Why Make 150k When 450k Is Out There?

[NewmansOwn]

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Thanks for adding a series of logical and well written posts to the thread. I'm disappointed that some students/MD's would think they have a monopoly on valid inference for all things medical.

Looking again at JPP's original question brings up a series of thoughts for me:

1) These figures of 150K, 450K, etc. are averages collected on surveys.
2) If you prefer a salaried position over ownership or part-ownership of a private practice, these averages are more likely to apply to your future income.
3) In private practice there is a greater variance in income, and there must be a logical reason for this variance.
4) My best explanation to date for this variance is that medicine is a business, and some businesses are simply run in a much more profitable manner than others.

This goes to the heart of what you touched on, which is understanding the financial aspects of medicine. Doing so may just permit you to chose the specialty you enjoy most AND make more than you otherwise would.

I agree. I think it's natural for us to look to averages as "comfortable" assurances, of sorts. After all, if we're going to invest nearly a decade attaining our professional goals, why not expect a substantial return on that investment?

BUT -- obsession over averages ignores the fact that we are different, marketable people living in a relatively free capitalist society. Private practices can and will position themselves to provide a highly demanded service or fill a coveted niche. Understanding microeconomics and paying close attention to local market demands (along with some common courtesy and a little work ethic) will likely ensure a modest increase in income.

Thus, as you say, one ought to pick the specialty one enjoys and focus on using their enthusiasm for said specialty to market their skills and work hard to maintain a loyal and large client/patient base.

 

[MedicineDoc]

I agree. I think it's natural for us to look to averages as "comfortable" assurances, of sorts. After all, if we're going to invest nearly a decade attaining our professional goals, why not expect a substantial return on that investment?

BUT -- obsession over averages ignores the fact that we are different, marketable people living in a relatively free capitalist society. Private practices can and will position themselves to provide a highly demanded service or fill a coveted niche. Understanding microeconomics and paying close attention to local market demands (along with some common courtesy and a little work ethic) will likely ensure a modest increase in income.

Thus, as you say, one ought to pick the specialty one enjoys and focus on using their enthusiasm for said specialty to market their skills and work hard to maintain a loyal and large client/patient base.

I would like to point out that the poster complimenting you above is not going into primary care judging from his/her large number of posts in the psychiatry forum. Secondly, reimbursements by insurance companies are tied to Medicare rates and your statements ignore this fact. This is why primary care salaries don't increase despite significant shortages that are increasing steadily as medical school graduates choose higher paying specialty residencies. The substantial shortage of primary care physicians largely due to the faulty reimbursement system paying out inordinate money for procedures and inadequate amounts for time consuming primary care workup leading to said procedures through specialty referrals not only causes huge salary gaps but also forces PCPs to limit time with patients and see more patients which obviously decreases quality of care. You can choose to stick your head in the sand and become part of the problem or you can contact your congressman and urge them to take actions on the recommendations of the Medicare advisory committee as outlined in this wall street journal article:


http://blogs.wsj.com/health/2008/04/...s/?mod=WSJBlog


Medicare Advisors: Pay More for Primary Care, Less for Procedures

Posted by Jacob Goldstein

Medicare should pay more for primary care and less for procedures and specialty care, a Medicare advisory board said at a meeting this week.
Plenty of people have been saying that lately, of course, but this comes from MedPac, a commission created by Congress to advise lawmakers on Medicare.
Health care winds up costing more when there's lots of specialty care, but outcomes aren't necessarily better. Having more primary-care docs, on the other hand, does tend to improve outcomes, a briefing document prepared for the meeting pointed out. Yet the payment system in this country tends to favor specialists, which is part of the reason fewer young docs are going into primary care.
"Accordingly," the document dryly noted, "primary care services are at risk for being underprovided to the Medicare population."
So Congress should bump up what Medicare pays for primary care, the commission said. And lawmakers should do it in a "budget-neutral" way, which means paying less for other kinds of care.
This sounds simple enough: If something is important for patients' health, and it's being undervalued, we should pay more for it. But in health care, where reimbursement has long been based on the resources required to provide a medical service, it represents a pretty big shift in how to approach health-care costs.

 

[jetproppilot]

I would like to point out that the poster complimenting you above is not going into primary care judging from his/her large number of posts in the psychiatry forum. Secondly, reimbursements by insurance companies are tied to Medicare rates and your statements ignore this fact. This is why primary care salaries don't increase despite SIGNIFICANT SHORTAGES that are INCREASING STEADILY as medical school graduates choose higher paying specialty residencies. The substantial shortage of primary care physicians largely due to the faulty reimbursement system paying out inordinate money for procedures and inadequate amounts for time consuming primary care workup leading to said procedures through specialty referrals not only causes huge salary gaps but also forces PCPs to limit time with patients and see more patients which obviously DECREASES QUALITY OF CARE. You can choose to STICK YOUR HEAD IN THE SAND and become part of the problem or you can contact your congressman and urge them to take actions on the recommendations of the Medicare advisory committee as outlined in this wall street journal article:











WOW.

I wish you wouldda been here, ohhh, about thirteen thousand views ago.

Flames or no flames, the OP is a real life issue.

And that needs to change.


btw, Kent, geez, 13,000 views! I know you're keeping track....where is that on the Top Ten list? 🙂laugh🙂 Brought some dudes/dudettes to the forum I'd say, huh? And thats a good thing.

 

[andwhat]

Welcome back, andwhat. I'm sorry your last account got banned. If you could leave me alone, I'd be appreciative. I've tried to reason with you, but this is bordering on creepy.

hey there buddy! Nope -- awwww! Didn't get banned unfortunately, I see that you are obviously wholeheartedly disappointed by that.
I am sorry that I did not reply to your insult right away, as I am a doctor that takes call.
I will not play along with your game; nonetheless I will thank you for the notoriety. Thank you I love being famous!
Keep it real! 👍

 

[ForbiddenComma]

I'm an MS3 who's going to be entering match season in a few months... and my choices at this point are primary care versus EM... and if you think about it, EM is primary care too. Here's why I've narrowed it down to those choices.

1. It's real medicine. Things like dermatology just don't feel like real medicine. Yeah sure you roll in the bank, but you're still just Pimple Popper M.D., and are completely expendable as far as societal value goes. Same general idea goes for other specialties like radiology.

2. I live for diagnosis. That's what I do. There is nothing better than picking up on a dx due to a lab value unnoticed by the residents, or a mole that nobody noticed, or an off-hand mention by the patient that they've been dropping things recently. Sure, procedures have their place, and the OR is a lot of fun for me... but not in the same way as solving problems. In my opinion, if you have to call in a consult and you don't have a diagnosis yet, you've lost.

3. I'm currently on my surgery rotation, and I see these staff anesthesiologists who don't interact with patients for even a minute of their day and instead supervise residents and CRNAs. I went to med school to practice medicine, not supervise workers like an MBA. This ties to point #1. Also, does anyone really think that anesthesiologists will continue to enjoy their rarefied role once CRNAs get all states to allow their independent practice in the next 10-20 years or so? With no legal reason to keep them around, hospitals and practices will fire overpaid anesthesiologists in the time it took you to read this sentence.

4. I want to work with the entire body, not just one organ system, or have one limited role. We aren't spending all of med school just looking at films, or only learning about skin conditions, right? Why throw away that broad base of knowledge? That vast breadth of knowledge, more than anything else, is what separates us from the nurse practitioners.

5. Because I don't care about what SDN posters think as far as which specialty is cooler. 🙂

 

[andwhat]

diagnosis is very very cool. It is amazing learning about new advancements in disease processes. Treating patients, its also great.
Pimple popper is at times an understatement, more like Oxycontin and Vicodin dispenser.
"what brings you here today?"
"Oxycontin 30 mg BID, but please write it as 20 mg and 10 mg due to insurance purposes"
That stuff needs to stop, however it does exist in almost every profession, but somehow is most rampant amongst primary care.

 

[ioh]

I would like to point out that the poster complimenting you above is not going into primary care judging from his/her large number of posts in the psychiatry forum. Secondly, reimbursements by insurance companies are tied to Medicare rates and your statements ignore this fact.

MedicineDoc, you caught me. I actually applied to Psychiatry, did not match, and successfully scrambled for FM. Hence the previous posts in the Psychiatry forum, and my current interest here.

I agree that Medicare/Medicaid rates largely determine reimbursements by insurance companies. However, my suggestion is that you must make your practice different from your competitor's. If you own a practice, it's a business, and you need to innovate if you want to be richly rewarded in a capitalist society (because Medicare likely won't do that). I know this sounds very general and possibly naive, yet I'm sure it has substance.

Still, I applaud your effort to inform us and get us involved politically to effect change.

 

[Tired]

You know, I followed this thread from the beginning. Initially I thought it was just an obnoxious jab at Primary Care from a specialist.

Then I started mulling over it more, and a question came to me.

I love Ortho. But if I were looking at a lifetime yearly rate topping out at 150-200k, would I have really chosen it over something more lucrative but less interesting to me (like Anesthesia)?

Hells no.

I mean, I get that y'all love primary care, working with a variety of populations, getting in some obstetric work, and maybe even a little surgery if you go way rural. But do you really like doing that $300,000 more than passing gas or sewing bowel? Because that's a lot of cash, and I would never make that choice.

I mean, let's be honest. Reimbursements in Primary Care are never going to go back up, and they will likely continue to trend down in real dollars. The nurses are going to continue to steal your turf.

Wouldn't have made more sense to go the Internal Medicine route? Then you could practice all the primary care you wanted until you got sick of making no money, then go do inpatient work. Or you could do one of the lucrative specialties like GI or Cards, and do a little of both so you could afford an Escalade.

I guess folks here must have pretty different motivations for going into medicine than I do. I like what I do, but not enough to bail on an extra 300k to do it.

Of course, this is probably the forum for people who really meant it when they told their med school interviewers, "Because I really want to help people." 😀

 

[Newdoc2002]

Friend just took a starting salary job in FM of $190,000 + benefits. 0 call. Completely salaried, no ownership in TX. I didn't ask other details, but it seems pretty decent to me.

Not unheard of and depends on what and where. That salary could be a teaser rate to get them in the door. At some point, they will have to put up the reimbursement to justify that figure. They also may find out that figure is capped for a long time.

 

[NewmansOwn]

hey there buddy! Nope -- awwww! Didn't get banned unfortunately, I see that you are obviously wholeheartedly disappointed by that.
I am sorry that I did not reply to your insult right away, as I am a doctor that takes call.
I will not play along with your game; nonetheless I will thank you for the notoriety. Thank you I love being famous!
Keep it real! 👍

Oh hey man. Sorry about the confusion -- that other poster reminded me of the 'previous you' and I wasn't exactly sure what your 'Account on Hold' meant. It's cool that you're friendly now though; welcome back. And no more insults from me, so no need to worry.

Medicine Doc: I totally agree. My head is most certainly not in the sand, I promise you. The lowering of reimbursements from Medicare/Medicaid whilst supply of primary care physicians dwindle is not just troublesome -- it's downright illogical and unfair. I am just personally uncomfortable with ignoring the individuality of physicians and their ability to create innovative practice models that capitalize on market demand and eschew the ossified and recalcitrant insurance companies as much as possible (see Jay Parkinson, MD, for instance). To blame the problem entirely on Medicare/Medicaid, which for many (obviously not all) physicians only pays a fraction of their income is ill advised. While I can't speak to all insurance companies, I know from my work that Cigna and Unicare have both recently risen their payments for well-child visits, initial H&Ps and a few other basic primary care stuff by an average of $15 bucks a pop in DC/Maryland/Virginia. It's heartening that at least in that one instance, they're not following suit with Medicare/Medicaid.

Also, the other poster's specialty is of little interest to me. Anyone in any profession can be well-read in these issues, if they so choose. Some of the medical students doing research here at the NIH know less about medical finance than my garbage man. I think everyone deserves a chance to participate in the conversation. And ultimately, the more individuals we have fighting to keep primary care lucrative, the better.

 

[andwhat]

Of course, this is probably the forum for people who really meant it when they told their med school interviewers, "Because I really want to help people." 😀[/QUOTE]

Nobody cares about "helping" people anymore. If there was a so called "primary care shortage" then people would figure out how to compensate primary care docs better, so that greater than 6% per year of US grads go into Family Medicine. Truth is nobody cares.

Instead now they are pushing harder and harder for "nurse doctors" and LPNs to take the place of real doctors.

I have to say that I agree with so much of that, being in primary care. "Because I really want to help people" Nobody cares about helping people anymore.

You are helping people being an Ortho doc -- you are fixing fractures, and saving lives also -- plus getting paid TONS more than primary care.
I don't think that changes will happen to increase reimbursement into primary care, probably a good thing that the majority of people are choosing specialty based careers.

Just the other day, a Surgeon's son graduated from a local high school. He is a local scholar. In his ad in the newspaper, it states that he is going to
"study pre-med, become a doctor, and then become an Orthopedic Surgeon"

At least his dad is smart for guiding him into a higher paying, and rewarding career. A short lived one at that however in my opinion.

I wouldn't call Anesthesia lucrative anymore though, it is under 'threat', esp at our local hospitals.

Rumor has it that the axe is coming soon. Future prediction, spoke with someone higher up, is that 25-30% of the current Anesthesiologists will be around within the next year, at our local hospitals.

A few Anesthesiologists have already quit, and found employment at the University. There is almost always job security at Universities -- lifestyle is much better too.

CRNAs are getting hired faster than any time in the past.

Its all about cutting costs, at any level possible.

This is a sad but very very true reality.

On the other side, you have to factor in the call perspective. As a specialist, Ortho doc, you will be taking call no matter where you go. Ortho call is usually brutal.

Ortho clinic is the WORST!!

"I had surgery with you last week, and I am still in pain"

you have to see 50 or MORE of these visits per DAY. That is not at all fun in my opinion, it would be horrible.
Worth the money? Probably not long term.

Ortho is a great field, but it is a short lived lifestyle. You have to look at the long term aspects of it also. Make a bunch of money, and then quit.

That doesn't sound like something intriguing to me.

I went to medical school, to pick a higher paying career -- then burn out, and try and find all of the money that I just spent over the last 10 years.
It is not worth it.

If you are primary care, you do not have to take call.


You can earn your $200 K paycheck, and go home at the end of the day -- and not have your own patients, or take call.

You can be a hospitalist.

It is not about money, it is about lifestyle.

Do you truly want to spend 5 brutal years of your life in Ortho residency, and then work at a higher stress level for the rest of your working life?

I wouldn't do it.

My two cents.

 

[jetproppilot]

Huh?

 

[lowbudget]

Is this thread dead yet?

Why would you do 150k (FM) when you could make 450k (like in Anesth)? My answer is: because these things swing unpredictably over time and free markets have little tolerance for excess. Anesthesiology is the *classic* example of how a well-earning specialty can be brought down to its knees by random swings in politics and economics.

Why hasn't anyone asked the question: What happened to Anesthesiology back in 1996? Anesthesia programs were closing all over the place. It got so bad that no medical student could possibly want to go into anesthesia! Just check out the data:

(NRMP Match Anesthesiology)
http://www.aafp.org/match2006/table12.htm

(Analysis of Match Stats by ASA)
http://www.asahq.org/Newsletters/1996/05_96/article1.htm

Anesthesia really had to fight and make themselves relevant again by reinventing themselves. Here's what they were saying back in 1997 (great article):

(Using anesthesiology as a model for change)
http://www.thefreelibrary.com/Using+anesthesiology+as+a+model+for+change-a0120184125

The one truism here is that as humans, we are always wrong when we try to predict the future. No one knows what the future lies for any of us. Not the Academy's "Future of FM". Not Nostradomus. Not Wall Street. Not the 6 o'clock weather man.

AND it can't get any worse for primary care. And I'm pretty happy. So for us young guys, it's on the up-and-up. Buy low. And it's good that JetPropPilot has been in practice for 11 years. Because as good as you have it now, good thing you won't be practicing very long. Sell high.

Nothing in that 1997 article has changed. We use different vocabulary now (medical home vs. gatekeeper), but all the concepts are the same. It has been that way since the Great Depression, Nixon, and Clinton.

And for the young people wanting to go into a field like anesthesia/radiology now? You're late. The excess will correct itself and it'll be downhill again. Buy high, sell low?

JetPropPilot, looks like you got in when the specialty was ultra-non-competitive. I mean, like, I-don't'-care-about-your-Boards-do-you-have-Airway-Breathing-Circulation sort of non-competitive. But it looks like now that you're a pretty smart guy for doing something that NO ONE wanted to do.

So... ask your question again? Why would we go for 150k when there's 450k out there?

Because we want to be like you.

 

[jetproppilot]

Is this thread dead yet?

Why would you do 150k (FM) when you could make 450k (like in Anesth)? My answer is: because these things swing unpredictably over time and free markets have little tolerance for excess. Anesthesiology is the *classic* example of how a well-earning specialty can be brought down to its knees by random swings in politics and economics.

Why hasn't anyone asked the question: What happened to Anesthesiology back in 1996? Anesthesia programs were closing all over the place. It got so bad that no medical student could possibly want to go into anesthesia! Just check out the data:

(NRMP Match Anesthesiology)
http://www.aafp.org/match2006/table12.htm

(Analysis of Match Stats by ASA)
http://www.asahq.org/Newsletters/1996/05_96/article1.htm

Anesthesia really had to fight and make themselves relevant again by reinventing themselves. Here's what they were saying back in 1997 (great article):

(Using anesthesiology as a model for change)
http://www.thefreelibrary.com/Using+anesthesiology+as+a+model+for+change-a0120184125

The one truism here is that as humans, we are always wrong when we try to predict the future. No one knows what the future lies for any of us. Not the Academy's "Future of FM". Not Nostradomus. Not Wall Street. Not the 6 o'clock weather man.

AND it can't get any worse for primary care. And I'm pretty happy. So for us young guys, it's on the up-and-up. Buy low. And it's good that JetPropPilot has been in practice for 11 years. Because as good as you have it now, good thing you won't be practicing very long. Sell high.

Nothing in that 1997 article has changed. We use different vocabulary now (medical home vs. gatekeeper), but all the concepts are the same. It has been that way since the Great Depression, Nixon, and Clinton.

And for the young people wanting to go into a field like anesthesia/radiology now? You're late. The excess will correct itself and it'll be downhill again. Buy high, sell low?

JetPropPilot, looks like you got in when the specialty was ultra-non-competitive. I mean, like, I-don't'-care-about-your-Boards-do-you-have-Airway-Breathing-Circulation sort of non-competitive. But it looks like now that you're a pretty smart guy for doing something that NO ONE wanted to do.

So... ask your question again? Why would we go for 150k when there's 450k out there?

Because we want to be like you.

Thats awesome.

 

[iatrosB]

Thats awesome.

That's very awesome!

And it's my philosophy exactly...buy low, sell high...primary care can't get any WORSE...I enjoy the work...and many specialties are going to go down in the years to come (not to nothing mind you, but it will be more like "why make 200K when 250K is out there")

 

[jetproppilot]

That's very awesome!

And it's my philosophy exactly...buy low, sell high...primary care can't get any WORSE...I enjoy the work...and many specialties are going to go down in the years to come (not to nothing mind you, but it will be more like "why make 200K when 250K is out there")

You've obviously forgotten the point of the thread, which is that many, many med students are mired with hundreds of thousands of dollars in student loan debt.

And specialty selection directly correlates to the ease of paying off said-incurred debt.

Monetarily speaking, you arent buying low and selling high.

Since you're assuming primary care is gonna go up, and specialty care is gonna go down. uhhhhh....medicare anesthesia reimbursement was INCREASED in 2008....and theres a HUGE paucity of clinicians in said specialty, which isnt reversible in the near future...AND....for DECADES AND DECADES, for whatever stupid reason, procedure-oriented specialties pay more...thats reality, Slim...don't hate da playa, hate the game....that kinda mires your theory already, huh?

I (really) hope you're right. But thats a big assumption.

As an aside, is that how you manage your personal finance portfolio?

Do you buy the most beaten-down stocks, and assume/hope they go up?

I've tried that, Slim. It usually doesnt work.

This thread is from a monetary standpoint, which is abrasive to many people here.

Thats OK.

Its still reality.

And yeah, I can hear the posts already....

but the message remains:

IF YOU ARE ONE OF MANY MED STUDENTS WITH SEVERAL HUNDRED THOUSAND IN STUDENT LOAN DEBT, YOUR SPECIALTY CHOICE WILL DIRECTLY AFFECT YOUR ABILITY TO PAY OFF DEBT/LIFESTYLE/MORTGAGE PAYMENTS/KIDS TUITIONS.

And, current day, there arent enough monetary incentives for a med student to go into primary care if they've encompassed alotta debt. This needs to change. But it continues to be reality. The statistics speak for themselves on how this directly affects med student specialty choice. You wanna ignore this fact? Thats your decision.

AND, its amazing how many myths about specialist's lifestyles are propegated in the academic millieau! (If you are really interested, my S.O. is a general surgeon. Theres a thread about her lifestyle in the anesthesia forum.)

Look, my objective is to provide people in training with reality.

So they can make informed decisions, since theres a PLETHORA of ACADEMIC MYTHS propegated by the whole academic system.....and if you are aimed at private practice, and you are a med student, you are being WEALTHILY UNINFORMED about many things.

Theres a huge gap between how your academic attendings practice (place your specialty of choice here) and how a private practice (place your specialty of choice here) practices. And how their lives are.

Some uninformed dude here posted about how orthopedists, yeah, make alotta money, but are tied to the hospital with endless hours and endless call.

Thats B.S.! Please come to my hospital. Or any other non-academic hospital. Efficient orthopedists have lives too.

JUST ANOTHER PROPEGATED ACADEMIC MYTH BY SOME UNINFORMED DUDE STILL IN THE ACADEMIC SYSTEM.

My goal is for people to be informed.

With accuracy.

So an informed decision can be made on a specialty.

Which brings us back to the OP, huh?

And yet people here fight reality......with presumptions (specialty reimbursement is gonna go down)

Thats not the point.

THE POINT is

HOW DEBT AFFECTS YOUR LIFE.

The OP was aimed at med students who are debt-laden.

DEBT AFFECTS YOUR LIFE AFTER YOUR RESIDENCY IS OVER.

In a BIG, ADVERSE way.

Nobody tells a med student this when they are selecting a specialty.

aside all the above....

theres alotta individuality that goes into the success of an individual physician. Regardless of specialty.

But if you're 250K in the hole to start, its alot easier if your bottom line is amongst the higher paying choices, wouldnt you agree?

 

[Beau Geste]

I'm going to start med school in a couple of months and I fully plan on returning to my extremely rural hometown. I've already met with the board of directors at the hospital and we're putting together a proposal that IF I happen to specialize in primary care (FP, peds, Gen IM, and they also consider gen. surg) and want to go there to practice, they will pay my student loan off year for year.

I submitted my the exact financial aid breakdown from my school for tuition + living expenses and will submit each year's breakdown to them for the official borrowing record.

They are so hard up for primary care docs in my hometown and surrounding area that they jumped at this when I sent a proposal letter to the board after hearing they've done it for 3 other hometown med students. It's no skin off my back - I'm not obligated to practice there and if I happen to go into a specialty other than primary care that's ok too (I made sure to emphasize people's minds change about specialties as time goes on through med school).

I mention this because I'm sure there are others out there that may want to return to rural areas that are hard up for primary care docs. It never hurts to ask about these things and it's nice to know there are some avenues for reducing or eliminating debt for a field you want to go into.

 

[iatrosB]

You've obviously forgotten the point of the thread,

It had a point?!

 

[iatrosB]

And specialty selection directly correlates to the ease of paying off said-incurred debt.

Monetarily speaking, you arent buying low and selling high.



But if you're 250K in the hole to start, its alot easier if your bottom line is amongst the higher paying choices, wouldnt you agree?

I absolutely agree that making more money makes paying off loans easier...no brainer.

But the point is, when med students are 6+ years away from making any said money, it is foolish to count on it. I hope that specialists aren't paid less in the future, I just want PC to pay more. However, I can't sit back and say "Gas makes 450K now, so they always will, I should do Gas cause I have debt." What happens if I get out 5 years later and dang, the PCP is making more than me! And I hate my job! That would suck...bottom line don't pick a career based on money (isn't that a high school principle or something). Money might not always be there (I hope for all of our sake it is, but who knows...not me).

But you refuse to accept any reason given (out of the multiple) because by golly we're just to naive to even know we're naive. You must pity us so...don't, we'll manage.

 

[Tired]

But you refuse to accept any reason given (out of the multiple) because by golly we're just to naive to even know we're naive. You must pity us so...don't, we'll manage.

He's not accepting your reasons because your reasons make no sense. You're looking at match data from 10 years ago, then use that to extrapolate the conclusion that anesthesiologists weren't making much money. Then you completely ignore the fact that FPs weren't making much more than they are now.

The "buy low, sell high" rationale only makes sense here if FP were ever high . . .


Of course, that being said, I think this recent theme of Jet's that "Private practice surgeons can make a million bucks a year and never take call" is a little distorted. From what I gather, he's started nailing some high-speed general surgeon with great hours and great money (and hopefully a great rack to complete the package).

But most private practice 'pods don't make 600k without taking call. Some do, obviously, and it sounds like Jet has been spending time with them in their ASCs in major metro areas. But those guys typically have quite a few years under their belt (or fat connections), extremely solid referral bases, and function as niche providers in heavily insured (or cash-flush) areas.

I know there's a lot of lies coming out of academic centers about the lifestyle of the private guys. But the scenarios he's describing are hardly the rule for most.

 

[jetproppilot]

He's not accepting your reasons because your reasons make no sense. You're looking at match data from 10 years ago, then use that to extrapolate the conclusion that anesthesiologists weren't making much money. Then you completely ignore the fact that FPs weren't making much more than they are now.

The "buy low, sell high" rationale only makes sense here if FP were ever high . . .


Of course, that being said, I think this recent theme of Jet's that "Private practice surgeons can make a million bucks a year and never take call" is a little distorted. From what I gather, he's started nailing some high-speed general surgeon with great hours and great money (and hopefully a great rack to complete the package).

But most private practice 'pods don't make 600k without taking call. Some do, obviously, and it sounds like Jet has been spending time with them in their ASCs in major metro areas. But those guys typically have quite a few years under their belt (or fat connections), extremely solid referral bases, and function as niche providers in heavily insured (or cash-flush) areas.

I know there's a lot of lies coming out of academic centers about the lifestyle of the private guys. But the scenarios he's describing are hardly the rule for most.

HAHAHAHAHAHAHAHAHAHAHA

Sitting here laughing at my computer!!!!

Nice.

ALTHOUGH, I never said these people didnt take call.

They do.....but its distributed amongst many PP groups which spaces it out...

and my argument is in the perception painted by people still in the academic milleau....who don't have a clue of what a PP specialist's lifestyle is....

Most doctors take some kinda call, Dude.

Regardless of specialty.

But to paint a picture of a specialist living at the hospital just aint right....and I beg to differ with you about your rule of most comment.

You guys arent being informed.

And I want you to be informed.

Accurately.

 

[jetproppilot]

This conversation isnt a plug for anesthesia, Dude. BTW, nobody in the real world calls anesthesia GAS....if you go to the front desk fresh outta residency and ask where the GAS office is, they, and the attendings alike, are gonna stare at you like a deer in headlights...

This conversation is about the dichotomy of reimbursement of ANY subspecialization in medicine verses primary care.....and how that affects a med students choice to pursue one or the other.

Current day, the vote is obvious.

And I feel that needs to change.

With BIG student loan-forgiveness incentives for a med student selecting primary care.

 

[jetproppilot]

But most private practice 'pods don't make 600k without taking call. Some do, obviously, and it sounds like Jet has been spending time with them in their ASCs in major metro areas. But those guys typically have quite a few years under their belt (or fat connections), extremely solid referral bases, and function as niche providers in heavily insured (or cash-flush) areas.

.

To redirect you, Dude, most fee-for-service MDs don't make much money on call.

Their insurance-paying elective cases pay the bills.

Not the drunk, young MVA dude with multiple fractures in the middle of the night, 99% of the time devoid of insurance.

Call is an obligation.

Not a conduit to doctor C-notes.

 

[jetproppilot]

So...what, she doesn't have a great rack? 😉

Kent, if we were referring to your wife, would you comment about her "rack" here?

 

[jetproppilot]

I'm going to start med school in a couple of months and I fully plan on returning to my extremely rural hometown. I've already met with the board of directors at the hospital and we're putting together a proposal that IF I happen to specialize in primary care (FP, peds, Gen IM, and they also consider gen. surg) and want to go there to practice, they will pay my student loan off year for year.

I submitted my the exact financial aid breakdown from my school for tuition + living expenses and will submit each year's breakdown to them for the official borrowing record.

They are so hard up for primary care docs in my hometown and surrounding area that they jumped at this when I sent a proposal letter to the board after hearing they've done it for 3 other hometown med students. It's no skin off my back - I'm not obligated to practice there and if I happen to go into a specialty other than primary care that's ok too (I made sure to emphasize people's minds change about specialties as time goes on through med school).

I mention this because I'm sure there are others out there that may want to return to rural areas that are hard up for primary care docs. It never hurts to ask about these things and it's nice to know there are some avenues for reducing or eliminating debt for a field you want to go into.

Thats an awesome, proactive plan.

 

[jetproppilot]

I liked your first response better (found the picture, too).

Try rebooting your sense of humor, "slim."

Yeah, you're right.


geez....you found it...that quick???? Pretty good, dude....pretty good...

 

[jetproppilot]

But you refuse to accept any reason given (out of the multiple) because by golly we're just to naive to even know we're naive. You must pity us so...don't, we'll manage.

I certainly don't pity you.

Nor am I advocating going into a specialty you don't like.

I'm an advocate for loan forgiveness for students going into primary care....or some other huge incentive....that will stop the never-ending trend of many med students overlooking primary care as a possibility because of reimbursement.

 

[MOHS_01]

Students must be made aware, prior to making any decision based upon promises for repayment, that any monies provided by any entity for debt repayment is handled as ordinary income for tax purposes. This is income that you don't "see" but are taxed on -- making for one painful tax day.


I plan to cover all of this in the lecture series that I am preparing for medical students (and residents, but the earlier that you learn the better off that you will be).

Specialty selection should, at the bare minimum, be based 75% on doing what you like... for reasons that will also be covered in my short course.

 

[Beau Geste]

Thats an awesome, proactive plan.

Thanks. As someone else posted here, the repayment is of course subject to tax, but knowing in advance what the tax burdens are can also help prepare, and it's a lot less than paying a 200k-300k loan + interest over 15-30 years (or so).

I'm really glad that MOHS is planning to teach some students and residents about this. I'm also really glad the financial planning bug bit me in the butt now rather than later.

 

[soonereng]

This is income that you don't "see" but are taxed on -- making for one painful tax day.

I don't see how paying the taxes on the loan amount can be more painful than actually paying off the principal and interest of the loan yourself...not really an issue in my opinion. It should be treated as imputed income because they paid it on your behalf.

And don't blast me for just being a medical student. I'm a nontrad and my household income between my wife and I used to be 150K, so I know the tax bracket that we're talking about.

As to the OP, I'm probably going to be going into FP or Med/Peds and as stated above, I know what it's like to make "only" 150K a year. 🙄 One of the main reasons that I want to do primary care is that you can set up shop pretty much anywhere and you will be needed. I want to start my own practice with my wife who is an NP when I get done with training. If I were to go into certain specialties, the demand for my services wouldn't necessarily be there in some locations.

Now, I'm leaving all my options on the table so if I change my mind after 3rd or 4th year rotations, then those other specialties will still be there. But I'm pretty sure I'll wind up FP or Med/Peds because of the variety of patients seen and the broad knowledge base that one must maintain.

 

[iatrosB]

He's not accepting your reasons because your reasons make no sense. You're looking at match data from 10 years ago, then use that to extrapolate the conclusion that anesthesiologists weren't making much money. Then you completely ignore the fact that FPs weren't making much more than they are now.

The "reasons" I was referring to actually had NOTHING to do with MONEY or MATCH data. I'm talking about reasons we like FM, which have been stated numerous times in this thread...it's OK, I don't expect you to get it.

 

[Beau Geste]

I don't see how paying the taxes on the loan amount can be more painful than actually paying off the principal and interest of the loan yourself...not really an issue in my opinion. It should be treated as imputed income because they paid it on your behalf.

And don't blast me for just being a medical student. I'm a nontrad and my household income between my wife and I used to be 150K, so I know the tax bracket that we're talking about.

As to the OP, I'm probably going to be going into FP or Med/Peds and as stated above, I know what it's like to make "only" 150K a year. 🙄 One of the main reasons that I want to do primary care is that you can set up shop pretty much anywhere and you will be needed. I want to start my own practice with my wife who is an NP when I get done with training. If I were to go into certain specialties, the demand for my services wouldn't necessarily be there in some locations.

Now, I'm leaving all my options on the table so if I change my mind after 3rd or 4th year rotations, then those other specialties will still be there. But I'm pretty sure I'll wind up FP or Med/Peds because of the variety of patients seen and the broad knowledge base that one must maintain.

I am a nontrad too in the same tax bracket, however we are a distinct minority when it comes to med students. Most graduate having never earned a wage that would support a family, let alone put themselves in a 150k tax bracket. Many med students don't pay much tax, if at all, and more than likely get refunds, making tax day for a scholarship repayment a real scary moment.

 

[iatrosB]

This conversation isnt a plug for anesthesia, Dude. BTW, nobody in the real world calls anesthesia GAS....if you go to the front desk fresh outta residency and ask where the GAS office is, they, and the attendings alike, are gonna stare at you like a deer in headlights...

Yeah, I know...I would never ask for the "gas department".

I just can't spell anesthesia

 

[Tired]

But to paint a picture of a specialist living at the hospital just aint right....and I beg to differ with you about your rule of most comment.

Fair enough on the "rule of most". Honestly, I guess I don't know what represents "most" private practice surgical subspecialists.

But I do know what I've seen between maybe 4 academic centers, and maybe 3-4 private hospitals I've been through. And it seems like, early in our careers (which of course occurs between like 30-40yo since our residencies are so long), we work a lot more than the older guys do.

True, the money is in the insured or cash elective cases. But it takes time to cultivate the relationship with the PCPs who refer to you. And it takes time to build this base. It's no accident that the young private guys (at least the ones I've trained under) have a couple typical patterns of work:

- solo or small practice with other young guys, slamming out large amounts of call and providing the best service they can to the ER and Primary Care groups to "get their name out" and draw the call cases into their clinics

- joining established practices with older guys where they are brutalized both in the call they take for the group and the money they make as non-partners

Then after a few years, the call goes down, the money goes up . . .

I seem to recall anes threads that basically said y'all go through the same thing?

 

[MOHS_01]

soonereng,

Best of luck to ya, buddy.... really. I feel no need to blast anyone for anything at this point. Just make sure that you have an accountant walk you through the numbers prior to signing anything. I never said that loan repayment was not preferable to servicing the debt with your own money; rather, there are implications to having someone else do so. One of the potential pitfalls is how your employer treats the loan forgiveness. What you do not want to happen, for instance, is to have your student loans paid off in full your first year out, when you really only have six months of non-resident income... only to find a fat 1099-misc in your mailbox come January. It has happened (not 300k, but 140k). There has been debate as to whether the hospital should report the income as 1099-misc or 1040-C; in any event, it clearly is taxable, and given our "pay as you go" income tax structure, you are liable from the date that the debt is forgiven.

I am only trying to help -- I did things the hard way (no one offered to pay my student loans off for me, though) and learned some valuable, even if they were painful, lessons along the way.

 

[soonereng]

I feel no need to blast anyone for anything at this point.

Thanks. I wasn't talking specifically to you as there is a tendency on SDN for people to assume that because they are farther along in their training that those behind them have no clue about things. I just wanted to state up front that I knew what I was talking about from personal experience with taxes and imputed income in the dollar range that you were talking about.

And yes, one should definitely know specifically the timeframe and tax reporting method on how their employer plans on repaying the loan before signing on any dotted lines.

 

[Strength&Speed]

well, since jet is the originator of the thread...maybe he could answer...what would you do if anesthesia made 150?

I would bet my life that if FP paid 450 and ortho or anes 150, you couldnt shut people up about how much they loved having long term relationships with their patients.

 

[secretwave101]

It's true. Continuity is one of the major perks of Family Medicine. But the majority of humans go to work to make money. Why deny it? If you want relationships, just hang out in a bar all day. FP is a tough way to make friends.

So many of my primary care colleagues start EVERY money discussion with, "I don't want to get rich..." WHY NOT? Is that a crime? Do you 'want to get poor' after working 60-80 hours a week your whole life with the stress of litigation, loan repayment, loss of family and friends? Does immunizing kids really warm your heart enough to offset the chill of all those missed soccer games, half-seen plays and finding your lonely wife in bed with the plumber?

Who - in all honesty - wants to work this hard with this much stress and NOT have an extremely high quality of life in return? Who truly wants the possibility of getting rich a priori removed from the equation? I'm sitting here throwing runs of PVC's (best case scenario) at 35 years old. I live on caffiene, never work out, sleep badly waiting for mid-night pages and barely see my kids. I'd like to see something substantial for this investment and sacrifice. Preferably, I'd like to see it before I drop into V-fib.

Family Docs make comparitively crappy salaries because they don't fight for better ones.

 

[acetre]

secretwave, you have thrown down the gauntlet and have said what others have have been refusing to acknowledge. I definitely want more for the sacrifice I will be making, but it has to be done with the realization that if being financially endowed is a goal of mine, I would need to look outside of medicine for that opportunity. I will say this though...there are a lot of other things we all could be doing to make money besides working towards "Vfib", but FP is what is still chosen by many (without any blame being placed here.) FP's are going to have to step-up across the country and do more to be heard across the country about the seemingly unsatisfactory pay. It has to become as strong of a political issue as the almost non-existent teacher salaries, or the economy, or that God foresakened Iraq War...POINT BLANK...PERIOD....FULL STOP!!!---acetre

It's true. Continuity is one of the major perks of Family Medicine. But the majority of humans go to work to make money. Why deny it? If you want relationships, just hang out in a bar all day. FP is a tough way to make friends.

So many of my primary care colleagues start EVERY money discussion with, "I don't want to get rich..." WHY NOT? Is that a crime? Do you 'want to get poor' after working 60-80 hours a week your whole life with the stress of litigation, loan repayment, loss of family and friends? Does immunizing kids really warm your heart enough to offset the chill of all those missed soccer games, half-seen plays and finding your lonely wife in bed with the plumber?

Who - in all honesty - wants to work this hard with this much stress and NOT have an extremely high quality of life in return? Who truly wants the possibility of getting rich a priori removed from the equation? I'm sitting here throwing runs of PVC's (best case scenario) at 35 years old. I live on caffiene, never work out, sleep badly waiting for mid-night pages and barely see my kids. I'd like to see something substantial for this investment and sacrifice. Preferably, I'd like to see it before I drop into V-fib.

Family Docs make comparitively crappy salaries because they don't fight for better ones.

 

[secretwave101]

I should add that 150k is perfectly adaquate compensation if there is no debt involved. Given that my debt load exceeds the yearly income of close to 8 middle-class Americans, the metric changes.

My financial portfolio for much of the forseeable future is effectively indentured servitude to banks (and distantly, the university). I have the worst of both worlds: a high gross income (with tax penalties and political class envy) but with a totally proletarian net take-home. Since I could make this ho-hum salary at a factory - never missing a game or birthday party, never getting sued etc - the inflated hours and risk of my job is simply unfair.

Practically, I'm not interested in fighting for "more money"; just less overhead. Then the 150 is fine. Or, alternatively, put it at 300 (like the specialists) and leave the overhead.

This is why new proposals to, for example, increase the "medical home" responsibilities of FP's, to add documentation requirements, to index quality indicatiors to pay, and a thousand other ideas out there, needs to be met by FP's collectively blowing a gasket. ANY addition to FP overhead is catastrophically unfair - even unethical - and this message needs to be sent constantly.

 

[deleted6669]

I should add that 150k is perfectly adaquate compensation if there is no debt involved. Given that my debt load exceeds the yearly income of close to 8 middle-class Americans, the metric changes.

My financial portfolio for much of the forseeable future is effectively indentured servitude to banks (and distantly, the university). I have the worst of both worlds: a high gross income (with tax penalties and political class envy) but with a totally proletarian net take-home. Since I could make this ho-hum salary at a factory - never missing a game or birthday party, never getting sued etc - the inflated hours and risk of my job is simply unfair.

Practically, I'm not interested in fighting for "more money"; just less overhead. Then the 150 is fine. Or, alternatively, put it at 300 (like the specialists) and leave the overhead.

This is why new proposals to, for example, increase the "medical home" responsibilities of FP's, to add documentation requirements, to index quality indicatiors to pay, and a thousand other ideas out there, needs to be met by FP's collectively blowing a gasket. ANY addition to FP overhead is catastrophically unfair - even unethical - and this message needs to be sent constantly.

while I agree that fp's are seriously underpaid( around here specialty pa's make more) I am wondering why you are not seriously looking at loan reapyment options....work rural for 4 yrs, all loans gone. move to city of choice and live well off "150k" with no debt.
a few yrs ago I was seriously looking at going back to medschool, becoming a full scope rural cowboy fp and being completely debt free within 4 years of the completion of residency....am I that naive? it seemed like places were lining up to offer loan repayment, both state and federal programs were offering year for year pay backs. an fp md buddy of mine just took a rural job that offered him every perk he asked for- loan repayment, sign on bonus, relocation, 3 mo free housing, 4 day workweek, ability to moonlight in the local er for more $, etc

 

[secretwave101]

Looked at tons of them. Most of them are classic government bait-and-switch:

Loan repayment is TAXED. They never mention this. Wasn't mentioned when I signed up for the Army reserve, either. Most repayment amounts are $25k. But that money is considered - for tax purposes - to be a "bonus", which means it's taxed higher than salary (already slammed because it's around 100k). So, 25K is really around 12-14k. A few years ago, that might have been meaningful, but with the debt load of today's incoming docs, it would take 19.678 years to pay off (if no interest).

Add to this that rural positions rarely pay what city markets bear. So, you get 25k - really 14 - and a salary of 80-90k. Often, because you're the only one out there, the call can be brutal too. So, you can forget your own family while your busy with everyone else's.

Have fun with the rural vs. city math. Many of us would practice in rural America - I went into FP thinking I would - but the deal is rapacious.

 

[deleted6669]

Looked at tons of them. Most of them are classic government bait-and-switch:

Loan repayment is TAXED. They never mention this. Wasn't mentioned when I signed up for the Army reserve, either. Most repayment amounts are $25k. But that money is considered - for tax purposes - to be a "bonus", which means it's taxed higher than salary (already slammed because it's around 100k). So, 25K is really around 12-14k. A few years ago, that might have been meaningful, but with the debt load of today's incoming docs, it would take 19.678 years to pay off (if no interest).

Add to this that rural positions rarely pay what city markets bear. So, you get 25k - really 14 - and a salary of 80-90k. Often, because you're the only one out there, the call can be brutal too. So, you can forget your own family while your busy with everyone else's.

Have fun with the rural vs. city math. Many of us would practice in rural America - I went into FP thinking I would - but the deal is rapacious.

my buddy's position is actually with a private organization on the oregon coast(providence hospital system in fact...) not a federal or state agency and they are paying off his loans without tax penalty. he's a big surfer so it was win:win for him. they recruited him out of the blue. he didn't even send them an app.
his call from home by the way- 1 weekend/mo. and no ob coverage.....

 

[secretwave101]

I have an uncle who won $500,000 in Vegas too. Most of us won't.

I'm not THAT jaded, though. Sounds like a great situation. They can look me up if they're still recruiting.

I'm speaking more on a meta-level. Most won't have opportunities like that. Notice that this is a NON-governmental program. And in fact there is a bunch of debate about how to report these repayment grants when a private hospital gives them. That Prov hospital might find trouble in the future.

Like I said, I've been looking at tons of these programs. Most are more deception than aid.

 

[iatrosB]

paying off his loans without tax penalty.

hmm...definately sweet...but I'm not sure how they're getting by with that. I had heard there was legislation coming through the works to make primary care loan repayment a special "non-taxed" deal, but I didn't think it was anywhere close to reality. I'd be very interested to find out how they got around taxes. 😕

 

[deleted87716]

Family Docs make comparitively crappy salaries because they don't fight for better ones.

Practically, I'm not interested in fighting for "more money"

So, you see the dilemma, eh?

What's that old saying? "If you're not part of the solution, you're part of the problem." 😉

You can focus on overhead all you want, but if the money isn't coming in, it doesn't matter if you work out of a trailer or the Taj Mahal. The bills ain't gonna get paid.

 

[MOHS_01]

Fellas,

This deserves a much longer post than I have time for at the moment, but there are several things to consider here.

First -- the widely lamented underpaid primary care (which I agree is true). The reason for this has little to nothing to do with primary care per se; rather, it is a byproduct of the relative devaluation of E&M services in comparison to some procedural services. Everyone is affected by this in varying degrees, specialists and primary care physicians alike.

Secondly (and more importantly) the primary care model is changing, for better or worse. Those who wish to practice "the old way" will either develop a niche or continue to earn less money than commercial pilots, some mid-level providers, etc. From a philosophical level I neither approve nor agree with the changes that are taking place, but I can understand them from a financial and civil service vantage point.

There are multiple models which can work better than the traditional way of practicing, allowing for personalization and a satisfactory balance of income, workload, and lifestyle. I hope (with the help of a rather prominent local MD with 20 years experience) to develop some of these models and take the application mainstream at some point over the next couple of years.

One last thing -- don't ignore the simple mathematics that rule the physician compensation equation -- revenue minus expenses equals physician compensation, ultimately. To focus on either part of the formula forsaking the other yield suboptimal results.

 

[MedicineDoc]

Fellas,

This deserves a much longer post than I have time for at the moment, but there are several things to consider here.

First -- the widely lamented underpaid primary care (which I agree is true). The reason for this has little to nothing to do with primary care per se; rather, it is a byproduct of the relative devaluation of E&M services in comparison to some procedural services. Everyone is affected by this in varying degrees, specialists and primary care physicians alike.

Secondly (and more importantly) the primary care model is changing, for better or worse. Those who wish to practice "the old way" will either develop a niche or continue to earn less money than commercial pilots, some mid-level providers, etc. From a philosophical level I neither approve nor agree with the changes that are taking place, but I can understand them from a financial and civil service vantage point.

There are multiple models which can work better than the traditional way of practicing, allowing for personalization and a satisfactory balance of income, workload, and lifestyle. I hope (with the help of a rather prominent local MD with 20 years experience) to develop some of these models and take the application mainstream at some point over the next couple of years.

One last thing -- don't ignore the simple mathematics that rule the physician compensation equation -- revenue minus expenses equals physician compensation, ultimately. To focus on either part of the formula forsaking the other yield suboptimal results.

I notice most of your posts are in the dermatology forum. Are we getting the opinions of a dermatologist on primary care who may fear the MedPac recommendations for a "budget neutral" increase in primary care pay (meaning taking money from specialists to invest in primary care)?

 

[MOHS_01]

No sir, no fear here... a significant portion of my billing is on the E&M side, which I have always contended was underpaid. I personally believe that E&M is undervalued a full 20% -- but you have to realize that, even if these codes were increased by that amount (which they most likely never will be for a host of reasons), I (or anyone else) would not see a corresponding 20% reduction in procedural fees.

Procedures will likely always be reimbursed at a relatively higher rate -- the skillset involved, risk assumed, costs associated with, etc are higher across the board for procedures compared to cognitive (with costs being the single largest factor in reimbursement differentials). Please understand that the RVU value associated with any service is not a random number pulled out of the AMA, CMS, or anyones a** -- it is derived based upon a quasi-scientific method.

Also keep in mind that general dermatologists will likely benefit more from a bump in E&M than any primary care doc because of the simple fact that we see more people on average.....

Fear of increasing primary care docs pay at my expense is a joke -- I want you guys to do better... I want everyone to do better.

 

[jetproppilot]

-- I want you guys to do better... I want everyone to do better.

Me too.