Rheumatology vs Infection disease fellowship prospectives

[KristinaV]

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So after working multiple years as a hospitalist in the metro area I decided to apply for the fellowship. Let’s say, I started my residency late, being IMG, now considering only 2 year fellowship options … before moving to pre retirement phase🙂)) . ID/Rheum/Nephro.
ID and nephro would be easier choice after multiple years working in the hospitals and managing pts by myself until I really required help from the specialists. But everyone is discouraging to go there… just want to mention that hospitalist’s salary in the big metro area is pretty low and I have no plan to move to rural.
Rheum is respected, sophisticated, interesting but competitive and likely required 1 year to prepare with publications… Plus concern about working as rheum in the metro area … is it really significant difference in the compensation between rheum, id or nephro in the metro areas like NYC, LA or Chicago ?

 

[dozitgetchahi]

So after working multiple years as a hospitalist in the metro area I decided to apply for the fellowship. Let’s say, I started my residency late, being IMG, now considering only 2 year fellowship options … before moving to pre retirement phase🙂)) . ID/Rheum/Nephro.
ID and nephro would be easier choice after multiple years working in the hospitals and managing pts by myself until I really required help from the specialists. But everyone is discouraging to go there… just want to mention that hospitalist’s salary in the big metro area is pretty low and I have no plan to move to rural.
Rheum is respected, sophisticated, interesting but competitive and likely required 1 year to prepare with publications… Plus concern about working as rheum in the metro area … is it really significant difference in the compensation between rheum, id or nephro in the metro areas like NYC, LA or Chicago ?

First, don’t do renal. Pay is bad, lifestyle is bad, jobs are not plentiful, and lots of renal doctors end up doing a ton of hospitalist work to make ends meet. Renal is not worth it.

ID? ID is interesting (I ultimately chose between ID, rheum and Heme/onc and went with rheum) but if you want a pay bump over being a hospitalist, it may not be there. (Remember too that you will be losing two years of attending income to make peanuts as a fellow again.)

Rheumatology…I happen to like rheumatology. I am a rheumatologist, and for me it has worked out well. I live in a semi rural area and pulled $540k last year in a private practice working 4.5 days a week. I became a partner recently and am on track to make even more this year. However, if you want to stay in the urban areas, the pay isn’t going to be this good (especially if you are employed by a hospital).

You also have to consider whether you like inpatient or outpatient work. ID is a predominantly inpatient specialty, whereas rheumatology is overwhelmingly outpatient (I don’t round in the hospital at all).

 

[NewYorkDoctors]

Read the Nephrology is Dead Thread before "thinking about nephrology because it might be better than hospitalist."

Yes not everyone needs or wants to make over one million a year chasing dialysis and ATN patients around ... a few entrepreneurial nephrologists can attain this with the proper "connections."

but in general, the most "stable" jobs are the hospital employed nephrology jobs whether academic or not.

without a HD panel yet, you could start as low as $150,000 a year and be given a clinical educator title perhaps if there are fellows/residents around in NYC. I kid you not.


sounds like you have admiration for Rheum. go for it.

 

[bronx43]

So after working multiple years as a hospitalist in the metro area I decided to apply for the fellowship. Let’s say, I started my residency late, being IMG, now considering only 2 year fellowship options … before moving to pre retirement phase🙂)) . ID/Rheum/Nephro.
ID and nephro would be easier choice after multiple years working in the hospitals and managing pts by myself until I really required help from the specialists. But everyone is discouraging to go there… just want to mention that hospitalist’s salary in the big metro area is pretty low and I have no plan to move to rural.
Rheum is respected, sophisticated, interesting but competitive and likely required 1 year to prepare with publications… Plus concern about working as rheum in the metro area … is it really significant difference in the compensation between rheum, id or nephro in the metro areas like NYC, LA or Chicago ?

Respected? By whom? I guess when compared to hospital medicine and neph...

As I've said numerous times on these forums, you're better off as a PCP in major metro areas like NYC, LA or Chicago. I seriously would rather go lift boxes at Costco than work in these cities as a rheumatologist.

If you have no plans to move to rural, then don't do rheum.

 

[dozitgetchahi]

Respected? By whom? I guess when compared to hospital medicine and neph...

As I've said numerous times on these forums, you're better off as a PCP in major metro areas like NYC, LA or Chicago. I seriously would rather go lift boxes at Costco than work in these cities as a rheumatologist.

If you have no plans to move to rural, then don't do rheum.

I agree that by income alone, I don’t see the advantage in doing a rheumatology fellowship if you’re going to work in an urban area. You’ll get paid about the same (possibly less) as a rheumatologist and lose two years of attending salary.

OP, do you like being a hospitalist? Do you really want to do something else, or do you just have a sense that you “should specialize” (a lot of people feel this way without realizing what drives that)? Do you like outpatient IM? Do you have any desire to be a PCP?

Another thought: if you really want to do a fellowship and want to keep it low impact, you could consider the one year fellowships. Of these, sleep probably would be the one that makes (some) sense…or maybe palliative, if you’re just looking for a change of pace. I think IM can do sports medicine, too?

 

[NewYorkDoctors]

dont forget many IMG/FMGs have a fascination of being a "specialist."

that IM is a "specialty" and card/GI/pulm/renal/rheum/hemeonc etc are "subspecialties" is not really acknowledged for some.

it is "generalist" versus "specialist."

This is not a criticism of others. I am just being empathetic to other's viewpoints. It's to point out specializing in a more "prestigious" subspecialty brings a ton of value to one's personal feeling of worth and overall life happiness. This is independent of income. If that is the case with OP, then OP should pursue the "more prestigious subspecialty."

 

[sloh]

think IM can do sports medicine, too?

I would not recommend sports med if OP wants to live in an urban location. It’s probably 2x worse than rheum in an urban location.

 

[dozitgetchahi]

I would not recommend sports med if OP wants to live in an urban location. It’s probably 2x worse than rheum in an urban location.

Yeah I wondered about that too. I figure that most of what gets dumped on sports medicine is the stuff I try as hard as I possibly can to keep out of my clinic, I.e. severe osteoarthritis.

 

[dozitgetchahi]

dont forget many IMG/FMGs have a fascination of being a "specialist."

that IM is a "specialty" and card/GI/pulm/renal/rheum/hemeonc etc are "subspecialties" is not really acknowledged for some.

it is "generalist" versus "specialist."

This is not a criticism of others. I am just being empathetic to other's viewpoints. It's to point out specializing in a more "prestigious" subspecialty brings a ton of value to one's personal feeling of worth and overall life happiness. This is independent of income. If that is the case with OP, then OP should pursue the "more prestigious subspecialty."

Right, but as Warren Buffet once said “price is what you pay, value is what you get”.

Giving up two years of attending pay to work as a peon trainee again just to satisfy some weird cultural “urge to subspecialize” where you won’t make any more money at the end is utterly stupid…unless you have a real desire to do the specialty.

This kind of thinking is how random FMG IM doctors end up doing renal fellowships, and hating their lives afterwards.

 

[NewYorkDoctors]

Well no Student debt like many AMGs certainly helps .

When you got nothing you got nothing to lose like Jack said to fabrizio . Fair enough .

Though reminder Jack did not make it off the titanic. Same analogy applies to the sinking ship that is nephrology

 

[KristinaV]

It’s really funny about IMG being specialised🙂)) I still believe in the higher pay as ID with some experience compare to Hospitalist. As Hospitalist we have 25 pts a day plus 2 hrs spending with residents and like 1 hour to talk to case managers … about walkers and so on… boring…. Pay the same, there is no “partner” in hospitalist word. The number of the patients is climbing up… every year.
ID should work for multispecialty group probably, job is on every corner, can do stewardship, see pts in the hospital without wasting time on case managers, can open own infusion clinic for osteo pts/hiv/hep/sylhilis/ulcers.
I looked for career as rheumo… the same pay as ID or less in urban areas…but ID can get pay because of volume … always high in metro areas. Not that complicated cases. Strait-forward..
Rheumo is required only in academic centers, but if you have to spend 1 hr on 1 complicated rheumo pt… you would not get volume…. And sitting in the office all day and doing only injection all day for money… sounds not as fascinating … Rheumo is not in high demand in metro areas but very good offers and high demand in rural.… though not sure about anything … just thoughts

 

[dozitgetchahi]

It’s really funny about IMG being specialised🙂)) I still believe in the higher pay as ID with some experience compare to Hospitalist. As Hospitalist we have 25 pts a day plus 2 hrs spending with residents and like 1 hour to talk to case managers … about walkers and so on… boring…. Pay the same, there is no “partner” in hospitalist word. The number of the patients is climbing up… every year.
ID should work for multispecialty group probably, job is on every corner, can do stewardship, see pts in the hospital without wasting time on case managers, can open own infusion clinic for osteo pts/hiv/hep/sylhilis/ulcers.
I looked for career as rheumo… the same pay as ID or less in urban areas…but ID can get pay because of volume … always high in metro areas. Not that complicated cases. Strait-forward..
Rheumo is required only in academic centers, but if you have to spend 1 hr on 1 complicated rheumo pt… you would not get volume…. And sitting in the office all day and doing only injection all day for money… sounds not as fascinating … Rheumo is not in high demand in metro areas but very good offers and high demand in rural.… though not sure about anything … just thoughts

Well, the hospitalist job you have right now sucks. But there are other hospitalist jobs out there which are much better than that. My last two jobs were with multispecialty private practices, and both of these practices had hospitalists that rounded at nearby hospitals…and these hospitalists were indeed partners. So you actually can do that. They don’t have residents and they don’t spend hours messing with care managers. You may just need to find a different hospitalist job.

Rheum is not “just required in academic centers”…I have had several community rheumatology jobs, and even in an urban area I was busy as **** with pretty legit rheumatologic issues. I did not do injections all day at any of my rheumatology jobs…in fact, as procedures they do not pay well and I avoid doing them as much as possible.

ID doesn’t usually pay that well. There’s a reason why ID is also having trouble filling the fellowship slots right now.

 

[Splenda88]

dont forget many IMG/FMGs have a fascination of being a "specialist."

that IM is a "specialty" and card/GI/pulm/renal/rheum/hemeonc etc are "subspecialties" is not really acknowledged for some.

it is "generalist" versus "specialist."

This is not a criticism of others. I am just being empathetic to other's viewpoints. It's to point out specializing in a more "prestigious" subspecialty brings a ton of value to one's personal feeling of worth and overall life happiness. This is independent of income. If that is the case with OP, then OP should pursue the "more prestigious subspecialty."

I kind of have that feeling reading OP's post.

 

[Splenda88]

It’s really funny about IMG being specialised🙂)) I still believe in the higher pay as ID with some experience compare to Hospitalist. As Hospitalist we have 25 pts a day plus 2 hrs spending with residents and like 1 hour to talk to case managers … about walkers and so on… boring…. Pay the same, there is no “partner” in hospitalist word. The number of the patients is climbing up… every year.
ID should work for multispecialty group probably, job is on every corner, can do stewardship, see pts in the hospital without wasting time on case managers, can open own infusion clinic for osteo pts/hiv/hep/sylhilis/ulcers.
I looked for career as rheumo… the same pay as ID or less in urban areas…but ID can get pay because of volume … always high in metro areas. Not that complicated cases. Strait-forward..
Rheumo is required only in academic centers, but if you have to spend 1 hr on 1 complicated rheumo pt… you would not get volume…. And sitting in the office all day and doing only injection all day for money… sounds not as fascinating … Rheumo is not in high demand in metro areas but very good offers and high demand in rural.… though not sure about anything … just thoughts

You must have bad hospitalist job.

I am not in a metro but in a small city. My last day of work was Wednesday 8/14/24 (I usually work 1-2 days extra) and I had 11 patients in my census and left the hospital 1:30pm. YTD income on today's paystub is $303,630.10

 

[KristinaV]

You must have bad hospitalist job.

I am not in a metro but in a small city. My last day of work was Wednesday 8/14/24 (I usually work 1-2 days extra) and I had 11 patients in my census and left the hospital 1:30pm. YTD income on today's paystub is $303,630.10

no discussion about rural areas for ID, rheum or IM.

this post is about metro area where you are so good that volume is not bothering you anymore . volume actually is good for private practices, more volume means more compensation.

by the way, just reviewed ACR. looks like the income for rheum is 50% more than mgma report in solo practice. likely due to treatment of back pain. mgma is more about data from hospital and academic setting. not every solo practice is giving you info about their compensation.
if you are out of network and just one in the area... you can charge as much as you want🙂)) my thoughts

 

[dozitgetchahi]

no discussion about rural areas for ID, rheum or IM.

this post is about metro area where you are so good that volume is not bothering you anymore . volume actually is good for private practices, more volume means more compensation.

by the way, just reviewed ACR. looks like the income for rheum is 50% more than mgma report in solo practice. likely due to treatment of back pain. mgma is more about data from hospital and academic setting. not every solo practice is giving you info about their compensation.
if you are out of network and just one in the area... you can charge as much as you want🙂)) my thoughts

I’m confused - so much here is not making sense. I’m not sure where you are getting some of these ideas.

Rural docs tend to make more than urban docs. This has to do with supply and demand for *doctors*, not patients (I have a more robust supply of referrals as a rheumatologist in a rural area because I’m not competing with a bazillion other rheumatologists in some saturated urban area for referrals.) It’s often easier to get patients in rural areas than urban areas, oddly enough.

Yes, PP rheumatologists often make more than hospital employed rheumatologists. This has nothing to do with treating back pain and everything to do with collecting ancillaries in PP, particularly infusion revenues. Regardless, you can’t just charge whatever you want for visits unless you’re a cash only concierge doctor or something…CMS rules, and all that.

 

[NewYorkDoctors]

while more volume = more revenue... there is dimnishing returns to this. As a subspecialist, you cannot possibly keep this on a linear curve without sacrificing quality of care

PCPs can do this nonsense. Demote oneself to the level of a midlevel in terms of usefulness and run a 99213 mill and refer away. But as a specialist, you really need to figure out the issues. Some issues are complex and need a lot of time to work out. A subspecialist who runs a mill and does not really do things properly is trash IMO and is better off just doing PCP and self demoting oneself to PA / NP rank, swallowing pride, and collecting that sweet 99213 mill cider.

 

[NewYorkDoctors]

A common thing I see in the community with community pulmonologists around me is they do NOT manage bronchiectasis properly at all.
Sure some focal post infectious bronchiectasis with no symptoms is whatever meh

But chronic cough with bronchiectasis does need a bit of a workup before saying "oh it's all TB." I have made a few diagnoses of adult onset CF. Upper lobe bronchiectasis without history of TB.... fortunately the Children's Hospital nearby is helpful with sweat testing then doing genetic testing... this stuff is a hueg time sink but it is the RIGHT thing to do

even takin the more common NTM and RML and lingular bronchiectasis.... the IDSA guidelines are not fully met and other community pulmos put patients onto RIF AZI EMB... then ALIS..... without every starting pulmonary hygiene or doing GERD / dietary / lifestyle modifications.
Getting nebulized saline, flutter valve, and chest physiotherapy is crucial... ,those things take some time to arrange but with a good offfice staff and RT staff this is not a big time sink at all.... but community pulmos just ignore all that because "anything that gets in the way of my maximizing my revenue / effort ratio will not be tolerated!"


but in general in the community there is no "peer oversight" as in an academic setting. Therefore, everyon takes shortcuts as long as the "standard of care" (bare minimum) is met


now don't get me wrong, I don't like to have patients spend 2 hours on a visit like the resident/fellow see patient then see attending then discuss and and learn and waste patient 2 hours of time... I have "automated" many of these "patient navigation" processes (i.e. DME ordering, prior auths, arranging for referrals to hospital facilities through EPIC, arranging for radiology scheduling by the radiology center) to save a lot of time. but a lot of effort was required to get this "automation" set up.


in general I see too many "shortcuts" being taken by community doctors. These shortcuts serve no real benefit to the patient. It just allows the doctor to leave on time and have "work life balance." Now I get if the doctor is an employee of a health system in which administrators are mooching off of their productivity. But for pure private practice hunt what you eat doctors, this kind of behavior is despicable. This is the same behavior I call about providers who overprescribe statins for PRIMARY prevention and never giving any talk about lifestyle modifications (bcause many of these providers are not doing the AHA recommended 150 minutes of moderate intensity exercise per week themselves)

 

[dozitgetchahi]

A common thing I see in the community with community pulmonologists around me is they do NOT manage bronchiectasis properly at all.
Sure some focal post infectious bronchiectasis with no symptoms is whatever meh

But chronic cough with bronchiectasis does need a bit of a workup before saying "oh it's all TB." I have made a few diagnoses of adult onset CF. Upper lobe bronchiectasis without history of TB.... fortunately the Children's Hospital nearby is helpful with sweat testing then doing genetic testing... this stuff is a hueg time sink but it is the RIGHT thing to do

even takin the more common NTM and RML and lingular bronchiectasis.... the IDSA guidelines are not fully met and other community pulmos put patients onto RIF AZI EMB... then ALIS..... without every starting pulmonary hygiene or doing GERD / dietary / lifestyle modifications.
Getting nebulized saline, flutter valve, and chest physiotherapy is crucial... ,those things take some time to arrange but with a good offfice staff and RT staff this is not a big time sink at all.... but community pulmos just ignore all that because "anything that gets in the way of my maximizing my revenue / effort ratio will not be tolerated!"


but in general in the community there is no "peer oversight" as in an academic setting. Therefore, everyon takes shortcuts as long as the "standard of care" (bare minimum) is met


now don't get me wrong, I don't like to have patients spend 2 hours on a visit like the resident/fellow see patient then see attending then discuss and and learn and waste patient 2 hours of time... I have "automated" many of these "patient navigation" processes (i.e. DME ordering, prior auths, arranging for referrals to hospital facilities through EPIC, arranging for radiology scheduling by the radiology center) to save a lot of time. but a lot of effort was required to get this "automation" set up.


in general I see too many "shortcuts" being taken by community doctors. These shortcuts serve no real benefit to the patient. It just allows the doctor to leave on time and have "work life balance." Now I get if the doctor is an employee of a health system in which administrators are mooching off of their productivity. But for pure private practice hunt what you eat doctors, this kind of behavior is despicable. This is the same behavior I call about providers who overprescribe statins for PRIMARY prevention and never giving any talk about lifestyle modifications (bcause many of these providers are not doing the AHA recommended 150 minutes of moderate intensity exercise per week themselves)

Agree about the shortcuts. A lot of what I do in rheumatology is what I call “detangling”…namely, fixing all the stuff done in the name of “shortcuts”.

I also agree that there is a lot of weird folklore and BS surrounding bronchiectasis. For instance, there is a pulm doc near me who seems to think that all bronchiectasis is Sjögren’s until proven otherwise. So for a while, my office was flooded with random sick patients with bronchiectasis, hacking up cupfuls of stuff, apparently sent because she thought they all needed workup for Sjogrens. Apparently she saw a case of this once (which is very rare, btw, and never the first thing anyone should think of when diagnosing bronchiectasis) and then thought everyone should be checked for it. This finally stopped after I had a phone conversation with her…but she has some other rather “interesting” habits, like bronching every single GPA patient annually whether or not they have any active ILD or need for a bronch, etc.

I agree that community medicine leaves some docs way too much latitude to go off script and do stupid **** sometimes, or pick up weird habits that aren’t rooted in any data or good practice…

 

[NewYorkDoctors]

doing the "right thing by the book" sometimes takes a lot of time and effort . It is often not possible to "do things by the book" unless you
- have residents/fellows or mid-levels
- good ancillary support staff

without cutting your patient volume.