What specialties provide the best continuity of care vs. salary?

[von Matterhorn]

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I'm getting to a point where I really need to make a concrete decision on what area of medicine I'm going to pursue, and I just feel stuck.

I entered medical school truly intent on going into FM. That was always what I envisioned for myself, and it's a good fit for me. But, I am struggling with the salary disparity evident in primary care vs. specialists. I never wanted salary to be a factor in my choice, but between undergrad and med school, I'm 400k+ in debt and growing every day. If I go the FM route, I will literally be in my 40's by the time I can enjoy the paycheck of an attending position, and that's kind of a daunting reality. I kick my own ass daily for not going to the cheaper school I was accepted to, but I digress...

I'm contemplating going gas -> pain management as I do have a big interest in working with chronic pain patients. It would provide a good mix of clinic/surgery, as well as a considerably higher pay ceiling. I considered IM -> some fellowship, but I kind of hated my IM rotation and I'm not sure I could suck up 3 years of that.

 

[bashwell]

I'm getting to a point where I really need to make a concrete decision on what area of medicine I'm going to pursue, and I just feel stuck.

I entered medical school truly intent on going into FM. That was always what I envisioned for myself, and it's a good fit for me. But, I am struggling with the salary disparity evident in primary care vs. specialists. I never wanted salary to be a factor in my choice, but between undergrad and med school, I'm 400k+ in debt and growing every day. If I go the FM route, I will literally be in my 40's by the time I can enjoy the paycheck of an attending position, and that's kind of a daunting reality. I kick my own ass daily for not going to the cheaper school I was accepted to, but I digress...

I'm contemplating going gas -> pain management as I do have a big interest in working with chronic pain patients. It would provide a good mix of clinic/surgery, as well as a considerably higher pay ceiling. I considered IM -> some fellowship, but I kind of hated my IM rotation and I'm not sure I could suck up 3 years of that.

I think it'd be helpful if you asked the anesthesia and pain forums too.

At least from my very limited experience, pain looks great on paper, but you really need to do a rotation in it to see if you can handle the pain patients and other issues in pain (e.g., opioid dependence, pill mills). Keep in mind academic pain can be quite different than private practice pain, but you'll most likely be working in private practice if you want that high salary and good lifestyle.

Also, I don't know if I would necessarily pick anesthesia just to go into pain. You have to also like anesthesia, especially if you can't get into pain. Four years is a long time if you don't like anesthesia. Personally I like anesthesia, even though it has its significant issues, but if you just consider the specialty itself, it is very cool in my opinion.

 

[ERDOC555]

I'm getting to a point where I really need to make a concrete decision on what area of medicine I'm going to pursue, and I just feel stuck.

I entered medical school truly intent on going into FM. That was always what I envisioned for myself, and it's a good fit for me. But, I am struggling with the salary disparity evident in primary care vs. specialists. I never wanted salary to be a factor in my choice, but between undergrad and med school, I'm 400k+ in debt and growing every day. If I go the FM route, I will literally be in my 40's by the time I can enjoy the paycheck of an attending position, and that's kind of a daunting reality. I kick my own ass daily for not going to the cheaper school I was accepted to, but I digress...

I'm contemplating going gas -> pain management as I do have a big interest in working with chronic pain patients. It would provide a good mix of clinic/surgery, as well as a considerably higher pay ceiling. I considered IM -> some fellowship, but I kind of hated my IM rotation and I'm not sure I could suck up 3 years of that.

If you truly like family I would go with it. From what I hear pain management can be challenging and not always the most enjoyable. However salary is also important as well. What are your geographic restrictions? There are plenty of FM jobs that pay 300k+ that aren't rural but also not in the heart of a major city either. I've also heard of rural FM making 350-400k and other PP FM with NPs or partners who make a lot of money as well.

What is your ideal salary? Ask yourself that and if you can hit that in a FM practice, (which I bet you can), then go with that. Personally I'd rather make 300k in something I love than 400k in something I don't enjoy as much.

 

[OrthoTraumaMD]

Pain medicine can be quite lucrative. And if you can stand the chronic pain patients, bless you.

 

[iBS1972]

Continuity of care is really not that big of a deal if you do anything medicine related (that means no EM). It's really not just FM. Perhaps you've realized that in your IM rotation, many times your residents or attendings will recognize a patient they've had before--that's continuity of care. Often times, you'll need to schedule a patient to follow up with someone after being discharged and that can be you if you want to (you'll likely do some outpatient work regardless of what field you go into, unless if you become a hospitalist)--that's contuinity of care. This is especially true if you go into a sub-specialty, where you will often see sicker patients, in which case it's quite common to have the same patient admitted at least once a month, even every other week because their disease is just so advanced, meaning you'll see them often whether you want to or not.
Even though family medicine physicians pride themselves of continuity of care, it's really not much more than any other specialty.

 

[WiseOne]

rad onc

 

[Postictal Raiden]

Kaiser is currently offering 240k for 4 days of work in FM. You could easily make 300k, while living in a desirable area, if you work 5-6 days a week.

I will graduate with close to 500k in debt (including my and my wife's undergrad). I'm going into neurology. I contemplated going into radiology mainly for the money (and I have the scores for it), but realized that it would be a mistake abandoning the field that I love because it paid a little less.

The gap between specialists and primary care earning is not as wide as it once was. This is even more pronounced when you consider the pay per hour. Psych is a very clear example of that.

 

[AlbinoHawk DO]

Kaiser is currently offering 240k for 4 days of work in FM. You could easily make 300k, while living in a desirable area, if you work 5-6 days a week.

I will graduate with close to 500k in debt (including my and my wife's undergrad). I'm going into neurology. I contemplated going into radiology mainly for the money (and I have the scores for it), but realized that it would be a mistake abandoning the field that I love because it paid a little less.

The gap between specialists and primary care earning is not as wide as it once was. This is even more pronounced when you consider the pay per hour. Psych is a very clear example of that.

Humble brag is strong on this one, and here I thought you didn't do radiology because it bored you out of your mind ;-)

 

[Crayola227]

Continuity of care is really not that big of a deal if you do anything medicine related (that means no EM). It's really not just FM. Perhaps you've realized that in your IM rotation, many times your residents or attendings will recognize a patient they've had before--that's continuity of care. Often times, you'll need to schedule a patient to follow up with someone after being discharged and that can be you if you want to (you'll likely do some outpatient work regardless of what field you go into, unless if you become a hospitalist)--that's contuinity of care. This is especially true if you go into a sub-specialty, where you will often see sicker patients, in which case it's quite common to have the same patient admitted at least once a month, even every other week because their disease is just so advanced, meaning you'll see them often whether you want to or not.
Even though family medicine physicians pride themselves of continuity of care, it's really not much more than any other specialty.

um, while you are correct there are other specialties, even ones that don't really "mean" to see the same patient repeatedly, FM or other outpt primary care fields offer enormous opportunities for continuity of care that is not matched by your examples

the school where I went was pretty obsessed with primary care and FM, and we got lots of exposure

I met more than one doc who had *birthed* more than one generation of patient in their clinic - basically they went from being someone's pediatrician to delivering that child's children and their children!

 

[Postictal Raiden]

Humble brag is strong on this one, and here I thought you didn't do radiology because it bored you out of your mind ;-)

Why so jealous of my scores? we may end up in the same residency program, after all.

 

[Crayola227]

Why so jealous of my scores? we may end up in the same residency program, after all.

which isn't really reassuring or a reason for someone to think you're less insufferable than you are.

 

[AlbinoHawk DO]

Why so jealous of my scores? we may end up in the same residency program, after all.

yeah man, why you think it's a reason to be less insufferable than you?! huh?!?!

 

[anbuitachi]

I'm getting to a point where I really need to make a concrete decision on what area of medicine I'm going to pursue, and I just feel stuck.

I entered medical school truly intent on going into FM. That was always what I envisioned for myself, and it's a good fit for me. But, I am struggling with the salary disparity evident in primary care vs. specialists. I never wanted salary to be a factor in my choice, but between undergrad and med school, I'm 400k+ in debt and growing every day. If I go the FM route, I will literally be in my 40's by the time I can enjoy the paycheck of an attending position, and that's kind of a daunting reality. I kick my own ass daily for not going to the cheaper school I was accepted to, but I digress...

I'm contemplating going gas -> pain management as I do have a big interest in working with chronic pain patients. It would provide a good mix of clinic/surgery, as well as a considerably higher pay ceiling. I considered IM -> some fellowship, but I kind of hated my IM rotation and I'm not sure I could suck up 3 years of that.

Definitely do not do anesthesiology then pain management if your main reason over FM is salary. You will likely be disappointed. There have been large cuts in pain procedures recently and possibly more in the future. It's also not easy at all making money as a pain physician in todays market. I see pain jobs salary start at 200k as an employee, higher depending on location. It will also be more stressful than FM due to the patient population, and tons of procedures and being exposed to radiation all day long. Your ceiling is definitely higher if you start your own practice but this is extremely difficult, and takes years to settle. You will have a large overhead/startup cost and few patients in your early years
Also pain is competitive. Many anesthesiologists apply to pain to get out of anesthesiology since that's the only real fellowship that lets you leave the ORs/quit working w surgeons. If you do not get into a pain fellowship you'll be stuck doing anesthesiology

 

[bashwell]

Isn't Anesthesia the "best" residency to get into Pain fellowship though? I know Psyc/PMR/Neuro can technically apply but i heard it's harder for them to get Pain fellowships.

Yeah, I agree, that's my understanding as well, that it's easier to get into pain from anesthesia (and also that anesthesia is more likely to get to primarily do interventional pain than the others). But I'm just saying, if OP doesn't like anesthesia, then it's going to be a very hard slog. That's why I also mentioned OP should do a rotation in pain if at all possible, or at least ask to shadow a pain physician somewhere, before committing to this long road. Maybe OP can tolerate an anesthesia residency like how some people tolerate IM in order to get into a fellowship, but OP didn't seem too happy about 3 years of IM for fellowships, so I'm just saying to OP to make sure that's not the same for anesthesia and pain too.

 

[WingedOx]

Ugh. Pain med sure as hell isn't the type of continuity of care I'd want.

 

[iBS1972]

um, while you are correct there are other specialties, even ones that don't really "mean" to see the same patient repeatedly, FM or other outpt primary care fields offer enormous opportunities for continuity of care that is not matched by your examples

the school where I went was pretty obsessed with primary care and FM, and we got lots of exposure

I met more than one doc who had *birthed* more than one generation of patient in their clinic - basically they went from being someone's pediatrician to delivering that child's children and their children!

You're completely right. In terms of span of continuity, FM is most likely first on the list. If you really want to have that multigenerational connection with patients, no other specialty will come close to FM. Though, if you just want to follow a patient through their disease course, then most specialties will allow you to do that. Also, keep in mind that as a family medicine physician, you will not have the same level of continuity for all of your patients. Many of your patients, especially if they're relatively healthy, will only see you once a year at max. While others will see you only a couple of times ever and then either don't think they nee your care anymore until they're sick or they'll move or you'll move. So, yes if you're looking for multigenerational coverage, FM is definitely the way to do, though only a fraction of your patients will truly fit into that multigenerational category, and you might not see them that often. Just some things to consider.

 

[ChrisMack390]

Medical oncology

 

[whatisthisstuff]

PM&R could be a pretty good choice. Can go pain that route too if you want.

 

[neoevolution]

You're completely right. In terms of span of continuity, FM is most likely first on the list. If you really want to have that multigenerational connection with patients, no other specialty will come close to FM. Though, if you just want to follow a patient through their disease course, then most specialties will allow you to do that. Also, keep in mind that as a family medicine physician, you will not have the same level of continuity for all of your patients. Many of your patients, especially if they're relatively healthy, will only see you once a year at max. While others will see you only a couple of times ever and then either don't think they nee your care anymore until they're sick or they'll move or you'll move. So, yes if you're looking for multigenerational coverage, FM is definitely the way to do, though only a fraction of your patients will truly fit into that multigenerational category, and you might not see them that often. Just some things to consider.

What is Fm like vs. Peds or Im outpatient? I had a FM doc who said he rarely gets peds patients because Ob Gyn refers them all to the local pediatricians

 

[iBS1972]

What is Fm like vs. Peds or Im outpatient? I had a FM doc who said he rarely gets peds patients because Ob Gyn refers them all to the local pediatricians

FM outpatient: lots of colds, ear infections, sinus infections, allergies, back pain, head ache, HTN, DM, HLD, basic stuff for everything
-the primary job of FM is to prevent disease from happening or catch it early, by making sure everyone gets the right preventative and screening tests that they should get. FM has the ability to provide basic services to kids in terms of milestones and general development, but kids really should pediatricians until they are at least late adolescent. Again, FM's job really isn't to treat, but rather to prevent things from happening, being able to detect when things are off (because they've known the patients for a while so they know when something isn't quite right), and they coordinate care (tells patients which specialists to see, and keeps track of what diseases they have and the patient's history of things.)
Peds outpatient: well child visits, colds, ear infections, diarrhea
- all children should have a pediatrician if they live close to hospitals/clinics that provide that service. If you live in rural areas, sometimes there aren't pediatricians around so family docs see the children. Peds outpatient makes sure kids meet their milestones when they're supposed to, makes sure their environment in their home is good, makes sure they are eating the right stuff, and refers them to specialists if they need to.
IM outpatient: same as FM but no kids or pregnant ladies. They see much of the same thing that FM sees, but can manage sicker/more complex patients.

 

[LoGo]

If you truly like family I would go with it. From what I hear pain management can be challenging and not always the most enjoyable. However salary is also important as well. What are your geographic restrictions? There are plenty of FM jobs that pay 300k+ that aren't rural but also not in the heart of a major city either. I've also heard of rural FM making 350-400k and other PP FM with NPs or partners who make a lot of money as well.

What is your ideal salary? Ask yourself that and if you can hit that in a FM practice, (which I bet you can), then go with that. Personally I'd rather make 300k in something I love than 400k in something I don't enjoy as much.

That one is complicated. 100% agree if we are talking love vs hate - but love vs like or don't love as much? suddenly that 100K difference seems appealing, especially if hours are similar. Make it 200K+ difference between love and like and I'm easily bought, and I'd just use that 200K difference to do other things that I love more than medicine.

 

[WhiteCoatWonder]

I think it'd be helpful if you asked the anesthesia and pain forums too.

At least from my very limited experience, pain looks great on paper, but you really need to do a rotation in it to see if you can handle the pain patients and other issues in pain (e.g., opioid dependence, pill mills). Keep in mind academic pain can be quite different than private practice pain, but you'll most likely be working in private practice if you want that high salary and good lifestyle.

Also, I don't know if I would necessarily pick anesthesia just to go into pain. You have to also like anesthesia, especially if you can't get into pain. Four years is a long time if you don't like anesthesia. Personally I like anesthesia, even though it has its significant issues, but if you just consider the specialty itself, it is very cool in my opinion.

this is great advice!

i loved the idea of pain in academia but when i shadowed one of the docs in private practice, it somehow all got dark very quickly. in general, the patients that i met with chronic pain concerns were not able to be "fixed" right away and that was challenging for me. i needs my results. also, at a conference that i went to recently, i was reminded of the fact that there are many patients who get set on a sailboat of opioid-based pain relief and feel that they have no easy way to return to shore...i found that troubling as i definitely considered specializing in pain to be more a part of the solution than helping to create another problem.

anyway, just some things to consider as youre tallying up what characterizes the type of continuity that you're seeking with your patient population. IMO, i dont need that kinda stress!

 

[von Matterhorn]

I think it'd be helpful if you asked the anesthesia and pain forums too.

At least from my very limited experience, pain looks great on paper, but you really need to do a rotation in it to see if you can handle the pain patients and other issues in pain (e.g., opioid dependence, pill mills). Keep in mind academic pain can be quite different than private practice pain, but you'll most likely be working in private practice if you want that high salary and good lifestyle.

Also, I don't know if I would necessarily pick anesthesia just to go into pain. You have to also like anesthesia, especially if you can't get into pain. Four years is a long time if you don't like anesthesia. Personally I like anesthesia, even though it has its significant issues, but if you just consider the specialty itself, it is very cool in my opinion.

Yeah, a rotation would be helpful. I've been working with a pain doc as kind of a mentor and I've generally liked it so far. Yeah, it's kind of 'dark' at times, but I was a chronic pain sufferer myself (for nearly 3 years) and I can 100% relate and empathize what people go with when they suffer from pain every day. It definitely helps derive a sense of purpose and desire to help in this field for me. Also, I enjoyed my gas rotation and would not be unhappy being 'just' an anesthesiologist if the pain route didn't work out.

If you truly like family I would go with it. From what I hear pain management can be challenging and not always the most enjoyable. However salary is also important as well. What are your geographic restrictions? There are plenty of FM jobs that pay 300k+ that aren't rural but also not in the heart of a major city either. I've also heard of rural FM making 350-400k and other PP FM with NPs or partners who make a lot of money as well.

What is your ideal salary? Ask yourself that and if you can hit that in a FM practice, (which I bet you can), then go with that. Personally I'd rather make 300k in something I love than 400k in something I don't enjoy as much.

Sadly, my family is pretty rooted/tied to the HCOL present in the west coast. I could live anywhere, but my wife/kids are tied to this region and I wouldn't uproot them just to earn more. ~250k or so is a pretty fair salary estimate out here in FM, unless I'm willing to give up all of my weekends (I'm not) to do side urgent care or something. As pitiful as it is to say, 250k is not a great salary here. Definitely a good salary, but not really commensurate with the hell of medical school IMO.

Continuity of care is really not that big of a deal if you do anything medicine related (that means no EM). It's really not just FM. Perhaps you've realized that in your IM rotation, many times your residents or attendings will recognize a patient they've had before--that's continuity of care. Often times, you'll need to schedule a patient to follow up with someone after being discharged and that can be you if you want to (you'll likely do some outpatient work regardless of what field you go into, unless if you become a hospitalist)--that's contuinity of care. This is especially true if you go into a sub-specialty, where you will often see sicker patients, in which case it's quite common to have the same patient admitted at least once a month, even every other week because their disease is just so advanced, meaning you'll see them often whether you want to or not.
Even though family medicine physicians pride themselves of continuity of care, it's really not much more than any other specialty.

IM is not really the continuity of care that I'm looking for. You're right, it does have its own version, but it's very different.

Kaiser is currently offering 240k for 4 days of work in FM. You could easily make 300k, while living in a desirable area, if you work 5-6 days a week.

I will graduate with close to 500k in debt (including my and my wife's undergrad). I'm going into neurology. I contemplated going into radiology mainly for the money (and I have the scores for it), but realized that it would be a mistake abandoning the field that I love because it paid a little less.

The gap between specialists and primary care earning is not as wide as it once was. This is even more pronounced when you consider the pay per hour. Psych is a very clear example of that.

I've done quite a bit of research and ~250k/yr is a pretty fair cap for FM in my area, unless you're willing to give up weekends for additional shifts (I'm not - have a family and I want to start spending more time with my kids). The other problem with FM is that there aren't a ton of opportunities to really boost that income - I've talked to FM docs and posted in the FM forum here and it's really just volume, and trading hours = dollars is never an efficient way to earn more. At least with neuro you can further specialize within the field and pull in big bucks if you decide that's what you want. FM doesn't really offer a similar opportunity IME.

Definitely do not do anesthesiology then pain management if your main reason over FM is salary. You will likely be disappointed. There have been large cuts in pain procedures recently and possibly more in the future. It's also not easy at all making money as a pain physician in todays market. I see pain jobs salary start at 200k as an employee, higher depending on location. It will also be more stressful than FM due to the patient population, and tons of procedures and being exposed to radiation all day long. Your ceiling is definitely higher if you start your own practice but this is extremely difficult, and takes years to settle. You will have a large overhead/startup cost and few patients in your early years
Also pain is competitive. Many anesthesiologists apply to pain to get out of anesthesiology since that's the only real fellowship that lets you leave the ORs/quit working w surgeons. If you do not get into a pain fellowship you'll be stuck doing anesthesiology

I actually enjoyed my rotation and there were no pain patients involved in it. I would be happy working as an anesthesiologist regardless of a fellowship, personally. I would just miss that clinic aspect, which is why I feel like it's a specialty that provides an opportunity for both types of practice.

Ophthalmology, and especially retina, provides continuity of care. It is a fantastic field but have to like the eye obviously. You probably won't be pulling ortho money on average but with some business skills and hard work you can make great money, especially as a subspecialist (per MGMA anyway). If you have any interest whatsoever in the eye go hang out in clinic/OR sometime.

I do not have the board scores, the research, nor the interest in optho to make that a reality 🙂