

Also, does it matter if they are both at a community vs. academic center? I guess for consistency’s sake, we should compare a community hospitalist to a community pulmonologist and the academic hospitalist to the academic pulmonologist.

Any help with this question would be greatly appreciated! I know physician reimbursement is a tricky thing to quantify and kind of a vague question on my part.

For what it’s worth, the reason I ask is because I love pulm/crit and have been very gung-ho about pursuing it for most of residency, but I think I’m leaning towards becoming a hospitalist instead now and I just want to get a sense of roughly how much money I would be leaving on the table when making this decision.

Thanks in advance!

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[chessknt]

There is no way to answer this accurately but if you make an assumption that current compensation remains constant (guaranteed not to happen) then you are looking about 100k/yr upside at an opportunity cost of about 750k so about 8 years to break even; over a 20 year career maybe looking at a 2 MM benefit to doing pulm/ccm in the end. Math isn't that simple because of taxes and investment returns. With collapse of hospital subsidies and encroachment of other specialties/midlevels pulmonary will be better positioned than either field to maintain current pay rates.

 

[DrMetal]

There is no way to answer this accurately but if you make an assumption that current compensation remains constant (guaranteed not to happen) then you are looking about 100k/yr upside at an opportunity cost of about 750k so about 8 years to break even; over a 20 year career maybe looking at a 2 MM benefit to doing pulm/ccm in the end. Math isn't that simple because of taxes and investment returns. With collapse of hospital subsidies and encroachment of other specialties/midlevels pulmonary will be better positioned than either field to maintain current pay rates.

Your math looks decent.

I would ask the OP @Sarcoid_Sorcerer how old are you, and how long do you intend to work? If you're 32 and intending to work another 35 years, I'd go Pulm CC for the money. If you're 45 and only want to work until 60, maybe the hospitalist track.

The general hospitalist track is doomed. In the eyes of our administrators, we're paid too well, to do a job that can likely be fully automated with the assistance of mid-levels and the other consulted physicians. I think we'll last maybe another 10-15 years, 20 at best. We're just not economically viable. I'll be retired by then.

 

[collegestud2013]

Hello! Internal medicine PGY-2 here!

I’m trying to decide if I want to apply to pulm/crit fellowships in a few months from now, or if I would prefer to be a hospitalist instead. I’m considering all aspects of this decision, one of which is the financial incentives of both jobs. Of course this decision is not based solely on money, I would never do something like that, but I just don’t know very much about this topic and I’d like to know more.

Like, all else being equal, roughly how much more would an intensivist earn than a hospitalist in a year? Let’s assume that they both work in a major US city and not somewhere rural.

Also, does it matter if they are both at a community vs. academic center? I guess for consistency’s sake, we should compare a community hospitalist to a community pulmonologist and the academic hospitalist to the academic pulmonologist.

Any help with this question would be greatly appreciated! I know physician reimbursement is a tricky thing to quantify and kind of a vague question on my part.

For what it’s worth, the reason I ask is because I love pulm/crit and have been very gung-ho about pursuing it for most of residency, but I think I’m leaning towards becoming a hospitalist instead now and I just want to get a sense of roughly how much money I would be leaving on the table when making this decision.

Thanks in advance!

Critical care/intensivist shifts are similar to hospitalist shifts in many ways, expect with critical care you are managing the sickest patients in the hospitalist rather than the more stable ones. The higher pay in critical care comes mainly from the higher RVUs from billing for critical time, as you can bill critical care time for nearly all your patients in the ICU (while if you did that as a hospitalist on too many stable floor patients you would probably get audited). Over 30 mins of CC gets 4.5 wRVUs while a level 3 follow-up now goes for 2.4 wRVUs, and a level 2 follow-up at 1.59 wRVUs.

Pay probably ends up being $50-100k more year depending on the location, patient volume, and other factors, though CC arguably does work harder for the extra pay, as managing high acuity ICU level patients simply takes more time and effort per patient. But keep in mind that CC/pulm fellowship takes 3 years longer, and at most physician's tax brackets, 40-45% is going to taxes. So even making an extra $100k per year pretax only comes out to $55-60k after tax. So it would take a long time to break even and you probably won't until late in your career. Not to mention that burnout rates for CC are among the highest compared to other specialties (and usually higher than hospitalist), so many don't even last that long. But if they did a combined pulm/CC fellowship and and IM residency, they could of course go back to doing outpatient pulm, hospitalist, or PCP work.

Another option would be to work as a hospitalist in an open ICU setting where you can also do critical care level work (eg managing vents, pressors, placing lines etc...) and you should in theory bill as many RVUs as an intensivist doing the same work. Though to do this safely and without significantly increasing your medicolegal risk, you need to take your ICU rotations in residency seriously and and be comfortable doing intensivist procedures independently without having doing a CC fellowship.

 

[DrMetal]

Another option would be to work as a hospitalist in an open ICU setting where you can also do critical care level work (eg managing vents, pressors, placing lines etc...) and you should in theory bill as many RVUs as an intensivist doing the same work.

I don't know about that. Some "open" ICUs aren't so open any more. I've worked in plenty, where there was always an intensivist consulted and she was running the show (and I was glad for it). My only role as the generalist was to be ready for a quick pop out and to help with case management issues.

If you are a generalist and you're truthfully doing critical care type work---lines, intubating, managing vents, etc---then I hope you're well insured and I hope your hospital is paying you well. If they're not, they're abusing you because they're too cheap to hire an intensivist.

 

[CCM-MD]

Critical care/intensivist shifts are similar to hospitalist shifts in many ways, expect with critical care you are managing the sickest patients in the hospitalist rather than the more stable ones. The higher pay in critical care comes mainly from the higher RVUs from billing for critical time, as you can bill critical care time for nearly all your patients in the ICU (while if you did that as a hospitalist on too many stable floor patients you would probably get audited). Over 30 mins of CC gets 4.5 wRVUs while a level 3 follow-up now goes for 2.4 wRVUs, and a level 2 follow-up at 1.59 wRVUs.

Pay probably ends up being $50-100k more year depending on the location, patient volume, and other factors, though CC arguably does work harder for the extra pay, as managing high acuity ICU level patients simply takes more time and effort per patient. But keep in mind that CC/pulm fellowship takes 3 years longer, and at most physician's tax brackets, 40-45% is going to taxes. So even making an extra $100k per year pretax only comes out to $55-60k after tax. So it would take a long time to break even and you probably won't until late in your career. Not to mention that burnout rates for CC are among the highest compared to other specialties (and usually higher than hospitalist), so many don't even last that long. But if they did a combined pulm/CC fellowship and and IM residency, they could of course go back to doing outpatient pulm, hospitalist, or PCP work.

Another option would be to work as a hospitalist in an open ICU setting where you can also do critical care level work (eg managing vents, pressors, placing lines etc...) and you should in theory bill as many RVUs as an intensivist doing the same work. Though to do this safely and without significantly increasing your medicolegal risk, you need to take your ICU rotations in residency seriously and and be comfortable doing intensivist procedures independently without having doing a CC fellowship.

MGMA 2022: CCM 455k, pulm: crit 462k, hospitalist 320k. The difference can be quite a bit more with 1099/locum work, rates are almost double for CC work compared to hospitalist work. At my current institution I can drop to 0.5 FTE and make the same as our hospitalists. IMO pulm crit is probably the most satisfying between them. Who works “harder”? Probably crit because of the acuity/procedures, but my census is half of our hospitalists and I have a midlevel. I also don’t discharge anyone and probably deal with much less BS. One could work significantly fewer CC shifts to make same pay as a hospitalist if less work is the goal.

Doing ICU work without the boards is probably the worst idea due to liability. And don’t expect intensivist pay because the primary reason these jobs exist is due to hospitals wanting to save a buck.

 

[gutonc]

MGMA 2022: CCM 455k, pulm: crit 462k, hospitalist 320k. The difference can be quite a bit more with 1099/locum work, rates are almost double for CC work compared to hospitalist work. At my current institution I can drop to 0.5 FTE and make the same as our hospitalists. IMO pulm crit is probably the most satisfying between them. Who works “harder”? Probably crit because of the acuity/procedures, but my census is half of our hospitalists and I have a midlevel. I also don’t discharge anyone and probably deal with much less BS. One could work significantly fewer CC shifts to make same pay as a hospitalist if less work is the goal.

Doing ICU work without the boards is probably the worst idea due to liability. And don’t expect intensivist pay because the primary reason these jobs exist is due to hospitals wanting to save a buck.

The bolded was honestly my favorite thing about being in the ICU as a resident. They either go to the floor, the morgue, or they elope. In any case, getting them out of the hospital isn't your problem.

 

[bochaw]

Critical care/intensivist shifts are similar to hospitalist shifts in many ways, expect with critical care you are managing the sickest patients in the hospitalist rather than the more stable ones. The higher pay in critical care comes mainly from the higher RVUs from billing for critical time, as you can bill critical care time for nearly all your patients in the ICU (while if you did that as a hospitalist on too many stable floor patients you would probably get audited). Over 30 mins of CC gets 4.5 wRVUs while a level 3 follow-up now goes for 2.4 wRVUs, and a level 2 follow-up at 1.59 wRVUs.

Pay probably ends up being $50-100k more year depending on the location, patient volume, and other factors, though CC arguably does work harder for the extra pay, as managing high acuity ICU level patients simply takes more time and effort per patient. But keep in mind that CC/pulm fellowship takes 3 years longer, and at most physician's tax brackets, 40-45% is going to taxes. So even making an extra $100k per year pretax only comes out to $55-60k after tax. So it would take a long time to break even and you probably won't until late in your career. Not to mention that burnout rates for CC are among the highest compared to other specialties (and usually higher than hospitalist), so many don't even last that long. But if they did a combined pulm/CC fellowship and and IM residency, they could of course go back to doing outpatient pulm, hospitalist, or PCP work.

Another option would be to work as a hospitalist in an open ICU setting where you can also do critical care level work (eg managing vents, pressors, placing lines etc...) and you should in theory bill as many RVUs as an intensivist doing the same work. Though to do this safely and without significantly increasing your medicolegal risk, you need to take your ICU rotations in residency seriously and and be comfortable doing intensivist procedures independently without having doing a CC fellowship.

Second this. And keep in mind that extra 900k is not just sitting in your bank. People in general earn extra 10-20% from the interest/stock etc. If you work as hospitalist and want to live like a fellow for 3 years, the difference is even bigger. One of my junior just graduated 3 years ago and now making 600-700k a year as a hospitalist.

 

[chessknt]

Second this. And keep in mind that extra 900k is not just sitting in your bank. People in general earn extra 10-20% from the interest/stock etc. If you work as hospitalist and want to live like a fellow for 3 years, the difference is even bigger. One of my junior just graduated 3 years ago and now making 600-700k a year as a hospitalist.

I know the same guy--works 2 hours a day goes home at 10 am after seeing his census of 4 then makes 10-100k daily trading stocks and dogecoin futures.

 

[Siggy]

Another option would be to work as a hospitalist in an open ICU setting where you can also do critical care level work (eg managing vents, pressors, placing lines etc...) and you should in theory bill as many RVUs as an intensivist doing the same work.

Every hospital I've been at has been an "open ICU" in regards to hospital policy.

Every hospital I've been at the hospitalists generally does limited work when their patients are in the ICU because there's an intensivist team following.

 

[JustPass]

I know the same guy--works 2 hours a day goes home at 10 am after seeing his census of 4 then makes 10-100k daily trading stocks and dogecoin futures.

I know this is sarcasm but I really do know a guy who works as a nocturnist at a hospital with open ICU and does part time at another hospital (closed ICU) doing 21 shifts a month who is going to break 600k. Just saying it's possible.
I'm a nocturnist doing about 21 shifts a month at a closed ICU (different part of country from guy above) looking to do just a little over 400K this year.
Health and relationship consequences are a different story....

 

[whoknows2012]

I know this is sarcasm but I really do know a guy who works as a nocturnist at a hospital with open ICU and does part time at another hospital (closed ICU) doing 21 shifts a month who is going to break 600k. Just saying it's possible.
I'm a nocturnist doing about 21 shifts a month at a closed ICU (different part of country from guy above) looking to do just a little over 400K this year.
Health and relationship consequences are a different story....

21 night shifts a month!! Geez don’t know how you do that. I don’t think that is physically sustainable but more power to ya

 

[Prehealth1011]

I know this is sarcasm but I really do know a guy who works as a nocturnist at a hospital with open ICU and does part time at another hospital (closed ICU) doing 21 shifts a month who is going to break 600k. Just saying it's possible.
I'm a nocturnist doing about 21 shifts a month at a closed ICU (different part of country from guy above) looking to do just a little over 400K this year.
Health and relationship consequences are a different story....

12 hour shifts?

 

[dozitgetchahi]

I know this is sarcasm but I really do know a guy who works as a nocturnist at a hospital with open ICU and does part time at another hospital (closed ICU) doing 21 shifts a month who is going to break 600k. Just saying it's possible.
I'm a nocturnist doing about 21 shifts a month at a closed ICU (different part of country from guy above) looking to do just a little over 400K this year.
Health and relationship consequences are a different story....

The craziest example I heard of was a new IM grad who simply wanted to make as much cash as possible straight out of residency…so they got a daytime PCP job and then signed on moonlighting night hospitalist shifts at as many hospitals as they could. Basically, they never went home - they just went from their day PCP job to their night hospitalist jobs, and tried to get as much sleep as they could each night. (Apparently, they tried to find “low impact” hospitalist jobs where they wouldn’t have to do much.)

Iirc, they were only able to keep this up for a year or so. I’m surprised they didn’t give out earlier than that.

 

[collegestud2013]

The craziest example I heard of was a new IM grad who simply wanted to make as much cash as possible straight out of residency…so they got a daytime PCP job and then signed on moonlighting night hospitalist shifts at as many hospitals as they could. Basically, they never went home - they just went from their day PCP job to their night hospitalist jobs, and tried to get as much sleep as they could each night. (Apparently, they tried to find “low impact” hospitalist jobs where they wouldn’t have to do much.)

Iirc, they were only able to keep this up for a year or so. I’m surprised they didn’t give out earlier than that.

There was someone at my place a few years ago who would frequently pull double shifts and frequently manage 40-50 patients per day. Not sure how much he was really seeing them all (probably just popped his head in the door real quick for each patient), and wasn't easy to get a hold of from nursing when paged. It was a major headache if you took over any of his patients after he switched off service. Pulled in about 16,000 RVUs in 1 year (or at least that's what he billed for), which is probably in top 1% of hospitalists. Came out to about $800k based on base + RVU pay structure at the time. He resigned and left after hospital admin stepped in and not allowed any of the hospitalists to do double shifts any anymore and stopped paying RVUs for extra shifts.

 

[chessknt]

I know this is sarcasm but I really do know a guy who works as a nocturnist at a hospital with open ICU and does part time at another hospital (closed ICU) doing 21 shifts a month who is going to break 600k. Just saying it's possible.
I'm a nocturnist doing about 21 shifts a month at a closed ICU (different part of country from guy above) looking to do just a little over 400K this year.
Health and relationship consequences are a different story....

Working 2 FTE is a different story, the way you wrote it originally made it sound like MT was the land of hospitalist milk and honey.

 

[grt398]

As much as I prefer ICU work, I likely would have come out ahead long term, in a purely financial sense at least, having skipped the fellowship and just doing 5 years of residency type hours as a hospitalist in the midwest. I knew two attendings in residency who were doing ~20 hospitalist shifts/month, split nights/days, pulling ~$450k/yr, and while it's an unpleasant lifestyle for a bit, honestly if you were ok living on $100k of that, and put the rest away into index funds to sit there for the next 30 years, you could basically work just for your living expenses after 5 yrs, maybe as few as 5 shifts/month. It's really hard to beat the effect of early savings/compounding returns ($850k total savings [170k/yr] at the end of year 5 @ 6% CAGR for 30 yrs = ~$4.9 million as an example).

 

[BicepsTriceps]

I know this is sarcasm but I really do know a guy who works as a nocturnist at a hospital with open ICU and does part time at another hospital (closed ICU) doing 21 shifts a month who is going to break 600k. Just saying it's possible.
I'm a nocturnist doing about 21 shifts a month at a closed ICU (different part of country from guy above) looking to do just a little over 400K this year.
Health and relationship consequences are a different story....

You're only making $1600 per night?

I hope you're sleeping half those shifts at least

 

[dozitgetchahi]

There was someone at my place a few years ago who would frequently pull double shifts and frequently manage 40-50 patients per day. Not sure how much he was really seeing them all (probably just popped his head in the door real quick for each patient), and wasn't easy to get a hold of from nursing when paged. It was a major headache if you took over any of his patients after he switched off service. Pulled in about 16,000 RVUs in 1 year (or at least that's what he billed for), which is probably in top 1% of hospitalists. Came out to about $800k based on base + RVU pay structure at the time. He resigned and left after hospital admin stepped in and not allowed any of the hospitalists to do double shifts any anymore and stopped paying RVUs for extra shifts.

That’s nuts, but I’ve definitely heard of it happening. In residency, there was a hospitalist attending with our institution who got canned because he was “secretly” taking simultaneous shifts rounding on patients at the VA while also rounding with the resident services at the county hospital next door…he would rush through county rounds and then run off to the VA. I think the turning point was where some patient coded at the VA, and he showed up super late for the code because he was running from the other hospital.

This guy was known for doing other crazy stuff like bringing his Xbox to the resident team rooms to play Halo, and telling the residents that most patients could be managed “through the computer” without seeing them. I don’t think he lasted too long.

 

[Nocturnist]

Hello! Internal medicine PGY-2 here!

I’m trying to decide if I want to apply to pulm/crit fellowships in a few months from now, or if I would prefer to be a hospitalist instead. I’m considering all aspects of this decision, one of which is the financial incentives of both jobs. Of course this decision is not based solely on money, I would never do something like that, but I just don’t know very much about this topic and I’d like to know more.

Like, all else being equal, roughly how much more would an intensivist earn than a hospitalist in a year? Let’s assume that they both work in a major US city and not somewhere rural.

Also, does it matter if they are both at a community vs. academic center? I guess for consistency’s sake, we should compare a community hospitalist to a community pulmonologist and the academic hospitalist to the academic pulmonologist.

Any help with this question would be greatly appreciated! I know physician reimbursement is a tricky thing to quantify and kind of a vague question on my part.

For what it’s worth, the reason I ask is because I love pulm/crit and have been very gung-ho about pursuing it for most of residency, but I think I’m leaning towards becoming a hospitalist instead now and I just want to get a sense of roughly how much money I would be leaving on the table when making this decision.

Thanks in advance!

The 3 year opportunity cost of PCCM is potentially much more significant than you're hearing here.

I'm a nocturnist in a community hospital in the northeast (so supposedly one of the least lucrative areas of the country). I made 1.7M my first 3 years out of residency working 18-20 night shifts. Add retirement contributions from my employer and it's closer to 1.8-1.9M. Add some compound interest/market gains to the portfolio and the appreciation and equity on the two homes i was able to buy and it's going to take an intensivist much longer than a decade to come out ahead.

Keep in mind the opportunity cost isn't just measured in cash. In those 3 years I was traveling every single month. I was able to see 25 states, half of Europe, and nearly the entire Caribbean. A pulmonologist may not be able to do that kind of traveling until they retired.

And following those 3 years? I've continued making 550-600k a year and traveling monthly.
Some will say the sky is falling on hospitalists without any evidence on the ground. Nationally, both salaries and subsidizations have increased steadily year after year. The per diem shifts rates I'm getting have increased as well, now routinely at 220-250/hr.

Not saying a similarly hard working intensivist cant work more or enjoy life as much. Just wouldn't necessarily do it for the $.

 

[CCM-MD]

The 3 year opportunity cost of PCCM is potentially much more significant than you're hearing here.

I'm a nocturnist in a community hospital in the northeast (so supposedly one of the least lucrative areas of the country). I made 1.7M my first 3 years out of residency working 18-20 night shifts. Add retirement contributions from my employer and it's closer to 1.8-1.9M. Add some compound interest/market gains to the portfolio and the appreciation and equity on the two homes i was able to buy and it's going to take an intensivist much longer than a decade to come out ahead.

Keep in mind the opportunity cost isn't just measured in cash. In those 3 years I was traveling every single month. I was able to see 25 states, half of Europe, and nearly the entire Caribbean. A pulmonologist may not be able to do that kind of traveling until they retired.

And following those 3 years? I've continued making 550-600k a year and traveling monthly.
Some will say the sky is falling on hospitalists without any evidence on the ground. Nationally, both salaries and subsidizations have increased steadily year after year. The per diem shifts rates I'm getting have increased as well, now routinely at 220-250/hr.

Not saying a similarly hard working intensivist cant work more or enjoy life as much. Just wouldn't necessarily do it for the $.

Time value of money is a real kicker. From a purely financial standpoint I don’t think any of the IM subs come out too far ahead when accounting for opportunity cost due to duration of training and bare minimum investment gains. Especially, if one works like a dog as the first few years of attendinghood.

 

[Nocturnist]

Time value of money is a real kicker. From a purely financial standpoint I don’t think any of the IM subs come out too far ahead when accounting for opportunity cost due to duration of training and bare minimum investment gains. Especially, if one works like a dog as the first few years of attendinghood.

Agreed. I'm not going to pretend my career earnings are going to come out neck to neck with an interventional cardiologist or GI, but between a)dimishing returns of further earnings at that tax rate, b) the financial and social opportunity cost of another 3-5 years of training and c) once exceeding 500k in income I dont believe making 700k or 800k meaningfully affects lifestyle. The next bump in lifestyle/satisfaction/happiness in my opinion would be in the professional athlete salary ranges.

I also don't believe the MGMA averages really tell the full story of just how easy it is to pull this kind of money in hospital medicine. The fellowship process of competitive subs such as PCCM tends to weed out folks who are averse to working like dogs or are just much more lifestyle focused. Such a significant proportion of my colleagues are parents working part time, or folks that just want to work the bare minimum needed to qualify for benefits and never care to see the inside of the available moonlighting shift emails. These folks pull the averages down. I'm sure there's some of that in PCCM, but I suspect much less. For those of us that are willing and want to work hard, hospital medicine is Iike an ATM- I can pull as much as I want anytime I want.

Not discouraging anyone from fellowships, especially PCCM. It's an amazing field, I was very close to pursuing it myself. Just wouldn't advise someone to pursue it for some perceived financial benefit that may not be realized until 10-20 years down the road.

 

[BicepsTriceps]

Agreed. I'm not going to pretend my career earnings are going to come out neck to neck with an interventional cardiologist or GI, but between a)dimishing returns of further earnings at that tax rate, b) the financial and social opportunity cost of another 3-5 years of training and c) once exceeding 500k in income I dont believe making 700k or 800k meaningfully affects lifestyle. The next bump in lifestyle/satisfaction/happiness in my opinion would be in the professional athlete salary ranges.

I also don't believe the MGMA averages really tell the full story of just how easy it is to pull this kind of money in hospital medicine. The fellowship process of competitive subs such as PCCM tends to weed out folks who are averse to working like dogs or are just much more lifestyle focused. Such a significant proportion of my colleagues are parents working part time, or folks that just want to work the bare minimum needed to qualify for benefits and never care to see the inside of the available moonlighting shift emails. These folks pull the averages down. I'm sure there's some of that in PCCM, but I suspect much less. For those of us that are willing and want to work hard, hospital medicine is Iike an ATM- I can pull as much as I want anytime I want.

Not discouraging anyone from fellowships, especially PCCM. It's an amazing field, I was very close to pursuing it myself. Just wouldn't advise someone to pursue it for some perceived financial benefit that may not be realized until 10-20 years down the road.

I'm a Hospitalist now who wanted to do PCC for the longest time.

After 3 years of hospitalist I just don't think it's worth it at all. As you said what will doing 3 years of PCC or hem/onc or 4 years of cardiology or GI add to my salary?

Wouldn't focusing on a side business for a solid 3 years bring you the same if not significantly more money?

I'm starting blue print of a fast food restaurant side business. I believe it would require a fraction of a fraction of time commitment compared to commiting to a whole new fellowship. I can stay full time or 0.7-0.9 hospitalist while working on my side business.

The restaurant is one idea. There is of course unlimited amount of ideas for a side business.

I think going to fellowship purely for money is falling into sunk cost fallacy. Stop. Re-evalute and think.

 

[collegestud2013]

I'm a Hospitalist now who wanted to do PCC for the longest time.

After 3 years of hospitalist I just don't think it's worth it at all. As you said what will doing 3 years of PCC or hem/onc or 4 years of cardiology or GI add to my salary?

Wouldn't focusing on a side business for a solid 3 years bring you the same if not significantly more money?

I'm starting blue print of a fast food restaurant side business. I believe it would require a fraction of a fraction of time commitment compared to commiting to a whole new fellowship. I can stay full time or 0.7-0.9 hospitalist while working on my side business.

The restaurant is one idea. There is of course unlimited amount of ideas for a side business.

I think going to fellowship purely for money is falling into sunk cost fallacy. Stop. Re-evalute and think.

Some of the highest paying IM subspecialities like heme-onc, GI, and interventional cardiology can definitely still come out ahead financially (even compared to a hospitalist working a good amount of extra shifts), though the break even time can be quite a while and not into later in career.

Recent data puts median hospitalist compensation at $353k for 2022 (Earning what you're worth) ; it doesn't mention number of shifts though that likely includes pay from extra shifts (and not just the standard 7on/7off). What limits hospitalist pay it the higher end s that most positions are employed and there is not much ownership opportunity. Specialties like GI and heme-onc have much more private practice jobs with partnership opportunities, and the senior partners can definitely come out ahead of hospitalists later in career (even when accounting for taxes, 3 years of additional training time, and 3 years of lost investment gains)

 

[Nocturnist]

Some of the highest paying IM subspecialities like heme-onc, GI, and interventional cardiology can definitely still come out ahead financially (even compared to a hospitalist working a good amount of extra shifts), though the break even time can be quite a while and not into later in career.

Recent data puts median hospitalist compensation at $353k for 2022 (Earning what you're worth) ; it doesn't mention number of shifts though that likely includes pay from extra shifts (and not just the standard 7on/7off). What limits hospitalist pay it the higher end s that most positions are employed and there is not much ownership opportunity. Specialties like GI and heme-onc have much more private practice jobs with partnership opportunities, and the senior partners can definitely come out ahead of hospitalists later in career (even when accounting for taxes, 3 years of additional training time, and 3 years of lost investment gains)

Truth. And I think that's an important point to discuss from both sides of this coin because just like hospitalist salary averages can be pulled downward by the under employed, some of these specialty averages are likely inflated by these over achievers- the practice owners, entrepreneurs, and those significantly later into their careers.

Keep in mind though- so many of us went the hospitalist route specifically because we wanted nothing to do with all that noise. There are ownership opportunities in primary care, that can be quite lucrative, but we chose this route because we want nothing to do with those headaches.

Partnership opportunities?
owning a practice?
management?
Nope. Hard pass.

I didn't want a "career", per se. I didnt want to stay in the rat race or have to keep climbing any corporate ladders. I certainly never wanted to deal with partners or the headache of managing people or a practice. I'm perfectly content being a cog in the wheel. It's a job. I enjoy it tremendously, and I feel like I'm good at it and making a difference- but it's just a job. And my favorite part? When the clock strikes 7, I peace the f out. Pager off, no results to sign off on, no patients to call back, no notes left to finish, no meetings to ever attend.

For folks of that same mindset, and I know there are alot of them out there- it's nice to know you can make that kind of money, straight out of residency, with zero further corporate/management BS. But the flip is if you're going into a fellowship thinking you can make those 75th or 90th percentile figures by just doctoring, think again.

 

[chessknt]

Apples to apples for those reading--working 20 nights/month as an intensivist should net you close to 800k+, working 20+ nights locums closer to 1MM. Pretending that the opportunity cost of 3 years of fellowship is the same as working 1.8 FTE of an attending is a stupid comparison (I moonlighted during 2/3 of my fellowship and pulled more than what the academic hospitalists were making at my hospital in combination with my fellow salary) but if we are going to make it might as well make it even and look at working 1.8 FTE as an intensivist.

I still stand by that you will absolutely come out ahead working ICU work under the current model and have the option to flex out to an outpatient lifestyle if the inpatient model falls apart. The benefit is even better for heme/onc, GI, and cards which, coincidentally, are quite competitive.

 

[the argus]

Apples to apples for those reading--working 20 nights/month as an intensivist should net you close to 800k+, working 20+ nights locums closer to 1MM. Pretending that the opportunity cost of 3 years of fellowship is the same as working 1.8 FTE of an attending is a stupid comparison (I moonlighted during 2/3 of my fellowship and pulled more than what the academic hospitalists were making at my hospital in combination with my fellow salary) but if we are going to make it might as well make it even and look at working 1.8 FTE as an intensivist.

I still stand by that you will absolutely come out ahead working ICU work under the current model and have the option to flex out to an outpatient lifestyle if the inpatient model falls apart. The benefit is even better for heme/onc, GI, and cards which, coincidentally, are quite competitive.

Thank you for this post. The devil is in the details. The majority of physicians across most specialties can make 500-600k per year if they are willing to work 1.5-2.0 FTE nights. Acting like hospital medicine is uniquely awesome or profitable in this regard is somewhat misleading.

 

[Mad Jack]

Your math looks decent.

I would ask the OP @Sarcoid_Sorcerer how old are you, and how long do you intend to work? If you're 32 and intending to work another 35 years, I'd go Pulm CC for the money. If you're 45 and only want to work until 60, maybe the hospitalist track.

The general hospitalist track is doomed. In the eyes of our administrators, we're paid too well, to do a job that can likely be fully automated with the assistance of mid-levels and the other consulted physicians. I think we'll last maybe another 10-15 years, 20 at best. We're just not economically viable. I'll be retired by then.

I can't even imagine how many people will die if that shift occurs. Having our sickest patients seen by nonphysicians should be a shame to our nation

 

[CCM-MD]

Apples to apples for those reading--working 20 nights/month as an intensivist should net you close to 800k+, working 20+ nights locums closer to 1MM. Pretending that the opportunity cost of 3 years of fellowship is the same as working 1.8 FTE of an attending is a stupid comparison (I moonlighted during 2/3 of my fellowship and pulled more than what the academic hospitalists were making at my hospital in combination with my fellow salary) but if we are going to make it might as well make it even and look at working 1.8 FTE as an intensivist.

I still stand by that you will absolutely come out ahead working ICU work under the current model and have the option to flex out to an outpatient lifestyle if the inpatient model falls apart. The benefit is even better for heme/onc, GI, and cards which, coincidentally, are quite competitive.

Good point, comparing hospitalist comp while essentially working 2 jobs to normal/below avg numbers for other fields is not a fair comparison. Guy in my group does 20 a month consistently, add in directorship stipends and it gets pretty close to 7 figures.

 

[DrMetal]

I can't even imagine how many people will die if that shift occurs. Having our sickest patients seen by nonphysicians should be a shame to our nation

It's not quite that dramatic. When patients die, they're usually on that trajectory way before they come to us. With the plethora of automated tools we have in the hospital (sepsis alerts, insulin management algorithms, antibiotics tracking, etc) it's becoming easier and easier for even a computer to do this job.

What keeps us hospitalists in business, is the demand that a physician still be on the chart, the demand from the patient/family to 'talk to a doctor', the plethora of paperwork (SNF, case management, home O2, DME, etc) that requires a doctor's signature (and hence some liability).

The subspecialists rarely like to deal with that, so it falls on the hospitalist. I'm very grateful for that! If those demands go away some day, so too does my job.

 

[aafisahar]

I know the same guy--works 2 hours a day goes home at 10 am after seeing his census of 4 then makes 10-100k daily trading stocks and dogecoin futures.

i saw him on vacation in belize while he boated on his yacht, lucky bastard

 

[Nocturnist]

Thank you for this post. The devil is in the details. The majority of physicians across most specialties can make 500-600k per year if they are willing to work 1.5-2.0 FTE nights. Acting like hospital medicine is uniquely awesome or profitable in this regard is somewhat misleading.

Yup, the devil is in the details. The only misleading detail here is thinking 18-20 shifts a month is going to equate to 2 FTEs in any other field.

From your homeboy's own post from September's thread "Pulm-Crit docs - how much do you work and make?"
"165 shifts (about 40% nights) last year 530k, good size city with an airport in an otherwise rural area"

My 1 FTE is 120 shifts a year, I would make over 300k. At 165 shifts a year, I'd be at 425-450k.
I never have to switch between nights and days, something I feel strongly is the most devastating kind of work on one's body.
I don’t have to live in a rural area, i'm less than 10 miles outside a major city.

Apples to apples- if comparing spending 3 years of your life at an opportunity cost well north of $1M, to make 75-100k more a year more at a similar shift commitment, constantly switching days and nights to be living somewhere your'e lucky if has a Chipotle is misleading? Well, let's just say that wasn't my intention.

No knock to PCC- it's a wonderful field.
You'll probably come out ahead, it may take you 15-20 years to break even. You'll make a little bit more than me per shift. It's going to cost you 3 of what would otherwise be some of the best years of your life. You're not going to be making as much close to civilization. You're probably going to have to work both nights and days. You'll likely have less flexibility in scheduling. I think that about covers it.

 

[bronx43]

Yup, the devil is in the details. The only misleading detail here is thinking 18-20 shifts a month is going to equate to 2 FTEs in any other field.

From your homeboy's own post from September's thread "Pulm-Crit docs - how much do you work and make?"
"165 shifts (about 40% nights) last year 530k, good size city with an airport in an otherwise rural area"

My 1 FTE is 120 shifts a year, I would make over 300k. At 165 shifts a year, I'd be at 425-450k.
I never have to switch between nights and days, something I feel strongly is the most devastating kind of work on one's body.
I don’t have to live in a rural area, i'm less than 10 miles outside a major city.

Apples to apples- if comparing spending 3 years of your life at an opportunity cost well north of $1M, to make 75-100k more a year more at a similar shift commitment, constantly switching days and nights to be living somewhere your'e lucky if has a Chipotle is misleading? Well, let's just say that wasn't my intention.

No knock to PCC- it's a wonderful field.
You'll probably come out ahead, it may take you 15-20 years to break even. You'll make a little bit more than me per shift. It's going to cost you 3 of what would otherwise be some of the best years of your life. You're not going to be making as much close to civilization. You're probably going to have to work both nights and days. You'll likely have less flexibility in scheduling. I think that about covers it.

Wait what? You switch more between nights and days as nocturnist at 120 shifts/year than a pulm/CC who does 40% nights at 165 shifts. Unless you literally just live a nocturnal lifestyle even on your off days, this doesn't add up.

 

[CCM-MD]

Yup, the devil is in the details. The only misleading detail here is thinking 18-20 shifts a month is going to equate to 2 FTEs in any other field.

From your homeboy's own post from September's thread "Pulm-Crit docs - how much do you work and make?"
"165 shifts (about 40% nights) last year 530k, good size city with an airport in an otherwise rural area"

My 1 FTE is 120 shifts a year, I would make over 300k. At 165 shifts a year, I'd be at 425-450k.
I never have to switch between nights and days, something I feel strongly is the most devastating kind of work on one's body.
I don’t have to live in a rural area, i'm less than 10 miles outside a major city.

Apples to apples- if comparing spending 3 years of your life at an opportunity cost well north of $1M, to make 75-100k more a year more at a similar shift commitment, constantly switching days and nights to be living somewhere your'e lucky if has a Chipotle is misleading? Well, let's just say that wasn't my intention.

No knock to PCC- it's a wonderful field.
You'll probably come out ahead, it may take you 15-20 years to break even. You'll make a little bit more than me per shift. It's going to cost you 3 of what would otherwise be some of the best years of your life. You're not going to be making as much close to civilization. You're probably going to have to work both nights and days. You'll likely have less flexibility in scheduling. I think that about covers it.

$2500-2700 per nocturnist shift is significantly higher than the rates I’ve seen. It’s more like 1800-2000 where I am. For comparison, in the same location, 20 CC night shifts a month comes close to 750k a year. Also keep in mind there are crit and pulm crit jobs where nights are covered by nocturnists or midlevels, 40% nights is not the norm. One could make similar pay working no nights, which may be a much better quality of life: for reference, I worked 182 day shifts a year at my last job and made well over 600k.

You are comparing your nocturnist job that is paying essentially at the 90th% to a pulm crit job that’s paying essentially at the median. That’s not a fair comparison either.

 

[the argus]

Yup, the devil is in the details. The only misleading detail here is thinking 18-20 shifts a month is going to equate to 2 FTEs in any other field.

From your homeboy's own post from September's thread "Pulm-Crit docs - how much do you work and make?"
"165 shifts (about 40% nights) last year 530k, good size city with an airport in an otherwise rural area"

My 1 FTE is 120 shifts a year, I would make over 300k. At 165 shifts a year, I'd be at 425-450k.
I never have to switch between nights and days, something I feel strongly is the most devastating kind of work on one's body.
I don’t have to live in a rural area, i'm less than 10 miles outside a major city.

Apples to apples- if comparing spending 3 years of your life at an opportunity cost well north of $1M, to make 75-100k more a year more at a similar shift commitment, constantly switching days and nights to be living somewhere your'e lucky if has a Chipotle is misleading? Well, let's just say that wasn't my intention.

No knock to PCC- it's a wonderful field.
You'll probably come out ahead, it may take you 15-20 years to break even. You'll make a little bit more than me per shift. It's going to cost you 3 of what would otherwise be some of the best years of your life. You're not going to be making as much close to civilization. You're probably going to have to work both nights and days. You'll likely have less flexibility in scheduling. I think that about covers it.

I think your logic is flawed. As already mentioned, do you just live as a night person year round? Even during your baller vacations? If not then you are also switching between nights and days.

And as for your example, he is making $100K more than you for the same total amount of shifts, and <50% of his shifts are nights. If he was working 100% nights as an intensivist, you would add at least another $100K to his salary. And your >$2500/nocturnist shift I think probably qualifies >90% percentile, while his intensivist rate is probably mid-range (and importantly isn't 100% nights).

 

[chessknt]

I think your logic is flawed. As already mentioned, do you just live as a night person year round? Even during your baller vacations? If not then you are also switching between nights and days.

And as for your example, he is making $100K more than you for the same total amount of shifts, and <50% of his shifts are nights. If he was working 100% nights as an intensivist, you would add at least another $100K to his salary. And your >$2500/nocturnist shift I think probably qualifies >90% percentile, while his intensivist rate is probably mid-range (and importantly isn't 100% nights).

Yea he is quite dishonest. If I had worked 168 night shifts I would have been able to make quite a bit more. Last year I worked less and made 615, 70% days. It is fine if someone wants to work nights but pretending that it is the best financial opportunity in existence is bull****, especially when pretending that working nights is so great for your social life when fellowship ruins it. I had a great time in fellowship and 18 of those months were 'research' where I alternated between moonlighting and having a great time with my family all weekends off. I made close to 200k/yr in year 3 and about 140 in year 2 so my opportunity cost wasn't 1MM. I have a family and I was working hard but not 20 nights a month hard.

 

[bochaw]

I would say its still closed or more than 1Mm. Everything else being equal, if u moonlight and made extra 200k during your fellowship, u can also say hospitalist can also take extra shift during that year and obtain even more than 200 k since the salary is higher as a hospitalist with same time /energy expenditure. And in year 1 (busiest year as a fellow), if a hospitalist spend equal amount of energy and time as a pccm fellow, he/she can easily make 600-700k a year

 

[the argus]

I would say its still closed or more than 1Mm. Everything else being equal, if u moonlight and made extra 200k during your fellowship, u can also say hospitalist can also take extra shift during that year and obtain even more than 200 k since the salary is higher as a hospitalist with same time /energy expenditure. And in year 1 (busiest year as a fellow), if a hospitalist spend equal amount of energy and time as a pccm fellow, he/she can easily make 600-700k a year

Even if it is 1 million (I would argue it is not), you will make that back in at maximum 5-7 years working in the higher paying subspecialties (PCCM, GI, heme-onc, cards) vs hospitalist medicine if you are comparing apples to apples (number of shifts/FTE, nights vs days, salary percentiles, geography, academic vs private, etc).

But this really doesn't matter. We all seem to be happy with our life choices and certainly earn enough money to live full and complete lives.

 

[Splenda88]

At my shop, hospitalists make 330k and intensivists make 450k. Both work 7 on/off. Hospitalists can leave at 5pm while the intensivists have to stay in the hospital until 7 pm. It's hard to compare the two. I am a hospitalist and would not do CCM fellowship because I think their job is harder.

 

[IM_to_ortho_hopeful]

Anybody know where I can find info on 1099 tele ICU jobs and whether they are readily available?

One thing may be the QOL difference if CCM can work from home

 

[wamcp]

There is no way to answer this accurately but if you make an assumption that current compensation remains constant (guaranteed not to happen) then you are looking about 100k/yr upside at an opportunity cost of about 750k so about 8 years to break even; over a 20 year career maybe looking at a 2 MM benefit to doing pulm/ccm in the end. Math isn't that simple because of taxes and investment returns. With collapse of hospital subsidies and encroachment of other specialties/midlevels pulmonary will be better positioned than either field to maintain current pay rates.

This is just plain wrong. If you want to make things actually fair, the hospitalist should be working as hard as pulmcc fellow and they would be making attending money on those extra hours for the first three years.

Spoiler alert: the power of compound interest is greater than you expect. You’ve completely underestimated the opportunity cost of fellowship.

Hospitalist can exceed pulmcc for an entire career lifetime. Pulmcc could never catch up financially.

Assume both work 72 hours a week and take 4 weeks vacation each for the first three years.

510K for 3 years as a hospitalist = 843K “take home” after taxes
70k for 3 years as pulm cc fellow = 147K “take home” after taxes

Assume the hospitalist and pulmcc have equal living expenses. Pulm cc spend every penny of the 147K on their 3 kids and wife and hospitalist will spend 147K equally on their family for the first 3 years.

so this means 696K the hospitalist is investing after three years. Pulmcc has 0 invested after three years.
Assume both have zero student loans.

Let’s make this simple and say the hospitalist begins investing (kept the 696K saved as cash until year 4) after year 3 and both of them earn 10% returns a year.

So when the hospitalist in year 4 and onward goes back to $330K (now normal working hours) and pulm cc becomes an attending making $450K (normal working hours), let’s suppose both only spend $100K a year.
So after taxes and living expenses, pulmcc is putting 147.5K a year to retirement and hospitalist adds 98K, starting in year 4.

Hospitalist
Year 4: 696K
Year 10: 2.066M
Year 14: 3.557M
Year 24: 11.3M
Year 30: 21.3M

Pulmcc
Year 4: 0
Year 10: 1.189M
Year 14: 2.456M
Year 24: 8.828M
Year 30: 16.8M

 

[bochaw]

This is just plain wrong. If you want to make things actually fair, the hospitalist should be working as hard as pulmcc fellow and they would be making attending money on those extra hours for the first three years.

Spoiler alert: the power of compound interest is greater than you expect. You’ve completely underestimated the opportunity cost of fellowship.

Hospitalist can exceed pulmcc for an entire career lifetime. Pulmcc could never catch up financially.

Assume both work 72 hours a week and take 4 weeks vacation each for the first three years.

510K for 3 years as a hospitalist = 843K “take home” after taxes
70k for 3 years as pulm cc fellow = 147K “take home” after taxes

Assume the hospitalist and pulmcc have equal living expenses. Pulm cc spend every penny of the 147K on their 3 kids and wife and hospitalist will spend 147K equally on their family for the first 3 years.

so this means 696K the hospitalist is investing after three years. Pulmcc has 0 invested after three years.
Assume both have zero student loans.

Let’s make this simple and say the hospitalist begins investing (kept the 696K saved as cash until year 4) after year 3 and both of them earn 10% returns a year.

So when the hospitalist in year 4 and onward goes back to $330K (now normal working hours) and pulm cc becomes an attending making $450K (normal working hours), let’s suppose both only spend $100K a year.
So after taxes and living expenses, pulmcc is putting 147.5K a year to retirement and hospitalist adds 98K, starting in year 4.

Hospitalist
Year 4: 696K
Year 10: 2.066M
Year 14: 3.557M
Year 24: 11.3M
Year 30: 21.3M

Pulmcc
Year 4: 0
Year 10: 1.189M
Year 14: 2.456M
Year 24: 8.828M
Year 30: 16.8M

this is similar to my post (4 posts above yours) and I totally agree with your calculation. This even worse for IMG on J1 visa, since they cannot moonlight

 

[Splenda88]

I don't think the money make a huge difference because both hospitalist and intensive can make 500k+ but hospitalists have to work more days/month--not necessarily harder based on my experience at two 200-300 bed hospitals.

I think you just have to pick what you dont want to deal with. If you dont want to deal with BS social issues, intensivist might be a better choice. In addition, hospitalist are the least respected physicians in the hospital. Not that I care but some people do.

On the other hand, if you dont want to deal with the sickest patients in the hospital and 98-yr dying granda whose family expectations are unrealistic, hospital medicine might be your choice.

If someone ask me if going into GI, heme/onc worth it, I would say yes. I would not say that for PCCM (and even cardio if they are not going into interventional or EP).

I made 405k last year as a hospitalist working an average of 17 days/month. Even with the extra 2 days, I think my job was less taxing than the intensivists at my place who work 15 days/month for 450k. Heck! I dont have to answer to every "effing" codes.

 

[wamcp]

this is similar to my post (4 posts above yours) and I totally agree with your calculation. This even worse for IMG on J1 visa, since they cannot moonlight

Yes, it is also much worse if:

Hospitalist invested the first three years immediately, instead of just save as cash first

Student loans are carried by both, especially if no PSLF assumed. That interest rate will hit hard both ways!

 

[chessknt]

This is just plain wrong. If you want to make things actually fair, the hospitalist should be working as hard as pulmcc fellow and they would be making attending money on those extra hours for the first three years.

Spoiler alert: the power of compound interest is greater than you expect. You’ve completely underestimated the opportunity cost of fellowship.

Hospitalist can exceed pulmcc for an entire career lifetime. Pulmcc could never catch up financially.

Assume both work 72 hours a week and take 4 weeks vacation each for the first three years.

510K for 3 years as a hospitalist = 843K “take home” after taxes
70k for 3 years as pulm cc fellow = 147K “take home” after taxes

Assume the hospitalist and pulmcc have equal living expenses. Pulm cc spend every penny of the 147K on their 3 kids and wife and hospitalist will spend 147K equally on their family for the first 3 years.

so this means 696K the hospitalist is investing after three years. Pulmcc has 0 invested after three years.
Assume both have zero student loans.

Let’s make this simple and say the hospitalist begins investing (kept the 696K saved as cash until year 4) after year 3 and both of them earn 10% returns a year.

So when the hospitalist in year 4 and onward goes back to $330K (now normal working hours) and pulm cc becomes an attending making $450K (normal working hours), let’s suppose both only spend $100K a year.
So after taxes and living expenses, pulmcc is putting 147.5K a year to retirement and hospitalist adds 98K, starting in year 4.

Hospitalist
Year 4: 696K
Year 10: 2.066M
Year 14: 3.557M
Year 24: 11.3M
Year 30: 21.3M

Pulmcc
Year 4: 0
Year 10: 1.189M
Year 14: 2.456M
Year 24: 8.828M
Year 30: 16.8M

This discussion is tiring but there are huge problems in your math, the biggest being a 10% ROI. It is unlikely we will ever see that in real terms for the next 20 years and is a pie in the sky number, real returns looking like 3-4% possibly less with inflation. No idea where you got 10 but I'd check that source in a hurry because it assumes that past returns are predictive of the future unless you think that the USA is still in the same geopolitical position it was in the 40s when the historical sp500 rate has hit that level.

You also have sequence risk if you do invest up front, if a hospitalist started in 2006 they would have come out super ****ed vs the ccm that comes out in 2009 because of the bear market which can be ignored since it is all random but we have had huge market swings and some people get very lucky.

Your assumption that working 2.0 FTE is the same as being a fellow is also flawed. Every training program is different but I sure as **** wasn't working 2.0 FTE all three years and I doubt the vast majority are.

I could easily re-run the same scenario with different numbers (hospitalist only gets 1.5 bumper years, 4% real roi, intensivist makes 500 to hospitalist 330) and determine hospitalist is a terrible financial decision but in the end nobody knows nothing and the only thing you have control over is your savings rate and your work conditions/pay. I think anyone reading at this looking at the money side needs to understand my original post which is that it is impossible to predict. You've completely overestimated the opportunity cost and underestimated the benefit of fellowship but it isn't a slam dunk like it is for henr onc and GI either.

 

[wamcp]

This discussion is tiring but there are huge problems in your math, the biggest being a 10% ROI. It is unlikely we will ever see that in real terms for the next 20 years and is a pie in the sky number, real returns looking like 3-4% possibly less with inflation. No idea where you got 10 but I'd check that source in a hurry because it assumes that past returns are predictive of the future unless you think that the USA is still in the same geopolitical position it was in the 40s when the historical sp500 rate has hit that level.

You also have sequence risk if you do invest up front, if a hospitalist started in 2006 they would have come out super ****ed vs the ccm that comes out in 2009 because of the bear market which can be ignored since it is all random but we have had huge market swings and some people get very lucky.

Your assumption that working 2.0 FTE is the same as being a fellow is also flawed. Every training program is different but I sure as **** wasn't working 2.0 FTE all three years and I doubt the vast majority are.

I could easily re-run the same scenario with different numbers (hospitalist only gets 1.5 bumper years, 4% real roi, intensivist makes 500 to hospitalist 330) and determine hospitalist is a terrible financial decision but in the end nobody knows nothing and the only thing you have control over is your savings rate and your work conditions/pay. I think anyone reading at this looking at the money side needs to understand my original post which is that it is impossible to predict. You've completely overestimated the opportunity cost and underestimated the benefit of fellowship but it isn't a slam dunk like it is for henr onc and GI either.

10% is the average nominal rate of return of the market

2.0 FTE was not used. 288 hospitalist shifts, which is 1.58 FTE, would be the equivalent of what i said (72hr workweek minus 4 weeks vacation).

You can easily run the numbers however you want but i was using MGMA medians to show that for the majority, if one works hard the first 3 years as a hospitalist and both invest/spend similarly, they will likely stay financially ahead of pulmcc due to the massive opportunity costs.

 

[chessknt]

10% is the average nominal rate of return of the market

2.0 FTE was not used. 288 hospitalist shifts, which is 1.58 FTE, would be the equivalent of what i said (72hr workweek minus 4 weeks vacation).

You can easily run the numbers however you want but i was using MGMA medians to show that for the majority, if one works hard the first 3 years as a hospitalist and both invest/spend similarly, they will likely stay financially ahead of pulmcc due to the massive opportunity costs.

You indeed can run the numbers however you want to make it look one way or another. The nominal historical market rate is cute but I accurate to prove your point. The mgma medians in my experience are not the most accurate either based on real numbers I have seen. But by all means I hope everyone stays a hospitalist and doesn't subspecialize, helps with scarcity and keeps those 6k/day ICU locums alive.

 

[Splenda88]

This discussion is tiring but there are huge problems in your math, the biggest being a 10% ROI. It is unlikely we will ever see that in real terms for the next 20 years and is a pie in the sky number, real returns looking like 3-4% possibly less with inflation. No idea where you got 10 but I'd check that source in a hurry because it assumes that past returns are predictive of the future unless you think that the USA is still in the same geopolitical position it was in the 40s when the historical sp500 rate has hit that level.

You also have sequence risk if you do invest up front, if a hospitalist started in 2006 they would have come out super ****ed vs the ccm that comes out in 2009 because of the bear market which can be ignored since it is all random but we have had huge market swings and some people get very lucky.

Your assumption that working 2.0 FTE is the same as being a fellow is also flawed. Every training program is different but I sure as **** wasn't working 2.0 FTE all three years and I doubt the vast majority are.

I could easily re-run the same scenario with different numbers (hospitalist only gets 1.5 bumper years, 4% real roi, intensivist makes 500 to hospitalist 330) and determine hospitalist is a terrible financial decision but in the end nobody knows nothing and the only thing you have control over is your savings rate and your work conditions/pay. I think anyone reading at this looking at the money side needs to understand my original post which is that it is impossible to predict. You've completely overestimated the opportunity cost and underestimated the benefit of fellowship but it isn't a slam dunk like it is for henr onc and GI either.

S&P 500 Average Returns and Historical Performance

See the historical performance of the S&P 500 Index. Learn more about the factors that affect the S&P 500 average return.

www.investopedia.com

 

[collegestud2013]

This discussion is tiring but there are huge problems in your math, the biggest being a 10% ROI. It is unlikely we will ever see that in real terms for the next 20 years and is a pie in the sky number, real returns looking like 3-4% possibly less with inflation. No idea where you got 10 but I'd check that source in a hurry because it assumes that past returns are predictive of the future unless you think that the USA is still in the same geopolitical position it was in the 40s when the historical sp500 rate has hit that level.

You also have sequence risk if you do invest up front, if a hospitalist started in 2006 they would have come out super ****ed vs the ccm that comes out in 2009 because of the bear market which can be ignored since it is all random but we have had huge market swings and some people get very lucky.

Your assumption that working 2.0 FTE is the same as being a fellow is also flawed. Every training program is different but I sure as **** wasn't working 2.0 FTE all three years and I doubt the vast majority are.

I could easily re-run the same scenario with different numbers (hospitalist only gets 1.5 bumper years, 4% real roi, intensivist makes 500 to hospitalist 330) and determine hospitalist is a terrible financial decision but in the end nobody knows nothing and the only thing you have control over is your savings rate and your work conditions/pay. I think anyone reading at this looking at the money side needs to understand my original post which is that it is impossible to predict. You've completely overestimated the opportunity cost and underestimated the benefit of fellowship but it isn't a slam dunk like it is for henr onc and GI either.

10% is the average nominal rate of return of the market

2.0 FTE was not used. 288 hospitalist shifts, which is 1.58 FTE, would be the equivalent of what i said (72hr workweek minus 4 weeks vacation).

You can easily run the numbers however you want but i was using MGMA medians to show that for the majority, if one works hard the first 3 years as a hospitalist and both invest/spend similarly, they will likely stay financially ahead of pulmcc due to the massive opportunity costs.

10% is near the long-term average of the S&P 500, which is not unreasonable assumption for someone with a more aggressive investment strategy who is in it for the long-term gains.

The point here isn't that specialties with high pay but long training time can't beat doing general IM. However they have a much high opportunity cost than meets the eye. It may be easy at first sight to see, without much context, that hospitalist median compensation is $340k, pulm/cc is $450k, and cardiology is $500k, and assume the latter two are doing a lot better off financially. This is the fallacy many med students and even residents fall into when evaluating a specialty's financial beneifts. But once you factor in 3-year late start, the ~40-50% in taxes paid at these income levels, the hours each is working to make those numbers, and lost investment gains for 3 years, the long-term after-tax financial gains are actually a lot more similar between these.

GI and heme/onc I agree do have a good chance of coming out ahead of hospitalist given their relatively high average hourly rate, but even then with extra income being taxed 40-50%, in many cases would require being in a senior partnership position or still working a lot. And would likely still take 10+ years post-residency to hit the break-even point.

 

[chessknt]

I have changed my mind and completely agree, absolutely do not subspecialize. Just do hospitalist--the opportunity cost is 7+ figures and you'll never recover it with guaranteed 10% returns year over year with your 100% stock portfolio that you keep all the way to retirement and no sequence risk. If I knew that I wouldn't have done it either.