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Rheumatology job offers

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bronx43

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Would any of the current fellows looking for a job share light on the market out there? Just curious what kind of options are available nowadays. Are most opportunities with private single specialty practices? Or are most with multispecialty practices? How about hospital based options? What are the differences in the offers between the different set ups? Are there ways to make money from infusion centers from any of them?

Are the markets in big or medium sized cities good?

Thanks.
 

Successor12

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Hope we can get some insight from rheum newly graduating fellows about how the job market is like these daysand some tips on making the best out of rheum training for a better practice?
 

PlutoBoy

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Full disclosure: Not a rheum fellow. My wife is a rheumatology fellow about to graduate.

No issues at all getting job offers even in the most desirable areas. She actually got tons of calls from everywhere, including yesterday!

Most offers were from single especialty groups or hospital owned practices.

You should get about $240,000 per year.

Hope that helps!
 
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*brobro*

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Full disclosure: Not a rheum fellow. My wife is a rheumatology fellow about to graduate.

No issues at all getting job offers even in the most desirable areas. She actually got tons of calls from everywhere, including yesterday!

Most offers were from single especialty groups or hospital owned practices.

You should get about $240,000 per year.

Hope that helps!

What kind of hours are we talkin here for 240k? Also, could you elaborate more on the pay structure? Like is this 240 base salary with RVU bonus after a certain quota or is there a possible partnership buy in down the road? Thanks for any additional info!
 

PlutoBoy

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What kind of hours are we talkin here for 240k? Also, could you elaborate more on the pay structure? Like is this 240 base salary with RVU bonus after a certain quota or is there a possible partnership buy in down the road? Thanks for any additional info!

She is working 8:30 AM to 5:00 PM with a one hour lunch break, Monday through Friday.

Pay is $245,000 plus RVUs. No possible partnership.
 

PlutoBoy

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We are really close with one of the other fellows and she signed for $200K+ in another state.
 

lakeofirefun

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We are really close with one of the other fellows and she signed for $200K+ in another state.
Thanks for this @PlutoBoy. Could you tell us what region you're in? Also, anyone else that would like to chime in on job market and salaries would be much appreciated. This info is so hard to come by. Particularly what academic rheum is paying just out of fellowship.
 

PlutoBoy

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Thanks for this @PlutoBoy. Could you tell us what region you're in? Also, anyone else that would like to chime in on job market and salaries would be much appreciated. This info is so hard to come by. Particularly what academic rheum is paying just out of fellowship.

Academics in my area: $150,00-170,000.
 

Rheumination1

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Colleagues of mine working in New Mexico rural region offers are M-Th no call outpatient only. Paying more or less $240k. This was the first job out of fellowship.


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bronx43

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Anyone here know people who start their own practice? Also, any idea what cities or regions have the highest demand and lowest supply of rheumatologists?
 

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Any new rheumatologists in the NE or NW? Interested in practice settings and approximate starting salary... Thanks!
 

Brahnold Bloodaxe

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She is working 8:30 AM to 5:00 PM with a one hour lunch break, Monday through Friday.

Pay is $245,000 plus RVUs. No possible partnership.

So the base salary tops out at mid 200s? That's less than hospitalist average for 7/7 and with no fellowship opportunity cost :(
 

Raryn

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So the base salary tops out at mid 200s? That's less than hospitalist average for 7/7 and with no fellowship opportunity cost :(
Thats not super unusual for rheum or endocrine and better than nephro or ID. You do the fellowship for the interest in the material and the lifestyle, not for the money. Most of us outside of say, GI, would be better off moving to rural areas and becoming hospitalists.
 
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gutonc

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    So the base salary tops out at mid 200s? That's less than hospitalist average for 7/7 and with no fellowship opportunity cost :(
    Not everybody's in it for the money.

    And the upside potential of a subspecialty like Rheum (procedures, infusions) is much greater than that of a hospitalist.
     
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    PlutoBoy

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    So the base salary tops out at mid 200s? That's less than hospitalist average for 7/7 and with no fellowship opportunity cost :(

    I was a Hospitalist obviously in the same town. I was being paid $260,000. $245,000 plus RVUS doesn't sound bad especially considering that your lifestyle is so much better.

    Believe me. You made the right choice :)
     
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    Brahnold Bloodaxe

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    I'm just a med student. The sad face was purely out of disappointment at the abstract injustice of it all. lol
     

    gutonc

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    I'm just a med student. The sad face was purely out of disappointment at the abstract injustice of it all. lol
    It's not very abstract* and it's not injustice.

    *Perhaps you meant "abject" here...it's still not, but that's a better word in that setting.
     
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    Rheumination1

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    Not writing H and P, doing Med recs, discharge summaries and a 28 year old admin screaming down your throat to shorten your length of stay is more than enough reason not to stay as a hospitalist for me. Others said it, I'll echo it--money isn't the only end point here.


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    Brahnold Bloodaxe

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    It's not very abstract* and it's not injustice.

    *Perhaps you meant "abject" here...it's still not, but that's a better word in that setting.

    Hmm...maybe 'abstract' wasn't the word but abject isn't it, either. I was trying to convey the idea that the injustice isn't important to me on a personal level since I'm not a rheumatologist but that I nevertheless recognize it as a neutral party.
     

    gutonc

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    Hmm...maybe 'abstract' wasn't the word but abject isn't it, either. I was trying to convey the idea that the injustice isn't important to me on a personal level since I'm not a rheumatologist but that I nevertheless recognize it as a neutral party.
    It's not injustice. There's no trickery at play. It's not like the data isn't out there (it may not be very good...but it's out there).

    If you don't know at least something about the pay in the specialty you're planning to go into, you deserve what you get on the backside.
     

    Brahnold Bloodaxe

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    I think length of training should have some bearing on compensation, so it's an injustice in my mind. But that's just my opinion.
     

    gutonc

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    I think length of training should have some bearing on compensation, so it's an injustice in my mind. But that's just my opinion.
    It does...it's just not linear. 5 years of training doesn't automatically get you 40% more money than 3 years of training. It's the nature of the beast.

    Also, by your logic, IM, FM and Peds should make more or less the same as EM does, since they all train for 3 years. Which we know isn't even remotely true.
     
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    lakeofirefun

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    Not writing H and P, doing Med recs, discharge summaries and a 28 year old admin screaming down your throat to shorten your length of stay is more than enough reason not to stay as a hospitalist for me. Others said it, I'll echo it--money isn't the only end point here.


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    This. I used to think medicine v. surgery was the salient decision/fork in the road when deciding on specialty but I realize outpatient v. inpatient is so much more important to me. I consider hospitalist medicine and rheumatology to be as different from each other as general surgery and primary care (a touch hyperbolic but I'm going with it :)
     
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    dozitgetchahi

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    Not everybody's in it for the money.

    And the upside potential of a subspecialty like Rheum (procedures, infusions) is much greater than that of a hospitalist.

    And (as I believe gutonc has so brilliantly put it previously): 'once you put the bullet in your head [as a hospitalist], the extra money doesn't matter'
     
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    KLycos

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    What is the typical day to day work like for Rheum? On my sports med rotation in med school the sports docs would have procedure days (i.e. joint injections under u/s). What is the variability like in Rheum? I feel like no one really talks about this. Is there one type of patient that dominates the day to day like RA? How many patients are you typically going to be seeing when you get into a new practice? How desperate are recruiters to find new rheumatologists?
     

    drfunktacular

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    I'm employed in my second year of practice in a private practice in a multispecialty group in a mid-sized town and make $245k, which is on the higher end but still typical. Any of the "cognitive" specialties (ID, endo, rheum, non-CC pulm) are going to be similar. You might expect a range $200-275k depending on the desirability of the location and how hard it is to recruit people--you're going to be on the lower end in all the places new graduates typically want to live like SF, NYC, Boston, Austin, etc because you're a dime a dozen. Pay will be much higher in rural and less "desirable" areas. Pay will also tend to increase as you get more experience and more seniority, particularly in a physician owned group. I am aware of rheumatologists making mid-$400k+ but they work like dogs and make some... "interesting"... patient care and care utilization choices. Participating in clinical research is another income opportunity and is in high demand, but carries a whole separate set of considerations and headaches with it on top of your day to day practice.

    Lifestyle is more or less what you want it to be. I'm here from about 8-6:30pm most days, seeing patients from about 8:30-5 with the rest of the time doing paperwork and reviewing results, with a hospital consult maybe twice a month. I'll typically see 18-24 patients in a day. I take call for my own patients during the week, and take about 1:6 weekends. In a whole month (including a weekend) I probably get 3 phone calls after hours and in 85% of cases the answer is either "call your usual rheumatologist on Monday" or "go to the ER". If you are in a partnership track, or an RVU-based employment model with production bonuses, you could choose to work more or less than me and your income would vary accordingly.

    Procedures are not a cash cow in rheumatology. If you want to make more money your main tool is increasing E&M. Joint injections pay a little but they're sort of an adjunct to most of what you do as a rheumatologist, which is making long-term treatment plans, assessing disease activity, and monitoring for treatment toxicity. For a while in the late 90's-early 00's infusions were a bonanza but now most practices make a small profit or just break even. CMMS has been cutting reimbursements on drugs, and now there is a proposed demonstration plan where reimbursement of drug costs will be cut to 1-3% of purchase price, which in many locations depending on business taxes, overhead, etc will put many practices underwater on infusions and they will stop providing them. Eventually I suspect most patients will be going to oncology practices, hospitals, or commercial infusion centers as are being started by Walgreen's etc to get their infusions because docs will be losing money trying to provide them for their patients.
     
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    KLycos

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    I think you provide some of the most helpful commentary on Rheumatology on this whole forum. Thanks!

    I'm employed in my second year of practice in a private practice in a multispecialty group in a mid-sized town and make $245k, which is on the higher end but still typical. Any of the "cognitive" specialties (ID, endo, rheum, non-CC pulm) are going to be similar. You might expect a range $200-275k depending on the desirability of the location and how hard it is to recruit people--you're going to be on the lower end in all the places new graduates typically want to live like SF, NYC, Boston, Austin, etc because you're a dime a dozen. Pay will be much higher in rural and less "desirable" areas. Pay will also tend to increase as you get more experience and more seniority, particularly in a physician owned group. I am aware of rheumatologists making mid-$400k+ but they work like dogs and make some... "interesting"... patient care and care utilization choices. Participating in clinical research is another income opportunity and is in high demand, but carries a whole separate set of considerations and headaches with it on top of your day to day practice.

    Lifestyle is more or less what you want it to be. I'm here from about 8-6:30pm most days, seeing patients from about 8:30-5 with the rest of the time doing paperwork and reviewing results, with a hospital consult maybe twice a month. I'll typically see 18-24 patients in a day. I take call for my own patients during the week, and take about 1:6 weekends. In a whole month (including a weekend) I probably get 3 phone calls after hours and in 85% of cases the answer is either "call your usual rheumatologist on Monday" or "go to the ER". If you are in a partnership track, or an RVU-based employment model with production bonuses, you could choose to work more or less than me and your income would vary accordingly.

    Procedures are not a cash cow in rheumatology. If you want to make more money your main tool is increasing E&M. Joint injections pay a little but they're sort of an adjunct to most of what you do as a rheumatologist, which is making long-term treatment plans, assessing disease activity, and monitoring for treatment toxicity. For a while in the late 90's-early 00's infusions were a bonanza but now most practices make a small profit or just break even. CMMS has been cutting reimbursements on drugs, and now there is a proposed demonstration plan where reimbursement of drug costs will be cut to 1-3% of purchase price, which in many locations depending on business taxes, overhead, etc will put many practices underwater on infusions and they will stop providing them. Eventually I suspect most patients will be going to oncology practices, hospitals, or commercial infusion centers as are being started by Walgreen's etc to get their infusions because docs will be losing money trying to provide them for their patients.
     

    Rheumination1

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    I'm employed in my second year of practice in a private practice in a multispecialty group in a mid-sized town and make $245k, which is on the higher end but still typical. Any of the "cognitive" specialties (ID, endo, rheum, non-CC pulm) are going to be similar. You might expect a range $200-275k depending on the desirability of the location and how hard it is to recruit people--you're going to be on the lower end in all the places new graduates typically want to live like SF, NYC, Boston, Austin, etc because you're a dime a dozen. Pay will be much higher in rural and less "desirable" areas. Pay will also tend to increase as you get more experience and more seniority, particularly in a physician owned group. I am aware of rheumatologists making mid-$400k+ but they work like dogs and make some... "interesting"... patient care and care utilization choices. Participating in clinical research is another income opportunity and is in high demand, but carries a whole separate set of considerations and headaches with it on top of your day to day practice.

    Lifestyle is more or less what you want it to be. I'm here from about 8-6:30pm most days, seeing patients from about 8:30-5 with the rest of the time doing paperwork and reviewing results, with a hospital consult maybe twice a month. I'll typically see 18-24 patients in a day. I take call for my own patients during the week, and take about 1:6 weekends. In a whole month (including a weekend) I probably get 3 phone calls after hours and in 85% of cases the answer is either "call your usual rheumatologist on Monday" or "go to the ER". If you are in a partnership track, or an RVU-based employment model with production bonuses, you could choose to work more or less than me and your income would vary accordingly.

    Procedures are not a cash cow in rheumatology. If you want to make more money your main tool is increasing E&M. Joint injections pay a little but they're sort of an adjunct to most of what you do as a rheumatologist, which is making long-term treatment plans, assessing disease activity, and monitoring for treatment toxicity. For a while in the late 90's-early 00's infusions were a bonanza but now most practices make a small profit or just break even. CMMS has been cutting reimbursements on drugs, and now there is a proposed demonstration plan where reimbursement of drug costs will be cut to 1-3% of purchase price, which in many locations depending on business taxes, overhead, etc will put many practices underwater on infusions and they will stop providing them. Eventually I suspect most patients will be going to oncology practices, hospitals, or commercial infusion centers as are being started by Walgreen's etc to get their infusions because docs will be losing money trying to provide them for their patients.

    Would you say it's a good idea to join a multi-specialty group with a lot of internal referrals as the first Rheumatologist? Say they're willing to bend over backwards for you (get MSK US, DXA, etc.). Or do you think it's more wise to join another rheum practice, get paid less but have that safety net of someone else being more experienced by your side?


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    drfunktacular

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    Particularly as a first job, overall I think you would probably be best off joining an established single-specialty (i.e., rheum only) group. The practice management and staff will all be finely attuned to what you need/want because it's all they do.

    When a multispecialty group "bends over backwards" for you they often have misguided/unrealistic expectations about what you need and what you can produce for the practice. Particularly if you are planning to do infusions--you may rapidly become the largest cost center in the practice, which can cause some annoyance for other people in the practice. Moreover, many multispecialty group practices are tailored to the whims of the highest earners (GI, cards, onc) so if those specialties are represented you will always be a step-child because you don't bring the big bucks. Regarding MSKUS my feelings are mixed. Reimbursements are declining and the day to day utility has not been as high as I was expecting so although I trained in it I very rarely use it. DXA is rapidly becoming a break-even or lose-slightly proposition, so the point of having one is mainly just convenience and service to your patients. I probably wouldn't buy one at this point with the idea of making beaucoup money on it.

    On the other hand you will be on more equal footing, and have a more synoptic view of the world if you are in a practice with other people practicing your specialty. Many surveys I have seen also indicate that average earnings are higher in single-specialty private groups as compared with multispecialty groups, likely for some of the reasons outlined above. Although as with all things in life, YMMV
     
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    bronx43

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    I'm employed in my second year of practice in a private practice in a multispecialty group in a mid-sized town and make $245k, which is on the higher end but still typical. Any of the "cognitive" specialties (ID, endo, rheum, non-CC pulm) are going to be similar. You might expect a range $200-275k depending on the desirability of the location and how hard it is to recruit people--you're going to be on the lower end in all the places new graduates typically want to live like SF, NYC, Boston, Austin, etc because you're a dime a dozen. Pay will be much higher in rural and less "desirable" areas. Pay will also tend to increase as you get more experience and more seniority, particularly in a physician owned group. I am aware of rheumatologists making mid-$400k+ but they work like dogs and make some... "interesting"... patient care and care utilization choices. Participating in clinical research is another income opportunity and is in high demand, but carries a whole separate set of considerations and headaches with it on top of your day to day practice.

    Lifestyle is more or less what you want it to be. I'm here from about 8-6:30pm most days, seeing patients from about 8:30-5 with the rest of the time doing paperwork and reviewing results, with a hospital consult maybe twice a month. I'll typically see 18-24 patients in a day. I take call for my own patients during the week, and take about 1:6 weekends. In a whole month (including a weekend) I probably get 3 phone calls after hours and in 85% of cases the answer is either "call your usual rheumatologist on Monday" or "go to the ER". If you are in a partnership track, or an RVU-based employment model with production bonuses, you could choose to work more or less than me and your income would vary accordingly.

    Procedures are not a cash cow in rheumatology. If you want to make more money your main tool is increasing E&M. Joint injections pay a little but they're sort of an adjunct to most of what you do as a rheumatologist, which is making long-term treatment plans, assessing disease activity, and monitoring for treatment toxicity. For a while in the late 90's-early 00's infusions were a bonanza but now most practices make a small profit or just break even. CMMS has been cutting reimbursements on drugs, and now there is a proposed demonstration plan where reimbursement of drug costs will be cut to 1-3% of purchase price, which in many locations depending on business taxes, overhead, etc will put many practices underwater on infusions and they will stop providing them. Eventually I suspect most patients will be going to oncology practices, hospitals, or commercial infusion centers as are being started by Walgreen's etc to get their infusions because docs will be losing money trying to provide them for their patients.

    Thanks for your input, funktacular.

    Are you working 5 days a week? If so, I am surprised that you're only getting $245k especially if you are seeing 18-24 pts per day. If the payor mix is good in your area of the woods, then you are bringing in hell of a lot more money for your practice than they are distilling back to you. Are you in a really competitive (albeit mid-size) part of the country?

    The two fellows in my program that left got pretty good gigs. Both are going to desirable, tier two cities on the West Coast. One is doing 5 days a week for $260k, and the other is getting $230k for 4 days a week.

    As far as the infusion cuts, this may or may not go through. Obviously, if it goes through, then that's probably the end game for a lot of private practice infusion centers. But, at the current 6% of purchase cost for drugs, are infusions still profitable? Don't you bill for the CPT code, as well as the markup for drug cost? I would think that most of the profit is from the actual service as opposed to from the drug, since most of our drugs aren't ridiculously priced like some of the onc drugs.

    How many patients do you need on infusions to even make a significant profit? The start up costs are fairly high and overhead is high as well. Also, why would patients even want infusions if they can just do SQ injections at home? With more and more options for home injections, do you see infusions as a dying phenomenon?
     
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    Rheumination1

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    The first option is usually Sq injections unless someone is morbidly obese in which using a Mg/kg dosing is probably more beneficial. People have different preferences. Some prefer needle sticks every week. Others prefer coming in once in 8 weeks for an infusion or even once in 6-9 months for rituxan. There's no generalized assumption you can make.


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    drfunktacular

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    I do work 5 days per week; however I am also eligible for partnership at 2 years, at which point I keep any collections in excess of overhead (sometimes referred to as an "eat what you kill" model). In some employed positions, even when RVU-based, your initial salary may be relatively higher, but then you have less control over your long term earning potential.

    Yes some patients prefer infusions over injections for some of the reasons listed above. For Medicare patients specifically, office based treatments are also financially favorable for the patient because they are covered by the Part B (medical) benefit rather than the Part D (pharmacy) benefit so copays and out of pocket expenditure are treated differently. The bottom line is many Medicare patients spend much less out of pocket for infusions compared with injections. Medicare plans also often don't require PA for office-based treatments so you have more flexibility, for example if you would prefer to start an RA patient on abatacept or tocilizumab without having first failed two TNF inhibitors.

    As far as profitability of infusions it really depends on too many factors to say easily. Certainly it is more likely to be profitable in a bigger practice where you can leverage bulk purchase prices for multiple providers. Most offices that are well-managed make a small profit at the 6% price, but not all offices are well-managed!
     
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    Successor12

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    I am curious to know how much you would make as a rheumatologist in private practice say 3 years into practice? I am also wondering about the challenges of working in private practice and how realistic it is to see say 20 plus patients a day? What are the money making potentials of a rheumatologist in private practice for someone who works hard not crazy though?
    I do realize that so many factors come into play here but I would appreciate an average estimate?
     

    drfunktacular

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    I am curious to know how much you would make as a rheumatologist in private practice say 3 years into practice? I am also wondering about the challenges of working in private practice and how realistic it is to see say 20 plus patients a day? What are the money making potentials of a rheumatologist in private practice for someone who works hard not crazy though?
    I do realize that so many factors come into play here but I would appreciate an average estimate?

    It really depends on too many factors to say. I wouldn't be surprised if someone working 4 days a week in a "desirable" major metro in a large multispecialty group practice (or especially in academics) was making $160k; I also wouldn't be surprised if someone in a rural area or "less desirable" metro was busting it working 65 hours a week and making $400k

    I see around 20 patients most days and it's pretty do-able although some days I am stuck at the office finishing notes and paperwork until 7PM (most days I'm out around 6 or 6:30). It depends quite a bit on how many of those patients are new (usually 3-4 per day for me) and how sick/complex your general patient population is. If you hang onto all your OA patients and check on them periodically those visits will be quick but will be low complexity (more 3's than 4's). If you're seeing a bunch of sick patients with vasculitis, active lupus, and bad arthritis, it's going to be tougher to see more patients. However, your average visit code will be higher in that case (more 4's than 3's) so to some degree it evens out.

    It also depends on how much you want your patients to like you. You can burn through 5 or 6 patients an hour and make beaucoup money if you don't explain anything to them and don't listen to them when they talk to you. But the turnover in your practice will be high because patients won't like you and will find other doctors (I know this because I regularly inherit many such patients).
     
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    bronx43

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    What funktacular said.

    I would also add that another option would be to be picky about your patient population early on, so that you collect a bunch of easy but "complex" patients that are stable. Your average stable RA patient should take no more than 15 minutes per visit (mostly less), and you bill 4s for them. The caveat to that is you will not make much money starting out. However, once you hit a critical threshold, you're golden.
     

    drfunktacular

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    What funktacular said.

    I would also add that another option would be to be picky about your patient population early on, so that you collect a bunch of easy but "complex" patients that are stable. Your average stable RA patient should take no more than 15 minutes per visit (mostly less), and you bill 4s for them. The caveat to that is you will not make much money starting out. However, once you hit a critical threshold, you're golden.

    I totally agree with this. I think the major mistake I made starting out was that I took all comers regardless of diagnosis, workup, or anything. I just wanted to fill my schedule. That was pretty good for my collections, but I have a much higher proportion of back pain, fibromyalgia, MUPS, etc than I would have in my "ideal" practice. In retrospect I would've spent more time twiddling my thumbs and wishing I was making more money for the first 6-12 months in exchange for having a more "real rheumatology" practice now. But I'm still happy with what I'm doing.
     
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    drk310

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    I totally agree with this. I think the major mistake I made starting out was that I took all comers regardless of diagnosis, workup, or anything. I just wanted to fill my schedule. That was pretty good for my collections, but I have a much higher proportion of back pain, fibromyalgia, MUPS, etc than I would have in my "ideal" practice. In retrospect I would've spent more time twiddling my thumbs and wishing I was making more money for the first 6-12 months in exchange for having a more "real rheumatology" practice now. But I'm still happy with what I'm doing.

    This is great practical advice. Thank you guys for chiming in and keeping the rheum topics alive, I'm learning a lot here.
     

    silentreader

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    How much RVU should a rheumatologist do to make in order to get 235-250K salary?
     

    bronx43

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    Thank you very much!

    around 15-20 patients per day?
    Depends on how many news/olds, and how you bill. New level 4 gets you 2.43 wRVU, and established level 4 gets you 1.5. I bill 90%+ level 4, so you can do the math there.
     
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