Trends in EM compensation (med students read this)

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It’s such a huge bummer reading threads like this when you’re deciding between EM and an IM sub-specialty. EM is just looking worse and worse as a long term career choice for med students like me who are on the fence. I get the “if you love EM just do it”, but choosing a specialty is ultimately a career choice with all the financial benefits or headaches that this entails.

What subspecialty?

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What subspecialty?
Really considering cardiology. Aside from EM, about the only other thing I’m remotely considering is Anesthesia and even that has its fair share of doom and gloom. I know I can find success in any field, but man the decision is tough. I keep heading that the decision will become clear during third year, but that hasn’t seemed to be the case yet haha. Just getting more confusing
 
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Really considering cardiology. Aside from EM, about the only other thing I’m remotely considering is Anesthesia and even that has its fair share of doom and gloom. I know I can find success in any field, but man the decision is tough. I keep heading that the decision will become clear during third year, but that hasn’t seemed to be the case yet haha. Just getting more confusing

I feel the same way currently in my 3rd year trying to figure out what specialty I want to commit to for life smh, not an easy decision at all. Love EM but reading all this makes me wanna change fields, but I know I wouldn't like those other fields as much. Really hoping ill have a better idea after this year's residents graduate and see the landscape of the market...
 
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Really considering cardiology. Aside from EM, about the only other thing I’m remotely considering is Anesthesia and even that has its fair share of doom and gloom. I know I can find success in any field, but man the decision is tough. I keep heading that the decision will become clear during third year, but that hasn’t seemed to be the case yet haha. Just getting more confusing
Have you looked into Heme-Onc at all? Right up the IM alley that you mentioned. Don't do RadOnc.
 
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Really considering cardiology. Aside from EM, about the only other thing I’m remotely considering is Anesthesia and even that has its fair share of doom and gloom. I know I can find success in any field, but man the decision is tough. I keep heading that the decision will become clear during third year, but that hasn’t seemed to be the case yet haha. Just getting more confusing

Do cards.
 
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I want to understand the salaries here a bit better.

If we generate ~150/hr and see 2 per hour, ideally we'd get paid 300, but an employer is probably going to take a piece of that and we end up somewhere around $200. I actually see closer to 1.6/hr and make over $200/hr so it seems like that's a pretty solid gig by these standards. But I also order CT, MRI, labs, etc. that make the hospital money and I figure that would be included in the "dollars generated by ED doc", right?

So when a purely democratic group takes end of year profits, is that all based on the $150/hr or is there other compensation that goes into that? For example, a friend of mine also sees ~1.6/hr but makes closer to $275/hr after "profit sharing" even though this math doesn't really work out.

Also, tying this into the popular cities like Denver, why would a democratic group in Denver pay 140/hr when their docs make $150/pt at 1.5-2pph? Shouldn't the profit share end up similar to other locations in the country?
 
I want to understand the salaries here a bit better.

If we generate ~150/hr and see 2 per hour, ideally we'd get paid 300, but an employer is probably going to take a piece of that and we end up somewhere around $200. I actually see closer to 1.6/hr and make over $200/hr so it seems like that's a pretty solid gig by these standards. But I also order CT, MRI, labs, etc. that make the hospital money and I figure that would be included in the "dollars generated by ED doc", right?

So when a purely democratic group takes end of year profits, is that all based on the $150/hr or is there other compensation that goes into that? For example, a friend of mine also sees ~1.6/hr but makes closer to $275/hr after "profit sharing" even though this math doesn't really work out.

Also, tying this into the popular cities like Denver, why would a democratic group in Denver pay 140/hr when their docs make $150/pt at 1.5-2pph? Shouldn't the profit share end up similar to other locations in the country?

You generate 150/hr from the physician fee which does not take into account anything that you order. In most work situations (SDG or CMG) the physician fee is the only money that is at play. Yes, the hospital is making money on other services but that isn't at play. Even as a hospital employee they really don't think of the physician asset as doing anything other than generating the physician fee. So ignore those other sources of hospital revenue.

200/hr isn't awful as long as you aren't supervising any midlevels. If you do, you need to add those numbers into consideration and then subtract what the midlevel is being paid. Oftentimes this translates to 50+ dollars per one of the patients that they see/you are liable for and that is going to whoever controls the physician fee revenue (the CMG/empoyer/democratic group). So the additional pay that your SDG friend makes is likely a combination of midlevel profit and then there's the fact that 150/patient is simply an average. Have a year with less self pay(I.e. no pay) patients? You'll bring that number up. More private insurance? Number will be higher. So I wouldn't say that his math doesn't work at all.

A democratic group in Denver would pay their pre-partner 140/hr because the local market will allow it and it allows their partners to make even more money. We would call this a predatory SDG. You are correct that there should be a "floor" of what an ER doc makes based on their billing, but as long as ER docs are removed from the billing and are instead treated like an employee subject to supply and demand economics, this is what happens.
 
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You generate 150/hr from the physician fee which does not take into account anything that you order. In most work situations (SDG or CMG) the physician fee is the only money that is at play. Yes, the hospital is making money on other services but that isn't at play. Even as a hospital employee they really don't think of the physician asset as doing anything other than generating the physician fee. So ignore those other sources of hospital revenue.

200/hr isn't awful as long as you aren't supervising any midlevels. If you do, you need to add those numbers into consideration and then subtract what the midlevel is being paid. Oftentimes this translates to 50+ dollars per one of the patients that they see/you are liable for and that is going to whoever controls the physician fee revenue (the CMG/empoyer/democratic group). So the additional pay that your SDG friend makes is likely a combination of midlevel profit and then there's the fact that 150/patient is simply an average. Have a year with less self pay(I.e. no pay) patients? You'll bring that number up. More private insurance? Number will be higher. So I wouldn't say that his math doesn't work at all.

A democratic group in Denver would pay their pre-partner 140/hr because the local market will allow it and it allows their partners to make even more money. We would call this a predatory SDG. You are correct that there should be a "floor" of what an ER doc makes based on their billing, but as long as ER docs are removed from the billing and are instead treated like an employee subject to supply and demand economics, this is what happens.
Thank you for the explanation. This makes a ton more sense.

to follow up: what determines my physician fee? It it just based on RVUs from complexity level billing? Or also from procedures and other RVU generating things?
 
Thank you for the explanation. This makes a ton more sense.

to follow up: what determines my physician fee? It it just based on RVUs from complexity level billing? Or also from procedures and other RVU generating things?

Total RVUs you bill for per patient encounter are made up of the ER encounter (this is where a majority of your RVUs come from) plus any procedures or EKG interpretations. So to answer your question, it's both. At my shop, I average 4 total RVUs per patient. For reference, CMS pays 36.08 per RVU in 2020.
 
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Plenty of hospitals are doing that already. That does not result in a better outcome for us though.

I disagree. I am in academics and a hospital employee. I feel treated fairly and have good comp.
 
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I disagree. I am in academics and a hospital employee. I feel treated fairly and have good comp.
That may have more to do with the fact that you're in academics and a W2 more than being in a CMG.
 
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How come?


Could you elaborate as to why?

It’s a personal opinion. But my medical director and department chair know the CEO and CFO. It’s a lot harder (although certainly not impossible) to try screw someone over when you have to look them in the eye vs. someone who lives several hundred miles away.
 
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How come?


Could you elaborate as to why?

Not the the poster, but here's my take. (I have experience at both hospital employed and cmg shops.) I would say that hospital-employed has the potential to be better, but it's not guaranteed, and it could be worse. It all really depends on administration and their priorities.

A CMG-run shop is all but guaranteed to be a ****-show. They are extractive institutions and staffing will never be better than just-above adequate (and most often worse), they will have no qualms about staffing with bad doctors and noctors, and good doctors will inevitably become burnt out (thus turning into bad ones). They will neglect the department as much as possible, allowing it to devolve back into its' natural state of near-anarchy. Problems with flow, care, etc will be dealt with by ignoring them to the extent possible and then papering over them w/ superficial solutions. Turnover among staff and administration is the norm (ever wonder why there are so many job postings for medical directors?).

Hospital employed can be better, but it's highly dependent on the particular ED. Do you work for an institution that values quality care, actual patient experience and staff morale? Or do you work somewhere that cares more about metrics and pt satisfaction surveys? Is the medical director committed to their current position or are they trying to move up the chain and get out of emergency medicine? Does nursing leadership foster a collegial environment, or do nurses spend half their shift writing each other and doctors up for perceived slights? With a good director, invested admin and strong nursing, a hospital employed job has the potential to be just fine and dandy. But, know this, you the front line pit doc will have no say.

On the plus side for hospital-employed, at least admin is invested in improvement ands are at least nominally aligned. But, it really depends on their priorities. Ultimately, a pleasant place to work requires an invested group of doctors and clinical support staff as well as a non-malignant administration. It's very difficult to get the former in a CMG. With a malignant administration the extra buffer of the CMG can be beneficial but you'll lack any true workplace protections.
 
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I have a question but I don't want to create another thread...


I just found out in FB that one of my classmates in med school just matched into a peds emergency fellowship... and that fellowship is 3-yr long. Is that the only pathway to become a peds emergency doc? If so, that seems strange... Is that overkill? Couldn't they have peds emergency residency that is 3-4 yrs like EM for adults?
 
I have a question but I don't want to create another thread...


I just found out in FB that one of my classmates in med school just matched into a peds emergency fellowship... and that fellowship is 3-yr long. Is that the only pathway to become a peds emergency doc? If so, that seems strange... Is that overkill? Couldn't they have peds emergency residency that is 3-4 yrs like EM for adults?
If they're doing the 3 years, either they are peds residency trained, or 50% chance EM (half of Peds EM programs are 3 years for all, while the other half is 2 years for EM, and 3 years for peds). The three years for fellowship is per the AAP.

And, what board would one get? Peds, EM, or only a Ped EM fellowship cert only?

So, your question is clear. The answers are murky.
 
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If they're doing the 3 years, either they are peds residency trained, or 50% chance EM (half of Peds EM programs are 3 years for all, while the other half is 2 years for EM, and 3 years for peds). The three years for fellowship is per the AAP.

And, what board would one get? Peds, EM, or only a Ped EM fellowship cert only?

So, your question is clear. The answers are murky.
He is peds trained...

You are correct about the answers being murky... You gotta love our medical education system.
 
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He is peds trained...

You are correct about the answers being murky... You gotta love our medical education system.
Well, 30 or 40 years ago (really), back room dealing meant a set up where, if you did EM/peds (5 years), you could sit for EM boards, and peds boards - but, affirmatively, NOT peds EM. Like Tip O'Neill said, "all politics is local". Now, the historical successors have to pay the price.
 
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Have you looked into Heme-Onc at all? Right up the IM alley that you mentioned. Don't do RadOnc.
Just wondering, why heme-onc? I do hear heme-onc makes very good money ($400k+), has a good lifestyle (almost bankers hours, as it‘s mostly outpatient in PP), and is in demand in most places (except maybe big coastal cities?). But regularly dealing with cancer patients seems like it could be challenging. I guess you need to have the right personality for it?

For someone who likes EM and cards, maybe pulm-ccm would be another good option?
 
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Just wondering, why heme-onc? I do hear heme-onc makes very good money ($400k+), has a good lifestyle (almost bankers hours, as it‘s mostly outpatient in PP), and is in demand in most places (except maybe big coastal cities?). But regularly dealing with cancer patients seems like it could be challenging. I guess you need to have the right personality for it?

For someone who likes EM and cards, maybe pulm-ccm would be another good option?
In addition to the excellent job market and compensation, I think like hospice/palliative care, it can paradoxically be very rewarding to work with these patients. I'm sure it is more fitting for certain personalities. It's also important to highlight that the specialty seems to be relatively and significantly more shielded from having to deal with the entitlement and vulgarity of humans.
 
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In addition to the excellent job market and compensation, I think like hospice/palliative care, it can paradoxically be very rewarding to work with these patients. I'm sure it is more fitting for certain personalities. It's also important to highlight that the specialty seems to be relatively and significantly more shielded from having to deal with the entitlement and vulgarity of humans.
Great points! Cancer patients are almost always very compliant and they also usually love their oncologists at least from what I’ve seen. I guess it’s a really good specialty if one likes caring for cancer patients.
 
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In addition to the excellent job market and compensation, I think like hospice/palliative care, it can paradoxically be very rewarding to work with these patients. I'm sure it is more fitting for certain personalities. It's also important to highlight that the specialty seems to be relatively and significantly more shielded from having to deal with the entitlement and vulgarity of humans.

This is true in my experience. All and all, the encounters in palliative medicine/hospice are very rewarding. In fact, it is tremendously rewarding.

The standard comment from outsiders about the field is "wow that must be so depressing"... the actual truth to that is analagous to the layman belief I get about EM "wow it must be so exciting saving lives all day long".

Great field with low burnout and high satisfaction -- for the right person
 
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This is true in my experience. All and all, the encounters in palliative medicine/hospice are very rewarding. In fact, it is tremendously rewarding.

The standard comment from outsiders about the field is "wow that must be so depressing"... the actual truth to that is analagous to the layman belief I get about EM "wow it must be so exciting saving lives all day long".

Great field with low burnout and high satisfaction -- for the right person
Curious - how does one do palliative from EM? Fellowship? Lots of personal reading/education on the topics?

I used to work with a real old school ED doc - she was IM boarded but doing EM with a part time palliative practice on the side, no formal training. Super rural setting.

Always thought it was an interesting practice model.
 
Curious - how does one do palliative from EM? Fellowship? Lots of personal reading/education on the topics?

I used to work with a real old school ED doc - she was IM boarded but doing EM with a part time palliative practice on the side, no formal training. Super rural setting.

Always thought it was an interesting practice model.

You can do fellowship vs. just picking it up on the side depending on the desirability if the job/city and market saturation.
 
Curious - how does one do palliative from EM? Fellowship? Lots of personal reading/education on the topics?

I used to work with a real old school ED doc - she was IM boarded but doing EM with a part time palliative practice on the side, no formal training. Super rural setting.

Always thought it was an interesting practice model.

Indeed there are multiple paths. The formal pathway, and most comprehensive foundation to build a career, is via fellowship -- which is 1 or 2 years depending on the program.

In the past, people could be grandfathered in -- that is no longer an option. Now you either do the training and get board-certified as a subspecialist in HPM or you try to pick it up the same way everyone else picks up new skills and knowledge without formal PGY training (i.e. conferences, seminars, reading, etc) and then apply for jobs as an outsider per se, cross your fingers, and pray you are doing your patients/families justice as you build up experience in realtime.

Historically, places have been quite desperate for docs, so would often welcome applicants without certification -- that phenomenon also has largely started to phase out -- and if you want to enter practice today at an academic institution or be involved as faculty, way more often than not the requirement will be to have completed fellowship.

There are a couple other SDN EM posters in hospice/palliative. I know one has done fellowship and one has not.

6 months into my own fellowship, I can say for me it was 100% necessary, as beyond primary palliative medicine, not much of this stuff was taught in EM residency. My personal opinion is to best serve these patients/families/docs, that are seeing you in search for your subspecialist-level knowledge, you should have the corresponding education and training of such. But, I realize I'm biased as it's the path I chose.

That said, not many medical students or EM residents know about it. I know much of my coresidents and EM faculty were confused during my PGY3 year. It's no worries, it worked out phenomenally. In truth, IM and FM residents get exposure during their residency training -- so it is no surprise that those fields make up the majority of palliative docs today. It is getting more popular over the years with EM. One of my incoming fellows next year at my faculty job is an EM doc that's been practicing as a hospice med director for some time and now returning for formal fellowship training.

Like all things, there is variety.

If you think this might be a career interest for you, explore our SDN sub-forum:
 
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How do most EM docs go about getting into fellowship programs? Every year I’m in practice is another year away from the medical education system where I could gain experience in almost anything if I asked. Now I can’t imagine being accepted into fellowship without building a portfolio of research and experience. But I also don’t know how I would go about getting that after/while working at a community ED
 
How do most EM docs go about getting into fellowship programs? Every year I’m in practice is another year away from the medical education system where I could gain experience in almost anything if I asked. Now I can’t imagine being accepted into fellowship without building a portfolio of research and experience. But I also don’t know how I would go about getting that after/while working at a community ED
What fellowship?
 
I am probably one of the more positive docs on here and I feel I am a realist. But 5 years for partnership track? That is downright unethical!!!!

Many years ago when we had a SDG, it was a 2 yr and almost everyone made partner unless you were truly the bottom 5%. I saw docs made partner that I just cringed.

So what is the point of 5 years other than having warm bodies to make $$$ for the partners? I can see 1 or 2 years to "prove" yourself b/c it is hard to get rid of a partner, but 5 years? And what is up with the 2 and 4 year vote? All this is comes down to a setup to string docs on while hanging the mythical partner carrot.

I am sorry to tell you this but you have probably the 2nd worse job I have ever seen. The worse being the dummies on the partnership track. Thank your lucky stars that you didn't sneak into the partnership track.
I think this is becoming normal. I looked into several SDGs recently and could not find any with guaranteed partnership tracts that didn't have insane red flags. Most were offering 5 year partnership tracks with no guarantee of partnership. I've talked to many people near me who were turned down for partnership after 5 years. I can't imagine how frustrating that would be after investing so much sweat equity.

All the offers I had were pre-pandemic. I'm sure it's even harder to find a good SDG job now than when I last looked.

I would love a 2 year guaranteed partnership track. If anybody has one in the Midwest, let me know! I bet you'd have hundreds of applicants fighting to get to the front of the line if it was at a semi decent hospital in a semi decent area.
 
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I think this is becoming normal. I looked into several SDGs recently and could not find any with guaranteed partnership tracts that didn't have insane red flags. Most were offering 5 year partnership tracks with no guarantee of partnership. I've talked to many people near me who were turned down for partnership after 5 years. I can't imagine how frustrating that would be after investing so much sweat equity.

All the offers I had were pre-pandemic. I'm sure it's even harder to find a good SDG job now than when I last looked.

I would love a 2 year guaranteed partnership track. If anybody has one in the Midwest, let me know! I bet you'd have hundreds of applicants fighting to get to the front of the line if it was at a semi decent hospital in a semi decent area.
There are never guarantees. All you can go on is historical facts. For example my current and former SDGs never turned anyone away from partnership within the time frame that mattered to me (pre partner and then since I joined those groups).
 
Find the lifestyle and compensation you want, THEN find a specialty that falls under that umbrella where the day-to-day work is least miserable.
Disagree. Everyone wants the best money and lifestyle. Find what you love to do. Then find the best way to do it or the closest approximation to it taking the lifestyle and money into consideration.

For example. Want to work with kids as number one priority? Sure peds is an option, but a big money loser. But there’s peds ED, peds versions of every surgical field, etc.
 
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I don’t think I am. I was raised lower middle class and think $200/hr is insane money. More money that I can imagine honestly.

I just got on the Obamacare marketplace last week to check things out. Premium for a Blue HMO was $1,700 a month, with a $17,000 a year annual deductible. A solid same-career disability policy will run you anywhere between $400-$500 a month. Throw $1750 a month at your student loans.

You're at $4,000 a month and you still haven't put a roof over your head, food on the table, a Kia in your driveway, or saved for retirement.

$200 an hour taxed at 30%+ isn't as much money as you think...particularly if you factor in the time value of money and the opportunity costs of starting your career when you're 30-34 years old (depending on your specialty) instead of 18-22.

 
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I just got on the Obamacare marketplace last week to check things out. Premium for a Blue HMO was $1,700 a month, with a $17,000 a year annual deductible. A solid same-career disability policy will run you anywhere between $400-$500 a month. Throw $1750 a month at your student loans.

You're at $4,000 a month and you still haven't put a roof over your head, food on the table, a Kia in your driveway, or saved for retirement.

$200 an hour taxed at 30%+ isn't as much money as you think...particularly if you factor in the time value of money and the opportunity costs of starting your career when you're 30-34 years old (depending on your specialty) instead of 18-22.


In my state we have two choices: Silver Summit Medicaid, or Death Plan Nevada (a United Healthcare product).

If you don't have a lot of chronic medical expenses, I'd recommend a short-term plan. The Trump administration made these legal, and I think they still are. You can buy up to 12 months of coverage, and they cost a fraction of what the marketplace plans cost.
 
Death Plan Nevada? Is that its real name or did you just make that up?
 
What is so desirable about Austin? I know lot of tech companies moving there. TX has no state income tax. Makes sense for tech workers but why do doctors want to move there? I've visited once but didn't find ton of stuff to do unlike Colorado, Oregon, Washington or Arizona.
Austin is for Peter Pan types, it’s best days are behind it for sure.
 
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This is a bummer of a read.

I remember reading similar posts in 2011 when I chose radiology as a specialty. Job market was so dire people your options were relegated to moving to Kansas or taking a corporate overnight job with incredibly unsafe volumes for 250k. Partnership tracks of 7 years were not uncommon. The cuts from congress were relentless with a perennial target from insurers. The field was over saturated and there was no end in sight.

Fast forward 10 years, and radiology job market is one of the hottest in medicine. Location, salary, style of practice. It’s all yours. You can name whatever you want. Nobody in a million years would have predicted this.

point is, things in medicine are cyclical. it’s easy to buy into the doom and gloom. The reality rarely plays out the way these posts predict. I heard about the end of opthomology before all that yet my neighbor is a 38 year old retinal surgeon with two Teslas.
 
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I wouldn't bet on the rads job market long term.
But rads also hasn't tripled their residencies while midlevels have completely taken over, which is a significant weakness for EM.
 
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I wouldn't bet on the rads job market long term.
But rads also hasn't tripled their residencies while midlevels have completely taken over, which is a significant weakness for EM.
Curious why you think so
 
This is a bummer of a read.

I remember reading similar posts in 2011 when I chose radiology as a specialty. Job market was so dire people your options were relegated to moving to Kansas or taking a corporate overnight job with incredibly unsafe volumes for 250k. Partnership tracks of 7 years were not uncommon. The cuts from congress were relentless with a perennial target from insurers. The field was over saturated and there was no end in sight.

Fast forward 10 years, and radiology job market is one of the hottest in medicine. Location, salary, style of practice. It’s all yours. You can name whatever you want. Nobody in a million years would have predicted this.

point is, things in medicine are cyclical. it’s easy to buy into the doom and gloom. The reality rarely plays out the way these posts predict. I heard about the end of opthomology before all that yet my neighbor is a 38 year old retinal surgeon with two Teslas.

A ton of radiologists are over 55. That market will be fine for some time.
 
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Any hospital based Specialty are vulnerable. What is good today is no guarantee when docs are not making the decisions.

I would not recommend anyone do a hospital based field. You don't know what will happen in 10 yrs when the med students are done with training.

Med students - find a field you will enjoy and make 200-250k/yr

Attendings - Make your money, it will end eventually
 
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200-250k?

Get outta here, Even pediatricians average 230k


Every field is vulnerable to wild swings in the job market and massive cuts in reimbursement. The steady state salary when the dust settles will never get that low. You can obsess over a doomsday scenario in any field, like the people telling me since 2007 that AI would take my job, and my job would be oursourced to India. the worst case scenario is rarely the reality

anesthesia job market did not collapse after the mid level encroachment. Neither will EM
 
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I do not subscribe to Dooms Day either. My point being if you are coming from a 400k salary and drops to 300k like many attendings, you will be unhappy.

If you come in with 250K expectations, you will be happy with 300K.

I think most specialist will make 300K/yr but may have to work harder, work in B type places, and deal with alot of admin Crap.
 
Sorry but that’s just wrong. I’ve been hearing for decades about how much salaries have dropped for various specialists but the data doesn’t back that up. See 2001 MGMA salaries where the average EM salary was around 180-200k

https://www.cga.ct.gov/2003/rpt/2003-R-0297.htm

sure, maybe some cuts here or there adjusting for inflation, and some specialties hit harder than others, more administrative bs and hours worked, but in general, salaries have only increased substantially across the board

I’ll believe a 30-50% specialty pay cut when I see it
 
I disagree. I am in academics and a hospital employee. I feel treated fairly and have good comp.
Would you be willing to share your gross income (all benefits included) per hour - at least ballpark? Including committee time, etc.
 
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