Rheum job- academic vs private

[Dr. Gogu]

I am a rheum fellow. I'm on J1 and looking for jobs. I noticed that most jobs available do not support the J1 waiver. There is an opportunity here in the university for a J1 waiver job as an assistant faculty. I would be working with my current attending physicians.

Aside from the lower pay and the more academic nature of the job (which I like), do you think it would be a good idea? Any pitfalls that I may be missing or any potential issues that may happen with the attending physicians?

Do you think a private job would be better and why (other than the higher pay)?

Thanks.

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[bronx43]

Not sure how it is like in your neck of the woods, but unless you've got grant money flowing in, academia is code word for "private practice volume for academic pay."

In other words, they'll use you, spit you out, and expect you to be thankful that they ever put the words "assistant professor" on your ID.

My advice? Get out there and make as money as you can before this whole gravy train crumbles under its own weight. Who knows how much longer it will be...

 

[Dr. Gogu]

When you say, "they'll use you", what do you mean?

 

[bronx43]

When you say, "they'll use you", what do you mean?

What I am saying is that they will pay you under market value for the value you add. Therefore, they're "using you" to their benefit of getting X amount of clinic work for less overhead.
What happens a lot at these academic centers is that they get a bunch of fresh graduates whom they work to death, while paying them chump change. The fresh grads take these jobs because of the "prestige" or whatever BS they're selling these days. And by the time they're about 5 years in, and realize that their bank accounts are anemic and they're doing a similar work load to their wealthier counterparts in private practice, they then pull up their panties and leave. But by then, there's a whole new set of fresh young meat. And so goes the exploitation carousel.

Like I said, make money while you can. Unless there's some special circumstance that ties you to an academic center, I would recommend leaving for a private gig with pay that is based on productivity.

 

[gutonc]

And this is not unique to rheumatology, or IM.

With the more or less complete collapse of research funding in the US, AMCs are now stuck with a bunch of work to do, and not enough grant funded faculty to help move the meet. Hence the rise of the "Clinical Assistant Professor".

Depending on the specialty and location, you will work PP hours for academic pay. Maybe it's worth it for you, in order to keep your visa. But don't pretend that you're being treated as a "colleague".

 

[Dr. Gogu]

Well, what you're saying makes sense. However, in my case, the workload is not as high as in PP. For instance, unless my contract will say something else, all attendings work only half days (8-10 pts). Around 3 of 5 of those half days are covered by fellows.

The contract - I was told, hasn't seen it yet - has 30% hospitalist, but the faculty told me I can "negotiate" that and make it 100% rheum (although I haven't checked if the pay will shrink).

She also stressed that the workload is nothing compared to PP. But what I'm concerned about is what could happen beyond the contract, e.g. extra shifts, extra research work...etc.

 

[drfunktacular]

Unless the salary is like $75k annually, there is no way they are going to pay you to work 3-5 half days per week. They would lose money on you. Maybe those other attendings attend on inpatient services, have research funding, administrative duties, etc. But you will be working at least full time, I assure you.

The only reason I would take a position in academic rheum is if I was dead set on research and had prospects for real funding (I'm not, and I don't). Otherwise, as others have said, you'll just be working like a slave for 50-75% of what you would get paid in private practice. Not to mention the fact that your work life will almost certainly be better in PP than academics, even with a potentially higher workload.

Universities and hospitals don't care about outpatient rheumatology because it makes them no money. If you're a busy cardiologist doing hundreds of caths every year along with stress tests and other ancillary testing, you make the hospital tons of money so they treat you well. Outpatient specialties like rheum, endo, etc are a necessary evil at best, and the hospital/AMC would prefer to not have to deal with you at all and replace your clinic space with another endoscopy suite. They will treat you accordingly

 

[bronx43]

Well, what you're saying makes sense. However, in my case, the workload is not as high as in PP. For instance, unless my contract will say something else, all attendings work only half days (8-10 pts). Around 3 of 5 of those half days are covered by fellows.

The contract - I was told, hasn't seen it yet - has 30% hospitalist, but the faculty told me I can "negotiate" that and make it 100% rheum (although I haven't checked if the pay will shrink).

She also stressed that the workload is nothing compared to PP. But what I'm concerned about is what could happen beyond the contract, e.g. extra shifts, extra research work...etc.

30% hospitalist? So, we're not really talking about true "academia" here, are we?

I mean, if they are honestly going to pay you respectable money for easy work, then go for it. How much is the base if you don't mind my asking?

 

[Dr. Gogu]

30% hospitalist? So, we're not really talking about true "academia" here, are we?

I mean, if they are honestly going to pay you respectable money for easy work, then go for it. How much is the base if you don't mind my asking?

$170k.

 

[gutonc]

Universities and hospitals don't care about outpatient rheumatology because it makes them no money.

So, I don't have a dog in this fight, nor am I interested in arguing with you, but I do happen to have "inside information" from 1 AMC and 1 community hospital system that directly contradicts this assertion.

At the AMC, outside of the Surgery dept (which encompasses all surgical sub-specialties), Hem-Onc and Cards trade the #1 and 2 spots from year to year for revenue...and Rheum is 3rd. GI is 4th, but it's not even close.

For the community system, which doesn't employ cards, hem/onc or rheum but does get the facility portion of all of their billing, it's Hem/Onc, Rheum and Cards in that order.

Set it up right and you can make a killing on Remicade infusions.

 

[bronx43]

So, I don't have a dog in this fight, nor am I interested in arguing with you, but I do happen to have "inside information" from 1 AMC and 1 community hospital system that directly contradicts this assertion.

At the AMC, outside of the Surgery dept (which encompasses all surgical sub-specialties), Hem-Onc and Cards trade the #1 and 2 spots from year to year for revenue...and Rheum is 3rd. GI is 4th, but it's not even close.

For the community system, which doesn't employ cards, hem/onc or rheum but does get the facility portion of all of their billing, it's Hem/Onc, Rheum and Cards in that order.

Set it up right and you can make a killing on Remicade infusions.

I second this. Our division is second in terms of profit after heme onc, despite the fact that we are easily the smallest division. Any rheumatology division that runs their own infusion center will be very profitable. The rheumatology divisions that don't run their own infusion suite are likely a money loser for their respective departments.

With that said, I do agree with funk that you will not be treated like a colleague, though it's not because of the field. It would be because you arent one of the prized researchers who brings NIH dollars to the institution.

 

[drfunktacular]

I second this. Our division is second in terms of profit after heme onc, despite the fact that we are easily the smallest division. Any rheumatology division that runs their own infusion center will be very profitable. The rheumatology divisions that don't run their own infusion suite are likely a money loser for their respective departments.

With that said, I do agree with funk that you will not be treated like a colleague, though it's not because of the field. It would be because you arent one of the prized researchers who brings NIH dollars to the institution.

Obviously you know your institution better than me but I find it unlikely that your division is second in terms of *profit*. If that were true why are they paying cardiologists 2-3x what they pay you?

I would not be surprised if it were second in gross *revenue* because of medication spending, but of course most of that is passed straight through to McKesson and drug companies

If you look at the Medicare spending data that was released a few years back you'll see that in most markets the rheumatologists are near the top of the spending ladder. But that is entirely inflated by drug costs. For example I personally bill out around $2 million annually in medications administered in office. But I actually keep about 1.5% of that and the rest of it goes straight to Janssen or Genentech

 

[bronx43]

Obviously you know your institution better than me but I find it unlikely that your division is second in terms of *profit*. If that were true why are they paying cardiologists 2-3x what they pay you?

I would not be surprised if it were second in gross *revenue* because of medication spending, but of course most of that is passed straight through to McKesson and drug companies

If you look at the Medicare spending data that was released a few years back you'll see that in most markets the rheumatologists are near the top of the spending ladder. But that is entirely inflated by drug costs. For example I personally bill out around $2 million annually in medications administered in office. But I actually keep about 1.5% of that and the rest of it goes straight to Janssen or Genentech

We are not top in revenue, but profit. The reason why cardiologists are paid much higher has nothing to do with division profit, but everything to do with the way most academic institutions pay their physicians. There's a very strict guideline for physician salaries, and everything is calculated with a percentile based on how other academic centers pay your specialty. And academia, as a whole, pay a certain % of MGMA. So since cardiologists in general make more, they get paid more in academia as well.
In fact, our cardiology division is a money LOSER because of the higher salaries for their faculty without high enough clinical volume. The only reason the administrators put up with this is that they can't afford to lose too many faculty in fear of compromising volume for the heart hospital.

Compare that to my division where our faculty makes peanuts, but our infusion center brings in good revenue by virtue of being the only game in town for non-oncologic infusions.

Profit = Revenue - Cost. Our cost is low, so our profit is high. It's unfortunate for our faculty, but that's the way it is.

On the other hand, do our faculty get treated well? Not unless they bring in funding and publish a lot, which brings me back to my original point...

 

[drk310]

Obviously you know your institution better than me but I find it unlikely that your division is second in terms of *profit*. If that were true why are they paying cardiologists 2-3x what they pay you?

I would not be surprised if it were second in gross *revenue* because of medication spending, but of course most of that is passed straight through to McKesson and drug companies

If you look at the Medicare spending data that was released a few years back you'll see that in most markets the rheumatologists are near the top of the spending ladder. But that is entirely inflated by drug costs. For example I personally bill out around $2 million annually in medications administered in office. But I actually keep about 1.5% of that and the rest of it goes straight to Janssen or Genentech

1.5% is awfully low. Are bigger physician groups and institutions really profitable because of sheer volume, or are their margins better for some reason? I was thinking about opening a solo practice in my hometown which is a rural area, but in order to offer patients infusions, it seems like it may not be cost effective if I want to stay afloat.

 

[bronx43]

1.5% is awfully low. Are bigger physician groups and institutions really profitable because of sheer volume, or are their margins better for some reason? I was thinking about opening a solo practice in my hometown which is a rural area, but in order to offer patients infusions, it seems like it may not be cost effective if I want to stay afloat.

If you're gonna open a rural practice, I wouldn't recommend starting an infusion center. You really need heavy volume in order to make an infusion center viable.
But, successful infusion centers can make bank. Our division owns our own infusion suite (10 chairs) where we get referrals from our own rheumatologists, GI and other miscellaneous fields. I believe our profit margins are around $3 mil a year.

 

[Rheum2019]

p

 

[PlutoBoy]

Well, what you're saying makes sense. However, in my case, the workload is not as high as in PP. For instance, unless my contract will say something else, all attendings work only half days (8-10 pts). Around 3 of 5 of those half days are covered by fellows.

The contract - I was told, hasn't seen it yet - has 30% hospitalist, but the faculty told me I can "negotiate" that and make it 100% rheum (although I haven't checked if the pay will shrink).

She also stressed that the workload is nothing compared to PP. But what I'm concerned about is what could happen beyond the contract, e.g. extra shifts, extra research work...etc.

30% hospitalist after completing your fellowship? Run away!