The Nocturnist Guide You Never Wanted But Are Getting Anyway. Also, like, AMA? I guess? If you really feel like it? Compliment compliment question?

[Planes2Doc]

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Is that 208/hr including the bonuses?

Then down to 170/hr after factoring in the extra apartment and 10 hour round trip commute per block?

Yeah pretty much. Having to pay for the apartment and commute sucks. The apartment isn't too bad though. Around $700 per month. A hotel would still be pricey unless I stayed in a very cheap motel. So this is a better option for me. It's the cost of having a much better position than what I could have had in Chicago.

 

[tantacles]

Ok, fun quick update.

Set a limit for yourself. 25 shifts in a month is too many. Love the paycheck I just got, but March was hell and I worked WAY too much.

Aiming for 15-16 shifts per month in the future. That puts me at a gross of around 400-450K.

 

[Splenda88]

Ok, fun quick update.

Set a limit for yourself. 25 shifts in a month is too many. Love the paycheck I just got, but March was hell and I worked WAY too much.

Aiming for 15-16 shifts per month in the future. That puts me at a gross of around 400-450K.

15-16 shifts/month is the average hospitalist/nocturnist job out there, and they pay nowhere close to 400k/yr...

I just had an interview for a nocturnist job and the total pay (base + incentive) might be 320k/yr and it's about 1 hr away from a big city. Your job is atypical.

 

[tantacles]

15-16 shifts/month is the average hospitalist/nocturnist job out there, and they pay nowhere close to 400k/yr...

I just had an interview for a nocturnist job and the total pay (base + incentive) might be 320k/yr and it's about 1 hr away from a big city. Your job is atypical.

Cool! My job is atypical, but it is still my job.

 

[Splenda88]

Cool! My job is atypical, but it is still my job.

You definitely have a cool gig. Wish I could find something similar. Tell me how to find a job like that as a new grad.

 

[Osteoth]

15-16 shifts/month is the average hospitalist/nocturnist job out there, and they pay nowhere close to 400k/yr...

I just had an interview for a nocturnist job and the total pay (base + incentive) might be 320k/yr and it's about 1 hr away from a big city. Your job is atypical.

10 12hr shifts per month?

 

[Splenda88]

10 12hr shifts per month?

15 12hr shifts...

 

[tantacles]

You definitely have a cool gig. Wish I could find something similar. Tell me how to find a job like that as a new grad.

ummmmmm network? Live in a very high cost of living city on the west coast?

 

[Osteoth]

15 12hr shifts...

Yeah. That’s the thing that I’ve found about general IM jobs, both hospitalist and PCP, there are a lot of trash offers out there.

Especially now, everyone is trying to take advantage of grads because of covid, but I’ve heard the market is slowly picking up.

 

[Osteoth]

ummmmmm network? Live in a very high cost of living city on the west coast?

I need a how to network guide next plz...

 

[deleted849476]

Do you try to be awake during the day on your time off, or are you just a vampire all month long? What other factors are there beyond circadian rhythm disturbances that might contribute to burnout as a nocturnist, if any?

Do you do any more/fewer procedures than the day crew (I imagine fewer...) and are there any that are more common or unique to night situations?

Is pt mortality/acuity at all related to nighttime? In general how common is it for pts to die in a hospital ward (not ICU) ? (M1 here)

Would skill atrophy be a concern of yours at any point if one day you wanted to do days or even just outpatient general IM? I believe I've heard its easier to transition from hospital to clinic in one's career than the other way around.

Lastly, how long has it taken into attendinghood to feel maximally comfortable in your job, or how long do you expect it to take?

Thanks again for the thread!

 

[Splenda88]

Yeah. That’s the thing that I’ve found about general IM jobs, both hospitalist and PCP, there are a lot of trash offers out there.

Especially now, everyone is trying to take advantage of grads because of covid, but I’ve heard the market is slowly picking up.

It was presented to me as a good gig... The market is rough right now and I hope things pick up since I am starting to get desperate.

 

[Osteoth]

It was presented to me as a good gig... The market is rough right now and I hope things pick up since I am starting to get desperate.

15 12s over 12 months is 2160 hours. $310k divided by 2160 is around $143/hr. Low for a nocturnist from what I’ve seen.

How long is their contract? How hard is it to get out? Is there a restrictive covenant?

Could always work it for a few months then either attempt to renegotiate or find a better job. I’ve been seeing 90 days as the notice you need to give before leaving.

Have you looked into the locums market? I’m curious what that’s like now a days

 

[Splenda88]

15 12s over 12 months is 2160 hours. $310k divided by 2160 is around $143/hr. Low for a nocturnist from what I’ve seen.

How long is their contract? How hard is it to get out? Is there a restrictive covenant?

Could always work it for a few months then either attempt to renegotiate or find a better job. I’ve been seeing 90 days as the notice you need to give before leaving.

Have you looked into the locums market? I’m curious what that’s like now a days

You are correct that it is low. Contract is only 2 yrs... I have not signed anything yet.

 

[tantacles]

Do you try to be awake during the day on your time off, or are you just a vampire all month long? What other factors are there beyond circadian rhythm disturbances that might contribute to burnout as a nocturnist, if any?

Switching back and forth isn’t hard for me but in non work life I’m one of those people who is up until 3am anyway.

Lack of support is a big thing. I will admit I sometimes feel blamed for things beyond my control. For example, couldn’t get in touch with a consultant overnight a few nights ago for an issue that probably didn’t need overnight intervention but I wasn’t sure. The consultant who was on call was listed incorrectly and I went through the answering service 5 times (as did the ED physician).

My boss’ answer when I told her? “Why didn’t you transfer the patient out?”

Sure, totally would have done that if it weren’t 2:30 am. And if the morning weren’t 4 hours away. But why am I being scolded because our consultants weren’t available?

Do you do any more/fewer procedures than the day crew (I imagine fewer...) and are there any that are more common or unique to night situations?

Our hospitalists don’t do procedures.

Is pt mortality/acuity at all related to nighttime? In general how common is it for pts to die in a hospital ward (not ICU) ? (M1 here)

Can’t speak for everywhere but I’ve only had two true code blues overnight since I started.

Would skill atrophy be a concern of yours at any point if one day you wanted to do days or even just outpatient general IM? I believe I've heard its easier to transition from hospital to clinic in one's career than the other way around.

I do more medicine than my day colleagues, not less. I make decisions on my own generally and they have much more help. I think their skills are more likely to atrophy than mine.

Lastly, how long has it taken into attendinghood to feel maximally comfortable in your job, or how long do you expect it to take?

If you are ever truly comfortable practicing medicine, you’re doing it wrong.

 

[Splenda88]

What's the average RVU for hospitalist?

I just got a contract that offer $18/wRVU above 430 per month. How many RVU can one generate per month seeing an average of 20 patients for 15 days (including a total of 30 admissions for the months)?

 

[Meerkatology]

thoughts/questions from a fellow nocturnist here -

background:
-i've been working close to 7 years as a fulltime nocturnist which is the only job i had since getting out of IM residency
-i have a light schedule for fairly low pay- i do 18 shifts a month averaging about 8 hours eachshift. and average about 2 admissions per shift with cross cover duties. with that said, most of the patients are very old/sick and alot of them need a translator. rare to get the healthy 40 year old with chole.
-theres close to 2 shifts worth of PTO per month and my pay is about 210k with option to cash out pto.
-we do manage icu patients but don't do procedures/codes. intensivist support is always available if needed

my reasons for becoming a nocturnist are pretty much the same as you. and like you i keep a daytime sleep schedule other than during extended off periods.

we are getting bought by another group and moving to a 7 on 7 off schedule with likely a small increase in census per hours as well. this will come with a pay raise but don't know how much yet. im trying to find out from other nocturnists regarding their workload vs salary to get an idea of whether im still getting a desirable gig or should i be looking for other opportunities. (location is southern california if it matters)
how many admissions do you average per night?

also do you guys feel that having an alternate, though consistent sleep schedule affects your health? i feel like im getting old rather quickly over the past 7 years but maybe its my imagination 😀

if there are anyone here who has been working for a longtime as an exclusive nocturnist, do you think it negatively affects your clinical skills? since we are seeing overall a less volume and are limited to admissions/er triaging.

 

[Splenda88]

thoughts/questions from a fellow nocturnist here -

background:
-i've been working close to 7 years as a fulltime nocturnist which is the only job i had since getting out of IM residency
-i have a light schedule for fairly low pay- i do 18 shifts a month averaging about 8 hours eachshift. and average about 2 admissions per shift with cross cover duties. with that said, most of the patients are very old/sick and alot of them need a translator. rare to get the healthy 40 year old with chole.
-theres close to 2 shifts worth of PTO per month and my pay is about 210k with option to cash out pto.
-we do manage icu patients but don't do procedures/codes. intensivist support is always available if needed

my reasons for becoming a nocturnist are pretty much the same as you. and like you i keep a daytime sleep schedule other than during extended off periods.

we are getting bought by another group and moving to a 7 on 7 off schedule with likely a small increase in census per hours as well. this will come with a pay raise but don't know how much yet. im trying to find out from other nocturnists regarding their workload vs salary to get an idea of whether im still getting a desirable gig or should i be looking for other opportunities. (location is southern california if it matters)
how many admissions do you average per night?

also do you guys feel that having an alternate, though consistent sleep schedule affects your health? i feel like im getting old rather quickly over the past 7 years but maybe its my imagination 😀

if there are anyone here who has been working for a longtime as an exclusive nocturnist, do you think it negatively affects your clinical skills? since we are seeing overall a less volume and are limited to admissions/er triaging.

Only 2 admits per night is good, but I think 210k/yr is too low. Almost all the nocturnist jobs I have seen pay 300k+/yr (12 hrs, 7 days on/off); however, the average admit is 8-12. In my opinion, more than 8 admits per night on a 12 hr-shift is not safe.

I interviewed for hospitalist job the other day, and the PD was also selling me an open nocturnist position that pays 385k/yr.... 12 hrs, 7 on/off and average admit was 8-10.

 

[Meerkatology]

ya i see alot of "10-12 admits per night" jobs. they pay well but sounds like hell especially if its 7 on 7 off. maybe if u did 10 shifts a month like that op that would be sustainable.

still 10-12 admits per night feels unsafe to me. nor would i ever want to do that many. i know 2 a night is extra cushy though its 18 shifts a month. my acceptable # of admits per night would probably be around 6 if it were to be a 7 on 7 off.

remember we are talking about an average, unless theres a failsafe mechanism, "average 10 admits a night" can easily be 15+ on a bad night espeically if u are the only one on... can't really imagine that

 

[wamcp]

Only 2 admits per night is good, but I think 210k/yr is too low. Almost all the nocturnist jobs I have seen pay 300k+/yr (12 hrs, 7 days on/off); however, the average admit is 8-12. In my opinion, more than 8 admits per night on a 12 hr-shift is not safe.

I interviewed for hospitalist job the other day, and the PD was also selling me an open nocturnist position that pays 385k/yr.... 12 hrs, 7 on/off and average admit was 8-10.

Not everyone is cut out for heavier volume admitting jobs. Some people burn out with 8 non-crit care admissions in 12 hours but are fine rounding 20+ patients as a day hospitalist.

I have done ~20 admitting/nocturnist shifts per month for three years in a row and generated over 10000 wRVU each year and find my job “cush” because I structure each shift to have at least 50% cumulative time spent as downtime in the callroom. Some people can do that, some can’t.

 

[gutonc]

What's the average RVU for hospitalist?

I just got a contract that offer $18/wRVU above 430 per month. How many RVU can one generate per month seeing an average of 20 patients for 15 days (including a total of 30 admissions for the months)?

Dude...you keep asking the same question when the answers are right in front of you.

H&P:
99221 - 1.92
99222 - 2.61
99223 - 3.86

Progress:
99231 - 0.76
99232 - 1.39
99233 - 2.0

Do the math. Or go here and let them do it for you.

 

[Splenda88]

Dude...you keep asking the same question when the answers are right in front of you.

H&P:
99221 - 1.92
99222 - 2.61
99223 - 3.86

Progress:
99231 - 0.76
99232 - 1.39
99233 - 2.0

Do the math. Or go here and let them do it for you.

Sorry dude. I did not even know what was an RVU and all these coding numbers? They don't talk about these things in residency. Got it now

 

[chessknt]

Sorry dude. I did not even know what was an RVU and all these coding numbers? They don't talk about these things in residency. Got it now

Youll find that there is a lot they didnt teach you in the meandering 3 years of residency. Like how important it is to keep CT surgeons and cardiologists happy.

 

[CCM-MD]

What's the average RVU for hospitalist?

I just got a contract that offer $18/wRVU above 430 per month. How many RVU can one generate per month seeing an average of 20 patients for 15 days (including a total of 30 admissions for the months)?

430/month is about 5200/year. That’s at 75th percentile MGMA for hospitalists. So 2 things: either unlikely to get over the threshold easily or its a really busy gig. The best way to get an idea about how much you can generate is by asking them how much the current hospitalists are generating.

 

[sloh]

Not everyone is cut out for heavier volume admitting jobs. Some people burn out with 8 non-crit care admissions in 12 hours but are fine rounding 20+ patients as a day hospitalist.

I have done ~20 admitting/nocturnist shifts per month for three years in a row and generated over 10000 wRVU each year and find my job “cush” because I structure each shift to have at least 50% cumulative time spent as downtime in the callroom. Some people can do that, some can’t.

Can you expand on how you structure each shift to have that much downtime? That's impressive

 

[wamcp]

Can you expand on how you structure each shift to have that much downtime? That's impressive

1.) I’ve found minimizing the actual time physically walking to see the patients matters a lot. Might be “obvious” but seriously, if you make ten round trips from call room to parient room across the hospital to see ten patients you will be way more tired the next day than if you bunched them up in batches, and waste way too much time traveling around. So, I like to wait until I get 3-4 patients before I exit the callroom to see them.

2.) Prepping the H/P note before seeing the patient is also much more efficient than seeing someone on the fly. You get to target your history taking when you already know the details of the chart rather than realizing you forgot to ask something or waste time asking things you would have learned from the record (chart says afib...on coumadin. Ok so when you do medrec don’t say “what blood thinners do you take and why”, now you can ask “any thinners you take besides coumadin”). Search relevant key words in EPIC “endoscopy” or “cardiac cath” to get better understanding of past history faster than you can get from asking the patient open endedly.

3.) Do some of your exam during history taking. “So when did your belly hurt?” Look at the belly at the same time.

4.) Make sure the ER calls appropriate consults for you. They want to admit for GIB? They better talk to them. ER want to admit covid and you aren’t sure about remdesivir? They should call ID. Because their ER secretary saves them time going through the operator.
(Your mileage may vary. The ER group at my main job is SDG and bend over backwards to keep everyone happy lest they risk losing their contract with hospital)

5.) The biggest time saver...I think really comes from experience and knowledge base. When 90% of your admits are iterations of the past encounters, you have built a mental template set for your history taking, exam, differential/likely plan. An example, if today I had to see a patient who just came from Somalia as a refugee and has fever, rash, abdominal pain you bet I will end up spending an hour reading literature and uptodate on how to approach the case. Or if I have to see a pt who had a lung transplant last month and here with a fever, same thing. But if you had seen patients like these all the time it would be super quick.

 

[Meerkatology]

i think you are quite lucky with that setup. i cover 2 different hospitals which are both very close to me <5minute communte, i work from home and go in when i get called. we are HMO med group and are expected to see admits pretty much as we get them due to the possibility of being able to discharge some pts from the ER (huge money saver). discharging takes alot longer than admitting

i do everything u mentioned but cant have ER call consults for me most of the time. infact calling consults takes alot of time for me as we are not the only group to operate in the said hospitals and need to use our own list of consults, whom are constantly changing and can be difficult to get ahold of after hours. i don't ask the ER to call them unless its urgent since im not going to wake up the surgeon at 3am to talk about a chole case. i call my nonurgent consults at the end of the shift

also one of my hospitals uses epic which is a time saver because typing in the HP as you talk to the patient is huge. while the other hospital uses cerner and we have to dictate which takes extra time after talking to the patient. (i know u can type in cerner too but its some kind of system issue)

another huge time sync is med rec, which one of my hospitals have a pharmacist that does it for u and that is also huge time saver when available

constantly gearing/degearing during covid era takes extra time too 🙁

adding everything together, i end up working for like half of my 7 hour shifts for 2 admits+xcover


all in all if u have a job where all the stars align
-being able to type HP while talking to pt
-ER calling consults for u
-pharmacy doing med rec for u
-being able to wait to stack a few admits before going in to save commute time
-not needing to worry about discharging from the ER
-having a call room / not having to do huge amounts of xcover

then ya probably 1admit per hour is sustainable as a nightshifter

and did i mention having to dig back at old records for every patient for billing? cuz u know need to document that aortic atheroscelorsis and senile purpura for HCC

 

[Splenda88]

Not everyone is cut out for heavier volume admitting jobs. Some people burn out with 8 non-crit care admissions in 12 hours but are fine rounding 20+ patients as a day hospitalist.

I have done ~20 admitting/nocturnist shifts per month for three years in a row and generated over 10000 wRVU each year and find my job “cush” because I structure each shift to have at least 50% cumulative time spent as downtime in the callroom. Some people can do that, some can’t.

Yeah I am not. I remember I had 8 admissions on a 12-hr shift as a PGY2 and it was overwhelming.

 

[rokshana]

Yeah I am not. I remember I had 8 admissions on a 12-hr shift as a PGY2 and it was overwhelming.

Yeaah... you may be in for a rude awakening in the real world...

 

[Splenda88]

Yeaah... you may be in for a rude awakening in the real world...

I guess I might have to adjust.

 

[Redpancreas]

I guess I might have to adjust.

Just wanted to chime in to say 8 overnight admissions overnight in PGY-2 is tough if we’re talking admit orders, notes, care coordination on top of cross covering a high acuity unit that’s stressful IMO.

If we’re talking 8 admits to the floor including stable ICU transfers (common on nights) then that’s more manageable.

The most I had was 6 CICU overnight by myself which was way easier because there are patterns (poly VTx2, Arrestx2, MIx1, Dissectionx1).

 

[Splenda88]

Just wanted to chime in to say 8 overnight admissions overnight in PGY-2 is tough if we’re talking admit orders, notes, care coordination on top of cross covering a high acuity unit that’s stressful IMO.

If we’re talking 8 admits to the floor including stable ICU transfers (common on nights) then that’s more manageable.

The most I had was 6 CICU overnight by myself which was way easier because there are patterns (poly VTx2, Arrestx2, MIx1, Dissectionx1).

It's all those except I had a PGY1 who was doing cross cover that at time I had to loosely supervise (eg., telling him what to do sometimes). Most of the patients weren't high acuity (PNA, HF exacerbation, Cellulitis etc...).

 

[Redpancreas]

It's all those except I had a PGY1 who was doing cross cover that at time I had to loosely supervise (eg., telling him what to do sometimes). Most of the patients weren't high acuity (PNA, HF exacerbation, Cellulitis etc...).

The PGY-1 writing notes helps! Supervision's stressfull still because you have to know everything without doing all the processes (have the meds, problems down pat without documenting them 100x).

 

[Splenda88]

The PGY-1 writing notes helps! Supervision's stressfull still because you have to know everything without doing all the processes (have the meds, problems down pat without documenting them 100x).

Wish the PGY1 was writing my admit notes; he was only responsible for cross cover. I think 8 admits is the max that I would feel comfortable doing as a nocturnist where I won't be worried about missing critical info.

 

[Redpancreas]

Wish the PGY1 was writing my admit notes; he was only responsible for cross cover. I think 8 admits is the max that I would feel comfortable doing as a nocturnist where I won't be worried about missing critical info.

Damn, that's a really comfortable night. How many patients was he cross-covering?

 

[Splenda88]

Damn, that's a really comfortable night. How many patients was he cross-covering?

I would say 80-90 patients.

 

[Redpancreas]

I would say 80-90 patients.

Ahh, so he's covering all the IM patients across teams. Still a very chill role if all he's doing is cross-cover. If I was a PD, I would incorporate this model as it allows for very detailed cross-coverage overnight, but then I would still worry about the preparation for the PGY-1s if they're not cross-covering/admitting simultaneously.

 

[experiment113]

My job is great! It's just hard because I don't get to compare my job with other jobs, so it's hard for me to say if my job is a unicorn job. I have a physician group that does a great job advocating for its doctors.

It must be a unicorn job if you have time to dislike others comments.

 

[tantacles]

It must be a unicorn job if you have time to dislike others comments.

Thanks for your concern.

 

[Splenda88]

There is a lot rich docs on this thread. Hope to join you in 5 years, when I can say my NW is > 1mil

 

[Siggy]

To piggy back on the efficiency issue. I'm almost a year out of my crit care fellowship and doing admits/consults now, compared to an IM PGY1 or 2 is a totally different ball game. By the time you get out of residency/fellowship you should have your own personal protocol/cook book on how you're managing common diagnosis. The "I already know what to do, so I don't have to think too hard" cuts down significantly on how long it takes.

COPD exacerbation? Sure... duonebs q4, solumedrol 40 q8, azithro, BiPAP PRN.

Decomped heart failure? Lasix, bipap/vent, nitro if BP is high (drip in the ICU... because ICU is full of easy buttons), ACI, continue home BB, echo, cardio consult per primary team's preference.

DKA? Fluids, insulin drip, q6 labs, more fluids. D5 when BGL under 200 or 250.


Want more efficiency? Make your own order sets. When I intubate someone I make 3 or 4 clicks and my vent power plan is in. It has my sedation (prop/fent), CXR, ABG, artificial tears, chlorhexadine mouth washes, and sputum culture already ordered. Also learn what short cuts you can make. I always order osmolyte 10ml/hr for my tube feeds. Why? First, tropic feeds alone gets most of the benefits of tube feeding. Second, the nutritionist is just going to submit a recommendation within the first 24 hours that I'm going to blindly accept anyways (assuming I'm happy with feeding the patient). So why spend time thinking about this.

Similarly, my hospital uses Cerner and we can have favorite orders saved. I have an entire folder for AM labs that are already defaulted to order for the next AM. So instead of writing out each of the labs and manually changing the date, it takes me 6 clicks for my AM CBC, BMP, Mg, Phos, CXR, ABG (CXR/ABG for vented patients).

 

[tantacles]

That's pretty nice. I need to figure out how to do custom order sets in epic.

 

[Redpancreas]

That's pretty nice. I need to figure out how to do custom order sets in epic.

Contact Epic Support! It may take some time to get everything you need but they're more helpful than your colleagues and will teach you how the system works.

 

[CaliPCCSM]

I am PCCM. we have nocturnists at my hospital. Some are good and some are extraordinary. My feeling is that the OP is in the latter group. Very insightful comment.

 

[tantacles]

I am PCCM. we have nocturnists at my hospital. Some are good and some are extraordinary. My feeling is that the OP is in the latter group. Very insightful comment.

Compliment accepted. Thank you.

Now if my self esteem only allowed me to believe it.

 

[TaroBubbleTea]

This thread has been extremely helpful. I’m currently a PGY2 preparing to apply to a largely outpatient sub speciality, but I never minded my block of nights in the hospital. In fact, I sometimes enjoy the isolation that comes with nights. I have been vacillating between sub specializing vs hospitalist for the past several weeks now. @tantacles or the other nocturnists in this thread, how do you guys maintain a social life? As someone who is still single, I want to eventually find a partner.

 

[Splenda88]

Does anyone know how one can somewhat passively add another 75k-100k/yr to his/her income using their medical license?

 

[tantacles]

This thread has been extremely helpful. I’m currently a PGY2 preparing to apply to a largely outpatient sub speciality, but I never minded my block of nights in the hospital. In fact, I sometimes enjoy the isolation that comes with nights. I have been vacillating between sub specializing vs hospitalist for the past several weeks now. @tantacles or the other nocturnists in this thread, how do you guys maintain a social life? As someone who is still single, I want to eventually find a partner.

I met my partner in med school and he and I couples matched together. Honestly, the key to maintaining a social life is basically don’t work too much. Any more than 13-14 shifts can really wear on your ability to be a reasonable human.

in addition, I personally like clumping shifts so I have several weeks off. It definitely helps.

And finally, learn to say no early. When I started last year, I really wanted to be a good guy, and if someone had a night shift they were desperate to get rid of, I would just take it. That has changed, and extra shifts have to be convenient for ME now, not them.

 

[chessknt]

Does anyone know how one can somewhat passively add another 75k-100k/yr to his/her income using their medical license?

Is this for real? You think there is a way just get money without effort by simply possessing a medical license?

best way I can think of it to marry someone who makes a lot of money (like greater than 1 m per year so ideally a ortho or neurosurgeon) then get divorced after a few years (make sure you don’t work during the marriage) and collect alimony.

 

[Splenda88]

Is this for real? You think there is a way just get money without effort by simply possessing a medical license?

best way I can think of it to marry someone who makes a lot of money (like greater than 1 m per year so ideally a ortho or neurosurgeon) then get divorced after a few years (make sure you don’t work during the marriage) and collect alimony.

Lol. I can be a pimp for BIG Pharma. 😛