Rheumatology fellowship: Help needed; future outlook

[Rheumie101]

Hi. I’m a current PGY-3 in IM and I am actively interviewing for Rheumatology fellowship as I type this. Interview season has been great and I’ve interviewed at ~20 programs so matching seems likely at this point.

I got into rheumatology because I value lifestyle and have always dreamed of owning my practice and being in charge. I find the subject interesting enough and I’m not concerned about that. I was under the assumption that out the gate rheum fellows can reach close to 350ish (this would include base + bonus + wRVU) and then with time you become partner/own and it goes up. For reference, I will most likely be in an Ohio metro/suburb due to spouses’ work restrictions. I have received discouragement in this regard from fellows who are looking right now. They say I’m some $100000 expecting higher than what I’ll get. The only reason I’m questioning it is because those who I spoke to sort of went into rheum for the 9-5 M-Th lifestyle, zero hustle. I’m not like that and I want to take it seriously. If I have to bust for the first 5 years and work 6 days/60 hours that’s fine by me but I don’t want to regret it financially.

I’m posting on this group and honestly am in dire need of some guidance. Other option is hospitalist (which I don’t hate. I think I can do but would much rather go ahead with the match since I’ve worked hard to reach to this stage and interview at good places). I will highly appreciate your help and response.

---

Members don't see this ad.

 

[danchiao]

Mgma data shows average around 270k This is usually 3-5 years of establish practice. Don’t try to beat the median

 

[mszzeta]

Hi. I’m a current PGY-3 in IM and I am actively interviewing for Rheumatology fellowship as I type this. Interview season has been great and I’ve interviewed at ~20 programs so matching seems likely at this point.

I got into rheumatology because I value lifestyle and have always dreamed of owning my practice and being in charge. I find the subject interesting enough and I’m not concerned about that. I was under the assumption that out the gate rheum fellows can reach close to 350ish (this would include base + bonus + wRVU) and then with time you become partner/own and it goes up. For reference, I will most likely be in an Ohio metro/suburb due to spouses’ work restrictions. I have received discouragement in this regard from fellows who are looking right now. They say I’m some $100000 expecting higher than what I’ll get. The only reason I’m questioning it is because those who I spoke to sort of went into rheum for the 9-5 M-Th lifestyle, zero hustle. I’m not like that and I want to take it seriously. If I have to bust for the first 5 years and work 6 days/60 hours that’s fine by me but I don’t want to regret it financially.

I’m posting on this group and honestly am in dire need of some guidance. Other option is hospitalist (which I don’t hate. I think I can do but would much rather go ahead with the match since I’ve worked hard to reach to this stage and interview at good places). I will highly appreciate your help and response.

In my interviews, my highest offer is 280K base in a major metropolitan city. However, they have a very high patient census (a rheumatologist just left) and need to see 25-30 pts each day (and a good proportion will be Spanish speaking...)

Ohio should have higher salary per workload.

 

[BorntobeDO?]

I have heard rhuem has cooled off again from where it was like 5 years ago. Less infusions now than prior. Doesnt matter to me, cant do fibro style msk stuff anymore. If I could deal with that I might as well stay in IM.

 

[dozitgetchahi]

Hi. I’m a current PGY-3 in IM and I am actively interviewing for Rheumatology fellowship as I type this. Interview season has been great and I’ve interviewed at ~20 programs so matching seems likely at this point.

I got into rheumatology because I value lifestyle and have always dreamed of owning my practice and being in charge. I find the subject interesting enough and I’m not concerned about that. I was under the assumption that out the gate rheum fellows can reach close to 350ish (this would include base + bonus + wRVU) and then with time you become partner/own and it goes up. For reference, I will most likely be in an Ohio metro/suburb due to spouses’ work restrictions. I have received discouragement in this regard from fellows who are looking right now. They say I’m some $100000 expecting higher than what I’ll get. The only reason I’m questioning it is because those who I spoke to sort of went into rheum for the 9-5 M-Th lifestyle, zero hustle. I’m not like that and I want to take it seriously. If I have to bust for the first 5 years and work 6 days/60 hours that’s fine by me but I don’t want to regret it financially.

I’m posting on this group and honestly am in dire need of some guidance. Other option is hospitalist (which I don’t hate. I think I can do but would much rather go ahead with the match since I’ve worked hard to reach to this stage and interview at good places). I will highly appreciate your help and response.

Some “hot take” points:

1) It’s totally possible to start in rheumatology private practice in the $300-325k range, and you may do better with partnership as you get your ancellaries and such. The better money is in private practice (with ancellaries) in an area with a strong payor mix. Think $350-400k at least, with some docs still pulling $600k+ with infusions. (To make the best money, you generally also need to go to less desirable areas - but you can still do very well near urban areas too.) Hospital rheumatology jobs are IMHO somewhat of a ripoff as you don’t get any cut of the ample ancellaries you make as a rheumatologist. Out of the 3 jobs I’ve had so far, my lowest pay was at a hospital system (starting pay at health system: $250k. @ private practice #1: $300k. @ private practice #2: $325k).

2) You can absolutely hustle in rheumatology. If you want to do 5 days of outpatient clinic a week, you can absolutely do that. I know people doing 5.5 days, and most jobs aren’t going to stop you if you really want to do 6 days. However, lifestyle is very important too and as you proceed longer in this medical life, you will want more time off and more control over your schedule. Working six days a week doesn’t sound so bad when you’re a resident…but trust me, that lifestyle actually blows and you won’t want to do that for a lifetime. You will burn out and be miserable. (I can tell you that I was much happier as a rheumatologist working 4.5 days a week vs a full 5. That half day of admin time makes a huge difference in quality of life, and not needing to take work home with you.) You want a specialty that can accommodate actual work life balance, and rheumatology is that.

3) Rheumatology is still “red hot”. I’m still getting called by recruiters every single day. There are lots of rheum jobs available in lots of places, and as far as I can tell the income is going up too. Many rheumatology jobs I encountered during my last job search are still open now. There is a paucity of available rheumatologists - many are retiring (average rheumatologist age right now is something like 55 iirc), many new rheumatology trainees are working part time, and the number of rheumatology training seats hasn’t changed much in several decades. Amidst all this, demand for rheums is rising sharply with the aging boomer population. From a business/financial standpoint I don’t regret doing the rheumatology fellowship at all. It’s good to be in demand.

 

[bronx43]

Some “hot take” points:

1) It’s totally possible to start in rheumatology private practice in the $300-325k range, and you may do better with partnership as you get your ancellaries and such. The better money is in private practice (with ancellaries) in an area with a strong payor mix. Think $350-400k at least, with some docs still pulling $600k+ with infusions. (To make the best money, you generally also need to go to less desirable areas - but you can still do very well near urban areas too.) Hospital rheumatology jobs are IMHO somewhat of a ripoff as you don’t get any cut of the ample ancellaries you make as a rheumatologist. Out of the 3 jobs I’ve had so far, my lowest pay was at a hospital system (starting pay at health system: $250k. @ private practice #1: $300k. @ private practice #2: $325k).

2) You can absolutely hustle in rheumatology. If you want to do 5 days of outpatient clinic a week, you can absolutely do that. I know people doing 5.5 days, and most jobs aren’t going to stop you if you really want to do 6 days. However, lifestyle is very important too and as you proceed longer in this medical life, you will want more time off and more control over your schedule. Working six days a week doesn’t sound so bad when you’re a resident…but trust me, that lifestyle actually blows and you won’t want to do that for a lifetime. You will burn out and be miserable. (I can tell you that I was much happier as a rheumatologist working 4.5 days a week vs a full 5. That half day of admin time makes a huge difference in quality of life, and not needing to take work home with you.) You want a specialty that can accommodate actual work life balance, and rheumatology is that.

3) Rheumatology is still “red hot”. I’m still getting called by recruiters every single day. There are lots of rheum jobs available in lots of places, and as far as I can tell the income is going up too. Many rheumatology jobs I encountered during my last job search are still open now. There is a paucity of available rheumatologists - many are retiring (average rheumatologist age right now is something like 55 iirc), many new rheumatology trainees are working part time, and the number of rheumatology training seats hasn’t changed much in several decades. Amidst all this, demand for rheums is rising sharply with the aging boomer population. From a business/financial standpoint I don’t regret doing the rheumatology fellowship at all. It’s good to be in demand.

I guess YMMV, but my experience has NOT been as rosy with respect to private practice.
Ancillaries are generally overrated unless you own an MRI machine and are very aggressive with ordering them. The capital expenditure for purchase and maintenance on those things is so high that it ends up pushing your overhead into illogical territories. 50%+ total overhead is a deal breaker for me.
Infusion profits are down big. The only two that make any sort of financial sense is Cimzia and Orencia. The other ones are barely profitable (if break even).

My current hospital employment gig is much much better than my private practice experience. My hospital based income is easily 2x that of the PP (though alot of that also comes from other factors). Hospitals in high demand/low physician recruitment areas pay a good amount per RVU, and it ends up being more than what you can collect from a private clinic situation in terms of E&M plus ancillaries.

 

[dozitgetchahi]

I guess YMMV, but my experience has NOT been as rosy with respect to private practice.
Ancillaries are generally overrated unless you own an MRI machine and are very aggressive with ordering them. The capital expenditure for purchase and maintenance on those things is so high that it ends up pushing your overhead into illogical territories. 50%+ total overhead is a deal breaker for me.
Infusion profits are down big. The only two that make any sort of financial sense is Cimzia and Orencia. The other ones are barely profitable (if break even).

My current hospital employment gig is much much better than my private practice experience. My hospital based income is easily 2x that of the PP (though alot of that also comes from other factors). Hospitals in high demand/low physician recruitment areas pay a good amount per RVU, and it ends up being more than what you can collect from a private clinic situation in terms of E&M plus ancillaries.

As I think I’ve said before, I think a lot of private practice “success” in the current political (and reimbursement) climate boils down to 1) the size of the practice 2) the business acumen of the partners 3) the priorities of the partnership, and how good they are at cost containment among other things. I agree that small single specialty practices are generally going to have a rough time. I think the sweet spot is larger multispecialty groups that have enough purchasing power (and partners) to divide at least some of the overhead costs more reasonably, and have the patient volume to achieve reasonable economies of scale. There are many larger multispecialty groups out there that have MRIs and many other types of profitable ancellaries where you can indeed make significant $$$ off them.

However, even there it all boils down to how business-minded the leadership is. I’ve interviewed with large private practices that just didn’t seem to understand how to contain costs, and also just couldn’t figure out how to make money. I’ve also seen private practices that had mastered this, and had a large number of partners doing very well for themselves. (I think a lot of it also comes down to how the partners are sharing profits; some partnerships are basically structured to siphon as much revenue off newcomers as possible so as to enrich greedy “old timers” at the top.) Working in areas where real estate is extremely expensive also significantly hampers profitability; it’s harder to make money if you have to pay $$$$$ to buy or rent your office space. Etc etc. I agree that some PP deals are awful (I certainly saw a few that were) but I’ve also seen several that were very lucrative, including the new contract I just signed.

 

[bronx43]

As I think I’ve said before, I think a lot of private practice “success” in the current political (and reimbursement) climate boils down to 1) the size of the practice 2) the business acumen of the partners 3) the priorities of the partnership, and how good they are at cost containment among other things. I agree that small single specialty practices are generally going to have a rough time. I think the sweet spot is larger multispecialty groups that have enough purchasing power (and partners) to divide at least some of the overhead costs more reasonably, and have the patient volume to achieve reasonable economies of scale. There are many larger multispecialty groups out there that have MRIs and many other types of profitable ancellaries where you can indeed make significant $$$ off them.

However, even there it all boils down to how business-minded the leadership is. I’ve interviewed with large private practices that just didn’t seem to understand how to contain costs, and also just couldn’t figure out how to make money. I’ve also seen private practices that had mastered this, and had a large number of partners doing very well for themselves. (I think a lot of it also comes down to how the partners are sharing profits; some partnerships are basically structured to siphon as much revenue off newcomers as possible so as to enrich greedy “old timers” at the top.) Working in areas where real estate is extremely expensive also significantly hampers profitability; it’s harder to make money if you have to pay $$$$$ to buy or rent your office space. Etc etc. I agree that some PP deals are awful (I certainly saw a few that were) but I’ve also seen several that were very lucrative, including the new contract I just signed.

Have you calculated your total comp per wRVU? Do you guys have a MRI?
I believe you said before that your group over head is around 40%.
My previous PP was around 50-55% total (including rent), and my comp per wRVU with semi-aggressive ancillaries was barely $50. That's on the low end of compensation for that particular locale.

 

[dozitgetchahi]

Have you calculated your total comp per wRVU? Do you guys have a MRI?
I believe you said before that your group over head is around 40%.
My previous PP was around 50-55% total (including rent), and my comp per wRVU with semi-aggressive ancillaries was barely $50. That's on the low end of compensation for that particular locale.

Both large multispecialty PP institutions I have worked for have MRI machines, as well as a full spectrum of imaging (DXA, US, XR, CT and PET/CT), and other ancellaries such as PT. In fact, the most lucrative ancillary my current practice owns is a parking garage (no joke!) - each partner is making a significant amount of money each month off parking garage proceeds, which (believe it or not) can be very substantial in an urban area where parking is scarce.

As far as my actual compensation goes, my *base* salary at each of my PP jobs ($300k at job 1, $325k at job 2) was higher than I ever earned on a wRVU system at my old hospital job (~$275k at best once I went on production after the income guarantee expired, and I was absolutely busting my ass for that $275k - 5 full days a week with admin trying to stuff 25 patients per day on the schedule - vs 4.5 days a week and 18-20 patients per day in PP). My experience is that I’ve been paid and treated much better in PP vs a hospital system. In my experience, it would be quite difficult to make even $325k as a rheumatologist on production on pretty much any hospital wRVU system I’ve ever encountered while interviewing. They’re mostly gauged to cut you off on no more than $290-300k at most, and that’s again with a level of production that will make you put your nose to the grindstone.

 

[bronx43]

Both large multispecialty PP institutions I have worked for have MRI machines, as well as a full spectrum of imaging (DXA, US, XR, CT and PET/CT), and other ancellaries such as PT. In fact, the most lucrative ancillary my current practice owns is a parking garage (no joke!) - each partner is making a significant amount of money each month off parking garage proceeds, which (believe it or not) can be very substantial in an urban area where parking is scarce.

As far as my actual compensation goes, my *base* salary at each of my PP jobs ($300k at job 1, $325k at job 2) was higher than I ever earned on a wRVU system at my old hospital job (~$275k at best once I went on production after the income guarantee expired, and I was absolutely busting my ass for that $275k - 5 full days a week with admin trying to stuff 25 patients per day on the schedule - vs 4.5 days a week and 18-20 patients per day in PP). My experience is that I’ve been paid and treated much better in PP vs a hospital system. In my experience, it would be quite difficult to make even $325k as a rheumatologist on production on pretty much any hospital wRVU system I’ve ever encountered while interviewing. They’re mostly gauged to cut you off on no more than $290-300k at most, and that’s again with a level of production that will make you put your nose to the grindstone.

Wait, 275k for 5 days a week at 25 pts/day? Did they not pay you after you hit your productivity goal? At 5 days a week 25 patients a day, that's easily 9000+ RVUs. Even if your schedule wasn't full and you end up seeing 20/day, that's still easily 8000. Assuming your comp/rvu is at the lower end scale at 50, that's still 400k minimum.
If that's the deal you were getting, then I can certainly see why you left hospital employment. My comp model is straight RVU productivity. At 8000 RVU, it's more or less guaranteed 500k.

 

[Zika]

Hi. I’m a current PGY-3 in IM and I am actively interviewing for Rheumatology fellowship as I type this. Interview season has been great and I’ve interviewed at ~20 programs so matching seems likely at this point.

I got into rheumatology because I value lifestyle and have always dreamed of owning my practice and being in charge. I find the subject interesting enough and I’m not concerned about that. I was under the assumption that out the gate rheum fellows can reach close to 350ish (this would include base + bonus + wRVU) and then with time you become partner/own and it goes up. For reference, I will most likely be in an Ohio metro/suburb due to spouses’ work restrictions. I have received discouragement in this regard from fellows who are looking right now. They say I’m some $100000 expecting higher than what I’ll get. The only reason I’m questioning it is because those who I spoke to sort of went into rheum for the 9-5 M-Th lifestyle, zero hustle. I’m not like that and I want to take it seriously. If I have to bust for the first 5 years and work 6 days/60 hours that’s fine by me but I don’t want to regret it financially.

I’m posting on this group and honestly am in dire need of some guidance. Other option is hospitalist (which I don’t hate. I think I can do but would much rather go ahead with the match since I’ve worked hard to reach to this stage and interview at good places). I will highly appreciate your help and response.

I am currently interviewing for rheum jobs and do not believe you can hit 350k+ just right off fellowship even if you go to a very successful PP, let alone starting your own practice which is much more loss than benefit in the beginning. it also depends on the geographic location and proximity to large cities. You may get those kind of salaries in Montana or Alaska or South, I don't know.
As to my experience interviewing with hospitals and PP on east coast, you will be lucky to find a 300k base salary possibly in the middle of no where in Pennsylvania.
Academia or better put Fakedemia is 200-210k.
Average hospital employed salary is 250k.
PP is variable and my experience is limited to east coast and not all of it, but they will pay the least amount possible to you especially starting off of fellowship, because they consider you will not make much in your first couple years, and will be a loss for them. And you need to be very smart as to which PP you want to end up in, as many of them, are not the best models to practice medicine.

 

[dozitgetchahi]

Wait, 275k for 5 days a week at 25 pts/day? Did they not pay you after you hit your productivity goal? At 5 days a week 25 patients a day, that's easily 9000+ RVUs. Even if your schedule wasn't full and you end up seeing 20/day, that's still easily 8000. Assuming your comp/rvu is at the lower end scale at 50, that's still 400k minimum.
If that's the deal you were getting, then I can certainly see why you left hospital employment. My comp model is straight RVU productivity. At 8000 RVU, it's more or less guaranteed 500k.

Yeah. There were a lot of issues surrounding compensation at that hospital job - I hardly ever saw RVU or other compensation numbers there despite asking for them. (Comp/RVU also sucked, at 46.) Now, I know I was getting ripped off. Then…it was my first job, and I was naive and also didn’t know exactly what to ask for or how to suss out if I was getting what I was due - and the hospital tried hard to cover for vastly underpaying me. I was also treated very poorly by management in a variety of other ways there too. They tried hard to squeeze every drop of productivity out of me they possibly could while not paying for it - and made me deal with some very hostile, gaslighting managers in the process. Let’s just say that the whole thing has left such a bad taste in my mouth that I doubt I will ever revisit hospital employment again in my career.

 

[bronx43]

Yeah. There were a lot of issues surrounding compensation at that hospital job - I hardly ever saw RVU or other compensation numbers there despite asking for them. Now, I know I was getting ripped off. Then…it was my first job, and I was naive and also didn’t know exactly what to ask for or how to suss out if I was getting what I was due - the hospital tried hard to cover for vastly underpaying me. I was also treated very poorly by management in a variety of other ways there too. They tried hard to squeeze every drop of productivity out of me they possibly could while not paying for it - and made me deal with some very hostile, gaslighting managers in the process. Let’s just say that the whole thing has left such a bad taste in my mouth that I doubt I will ever revisit hospital employment again in my career.

Sorry to hear that man. I felt the same way with my fakedemic job and now am much much happier with my community hospital employer. I get paid fairly and they track and pay for every rvu I make.
I didn’t care for my physician owned group since my partner hoarded all the high paying infusion patients while I got stuck with making half the amount doing double the work cranking out 99204s. The overhead was also far too high for me.

 

[dozitgetchahi]

I am currently interviewing for rheum jobs and do not believe you can hit 350k+ just right off fellowship even if you go to a very successful PP, let alone starting your own practice which is much more loss than benefit in the beginning. it also depends on the geographic location and proximity to large cities. You may get those kind of salaries in Montana or Alaska or South, I don't know.
As to my experience interviewing with hospitals and PP on east coast, you will be lucky to find a 300k base salary possibly in the middle of no where in Pennsylvania.
Academia or better put Fakedemia is 200-210k.
Average hospital employed salary is 250k.
PP is variable and my experience is limited to east coast and not all of it, but they will pay the least amount possible to you especially starting off of fellowship, because they consider you will not make much in your first couple years, and will be a loss for them. And you need to be very smart as to which PP you want to end up in, as many of them, are not the best models to practice medicine.

So this reminds me of a lot of conversations I’ve had with residents, rheumatology fellows, and even other rheumatologists over the years regarding rheum income:

Them: Rheumatology sucks! We make crap! I’m looking at academic rheum jobs that pay like $150k! There’s no good jobs anywhere!

Me: Ok so for starters, academia sucks. You want at least community hospital practice, if not PP. Here’s a PP job in rural Alabama that starts at $300k, with big income potential. Here’s another PP job in rural Indiana that starts at $325k. And here’s one in Louisiana that starts at $330k.

Them: Wait, rural Indiana? Alabama? Louisiana? I don’t wanna live in those places!

Me: …

Point is, the good jobs exist. You just have to be willing to go to where the money is, which won’t be near the coasts or big cities. The flip side is that you stay in the big cities, where doctors congregate in oversaturated medical markets - and get paid and treated like garbage. There’s no incentive for these urban institutions to treat you well when they know they have 10 other chump doctors lined up behind you to take a crappy deal just because it’s located in DC, or NYC, or LA, or whatever. Outside the big cities and coasts, you’ll get paid better and these institutions will actually go out of their way to treat you well because they know if they lose you it’s not going to be easy to find the next one.

 

[Rheumie101]

So to update: I did end up matching at my #1 choice at a big academic power house in southern Ohio. Hooray.

I know it's early but never too early to get a feel for the market and plan accordingly. How do you guys see the market currently for new jobs right after grad. For me academic is not even an option at this point because of the general low ball offers/no interest either. Would be okay with any other setting including community hospital/multispecialty PP/single specialty PP. Not looking to go solo so early on in my career. Wanna gain some experience first. @dozitgetchahi and @bronx43 you 2 seem to be the most active posters related to Rheumatology in general. @bronx43 I have seen from some of your posts that straight RVU's and with a decent wRVU comp can get to 400-450 type numbers if one is seeing around 20-22 patients daily, 4.5 days a week, close to 200 days a year. Am I understanding these numbers correctly? I ultimately want to be private but the starting salaries in those are ofcourse lower and I have loans and a young family to support so want to start off a bit higher if that makes sense. Any tips for during fellowship to get myself ready for real world practice? I understand volume will regardless always help (even if other streams slow down) so any tips to improve that during fellowship?

Thanks for all the information these past few months. Been very helpful for me.

 

[bronx43]

So to update: I did end up matching at my #1 choice at a big academic power house in southern Ohio. Hooray.

I know it's early but never too early to get a feel for the market and plan accordingly. How do you guys see the market currently for new jobs right after grad. For me academic is not even an option at this point because of the general low ball offers/no interest either. Would be okay with any other setting including community hospital/multispecialty PP/single specialty PP. Not looking to go solo so early on in my career. Wanna gain some experience first. @dozitgetchahi and @bronx43 you 2 seem to be the most active posters related to Rheumatology in general. @bronx43 I have seen from some of your posts that straight RVU's and with a decent wRVU comp can get to 400-450 type numbers if one is seeing around 20-22 patients daily, 4.5 days a week, close to 200 days a year. Am I understanding these numbers correctly? I ultimately want to be private but the starting salaries in those are ofcourse lower and I have loans and a young family to support so want to start off a bit higher if that makes sense. Any tips for during fellowship to get myself ready for real world practice? I understand volume will regardless always help (even if other streams slow down) so any tips to improve that during fellowship?

Thanks for all the information these past few months. Been very helpful for me.

Those numbers are correct but keep in mind that if you and your young family want to live in a nice area with the normal amenities you likely have grown accustom to, those numbers are difficult to do. If you want those numbers in a large metro area (like the one you matched at), you’ll basically need to practice like a pain doc. You’ll have to hustle to try to get referrals from anyone you can and deal with all msk issues, chronic pain, neuropathy, fatigue. Even then it’ll be hard since the market for msk is hyper saturated.

Fellows typically have a false sense of the prevalence of real rheumatic diseases until
They get out into the real world and realize that it’s hard to accumulate a bunch of RA patients. So if you want the productivity it’ll have to come from elsewhere. And it may even take a bit of leg work to fill up at all. 20-22 pts a day isn’t something that just comes to you, especially these days when everyone has high out of pocket costs of healthcare. Even pain patients stop coming when they realize you’re peddling the same old gabapentin and duloxetine that their pcps, pain docs, sports med docs pushed on them for the past 10 years. They’ll certainly come back for controlled substances.

 

[Rheumie101]

Those numbers are correct but keep in mind that if you and your young family want to live in a nice area with the normal amenities you likely have grown accustom to, those numbers are difficult to do. If you want those numbers in a large metro area (like the one you matched at), you’ll basically need to practice like a pain doc. You’ll have to hustle to try to get referrals from anyone you can and deal with all msk issues, chronic pain, neuropathy, fatigue. Even then it’ll be hard since the market for msk is hyper saturated.

Fellows typically have a false sense of the prevalence of real rheumatic diseases until
They get out into the real world and realize that it’s hard to accumulate a bunch of RA patients. So if you want the productivity it’ll have to come from elsewhere. And it may even take a bit of leg work to fill up at all. 20-22 pts a day isn’t something that just comes to you, especially these days when everyone has high out of pocket costs of healthcare. Even pain patients stop coming when they realize you’re peddling the same old gabapentin and duloxetine that their pcps, pain docs, sports med docs pushed on them for the past 10 years. They’ll certainly come back for controlled substances.

Hmm interesting take.. I think these are somethings which I already knew prior to deciding on Rheumatology. I believe I got a good mix of attendings during my residency and that gave me perspective. I rotated with an ACR SLE "master", whose focus is research and sees very few patients and then also with an attending who strictly sees patients; 26-30/day, does a bunch of injections, works 5 days a week and goes home at 5pm every day. Says he makes 600-650 year in year out. Provided that yes he's not super selective with his patient population but is also not running a pill mill. Probably wanna gain more inspiration from the latter. This is at an academic facility in the Northeast.

The part that I have come to terms with is that infusions don't make the same money they did previously and that it may keep decreasing over time. The part where you say that it's difficult to build a patient panel.. I don't know if I quite agree with that since every rheumatologist I speak to says they don't have enough time OR help to cater to all the referrals. Again... I definitely respect your opinion since you're practicing already but are you sure your perspective is not heavily skewed since you don't enjoy your patient population and not necessarily related to the job itself?

 

[Rheumie101]

So if you want the productivity it’ll have to come from elsewhere

What would these be?

 

[bronx43]

Hmm interesting take.. I think these are somethings which I already knew prior to deciding on Rheumatology. I believe I got a good mix of attendings during my residency and that gave me perspective. I rotated with an ACR SLE "master", whose focus is research and sees very few patients and then also with an attending who strictly sees patients; 26-30/day, does a bunch of injections, works 5 days a week and goes home at 5pm every day. Says he makes 600-650 year in year out. Provided that yes he's not super selective with his patient population but is also not running a pill mill. Probably wanna gain more inspiration from the latter. This is at an academic facility in the Northeast.

The part that I have come to terms with is that infusions don't make the same money they did previously and that it may keep decreasing over time. The part where you say that it's difficult to build a patient panel.. I don't know if I quite agree with that since every rheumatologist I speak to says they don't have enough time OR help to cater to all the referrals. Again... I definitely respect your opinion since you're practicing already but are you sure your perspective is not heavily skewed since you don't enjoy your patient population and not necessarily related to the job itself?

Out of my colleagues and friends who are younger rheumatologists, no one is consistently seeing 20/day. I am probably the highest at 18 per day on average. I wouldn’t say it’s impossible to see 20/day but in a big city it’ll take you 3-5 years to build up to anything close to that. And most of it won’t be real rheumatic diseases.
So I guess the difficult part is more about getting the panel that you want. An injection heavy practice is harder and harder to do. I’m sure older docs already carved out their niche but it’s not something that you can arrive on day 1 and have a healthy panel of injections and msk.

But like I said before, most of this applies to major metros. Rural areas are usually underserved and you can do whatever you want.

Ultimately I guess ymmv. Some of my friends like rheum. Others tolerate it for the hours. Some hate it as much as me. It is what it is, and ultimately I can’t complain too much given the easy hours.

 

[Renal_Prometheus]

The part where you say that it's difficult to build a patient panel.. I don't know if I quite agree with that since every rheumatologist I speak to says they don't have enough time OR help to cater to all the referrals.

I'm not rheum. But I've had similar experiences as a neph fellow where nephrologist in academia(an some in private practice) seem super happy and content with their jobs. Once I got into the real world I realized private practice nephrology really is as horrible as they say it is. My point is, what you see as a resident/fellow is completely divorced from reality and the real world is much more brutal. In any case, rheum lifestyle is really good and worth going into for that alone; just don't be disappointed, like bronx43 has mentioned, that the financial rewards is not as high as expected.

 

[Rheumie101]

most of this applies to major metros. Rural areas are usually underserved and you can do whatever you want

I really want to understand since this sentence is used a lot (in any field). Are people usually referring to the LA, Chicago, NYCs or like the top 20-top 30 metros by population?

 

[Rheumie101]

just don't be disappointed the financial rewards is as high as expected

Haha trying not to settle for this so early when fellowship hasn't even started for me. But yes I do enjoy the pathology, lifestyle and the aspect of loads and loads of counseling/pain expectations that come with MSK fields. Surprisingly it does not bother me. Let's see if that changes in the future, hopefully not!

 

[bronx43]

I really want to understand since this sentence is used a lot (in any field). Are people usually referring to the LA, Chicago, NYCs or like the top 20-top 30 metros by population?

No, I mean most metros with population 2M or more. In you stay in the area that you train as a fellow (which you said is southern ohio academic center) then that qualifies.

 

[dozitgetchahi]

Hmm interesting take.. I think these are somethings which I already knew prior to deciding on Rheumatology. I believe I got a good mix of attendings during my residency and that gave me perspective. I rotated with an ACR SLE "master", whose focus is research and sees very few patients and then also with an attending who strictly sees patients; 26-30/day, does a bunch of injections, works 5 days a week and goes home at 5pm every day. Says he makes 600-650 year in year out. Provided that yes he's not super selective with his patient population but is also not running a pill mill. Probably wanna gain more inspiration from the latter. This is at an academic facility in the Northeast.

The part that I have come to terms with is that infusions don't make the same money they did previously and that it may keep decreasing over time. The part where you say that it's difficult to build a patient panel.. I don't know if I quite agree with that since every rheumatologist I speak to says they don't have enough time OR help to cater to all the referrals. Again... I definitely respect your opinion since you're practicing already but are you sure your perspective is not heavily skewed since you don't enjoy your patient population and not necessarily related to the job itself?

I have a different take.

At every job I’ve had so far as a rheumatologist, I’ve had so many legitimate referrals that I’ve been able to filter out nonsense. Even when I lived near a major Midwest metro for my first job, there was plenty of legit pathology. At that job, I “started slow” because I was fresh out of fellowship and by 9 months in, I was seeing 13-15 a day easily. By a year, I was seeing 18-20. Two years in, I was fighting with admin to keep to less than 22-24 a day. Volume and quality were never problems. My next two jobs in semi rural America grew a lot faster - hell I’ve been at my current job since November and I’m already seeing 14-16 a day, at least 80% of which is legit. I’m already booked till the end of May and I’m trying to figure out how to fit more people into the schedule each day. I don’t have any desire to see OA, MSK complaints, and most fibro patients either…so I don’t. In fact, I pull those referrals out of the queue because I don’t want all the actually sick patients (which there are plenty of) waiting forever to get in. I have good pain management and sports med docs in my practice, and I deflect that stuff to them.

I have never had any trouble building a good rheumatology patient panel (and quickly too) across 3 jobs in 3 different states. I would imagine that the only place you would experience this issue is ultrasaturated, really huge urban markets where doctors congregate like lemmings, often wondering why their lives suck.

 

[dozitgetchahi]

I really want to understand since this sentence is used a lot (in any field). Are people usually referring to the LA, Chicago, NYCs or like the top 20-top 30 metros by population?

In my experience, this refers to the LA/Chicago/NYC/Houston dynamic.

My first job was in a different major metro in the Midwest - definitely top 20. In terms of referral quality and volume, it was just fine and I was not overrun with bull**** consults.

 

[dozitgetchahi]

I'm not rheum. But I've had similar experiences as a neph fellow where nephrologist in academia(an some in private practice) seem super happy and content with their jobs. Once I got into the real world I realized private practice nephrology really is as horrible as they say it is. My point is, what you see as a resident/fellow is completely divorced from reality and the real world is much more brutal. In any case, rheum lifestyle is really good and worth going into for that alone; just don't be disappointed, like bronx43 has mentioned, that the financial rewards is not as high as expected.

I think there are very few parallels between academic/PP renal and rheumatology.

PP rheumatology isn’t horrible, in fact it’s quite the opposite.

 

[Renal_Prometheus]

I think there are very few parallels between academic/PP renal and rheumatology.

PP rheumatology isn’t horrible, in fact it’s quite the opposite.

I think you misunderstood me. I think rheum pp is quite good. I was just making the observation that my perception of my own specialty during fellowship was completely different than what it is now. Experience changes perception over time.

 

[berenjena89]

Stay as hospitalist. You will make more.. if you want to make money in rheum you have to really work hard and you ll see that money 2-3 years after you start working ( private practice) and no right away.

As Hospitalist you start making good money right away… other option is to try a different fellowship, what about Hem/ onc or GI? Money is not everything but it’s very important specially when you are in medicine. After long years and hard work

 

[Rheumie101]

Stay as hospitalist. You will make more.. if you want to make money in rheum you have to really work hard and you ll see that money 2-3 years after you start working ( private practice) and no right away.

As Hospitalist you start making good money right away… other option is to try a different fellowship, what about Hem/ onc or GI? Money is not everything but it’s very important specially when you are in medicine. After long years and hard work

Interesting take. How do you reason that? Hospitalist other than big big cities maybe max would be around 300k unless you pick up extra shifts/nights etc.. (sure you can do that.. I don’t want to for the rest of my life)

Most rheum employed jobs I am seeing are pretty much same money as hospitalist but the base expectation of work at most of these places is much lesser. Typically 36 hour work weeks (which can be 4 or 4.5, depending how you want to do it) and 14-16 patients per day. It’s very easy to ramp up volume from there if you want to provided you’re an efficient worker. As a hospitalist I’m not sure how my efficiency will make me higher $/hr. Only way I see making more $ as a hospitalist is working extra shifts.

 

[Rheumie101]

Not a Rheum applicant but curious, so does 300k+ (base) in Rheum typically mean owning a private practice and/or giving infusions?

No most jobs in rheum are right around that. Maybe not so much breaking 300k yet but around 270-290k base + whatever else. This is typically 14-18 ppd 4 or 4.5 work days. So more is easily doable if you can see more patients going forward which most can. Obviously you can also make less if you’re not efficient and want to see even less patients than that. But then again keep in mind (and confirm with others too).. the jobs you see paying 500k for cards/GI/hemeonc etc are not giving that money to sit on your ass either. All of those are about productivity as well and every job in medicine pushes you in a single direction only. See more today in less time than you did yesterday. That is the name of the game unfortunately.

 

[bochaw]

Interesting take. How do you reason that? Hospitalist other than big big cities maybe max would be around 300k unless you pick up extra shifts/nights etc.. (sure you can do that.. I don’t want to for the rest of my life)

Most rheum employed jobs I am seeing are pretty much same money as hospitalist but the base expectation of work at most of these places is much lesser. Typically 36 hour work weeks (which can be 4 or 4.5, depending how you want to do it) and 14-16 patients per day. It’s very easy to ramp up volume from there if you want to provided you’re an efficient worker. As a hospitalist I’m not sure how my efficiency will make me higher $/hr. Only way I see making more $ as a hospitalist is working extra shifts.

its based on 2 year opportunity of earning as an attending. For example, let say hospitalist make 300k. let say during 2 year fellowship u are able to earn 120k, so there is 480k difference. To breakeven in 20 years, rheum needs to make 325k / year. If we also include the opportunity of investing and earn 5%/year (from the 480k difference), then rheum needs to make 350k/year to breakeven in 20 years. I think it is not easy to earn that much as a rheum if you are within 95% percentile of common people based on MGMA report.

The total working hours are quite similar, since hospitalist shift usually 12 hours on paper (in general, unless the hospitalist is on call, they only stay for 9-10 hours of clinical encounter + 1-2 hour administrative work). For specialist, usually it will be 36 hour clinical work + 4 hour administrative (unavoidable, you need to reply in basket message, doing billing etc). So total work hour in 2 weeks for hospitalist vs rheum is 84 hours vs 80 hours.

 

[Renal_Prometheus]

its based on 2 year opportunity of earning as an attending. For example, let say hospitalist make 300k. let say during 2 year fellowship u are able to earn 120k, so there is 480k difference. To breakeven in 20 years, rheum needs to make 325k / year. If we also include the opportunity of investing and earn 5%/year (from the 480k difference), then rheum needs to make 350k/year to breakeven in 20 years. I think it is not easy to earn that much as a rheum if you are within 95% percentile of common people based on MGMA report.

The total working hours are quite similar, since hospitalist shift usually 12 hours on paper (in general, unless the hospitalist is on call, they only stay for 9-10 hours of clinical encounter + 1-2 hour administrative work). For specialist, usually it will be 36 hour clinical work + 4 hour administrative (unavoidable, you need to reply in basket message, doing billing etc). So total work hour in 2 weeks for hospitalist vs rheum is 84 hours vs 80 hours.

One aspect that you may have overlooked is that hospitalist can increase their income by picking up extra shifts(locum shifts typically pay higher than regular shifts). Most of my hospitalist friends are working 3 weeks out of the month and are clearing over 400k/yr. So the opportunity cost may be higher than you think. However, not everything is about money and you are more likely to get burned out as a hospitalist.

 

[berenjena89]

Interesting take. How do you reason that? Hospitalist other than big big cities maybe max would be around 300k unless you pick up extra shifts/nights etc.. (sure you can do that.. I don’t want to for the rest of my life)

Most rheum employed jobs I am seeing are pretty much same money as hospitalist but the base expectation of work at most of these places is much lesser. Typically 36 hour work weeks (which can be 4 or 4.5, depending how you want to do it) and 14-16 patients per day. It’s very easy to ramp up volume from there if you want to provided you’re an efficient worker. As a hospitalist I’m not sure how my efficiency will make me higher $/hr. Only way I see making more $ as a hospitalist is working extra shifts.

The never ending of replying to the in basket messages/ tasks , reviewing previous labs etc. that adds much more hours than the 36 hours work week. They ending up working about the same amount of time per month. Plus the 2 years of fellowship- opportunity cost.. financially speaking it is a bad decision unless you really really love rheum, endo , ID and you don’t see your self doing anything else at all.. Everything becomes monotonous with time after a couple of years so I think that compensation for your hard work and time it’s a huge factor to take into account

 

[Rheumie101]

The never ending of replying to the in basket messages/ tasks , reviewing previous labs etc. that adds much more hours than the 36 hours work week. They ending up working about the same amount of time per month. Plus the 2 years of fellowship- opportunity cost.. financially speaking it is a bad decision unless you really really love rheum, endo , ID and you don’t see your self doing anything else at all.. Everything becomes monotonous with time after a couple of years so I think that compensation for your hard work and time it’s a huge factor to take into account

All jobs I’ve seen so far have a half day of admin time which is essentially relaxing on your couch and completing these tasks from home.

I think comparing employed rheum jobs to hospitalist jobs (which obviously are always employed) is maybe still a fair comparison.. even though I personally know two high functioning/high efficiency rheumatologists working 4.5 days a week and making well > 500k. I don’t know any hospitalists who works 7 on 7 off and makes even close to that. Only way you make >300-350 in hospital medicine is by doing extra shifts. For me personally being highly efficient/highly productive within a set number of hours >>>>> having no measure of productivity and only make more by working more hours/days (hospital medicine extra shifts). This is still comparing employed vs employed jobs.

Private practice rheumatology is 100% a goldmine and there’s no way hospital medicine can compete with it. I’ve seen multiple offers starting around 250 within major metros (pp starting tends to be lower since the group loses money on you initially) and within 2-3 years (once you make partner) you’re easily between 400-500k working 4-4.5 days a week. Also seen more than a few jobs which claim to reach > 700-800 by year 4 (but don’t personally know anyone doing that).

I will end by saying that I have nothing against hospital medicine. I infact like how relaxed and chill it is and in the future if I can somehow work out a mix of both then I’d be open to that. In fact I’m already looking at moonlighting opportunities during fellowship years to make up a little bit for the ~ 200k/year which I miss out on for 2 years.

For anyone thinking about pursuing rheumatology and basing their decision at least a bit on finances.. remember that not everything you see on SDN is true. SDN believes anything other than GI/cards/hemeonc is not worth it and people here seem to believe Rheumatology = 200k for the rest of your life. Not true unless you wanna be academic and see 10 patients a day.

 

[sloh]

All jobs I’ve seen so far have a half day of admin time which is essentially relaxing on your couch and completing these tasks from home.

I think comparing employed rheum jobs to hospitalist jobs (which obviously are always employed) is maybe still a fair comparison.. even though I personally know two high functioning/high efficiency rheumatologists working 4.5 days a week and making well > 500k. I don’t know any hospitalists who works 7 on 7 off and makes even close to that. Only way you make >300-350 in hospital medicine is by doing extra shifts. For me personally being highly efficient/highly productive within a set number of hours >>>>> having no measure of productivity and only make more by working more hours/days (hospital medicine extra shifts). This is still comparing employed vs employed jobs.

Private practice rheumatology is 100% a goldmine and there’s no way hospital medicine can compete with it. I’ve seen multiple offers starting around 250 within major metros (pp starting tends to be lower since the group loses money on you initially) and within 2-3 years (once you make partner) you’re easily between 400-500k working 4-4.5 days a week. Also seen more than a few jobs which claim to reach > 700-800 by year 4 (but don’t personally know anyone doing that).

I will end by saying that I have nothing against hospital medicine. I infact like how relaxed and chill it is and in the future if I can somehow work out a mix of both then I’d be open to that. In fact I’m already looking at moonlighting opportunities during fellowship years to make up a little bit for the ~ 200k/year which I miss out on for 2 years.

For anyone thinking about pursuing rheumatology and basing their decision at least a bit on finances.. remember that not everything you see on SDN is true. SDN believes anything other than GI/cards/hemeonc is not worth it and people here seem to believe Rheumatology = 200k for the rest of your life. Not true unless you wanna be academic and see 10 patients a day.

Maybe @bronx43 can comment on how possible this actually is for new grads and dependent on location

 

[Rheumie101]

Maybe @bronx43 can comment on how possible this actually is for new grads and dependent on location

Sure he can but a quick search of job postings and speaking to a few recruiters can also answer that question. I would trust those more over just ONE persons experience.

 

[Prehealth1011]

Sure he can but a quick search of job postings and speaking to a few recruiters can also answer that question. I would trust those more over just ONE persons experience.

Based on this, shouldn’t we trust MGMA data? Which shows that median comp is similar to what a hospitalist makes

 

[Rheumie101]

Based on this, shouldn’t we trust MGMA data? Which shows that median comp is similar to what a hospitalist makes

You should and I do too! Median is exactly what it sounds like: that MOST rheumatologists earn similar to what MOST hospitalists earn. I didn’t argue against that at all.

 

[bronx43]

Sure he can but a quick search of job postings and speaking to a few recruiters can also answer that question. I would trust those more over just ONE persons experience.

You're right in that it doesn't matter what people say. I've spoken to more recruiters in my time than I really care to, and honestly it doesn't even matter what they try to sell. It's all the same thing at the end of the day, with some adjustments based on location/market.

The only thing that truly matters is HOW people in rheumatology (or any other specialty for that matter) make money. For us, compensation derives from only a few avenues: wRVUs via employer, direct dollar reimbursement by third party payer, or drug profit via buy and bill. Certainly the second two income streams are only possible via private practice route.

So whenever I see people talk about XYZ salary within any period of time, the only thing I ask is how they're doing it. In private practice, the ways to make 400-500k is by infusions and/or sheer volume along with low overhead (which isn't as common as people think). My experience in physician owned group was 50-55% overhead pre-COVID. I suspect most are higher than that now.
Ancillary revenue is dwindling and a lot of groups barely break even with their labs and imaging. Dozitgetchai talks about his group profiting from parking, but this is rare and I wouldn't go into a multispecialty or single specialty practice expecting this. Infusions are almost dead in the water due to a variety of reasons. Only older rheumatologists with legacy Medicare with supplement patients can make good money with infusions. Most patients nowadays can't afford the co-insurance or get infusions denied by their private insurer or MA plan. So for a new rheumatologist to "make partner" in a few years and make 400-500k would mean they're seeing a TON of patients or somehow won the jackpot by inheriting infusion patients from a newly retired doc. However, even this jackpot scenario is becoming less likely since the most likely scenario is that the other existing rheumatologists in the practice would immediately divide those pts up before the new guy even sees his/her first patient in clinic.

RVUs are RVUs. There's not really a short cut and you're just grinding it out for a productivity bonus. It really all comes down to where you are and what type of patients you're willing to accept. There's an unfortunate inverse relationship between your own sanity and your patient volume. You can ramp up early by taking all garbage referrals, but you're paying for it with a pound of flesh. If you're in rural, then this is less applicable. But, that means you either commute or live in rural.

In terms of comparison to hospitalist, I would agree that rheum has a far higher ceiling, though a lot of it comes with luck, location, and willingness to handle THAT KIND of rheum patient (we all know what I'm talking about).

 

[Rheumie101]

You're right in that it doesn't matter what people say. I've spoken to more recruiters in my time than I really care to, and honestly it doesn't even matter what they try to sell. It's all the same thing at the end of the day, with some adjustments based on location/market.

The only thing that truly matters is HOW people in rheumatology (or any other specialty for that matter) make money. For us, compensation derives from only a few avenues: wRVUs via employer, direct dollar reimbursement by third party payer, or drug profit via buy and bill. Certainly the second two income streams are only possible via private practice route.

So whenever I see people talk about XYZ salary within any period of time, the only thing I ask is how they're doing it. In private practice, the ways to make 400-500k is by infusions and/or sheer volume along with low overhead (which isn't as common as people think). My experience in physician owned group was 50-55% overhead pre-COVID. I suspect most are higher than that now.
Ancillary revenue is dwindling and a lot of groups barely break even with their labs and imaging. Dozitgetchai talks about his group profiting from parking, but this is rare and I wouldn't go into a multispecialty or single specialty practice expecting this. Infusions are almost dead in the water due to a variety of reasons. Only older rheumatologists with legacy Medicare with supplement patients can make good money with infusions. Most patients nowadays can't afford the co-insurance or get infusions denied by their private insurer or MA plan. So for a new rheumatologist to "make partner" in a few years and make 400-500k would mean they're seeing a TON of patients or somehow won the jackpot by inheriting infusion patients from a newly retired doc. However, even this jackpot scenario is becoming less likely since the most likely scenario is that the other existing rheumatologists in the practice would immediately divide those pts up before the new guy even sees his/her first patient in clinic.

RVUs are RVUs. There's not really a short cut and you're just grinding it out for a productivity bonus. It really all comes down to where you are and what type of patients you're willing to accept. There's an unfortunate inverse relationship between your own sanity and your patient volume. You can ramp up early by taking all garbage referrals, but you're paying for it with a pound of flesh. If you're in rural, then this is less applicable. But, that means you either commute or live in rural.

In terms of comparison to hospitalist, I would agree that rheum has a far higher ceiling, though a lot of it comes with luck, location, and willingness to handle THAT KIND of rheum patient (we all know what I'm talking about).

Let’s assume you’re on point about everything; Private practice has gone to ****, only rheumatology patients left to be seen are fibro and psychosomatic, infusion profits are non existent and ancillary income streams don’t exist.

Tell me this.. Just a straight RVU doc, seeing 20 patients a day, 4.5 days, 46 weeks a year at an average of 1.9 RVUs with a conversion factor of 50$/RVU still is making ~400k, no? This is not considering that a major metro that I want to stay in recently offered >50/RVU conversion factor.

 

[bronx43]

Let’s assume you’re on point about everything; Private practice has gone to ****, only rheumatology patients left to be seen are fibro and psychosomatic, infusion profits are non existent and ancillary income streams don’t exist.

Tell me this.. Just a straight RVU doc, seeing 20 patients a day, 4.5 days, 46 weeks a year at an average of 1.9 RVUs with a conversion factor of 50$/RVU still is making ~400k, no? This is not considering that a major metro that I want to stay in recently offered >50/RVU conversion factor.

With those numbers you’re easily making 400k. Though it’s not easy to get 20 pts a day in a metro area.

Just for the record I never said those other things. I simply addressed what you said about pp being a goldmine.

 

[Rheumie101]

With those numbers you’re easily making 400k. Though it’s not easy to get 20 pts a day in a metro area.

Just for the record I never said those other things. I simply addressed what you said about pp being a goldmine.

You commented on infusion profits and ancillary revenues being non existent and mentioned “THAT” rheumatology patient which I’m sure you were referring to fibro/psychosomatic/OA.. I’m not sure how I misquoted you?

If it’s not even easy to get 20 patients a day in rheumatology then I guess that’s the last nail in the coffin? Obviously I don’t agree since any direction I look in, rheumatologists are booked out for 3-6 months.. I guess this probably goes back to your comment about “THAT” patient population.

I hate to break it but medicine isn’t perfect. Every specialty has THAT population. Functional abdominal pain for GI, IDA for heme, short of breath COPD who doesn’t stop smoking for Pulm. It’s what you make of it and move on.

Also you had just mentioned that you need to see a TON of patients to make 400-500 but then seem to agree that seeing 20 patients a day, 4.5 days a week with 6 weeks off a year would still get at least 400k. Do you label seeing 20 patients a day as a TON?

 

[sloh]

You commented on infusion profits and ancillary revenues being non existent and mentioned “THAT” rheumatology patient which I’m sure you were referring to fibro/psychosomatic/OA.. I’m not sure how I misquoted you?

If it’s not even easy to get 20 patients a day in rheumatology then I guess that’s the last nail in the coffin? Obviously I don’t agree since any direction I look in, rheumatologists are booked out for 3-6 months.. I guess this probably goes back to your comment about “THAT” patient population.

I hate to break it but medicine isn’t perfect. Every specialty has THAT population. Functional abdominal pain for GI, IDA for heme, short of breath COPD who doesn’t stop smoking for Pulm. It’s what you make of it and move on.

Also you had just mentioned that you need to see a TON of patients to make 400-500 but then seem to agree that seeing 20 patients a day, 4.5 days a week with 6 weeks off a year would still get at least 400k. Do you label seeing 20 patients a day as a TON?

20 fibro patients a day seems like a ton. These aren’t quick visits.

 

[Rheumie101]

20 fibro patients a day seems like a ton. These aren’t quick visits.

Didn’t say 20 fibro patients. I said I do agree that some out of a daily 20 will be fibro and that’s okay since every specialty has that.

Worked 3 years in rheum at least a combined total of 16 weeks. Saw some fibro here and there but not too much at all. It’s blown out of proportion by people who see the glass half full always

 

[sloh]

Didn’t say 20 fibro patients. I said I do agree that some out of a daily 20 will be fibro and that’s okay since every specialty has that.

Worked 3 years in rheum at least a combined total of 16 weeks. Saw some fibro here and there but not too much at all. It’s blown out of proportion by people who see the glass half full always

Do you think this differs based off rural vs metro? Essentially scraping the bottom of the barrel in a saturated metro and ending up having to see a lot of ANA+/fibro just to maintain the volume?

 

[Rheumie101]

Do you think this differs based off rural vs metro? Essentially scraping the bottom of the barrel in a saturated metro and ending up having to see a lot of ANA+/fibro just to maintain the volume?

Of course it would differ. I think rural you would have the luxury of just refusing those referrals.

Metro I imagine every 1 in 3 or 1 in 4 would be this. But also, most PP I’ve seen have a physician to APP ratio of 1:1 or even more extreme. I imagine that is where this population gets turfed to.

Bottom line I think productivity will always be king. If infusion profits seem to go away completely over time then even more so. I guess if you’re one who delves into charts and tries to tee up a patient at every visit and figure out their social determinants of health then you’ll struggle to be productive in any specialty not just Rheum. Your neighborhood GI who makes 750 every year does 15-20 screening colonoscopies every day too. Your mammo rads who makes 750 with 12 weeks of vacation reads a study every 5 minutes. Not every aspect of it is supposed to be exciting or “intellectually stimulating”. Some of it is work. Some of it is fun. Get it done and move on.

 

[bronx43]

You commented on infusion profits and ancillary revenues being non existent and mentioned “THAT” rheumatology patient which I’m sure you were referring to fibro/psychosomatic/OA.. I’m not sure how I misquoted you?

If it’s not even easy to get 20 patients a day in rheumatology then I guess that’s the last nail in the coffin? Obviously I don’t agree since any direction I look in, rheumatologists are booked out for 3-6 months.. I guess this probably goes back to your comment about “THAT” patient population.

I hate to break it but medicine isn’t perfect. Every specialty has THAT population. Functional abdominal pain for GI, IDA for heme, short of breath COPD who doesn’t stop smoking for Pulm. It’s what you make of it and move on.

Also you had just mentioned that you need to see a TON of patients to make 400-500 but then seem to agree that seeing 20 patients a day, 4.5 days a week with 6 weeks off a year would still get at least 400k. Do you label seeing 20 patients a day as a TON?

I never said they're totally non-existent or that the only patients around are psychosomatic. I simply said that infusions and ancillaries are not a huge profit maker, and are becoming less so over time. Some groups barely break even, and others can make some money. You obviously still have real rheumatic diseases, but the higher your volume, the lower the percent of real disease simply due to the fact that the demand there is inelastic. You can always find more fatigue/pain patients, but the same cannot be said for RA/PsA/AS patients.

Most rheumatologists are not seeing 20 pts a day. Some do, but most don't. But then again, most rheumatologists aren't out here trying to make 500k. Most are making high 200s, low 300s as we can obviously see on MGMA.

The comment about seeing a ton to make 400-500k was directed towards the private practice model (non-hospital employment). Your comp/RVU is higher in a hospital employed position, so you can make that with 20 pts/day.

 

[bronx43]

Of course it would differ. I think rural you would have the luxury of just refusing those referrals.

Metro I imagine every 1 in 3 or 1 in 4 would be this. But also, most PP I’ve seen have a physician to APP ratio of 1:1 or even more extreme. I imagine that is where this population gets turfed to.

Bottom line I think productivity will always be king. If infusion profits seem to go away completely over time then even more so. I guess if you’re one who delves into charts and tries to tee up a patient at every visit and figure out their social determinants of health then you’ll struggle to be productive in any specialty not just Rheum. Your neighborhood GI who makes 750 every year does 15-20 screening colonoscopies every day too. Your mammo rads who makes 750 with 12 weeks of vacation reads a study every 5 minutes. Not every aspect of it is supposed to be exciting or “intellectually stimulating”. Some of it is work. Some of it is fun. Get it done and move on.

In my experience it's much higher than 1 in 4 in a major metro.

Productivity is the way things are going, but clinic production is just a raw deal. You can do the math on it. Medicare pays $128 for a level 4 return. Depending on negotiating power, UHC can pay you less than that. Other insurers may pay a bit more. Overhead is 50% minimum, and only going up due to labor shortages. The numbers get paltry real quick.

 

[Rheumie101]

I never said they're totally non-existent or that the only patients around are psychosomatic. I simply said that infusions and ancillaries are not a huge profit maker, and are becoming less so over time. Some groups barely break even, and others can make some money. You obviously still have real rheumatic diseases, but the higher your volume, the lower the percent of real disease simply due to the fact that the demand there is inelastic. You can always find more fatigue/pain patients, but the same cannot be said for RA/PsA/AS patients.

Most rheumatologists are not seeing 20 pts a day. Some do, but most don't. But then again, most rheumatologists aren't out here trying to make 500k. Most are making high 200s, low 300s as we can obviously see on MGMA.

The comment about seeing a ton to make 400-500k was directed towards the private practice model (non-hospital employment). Your comp/RVU is higher in a hospital employed position, so you can make that with 20 pts/day.

I think you said it right there. Most rheumatologists aren’t out here trying to make that money to begin with. I saw that trend in all the fellows I worked with over my 3 years of residency too. More than half of them couldn’t wait to finish fellowship to start their 3.5 days a week job (with admin and research time built into the 3.5 days) and were happy making 200k because that’s what their priority was.

On the contrary the attending who saw 30+ patients/day in addition to APP supervision was making 650-700 year in year out because that’s what he WANTED to do. (Again, im not looking to do that, but want to be somewhere between the 2 extremes)

I think that’s how I look at it. The specialty gives you the flexibility. It can really serve as the most “chill” specialty in medicine as far as work hours are concerned with absolutely no nights, weekends, calls ever. At the same time if you’re efficient and productive within those said hours you can make decent money.

 

[dozitgetchahi]

You're right in that it doesn't matter what people say. I've spoken to more recruiters in my time than I really care to, and honestly it doesn't even matter what they try to sell. It's all the same thing at the end of the day, with some adjustments based on location/market.

The only thing that truly matters is HOW people in rheumatology (or any other specialty for that matter) make money. For us, compensation derives from only a few avenues: wRVUs via employer, direct dollar reimbursement by third party payer, or drug profit via buy and bill. Certainly the second two income streams are only possible via private practice route.

So whenever I see people talk about XYZ salary within any period of time, the only thing I ask is how they're doing it. In private practice, the ways to make 400-500k is by infusions and/or sheer volume along with low overhead (which isn't as common as people think). My experience in physician owned group was 50-55% overhead pre-COVID. I suspect most are higher than that now.
Ancillary revenue is dwindling and a lot of groups barely break even with their labs and imaging. Dozitgetchai talks about his group profiting from parking, but this is rare and I wouldn't go into a multispecialty or single specialty practice expecting this. Infusions are almost dead in the water due to a variety of reasons. Only older rheumatologists with legacy Medicare with supplement patients can make good money with infusions. Most patients nowadays can't afford the co-insurance or get infusions denied by their private insurer or MA plan. So for a new rheumatologist to "make partner" in a few years and make 400-500k would mean they're seeing a TON of patients or somehow won the jackpot by inheriting infusion patients from a newly retired doc. However, even this jackpot scenario is becoming less likely since the most likely scenario is that the other existing rheumatologists in the practice would immediately divide those pts up before the new guy even sees his/her first patient in clinic.

RVUs are RVUs. There's not really a short cut and you're just grinding it out for a productivity bonus. It really all comes down to where you are and what type of patients you're willing to accept. There's an unfortunate inverse relationship between your own sanity and your patient volume. You can ramp up early by taking all garbage referrals, but you're paying for it with a pound of flesh. If you're in rural, then this is less applicable. But, that means you either commute or live in rural.

In terms of comparison to hospitalist, I would agree that rheum has a far higher ceiling, though a lot of it comes with luck, location, and willingness to handle THAT KIND of rheum patient (we all know what I'm talking about).

Some points on this:

- My last group was the one that claimed to make money off the parking garage…however as I’ve detailed in other posts, that group was basically committing fraud and is being investigated by CMS so who knows if any of that was real (I left after not even 1 year).

- My current group, on the other hand, is the one where the other incumbent rheumatologist is a big time infuser and where a portion of the ancillary proceeds are split within the department after 6 months. (I have also been building up my infusion cohort relatively quickly because several other nearby rheums left suddenly.) Long story short…my 6 months hit, the ancillary split happened, and I received a $30k bonus for my 2nd quarter of working here. With my base of $325k and these bonuses (which should get larger as my practice keeps growing and adding more to the ancillary pool), I’m on track to hit about $400k in my first year, if you include the signon of $25k. And I’m not even technically a partner yet (that’s year two).

- As a comparison, the other rheum in my practice averages about $800k/yr. He has been here a while and sees about 30 pts/day 4 days a week. I’m seeing about 16-18 patients a day at this point and continuing to grow the practice (I don’t anticipate seeing more than about 20-24 a day or so at most, though, so my salary potential is going to be somewhat lower than his - but still not half bad.) I’m not seeing a lot of fibro, CFS, etc either. The referral stream is very robust and has a lot of legitimate rheumatology patients. I decline a fair number of inappropriate consults and make sure that most of the other nonsense that slips through the filters gets rescheduled elsewhere after I see it.

So, it is indeed possible to make this sort of money as a rheumatologist. I also take no call and do no hospital rounding whatsoever. I currently work 8:30-5 4 days a week, with a half day on Fridays. That said, you have to find the right rheumatology job with the right kind of bonus structure to pull this off. I saw a lot of crappy deals on the interview trail. Some groups are run poorly and don’t know how to contain costs or make money…other groups know how to make money, but the greedy folks at the top are trying to keep all of it in their pockets. You have to find a group that makes money that wants everyone involved to share the wealth. I realize that’s hard to find (it took me four tries.)

I totally agree with rheumie43 that my biggest priority in choosing a specialty was lifestyle. I had no intention of working myself to death after training ended. I wanted nights and weekends free…and most importantly I wanted to be 100% outpatient because I really dislike dealing with inpatient work. Rheumatology has delivered beautifully on this. The income I’m receiving at this point is only icing on the cake.

If someone asked me whether I wanted to be a hospitalist or do my current job in rheumatology…I’d do rheumatology any day of the damn week. My current situation blows virtually all hospitalist jobs I’ve ever heard of out of the water. Even without a scribe, I’m able to be very efficient with notes because of Epic, and the time associated with charting/in basket tasks is steadily dropping with each month as my clinic starts running more smoothly. I also really like that I’m a specialist who delivers important care within a niche, and not a dumpster for everything everyone else doesn’t want to deal with/chart writing monkey for surgeons whose ass gets kissed by the hospital.

I’d never choose to be a hospitalist instead of this. YMMV, I guess.