Rheumatology job prospects

[dozitgetchahi]

I believe the proposed cuts to Medicare were voted down by Congress. It's "possible" that it may drop some time in the future, but I think the likelihood is rather low. CMS loves to act like they're going to do heavy cuts across the board, but it's politically difficult. They usually opt for rearranging reimbursement rather than true cuts that would affect all specialties.

Btw, can I ask what your ballpark monthly overhead was back when you were in private practice? Just trying to get a general sense of what other people are paying.

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[bronx43]

Btw, can I ask what your ballpark monthly overhead was back when you were in private practice? Just trying to get a general sense of what other people are paying.

It was around 55% but some quarters were up almost at 60%. Honestly, far too high unless you are collecting heavy duty ancillary revenue. This is my main issue with pure private groups. When you’re surviving on 99214s, you can’t afford to lose 60% right the top. The older guys with the infusion income has a buffer and make good money.

 

[90sportsfan]

Couldn't agree more. Take it from someone who is about to leave fakedemia - don't join. Unless you can't see yourself doing anything but research AND have a NIH grant, then it's a complete scam. Even for people that like research and want to try their hand in it, don't do it. Because, the chance of you succeeding and getting a K or R01 grant approaches zero. And if you're not bringing in research dollars, then you're basically a beast of burden for the higher ups. The whole system is designed to enrich the established faculty members/administrators at the expense of the younger faculty.

There's honestly no viable job outside of private these days. I think true private practice is still viable as long as the infusion money keeps flowing. However, one thing that I've mentioned before is that infusions are more difficult to get due to the plethora of SC and oral therapies. Furthermore, a lot of Medicare Advantage plans simply won't cover the whole cost of the drug, so the co-insurance falls on the shoulder of patients, most of whom can't afford it. When I was in a purely private group (billing minus overhead), I was struggling to get infusions and ultimately couldn't make enough to justify the cost structure.

I've found that you really need 50-100 infusion patients to make it worth it, otherwise the high overhead you're paying may not make it all that profitable. Also, you need an MRI to really generate high ancillary revenue, which also eats significantly into the group overhead. Labs can be a money maker, but you need really high volume or else it's more or less a wash. Return rheum patients don't typically generate high ancillaries without infusions. Xrays are generally a money sink. We didn't have PT so that didn't really factor in. However, the complete autonomy is a significant upside - I would probably give up a chunk of cash for it.

This can’t be stressed enough. Granted I am pursuing Neurology, and looking into this, I and many people have grandeur for having a nice academic, physician-scientist job with lots of protected research time and NIH funding. The reality is, as you point out, getting an NIH grant (even a K) is like winning the lottery, let alone getting an R grant. The reality is that many of us will not get one, and “academics” (whatever specialty) looks a lot different than what we think.

 

[CoolMikeyMike]

Hello all. Chronic pain doc here. We have a multispecialty practice that includes interventional pain, rheumatology, and internal medicine located near charlotte, NC. Our rheumatologist is very busy and looking on cutting back as he looks toward retirement in the next few years. I was hoping to find a website for rheumatology job posting. In anesthesia we use Gaswork.com rather than ZipRecruiter and Indeed. is there an equivalent website for rheum? In case anyone here is interested please PM me. We have a stable group with a partnership track and salary for rheumatology that will not disappoint.

 

[Legend of Link]

310? Sorry, but the only jobs that you'll see 300k base is 1.5 hours away from any metropolitan.

Anything in a desirable location is under 260, with the exception of the south.

OP, look at the ACR career site and search your desired geographic location. More likely than not, there will not be any good jobs.

how possible is it to break the 400K mark as a rheumatologist if you work 5 days/ week, 8-10 hour days? I am kind of split between heme/onc and rheuma (interested in both subject material) but it seems like rheuma provides with better lifestyle

 

[bronx43]

how possible is it to break the 400K mark as a rheumatologist if you work 5 days/ week, 8-10 hour days? I am kind of split between heme/onc and rheuma (interested in both subject material) but it seems like rheuma provides with better lifestyle

Very possible. Even in a major metro you’ll be able to make that amount after you become established. The main issue with rheum isn’t the income - it’s what kind of patients you need to see to make any money at all. My recommendation is to do heme onc. They do work more but the other factors more than make it for it.

 

[dozitgetchahi]

how possible is it to break the 400K mark as a rheumatologist if you work 5 days/ week, 8-10 hour days? I am kind of split between heme/onc and rheuma (interested in both subject material) but it seems like rheuma provides with better lifestyle

It does.

I was in your exact same dilemma (heme/onc vs rheum) as a resident and I’m 100% happy with my decision to do rheumatology.

The lifestyle is a lot better (I don’t round in the hospital at all, which is a big deal to me as I detest hospital work). Right now I work 4.5 days a week for $325k. Once I am established, I anticipate easily breaking $400k and working 4 days a week. Our drugs actually work, unlike onc (despite all the progress that has been made with that). Hoards of my patients aren’t dying all the time, as they would be in onc. And at least where I work, the pathology is very legit and I spend most of my day managing real rheumatologic illnesses. I’ll trade a small handful of fibro any day for the massive amounts of BS oncology has to put up with.

Most rheumatologists are happy, and burnout levels are overall lower than they are with onc.

 

[bronx43]

Most rheumatologists are happy, and burnout levels are overall lower than they are with onc.

I am pretty sure that is inaccurate. Recent surveys have rheum as one of the higher burnout specialties. And honestly I can see how that is with the type of patients that often that get dumped on us in major metro areas.
And it’s not the fibros. I don’t mind seeing fibros. In the big cities, it’s the people with fibro/fatigue who are convinced they have something rheumatic due to their positive ANA or “high” inflammatory markers. Or they come into your office with a 14 inch stack of medical records and a 3 page printout of all their “complex medical history” and symptoms. Telling them they have no discernible rheumatic disease often ends with a heated debate and a likely complaint or negative review.


*Now granted I think my experience at a fakedemic institution magnified these unsavory qualities since the institution was the dump for all referrals in 1/3 of the state. They were also money hungry and took 100% of referrals which lead to hyperconcentration of the worst of the worst nonsense.

 

[dozitgetchahi]

I am pretty sure that is inaccurate. Recent surveys have rheum as one of the higher burnout specialties. And honestly I can see how that is with the type of patients that often that get dumped on us in major metro areas.
And it’s not the fibros. I don’t mind seeing fibros. In the big cities, it’s the people with fibro/fatigue who are convinced they have something rheumatic due to their positive ANA or “high” inflammatory markers. Or they come into your office with a 14 inch stack of medical records and a 3 page printout of all their “complex medical history” and symptoms. Telling them they have no discernible rheumatic disease often ends with a heated debate and a likely complaint or negative review.


*Now granted I think my experience at a fakedemic institution magnified these unsavory qualities since the institution was the dump for all referrals in 1/3 of the state. They were also money hungry and took 100% of referrals which lead to hyperconcentration of the worst of the worst nonsense.

To be honest, I simply do not believe those “newer” studies by Medscape in that regard. For many years they had us ranked near the very bottom for burnout. Now, suddenly, it’s “above average”. Nothing meaningful about rheumatology has changed in that timeframe and my colleagues and I don’t feel any differently about the field than we did in the beginning.

My points about the specialty still stand. I get that you don’t like it and that you seem to feel it was a poor choice. I’d like to point out that most in our specialty don’t feel that way, to be brutally honest. Most rheums I have talked to throughout my career are very very happy with it.

Practicing in “desirable big cities” sucks for a lot of reasons. I guess I’m not like most doctors in that I don’t find big expensive cities that are oversaturated with doctors to be “desirable” places to live. What you get is too many docs competing with each other for scraps, and rheumatologists wasting their training basically acting like sports medicine doctors seeing OA and looney fibro patients. However, even when I worked in non-Chicago big midwestern cities, I wasn’t dealing with that. Now in the semi-rural Midwest, I actually see very little of it.

I like rheumatology and if I had to go back to residency and do it all over again, I’d still choose it.

 

[bronx43]

To be honest, I simply do not believe those “newer” studies by Medscape in that regard. For many years they had us ranked near the very bottom for burnout. Now, suddenly, it’s “above average”. Nothing meaningful about rheumatology has changed in that timeframe and my colleagues and I don’t feel any differently about the field than we did in the beginning.

My points about the specialty still stand. I get that you don’t like it and that you seem to feel it was a poor choice. I’d like to point out that most in our specialty don’t feel that way, to be brutally honest. Most rheums I have talked to throughout my career are very very happy with it.

Practicing in “desirable big cities” sucks for a lot of reasons. I guess I’m not like most doctors in that I don’t find big expensive cities that are oversaturated with doctors to be “desirable” places to live.

I like rheumatology and if I had to go back to residency and do it all over again, I’d still choose it.

I looked back at the last 8 years of Medscape surveys (which are usually accepted to the most robust). 6/8 years showed higher burnout for rheum.

2015: rheum (43%), oncology (44%)
2016: rheum (47%), oncology (46%)
2017: rheum (54%), oncology (47%)
2018: rheum (38%), oncology (39%)
2019: rheum (41%), oncology (39%)
2020: rheum (46%), oncology (42%)
2021: rheum (50%), oncology (33%)
2022: rheum (46%), oncology (36%)

In fact, the trends diverged several years ago. Oncology has had a drop in burnout, which was actually quite obvious to me speaking to younger onc grads. At my previous institution, the heme/onc people were basically given whatever they wanted. Fewer clinics, scribes, midlevels to do grunt work, etc. Rheumatology had none of that... instead, we got more patients, less referral screening, and stagnant pay. The advent of immunotherapy and other higher cost drugs has actually made oncology a BIGGER moneymaker for hospitals (or physician owned groups that buy/bill). Meanwhile, rheum drugs became subcutaneous, more crowded, and lower reimbursed. It’s actually kind of pathetic to see the private docs desperately hovering around the last two profitable biologics -orencia and cimzia - like flies around a carcass.

It's cool to like rheumatology. I'm happy for you. But, I don't think objectively speaking, one can claim that rheumatology is at all superior or even non-inferior to oncology, which is more or less the golden child of modern medicine.

 

[dozitgetchahi]

I (like all of us) can only speak from our own experiences. I can tell you that the oncologists I’ve known are in no way less stressed or happier than the rheumatologists - not by a long shot.

Again, I’d like to emphasize that among the rheumatologists I know and interact with, you are something of an outlier. Do I think it’s the perfect specialty? Nope. But I simply do not hear the volume of griping and complaining among rheumatologists that I’ve heard from you here. You make it sound like the specialty is hopeless when, in reality, rheumatology incomes have gone up substantially, rheums are in very high demand in most of the country, and the vast majority of rheumatologists I’ve ever encountered are quite happy with their jobs. Within IM, rheumatology is basically the polar opposite of renal at this point. (I would have been miserable as an oncologist, and I think most rheums would be also.)

Let me ask you this - are you happy with being a doctor? Judging from some of your posts elsewhere, it sounds like you aren’t, and I think that’s coloring your opinion of the specialty.

 

[Renal_Prometheus]

Within IM, rheumatology is basically the polar opposite of renal at this point.

Thanks for throwing shade at nephrology. LOL. I don't see why you two are bickering. Doesn't matter how dissatisfied you guys are, the lifestyle of rheum trumps nephrology any day of the week.

 

[NewYorkDoctors]

Thanks for throwing shade at nephrology. LOL. I don't see why you two are bickering. Doesn't matter how dissatisfied you guys are, the lifestyle of rheum trumps nephrology any day of the week.

I can imagine not having to travel around to mutliple centers, having meds that actually work for real disease, doing some joint aspiration / injection procedures, MSK ultrasound, and not having any emergency night calls is far superior to what nephrology does.

 

[dozitgetchahi]

I can imagine not having to travel around to mutliple centers, having meds that actually work for real disease, doing some joint aspiration / injection procedures, MSK ultrasound, and not having any emergency night calls is far superior to what nephrology does.

I mean, I think it’s great and I quite like it. I wanted a good lifestyle and the opportunity to make a good (if not necessarily extravagant) salary while working 100% outpatient, and rheumatology has delivered on that so far.

 

[bronx43]

Thanks for throwing shade at nephrology. LOL. I don't see why you two are bickering. Doesn't matter how dissatisfied you guys are, the lifestyle of rheum trumps nephrology any day of the week.

lol true but the debate here was regarding heme onc vs rheum, which I still contend heme onc offers most of what rheum offers in terms of outpatient based with lack of night call but with more money, respect from hospital employers, and imo a better patient population in major metros.

 

[HemeOncHopeful19]

Our drugs actually work, unlike onc (despite all the progress that has been made with that)…

I’ll trade a small handful of fibro any day for the massive amounts of BS oncology has to put up with.

???

I agree with the others, clearly Rheum is a better fit for you but I’m not sure how accurate your understanding of Onc is. They’re just very different fields I think with the only overlap being they’re outpatient and the use of infusion drugs.

For example I actually love that there is minimal “BS” in Heme/Onc (although I have heard we have our own Fibro in the form of mast cell disorders there is actually a blood test that can bail us out).

 

[bronx43]

For example I actually love that there is minimal “BS” in Heme/Onc (although I have heard we have our own Fibro in the form of mast cell disorders there is actually a blood test that can bail us out).

if there is a good blood test that bails you out then it’s not even a problem. One major issue with rheum is that we have the opposite. Instead of being bailed out, we have blood tests (ANA) that create major headaches. The state of rheumatology can be vastly improved if the ANA is limited to a test that only rheumatologists can order. Or if the ANA assay can be changed where you reverse the characteristics so that the sensitivity is low but specificity is high.

 

[Legend of Link]

if there is a good blood test that bails you out then it’s not even a problem. One major issue with rheum is that we have the opposite. Instead of being bailed out, we have blood tests (ANA) that create major headaches. The state of rheumatology can be vastly improved if the ANA is limited to a test that only rheumatologists can order. Or if the ANA assay can be changed where you reverse the characteristics so that the sensitivity is low but specificity is high.

Does it get frustrating to not have clear cut diagnostics in rheumatology due to significant overlap of symptoms and seronegative diseases? How frequent are those patients?
Also at an earlier post you mentioned that it's not the pay of rheuma that's the concern, rather the type of patient that you see. What types of pathologies reimburses the best?
I know heme onc is also mostly out patient based speciality but I have heard from others that they do get a fair share of nights and weekends, specially if you are in private practice. Idk if that's true.
Honestly I do love medicine. But I also love my time with family more and I love my personal time to pursue other hobbies. I think of medicine just a job. Hence I am looking at a speciality where I don't have to think about a billion different things ( I wanted to do primary care, but I ruled it out due to this), low stress, a reasonable pay (since I have loans to pay and I come from a low income family) and outpatient since I really don't like being in the hospital. Rheuma felt like the best bang for the buck and so did hemeonc. I also thought about allergy a bit but all the talk about bad job market kind of scared me away

 

[Legend of Link]

It does.

I was in your exact same dilemma (heme/onc vs rheum) as a resident and I’m 100% happy with my decision to do rheumatology.

The lifestyle is a lot better (I don’t round in the hospital at all, which is a big deal to me as I detest hospital work). Right now I work 4.5 days a week for $325k. Once I am established, I anticipate easily breaking $400k and working 4 days a week. Our drugs actually work, unlike onc (despite all the progress that has been made with that). Hoards of my patients aren’t dying all the time, as they would be in onc. And at least where I work, the pathology is very legit and I spend most of my day managing real rheumatologic illnesses. I’ll trade a small handful of fibro any day for the massive amounts of BS oncology has to put up with.

Most rheumatologists are happy, and burnout levels are overall lower than they are with onc.

How many patients are you seeing per day on average? Is this in a private practice /with a partnership track? How do you think the future reimbursement and pay will be with the drugs switching to subQ? I heard that big corporations are taking over all private practices, will there be any left to work at once I'm done with my fellowship in 4 to 5 years?
I honestly think fibro is not really that bad as long as you are willing to sit down and listen to them and be open minded.
What kind of BS have you seen in ONC as a resident that averted you away from the speciality? Does the cancer factor weigh really heavy on the physicians as well in terms of mental health? I tend to also feel the emotions that my patients go through that's why I started disliking hospital medicine due to how sick the people can get there.

 

[dozitgetchahi]

How many patients are you seeing per day on average? Is this in a private practice /with a partnership track? How do you think the future reimbursement and pay will be with the drugs switching to subQ? I heard that big corporations are taking over all private practices, will there be any left to work at once I'm done with my fellowship in 4 to 5 years?
I honestly think fibro is not really that bad as long as you are willing to sit down and listen to them and be open minded.
What kind of BS have you seen in ONC as a resident that averted you away from the speciality? Does the cancer factor weigh really heavy on the physicians as well in terms of mental health? I tend to also feel the emotions that my patients go through that's why I started disliking hospital medicine due to how sick the people can get there.

Does it get frustrating to not have clear cut diagnostics in rheumatology due to significant overlap of symptoms and seronegative diseases? How frequent are those patients?
Also at an earlier post you mentioned that it's not the pay of rheuma that's the concern, rather the type of patient that you see. What types of pathologies reimburses the best?
I know heme onc is also mostly out patient based speciality but I have heard from others that they do get a fair share of nights and weekends, specially if you are in private practice. Idk if that's true.
Honestly I do love medicine. But I also love my time with family more and I love my personal time to pursue other hobbies. I think of medicine just a job. Hence I am looking at a speciality where I don't have to think about a billion different things ( I wanted to do primary care, but I ruled it out due to this), low stress, a reasonable pay (since I have loans to pay and I come from a low income family) and outpatient since I really don't like being in the hospital. Rheuma felt like the best bang for the buck and so did hemeonc. I also thought about allergy a bit but all the talk about bad job market kind of scared me away

As a rheumatologist, you have to be a sharp clinician - and you have to be comfortable with uncertainty. Our treatments are cutting edge; our labs are stuck in the 1980s or so. So you have to use your brain, sniffing around lots of symptoms and manifestations for clues, and even then often you are in a “grey zone” where you just have to make the best diagnosis that makes some sense and start treatment from there. To me, this is part of what makes the specialty interesting - the physical exam still matters here, unlike in a lot of other specialties, and it’s not “cookbook medicine” where you simply follow a flowchart. There is no real evidence based “script” for a lot of what we do. (This is why in some vague/unusual situations, you can ask five rheums and hear five different diagnoses.) We rheums generally live for this stuff, but I get that it drives a lot of other docs nuts, and it probably contributes to the perception among other specialties that rheumatology is some sort of impenetrable “dark art” that nobody else can make sense of.

How common are the “gray zone” patients? Sometimes 50% of my day.

I also prioritized lifestyle, and similarly to you I view medicine very much as “just a job”. Rheumatology has delivered an excellent lifestyle with what I view to be very good pay too.

I’ll write more about the rest later.

 

[dozitgetchahi]

???

I agree with the others, clearly Rheum is a better fit for you but I’m not sure how accurate your understanding of Onc is. They’re just very different fields I think with the only overlap being they’re outpatient and the use of infusion drugs.

For example I actually love that there is minimal “BS” in Heme/Onc (although I have heard we have our own Fibro in the form of mast cell disorders there is actually a blood test that can bail us out).

“BS” for me…equals things like inpatient rounding, having large numbers of patients dying or near death, and such. I have yet to encounter a heme/onc doc who is 100% outpatient (how often does that happen, anyway?) and it was sort of a priority for me as between IM residency and rheum fellowship I realized I really had a distaste for inpatient work and belonged in the clinic. I wanted to be fully outpatient.

At least at my IM program, the rheumatology department was a lot happier, less stressed, and just seemed to be enjoying themselves at work more than the oncologists. That certainly colored my view of the two specialties, but it is also a viewpoint that has held up throughout fellowship and into practice. My rheum fellowship was very busy and probably harder than most rheum fellowships out there, but we still didn’t work nearly as hard as the onc fellows at that institution, and we were definitely happier too. I honestly haven’t met too many rheumatologists who are grumpy, stressed, miserable, or who regret choosing the specialty. If anything, I’ve encountered rheums who seem to feel that it’s something of the “best kept secret” in IM.

 

[NewYorkDoctors]

“BS” for me…equals things like inpatient rounding, having large numbers of patients dying or near death, and such. I have yet to encounter a heme/onc doc who is 100% outpatient (how often does that happen, anyway?) and it was sort of a priority for me as between IM residency and rheum fellowship I realized I really had a distaste for inpatient work and belonged in the clinic. I wanted to be fully outpatient.

At least at my IM program, the rheumatology department was a lot happier, less stressed, and just seemed to be enjoying themselves at work more than the oncologists. That certainly colored my view of the two specialties, but it is also a viewpoint that has held up throughout fellowship and into practice. My rheum fellowship was very busy and probably harder than most rheum fellowships out there, but we still didn’t work nearly as hard as the onc fellows at that institution, and we were definitely happier too. I honestly haven’t met too many rheumatologists who are grumpy, stressed, miserable, or who regret choosing the specialty. If anything, I’ve encountered rheums who seem to feel that it’s something of the “best kept secret” in IM.

just curious. what kind of procedures do you routinely do? i mean I have some idea based on what academic rheumatologists do.

I can imagine you do arthrocenteses in any joints, steroid injections (like a sports medicine or orthopedic doctor), MSK ultrasound as point of care, perhaps run some IV infusions if you have the set up to do so, DEXA scans (does that still get reimbursed outside the radiology center? I see some older endo or rheum stilll do in office DEXA)?

 

[dozitgetchahi]

just curious. what kind of procedures do you routinely do? i mean I have some idea based on what academic rheumatologists do.

I can imagine you do arthrocenteses in any joints, steroid injections (like a sports medicine or orthopedic doctor), MSK ultrasound as point of care, perhaps run some IV infusions if you have the set up to do so, DEXA scans (does that still get reimbursed outside the radiology center? I see some older endo or rheum stilll do in office DEXA)?

Sure - all of the above. I’m in a large multispecialty private practice that has two rheumatologists. We have the capability of doing pretty much any imaging modality as an ancillary (aside from PET/CT), including MSK US, DEXA, MRI, etc. I read my own DEXAs.

We have a very busy infusion clinic at my current practice, and local insurance protocols are set up to make it surprisingly easy to get patients authed for infusions, so I’ve already picked up quite a few infusion patients despite being at this job for a few months.

 

[Legend of Link]

Sure - all of the above. I’m in a large multispecialty private practice that has two rheumatologists. We have the capability of doing pretty much any imaging modality as an ancillary (aside from PET/CT), including MSK US, DEXA, MRI, etc. I read my own DEXAs.

We have a very busy infusion clinic at my current practice, and local insurance protocols are set up to make it surprisingly easy to get patients authed for infusions, so I’ve already picked up quite a few infusion patients despite being at this job for a few months.

it sounds like you have a fantastic job setup. Is your pay based on RVU? if it is, you are generating a lot of profit from all those imaging, lab orders, and infusions (also you mentioned it's easy to get the meds prior authed so it makes the job much easier). Do you get any profit sharing at all? Are you on any partnership track with the practice?
How likely it is to find a job like this if I am geographically flexible? In 4-5 years when I'm out there practicing?
If you wouldn't mind sharing, how long have you been practicing as a rheumatologist?
Honestly, talking to you makes me really want to go into rheumatology reading how good your setup is.

 

[dozitgetchahi]

it sounds like you have a fantastic job setup. Is your pay based on RVU? if it is, you are generating a lot of profit from all those imaging, lab orders, and infusions (also you mentioned it's easy to get the meds prior authed so it makes the job much easier). Do you get any profit sharing at all? Are you on any partnership track with the practice?
How likely it is to find a job like this if I am geographically flexible? In 4-5 years when I'm out there practicing?
If you wouldn't mind sharing, how long have you been practicing as a rheumatologist?
Honestly, talking to you makes me really want to go into rheumatology reading how good your setup is.

So, this is a partnership track practice. You get partnership after 1 year for a $10k buy-in. My base salary is $325k, with a $25k signon. You can bonus from day one here. Within the institution, we have a very wide range of services and thus you can collect ancillary income on practically anything - PT (we have our own PT department), all imaging, all sorts of labs (we are one of the biggest labs in the local area so we do almost all rheumatology relevant labs ourselves), PFTs, infusions, swallow evals, EMGs, etc so you can imagine the ancillary potential for a rheumatologist who orders a lot of diverse studies all the time. Like many private practice docs, I’m paid on collections (not RVUs) and in some ways this is better as long as you limit your patient panel to insurance that reimburses well.

However, the one thing that made this job a really really good deal was this. My partner is one of those old school, infusion heavy rheumatologists who makes about $800k a year. The policy of this practice is that all new docs onboarded in a department share the ancillary portion of the department’s income after 6 months. About half his income is ancillaries from infusions, and he was the only person in the department. You can imagine what this means for me in a few months. The rest of the docs in the practice have confirmed that it’s real, and that they got their “cut” in their departments when they joined.

I’ve been practicing almost 5 years now. This is my 3rd job. My first was a hospital job that was totally horrible, and from which I fled for private practice. My first PP job was partnership track in the semi rural south, and the starting pay was good ($300k), but the practice was very mismanaged and turned out to have major financial (and legal) problems. I bailed out of that job after 10 months, when I realized I did not want to be a partner in that institution. This job seems to be much better than either of the first two were.

 

[Legend of Link]

So, this is a partnership track practice. You get partnership after 1 year for a $10k buy-in. My base salary is $325k, with a $25k signon. You can bonus from day one here. Within the institution, we have a very wide range of services and thus you can collect ancillary income on practically anything - PT (we have our own PT department), all imaging, all sorts of labs (we are one of the biggest labs in the local area so we do almost all rheumatology relevant labs ourselves), PFTs, infusions, swallow evals, EMGs, etc so you can imagine the ancillary potential for a rheumatologist who orders a lot of diverse studies all the time. Like many private practice docs, I’m paid on collections (not RVUs) and in some ways this is better as long as you limit your patient panel to insurance that reimburses well.

However, the one thing that made this job a really really good deal was this. My partner is one of those old school, infusion heavy rheumatologists who makes about $800k a year. The policy of this practice is that all new docs onboarded in a department share the ancillary portion of the department’s income after 6 months. About half his income is ancillaries from infusions, and he was the only person in the department. You can imagine what this means for me in a few months. The rest of the docs in the practice have confirmed that it’s real, and that they got their “cut” in their departments when they joined.

I’ve been practicing almost 5 years now. This is my 3rd job. My first was a hospital job that was totally horrible, and from which I fled for private practice. My first PP job was partnership track in the semi rural south, and the starting pay was good ($300k), but the practice was very mismanaged and turned out to have major financial (and legal) problems. I bailed out of that job after 10 months, when I realized I did not want to be a partner in that institution. This job seems to be much better than either of the first two were.

I heard at private practice some senior partners can ''hog'' all the infusion patients and that can hurt the junior doctors financially. Did you notice something like that in your previous private practice? What made you quit if you don't mind me asking? how much were the partners making at that previous practice?
Also, it seems like rheumatologists make the most of their money from patients on infusion. Do you think infusion would still be a thing in the future with all these new subcutaneous drugs? If infusion goes away, will rheumatologist would still be able to generate a good amount of revenue through their other procedures (idk if joint injections pay well) and ancillary?
What would you advise a future budding rheumatologist to look for in a private practice to avoid like the previous one you left and find a good practice like your current one?
I apologize for so many questions..and I really appreciate you taking the time for answering them and helping me and helping all the future rheumatologists on this forum.

 

[dozitgetchahi]

I heard at private practice some senior partners can ''hog'' all the infusion patients and that can hurt the junior doctors financially. Did you notice something like that in your previous private practice? What made you quit if you don't mind me asking? how much were the partners making at that previous practice?
Also, it seems like rheumatologists make the most of their money from patients on infusion. Do you think infusion would still be a thing in the future with all these new subcutaneous drugs? If infusion goes away, will rheumatologist would still be able to generate a good amount of revenue through their other procedures (idk if joint injections pay well) and ancillary?
What would you advise a future budding rheumatologist to look for in a private practice to avoid like the previous one you left and find a good practice like your current one?
I apologize for so many questions..and I really appreciate you taking the time for answering them and helping me and helping all the future rheumatologists on this forum.

I was the only rheumatologist at the last private practice (another large multispecialty group). They were trying to “build an infusion clinic” and have me infuse there. Problem was that they basically didn’t have the money to do this, and their CEO was lying to everyone about the state of the business (it was going under), and they were getting investigated by CMS for billing fraud committed by several of their docs, and some other docs there were getting investigated by the state board for various crimes, etc etc etc. It was just a total ****show, and that was why I left. Most rheumatology jobs aren’t like that. It was just a really bad private practice basically run by criminals. You avoid that experience by getting a full set of financial information on the practice before you sign to start working (and certainly before you become a partner).

Infusion ancillary income is a huge topic unto itself. Most of the money made from infusions is from practices “buying and billing” drugs and keeping the profit. CMS has been trying to cut back on this for years. You can still make a very decent salary ($350k+) as a rheumatologist from billing the visits and getting the imaging/diagnostic ancillaries. The infusion income is the cherry on top.

 

[NewYorkDoctors]

I was the only rheumatologist at the last private practice (another large multispecialty group). They were trying to “build an infusion clinic” and have me infuse there. Problem was that they basically didn’t have the money to do this, and their CEO was lying to everyone about the state of the business (it was going under), and they were getting investigated by CMS for billing fraud committed by several of their docs, and some other docs there were getting investigated by the state board for various crimes, etc etc etc. It was just a total ****show, and that was why I left. Most rheumatology jobs aren’t like that. It was just a really bad private practice basically run by criminals. You avoid that experience by getting a full set of financial information on the practice before you sign to start working (and certainly before you become a partner).

Infusion ancillary income is a huge topic unto itself. Most of the money made from infusions is from practices “buying and billing” drugs and keeping the profit. CMS has been trying to cut back on this for years. You can still make a very decent salary ($350k+) as a rheumatologist from billing the visits and getting the imaging/diagnostic ancillaries. The infusion income is the cherry on top.

are we talking about "annual nuclear stress test for just because the patient has a heart" kind of fraud?

or are we talking about fabricate stuff and hope the patient does not know how to read the EOB?

 

[dozitgetchahi]

are we talking about "annual nuclear stress test for just because the patient has a heart" kind of fraud?

or are we talking about fabricate stuff and hope the patient does not know how to read the EOB?

I’m talking about at least two doctors literally didn’t write a note for two years, and somehow still saw patients, billed CMS and private insurance, and got paid. Said doctor would send me referrals for patients whom he had seen repeatedly, with no documentation written whatsoever.

Another doc saw every single patient through a robot with a camera, because he had been caught groping patients by the practice and had a “gentleman’s agreement” with them that he would see all of them “remotely” even though they were in the room next to him.

Another doc was literally living in his office and had been doing so for years. He apparently had used condoms sitting under his desk all the time.

Another doc was drinking and doing drugs in his office, and writing controlled substance scripts that he was sharing with his office staff. The medical board sent investigators that searched his office and found his drugs and booze.

Another doc got investigated after she asked a patient if they knew where she could find cocaine for her husband.

There was more going on that I don’t even want to get into.

Like I said, ****show. I left.

 

[NewYorkDoctors]

I’m talking about at least two doctors literally didn’t write a note for two years, and somehow still saw patients, billed CMS and private insurance, and got paid. Said doctor would send me referrals for patients whom he had seen repeatedly, with no documentation written whatsoever.

Another doc saw every single patient through a robot with a camera, because he had been caught groping patients by the practice and had a “gentleman’s agreement” with them that he would see all of them “remotely” even though they were in the room next to him.

Another doc was literally living in his office and had been doing so for years.

Another doc was drinking and doing drugs in his office, and writing controlled substance scripts that he was sharing with his office staff. The medical board sent investigators that searched his office and found his drugs and booze.

Like I said, ****show. I left.

yeah that's pretty bad lol. Lionel Hutz and Dr Nick Riviera all in the same building.

i mean honestly most doctors in the office don't write any meaningful notes at all and just do note bloat and make sure to add in some line about "meaningful use."

though with the presence of copy forward, I find writing very sophisticated notes helps me remember what happened the last time... because I just copy it forward and update it.

I can see how writing a dissertation in the era of paper notes would have been very.... time consuming...

but no excuses in the modern era with Copy Forward on EMR

 

[dozitgetchahi]

yeah that's pretty bad lol. Lionel Hutz and Dr Nick Riviera all in the same building.

i mean honestly most doctors in the office don't write any meaningful notes at all and just do note bloat and make sure to add in some line about "meaningful use."

though with the presence of copy forward, I find writing very sophisticated notes helps me remember what happened the last time... because I just copy it forward and update it.

I can see how writing a dissertation in the era of paper notes would have been very.... time consuming...

but no excuses in the modern era with Copy Forward on EMR

Agreed.

Like I said, though, this was a big multispecialty practice (like 80+ docs) and I don’t think what happened there really had anything to do with rheumatology, or even with my specialty. The leadership at that practice was simply money hungry to the point of criminality, and I think they saw rheumatology infusion as some sort of cash cow that they intended to milk for all it was worth (and keep the profit for themselves). Problem was, they had no understanding of rheumatology or infusion in general (and they were also so arrogant and power hungry that they didn’t want to let me tell them how to make it work), and much like the rest of their mismanaged practice, it’s collapsing now.

My current multispecialty practice is nothing like this. Things are well oiled and efficient. Doctors make money, but aren’t greedy or dishonest about it. The infusion suite works, and the previous rheumatologist already has a lot of patients infusing there so we already get significant quantity discounts on infusion drugs.

 

[admitone01]

This is slightly off topic -- but are there any resources to understand what fair compensation is for academic jobs in certain cities? I have no idea of having any idea if what I am being offered is under/average/over to what other starting rheumatologists make in that city. This is for a city in the south that does not have a lot of rheumatologists.

 

[bronx43]

This is slightly off topic -- but are there any resources to understand what fair compensation is for academic jobs in certain cities? I have no idea of having any idea if what I am being offered is under/average/over to what other starting rheumatologists make in that city. This is for a city in the south that does not have a lot of rheumatologists.

Academia or “fakedemia” is sort of in turmoil right now. There is a very wide range of offers when you decide to work for a university affiliated hospital. My previous fakedemic insitutiton was making the faculty see private practice volume and RVU targets for research pay.
A ton of people left and they ended up being forced to increase the pay by literally 40-50%. Now it’s somewhat competitive with what the other jobs in the area are offering.

My advice is that unless you’re going to academia for research, then just compare the pay to private hospital employment and use mgma. Because it’s actually nothing but fakedemia - aka do a clinical job for crappy research pay.

 

[admitone01]

Academia or “fakedemia” is sort of in turmoil right now. There is a very wide range of offers when you decide to work for a university affiliated hospital. My previous fakedemic insitutiton was making the faculty see private practice volume and RVU targets for research pay.
A ton of people left and they ended up being forced to increase the pay by literally 40-50%. Now it’s somewhat competitive with what the other jobs in the area are offering.

My advice is that unless you’re going to academia for research, then just compare the pay to private hospital employment and use mgma. Because it’s actually nothing but fakedemia - aka do a clinical job for crappy research pay.

Thank you for this answer! Also I feel like I should already know this but where do I get the 2022 MGMA data? Do I have to purchase it? Thank you.

 

[Legend of Link]

Agreed.

Like I said, though, this was a big multispecialty practice (like 80+ docs) and I don’t think what happened there really had anything to do with rheumatology, or even with my specialty. The leadership at that practice was simply money hungry to the point of criminality, and I think they saw rheumatology infusion as some sort of cash cow that they intended to milk for all it was worth (and keep the profit for themselves). Problem was, they had no understanding of rheumatology or infusion in general (and they were also so arrogant and power hungry that they didn’t want to let me tell them how to make it work), and much like the rest of their mismanaged practice, it’s collapsing now.

My current multispecialty practice is nothing like this. Things are well oiled and efficient. Doctors make money, but aren’t greedy or dishonest about it. The infusion suite works, and the previous rheumatologist already has a lot of patients infusing there so we already get significant quantity discounts on infusion drugs.

Do you feel like it ever gets tough to get reimbursed for treatment for a specific pathology since many of the diagnoses are in the grey zone? For example, if a patient is indeed in need of an infusion drug but the insurance is denying to reimburse due to diagnostic ambiguity (may be seronegative disease)?
Also, if most of your patients end up actually needing infusion, do you think it's treading in risky waters in terms of the audit?

 

[bronx43]

Do you feel like it ever gets tough to get reimbursed for treatment for a specific pathology since many of the diagnoses are in the grey zone? For example, if a patient is indeed in need of an infusion drug but the insurance is denying to reimburse due to diagnostic ambiguity (may be seronegative disease)?
Also, if most of your patients end up actually needing infusion, do you think it's treading in risky waters in terms of the audit?

You won’t be able to get most patients infusions. That ship has sailed. Infusions are only really possible in patients with Medicare plus a supplemental insurance. Depending on location, this is like 25% of the population (could be less in less affluent locations). It's almost impossible to get someone infusions if they have private insurance, given that there are literally 10 hoops to jump through to get anything. You want Simponi Aria? Too bad, cuz UHC says you have to have tried Humira, Enbrel, Actemra, Xeljanz, and Orencia beforehand. You want IV Orencia? Aetna says "LOL no, use the SC form."

And Medicare Advantage? It's an option IF your patient has the cash on hand to pay 20% co-insurance, which amounts to like 10k a year for any infusion. AKA no one.

Diagnoses are not the problem, you can always code "seronegative RA." The problem is that the infusion game is in the 4th quarter and there are 10 seconds left on the clock. Don't go into rheumatology thinking you'll be able to hit the game winner and profit from them to any significant extent. Most likely you'll survive off 99214s and maybe a few low profit margin ancillaries if you are in PP. For what it's worth, I used to be in a multispecialty physician owned group. I left real quick once I realized the impossibility of getting new infusion patients. It's rare to be in a situation like dozitgetchahi, where the incumbent rheumatologist shares infusion profits. The vast majority just want to use you to appease the group so that "patients can get in" while he/she sits pretty seeing return level 4s and collect the infusion cash. Meanwhile, you're busting your butt seeing the deluge of new positive ANA and "joint pain" referrals.

 

[bronx43]

Thank you for this answer! Also I feel like I should already know this but where do I get the 2022 MGMA data? Do I have to purchase it? Thank you.

If you're in an academic place right now, they may have a copy at the library. Otherwise, you can ask your colleagues... someone usually has a copy.

 

[dozitgetchahi]

You won’t be able to get most patients infusions. That ship has sailed. Infusions are only really possible in patients with Medicare plus a supplemental insurance. Depending on location, this is like 25% of the population (could be less in less affluent locations). It's almost impossible to get someone infusions if they have private insurance, given that there are literally 10 hoops to jump through to get anything. You want Simponi Aria? Too bad, cuz UHC says you have to have tried Humira, Enbrel, Actemra, Xeljanz, and Orencia beforehand. You want IV Orencia? Aetna says "LOL no, use the SC form."

And Medicare Advantage? It's an option IF your patient has the cash on hand to pay 20% co-insurance, which amounts to like 10k a year for any infusion. AKA no one.

Diagnoses are not the problem, you can always code "seronegative RA." The problem is that the infusion game is in the 4th quarter and there are 10 seconds left on the clock. Don't go into rheumatology thinking you'll be able to hit the game winner and profit from them to any significant extent. Most likely you'll survive off 99214s and maybe a few low profit margin ancillaries if you are in PP. For what it's worth, I used to be in a multispecialty physician owned group. I left real quick once I realized the impossibility of getting new infusion patients. It's rare to be in a situation like dozitgetchahi, where the incumbent rheumatologist shares infusion profits. The vast majority just want to use you to appease the group so that "patients can get in" while he/she sits pretty seeing return level 4s and collect the infusion cash. Meanwhile, you're busting your butt seeing the deluge of new positive ANA and "joint pain" referrals.

Of note, the other aspect of my current situation that is making the infusion volume rise faster is that two of the five rheumatologists in a 30 mile radius have left in the last 3 months. My partner has a more or less full clinic, and the other doc is about 30 min away and also doesn’t seem to have the capacity to take on many more new patients. We’re the only rheumatologists for about 2 hours or so. This means I’m inheriting large numbers of already authed infusion patients, and it’s increasing at an increasing rate. I have been working for 3 months and already have probably 25-30 people infusing. Now that the referral pipeline is flowing from these docs that exited their practices, I send 2-3 new patients per day to our infusion clinic.

Now I agree that this is an unusual situation…it certainly wasn’t the case at my last job in the south, where I don’t even think I had accrued 10 infusion patients in the entire 10 months I was there.

Also, I will say that in the states where I’ve worked my last two jobs, authing infusions was much easier than it was where I worked my first hospital job. In my current town, it seems that the local rheumatologists have lots of infusion patients…and if you look at the prior auth flowcharts for RA or PsA for most local insurers, surprisingly Simponi Aria and/or Remicade are listed as first line options for many of them. This definitely isn’t the case in some states (hell, it certainly l wasn’t the case at my first job, where I rarely infused anything other than Rituxan and Reclast).

 

[sloh]

Also, I will say that in the states where I’ve worked my last two jobs, authing infusions was much easier than it was where I worked my first hospital job. In my current town, it seems that the local rheumatologists have lots of infusion patients…and if you look at the prior auth flowcharts for RA or PsA for most local insurers, surprisingly Simponi Aria and/or Remicade are listed as first line options for many of them. This definitely isn’t the case in some states (hell, it certainly l wasn’t the case at my first job, where I rarely infused anything other than Rituxan and Reclast).

Is this more state/location dependent or practice dependent?

 

[dozitgetchahi]

Is this more state/location dependent or practice dependent?

I think it’s more state/location because it seems to depend on how easily the local insurers will auth infusions.

 

[Legend of Link]

I was the only rheumatologist at the last private practice (another large multispecialty group). They were trying to “build an infusion clinic” and have me infuse there. Problem was that they basically didn’t have the money to do this, and their CEO was lying to everyone about the state of the business (it was going under), and they were getting investigated by CMS for billing fraud committed by several of their docs, and some other docs there were getting investigated by the state board for various crimes, etc etc etc. It was just a total ****show, and that was why I left. Most rheumatology jobs aren’t like that. It was just a really bad private practice basically run by criminals. You avoid that experience by getting a full set of financial information on the practice before you sign to start working (and certainly before you become a partner).

Infusion ancillary income is a huge topic unto itself. Most of the money made from infusions is from practices “buying and billing” drugs and keeping the profit. CMS has been trying to cut back on this for years. You can still make a very decent salary ($350k+) as a rheumatologist from billing the visits and getting the imaging/diagnostic ancillaries. The infusion income is the cherry on top.

Is it possible to make that 350k+ seeing patients 4 days /week with zero infusions? Ik it depends on a lot of factors, but is it attainable somewhere in midwest? How many patients would you need to see on average per day?

 

[dozitgetchahi]

Is it possible to make that 350k+ seeing patients 4 days /week with zero infusions? Ik it depends on a lot of factors, but is it attainable somewhere in midwest? How many patients would you need to see on average per day?

Possible? Yes. Possible in Midwest? Definitely yes, because my partner does it already.

If you subtract the infusion income off, my partner makes something like $400-425k just billing the visits; however, he sees 30-32 patients per day 4 days a week, which for rheumatology I think is a bit much if you want to give every patient the attention they deserve. If you have a scribe (he does), then imho 22-25/day is comfortable/pushing your limits a bit. If you don’t have a scribe, 18-20 pts per day starts to feel like a lot.

Keep in mind that all of this depends on a lot of things…if you’re employed, what is your $/wRVU and what’s the RVU threshold for bonusing etc…if you’re PP, then it’s all about your overhead, which ancillaries you pull (if you work in a private practice that has PT as an ancillary, that can be another major revenue source), whether you can get substantial infusion income, etc. In my case, for instance, my goal is to try to infuse a fair amount and use that income to help decrease my overall pt volume somewhat. My big priority is lifestyle - I’d like to average no more than 20 pts per day and work 4-4.5 days a week, but I also want to hustle and make money (like all of us, I got loans and bills to pay). My goal is at least $400k, and hopefully 500k. We’ll see how many pts/day it takes to get there, and adjust expectations accordingly.

As far as other specialties - my choice of rheumatology was, again, largely driven by lifestyle. I’d be miserable rounding in the hospital and being on call as GI, cards, whatever. I’m 100% outpatient and zero call and that is worth a ton to me. You frankly couldn’t pay me enough to do call or round. If I can make $350-500k working 4.5 days a week with zero call and zero inpatient, that sounds pretty freaking good to me.

 

[Legend of Link]

For the salary ranges you're interested in, I would stick to GI/Cards/PCCM/Heme-onc. Starting at 400k+ is typical for these specialties

For your benefit though,
Rheum compensation in the Midwest per MGMA 2020 (based on 2019 data)
75th percentile is 307k
90th percentile is 397k

vs IM hospitalists: 376k, 459k

I was thinking about heme/onc but I worry if that would take a toll on my mental health. I ruled out GI/Cardio since I wanted a bit of a regular life after fellowship.

 

[Legend of Link]

Possible? Yes. Possible in Midwest? Definitely yes, because my partner does it already.

If you subtract the infusion income off, my partner makes something like $400-425k just billing the visits; however, he sees 30-32 patients per day 4 days a week, which for rheumatology I think is a bit much if you want to give every patient the attention they deserve. If you have a scribe (he does), then imho 22-25/day is comfortable/pushing your limits a bit. If you don’t have a scribe, 18-20 pts per day starts to feel like a lot.

Keep in mind that all of this depends on a lot of things…if you’re employed, what is your $/wRVU and what’s the RVU threshold for bonusing etc…if you’re PP, then it’s all about your overhead, which ancillaries you pull (if you work in a private practice that has PT as an ancillary, that can be another major revenue source), whether you can get substantial infusion income, etc. In my case, for instance, my goal is to try to infuse a fair amount and use that income to help decrease my overall pt volume somewhat. My big priority is lifestyle - I’d like to average no more than 20 pts per day and work 4-4.5 days a week, but I also want to hustle and make money (like all of us, I got loans and bills to pay). My goal is at least $400k, and hopefully 500k. We’ll see how many pts/day it takes to get there, and adjust expectations accordingly.

As far as other specialties - my choice of rheumatology was, again, largely driven by lifestyle. I’d be miserable rounding in the hospital and being on call as GI, cards, whatever. I’m 100% outpatient and zero call and that is worth a ton to me. You frankly couldn’t pay me enough to do call or round. If I can make $350-500k working 4.5 days a week with zero call and zero inpatient, that sounds pretty freaking good to me.

Exactly are the reasons I'm leaning toward rheumatology.i want a stable life to spend with my loving family, pursuing hobbies (lifting, gaming, hiking etc) and just think of medicine as a job. Rheumatology does indeed come with the best lifestyle and pay to work ratio.

Money doesn't mean everything but not having enough is tough. Coming from a very low earning family/ 1st generation immigrants, also having med school loans to pay off, I wanted to go into a speciality where the pay is good but did not really want to slave away my life without sleeping and being constantly called in the hospital(I don't like I patient as well, and I love clinics). At the same time I didn't want to cap out on the income potential/ ceiling being too low. I want to give myself and my family a better future.

Rheuma felt like the best match. If ~350-500k is attainable in rheuma with 4-5 days of work than that's my goal. I want to work to live happily, not live to work and slave away and die with regrets.

 

[bronx43]

Exactly are the reasons I'm leaning toward rheumatology.i want a stable life to spend with my loving family, pursuing hobbies (lifting, gaming, hiking etc) and just think of medicine as a job. Rheumatology does indeed come with the best lifestyle and pay to work ratio.

Money doesn't mean everything but not having enough is tough. Coming from a very low earning family/ 1st generation immigrants, also having med school loans to pay off, I wanted to go into a speciality where the pay is good but did not really want to slave away my life without sleeping and being constantly called in the hospital(I don't like I patient as well, and I love clinics). At the same time I didn't want to cap out on the income potential/ ceiling being too low. I want to give myself and my family a better future.

Rheuma felt like the best match. If ~350-500k is attainable in rheuma with 4-5 days of work than that's my goal. I want to work to live happily, not live to work and slave away and die with regrets.

do you want to live in a major metropolitan area? IMO this is the most important and first question someone should ask themselves before they do rheum.

If the answer is yes then I would steer clear away from rheum. If the answer is no then rheum is viable and offers everything you listed above.

Practicing rheum in a major metro area is a fate I wouldn’t wish on my worst enemies. But at the same time, living in a rural area isn’t for everyone.

 

[dozitgetchahi]

Based on the MGMA numbers alone, I would stick to the other 4 specialties. You basically want the 75th-90th percentile income for Rheum. Maybe that's possible by working an extra day, working rural, seeing more patients +/- infusions etc. For reference, 75th/90th outpatient PCP comp in the midwest are 343k, 398k (both higher than Rheum). SDN is a great resource of course, but I wouldn't totally discount MGMA either.

Have you read his posts? He doesn’t care only about money - he cares about lifestyle too. That’s the point I’ve been making here. You can do well with rheumatology and live a reasonable lifestyle. If you don’t like call and/or inpatient medicine, rheumatology (and perhaps allergy/immunology) are where it’s at. If you want to go balls to the wall and work 90 hours a week doing cards or whatever, knock yourself out - but just know that you can also do that with rheum, and make a decent amount of additional money as well, and never enter a hospital or do call. I’d be miserable doing call and rounding, and more and more docs feel this way too.

I understand that SDN reasoning is usually all about the benjamins, but in the real world there’s more to focus on/care about. Y’all need to broaden your horizons a bit.

 

[Legend of Link]

do you want to live in a major metropolitan area? IMO this is the most important and first question someone should ask themselves before they do rheum.

If the answer is yes then I would steer clear away from rheum. If the answer is no then rheum is viable and offers everything you listed above.

Practicing rheum in a major metro area is a fate I wouldn’t wish on my worst enemies. But at the same time, living in a rural area isn’t for everyone.

Growing up in a big city and then living in NYC after I came to the US, I came to really despise living in big cities. I do not like it at all.

I have always liked rural settings since my childhood and that's what I have always wanted to do after my residency and fellowship. To go to a rural town, stay there in peace, and make a good living.

Honestly, I felt lucky when I learned that salary is much better in rural areas cause I am just tired of living in big metros by now.

 

[Legend of Link]

Have you read his posts? He doesn’t care only about money - he cares about lifestyle too. That’s the point I’ve been making here. You can do well with rheumatology and live a reasonable lifestyle. If you don’t like call and/or inpatient medicine, rheumatology (and perhaps allergy/immunology) are where it’s at. If you want to go balls to the wall and work 90 hours a week doing cards or whatever, knock yourself out - but just know that you can also do that with rheum, and make a decent amount of additional money as well, and never enter a hospital or do call. I’d be miserable doing call and rounding, and more and more docs feel this way too.

I understand that SDN reasoning is usually all about the benjamins, but in the real world there’s more to focus on/care about. Y’all need to broaden your horizons a bit.

It's really good to see there are still other physicians out there that really value lifestyle and it's not only about money. Thank you so much for your input.

I wanted to ask which states do you think would be best to practice as a rheuma? I remember you mentioning in some states it is easier to get auth by local insurance for infusion. Which states would that be? Is there any resources/ website I can access for that kind of info?

 

[Legend of Link]

I did. How does outpatient pcp lifestyle compare to rheum? Genuine question because I don’t know. They also don’t have inpatient rounding, work weekends, take call, and salary appears comparable based on mgma numbers

I initially wanted to do PCP as well but came to not like it anymore after a few rotations. At places, you become a glorified referral machine cause your income is mostly tied to how many patients you can see a day (some can see up to 30+), not on the quality of care for each patient.

Also, you have to deal with a lot of non-evidence-based things. It's common in all specialties, but it's the most in PCP.

Also rhema has more income potential. I think MGMA does not really capture all revenues.

Not to mention in rheuma you can get involved with pharmaceutical consulting (biologics are always evolving). But I may be wrong. Maybe the attendings can put more insight into that.

 

[bronx43]

I initially wanted to do PCP as well but came to not like it anymore after a few rotations. At places, you become a glorified referral machine cause your income is mostly tied to how many patients you can see a day (some can see up to 30+), not on the quality of care for each patient.

Also, you have to deal with a lot of non-evidence-based things. It's common in all specialties, but it's the most in PCP.

Also rhema has more income potential. I think MGMA does not really capture all revenues.

Not to mention in rheuma you can get involved with pharmaceutical consulting (biologics are always evolving). But I may be wrong. Maybe the attendings can put more insight into that.

The whole biologic obsession is mostly hot air to be honest. Not sure why people think biologics are so sexy… they’re not. Most of them are for like 3 indications and simply crowd the market instead of advancing the scope of the specialty. They’ve also been around for decades now so most aren’t even “new and exciting.” If anything, rheum is going the way of small molecule medications and not biologics. You know what are actually new and exciting biologics? The new diabetes drugs like Ozempic.

They’re also a pain in the a**. You have to hire staff just to run prior authorizations and fight the insurers. You need to do paperwork to get people on assistance programs - none of which would the clinic be reimbursed. So you’re basically expending resources to enrich the pharmaceuticals and save insurers money.

Can you consult for pharma? Kind of. It’s harder to break in than you think. Speaking opportunities are dwindling as well.

My view of rheum is that we are about to enter another dark ages. Infusions are on its death bed since every new drug that comes out is subcutaneous, oral, or lowly reimbursed. Even with discounts with bulk buying, the profit margins on most drugs are slim. Only two drugs are anything close to a “cash cow.” Ultrasounds are getting cut every year. Injections are whatever. There was the biologic renaissance in the early 2000s but it’s basically over. Research breakthroughs have slowed down again. I highly doubt we see anything meaningful for our bread and butter in the near future.