Would you do it again old heads?

[AnonymousDoctorGuyPerson]

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Came into residency planning to do PCCM. I genuinely love the MICU and all it has to offer (vent management, navigating shock, diversity of pathophysiology, other interesting support devices). It’s the kind of stuff that makes me feel like I’m really practicing medicine. That said, I’ve noticed that a lot of our attendings seem a little jaded, not necessarily burned out, but definitely more ambivalent about their career choice than I expected. However it it's difficult to tease that from the individuals, most are pulm researchers with an ICU obligation so ofc they'd maybe not be having the best time there.

On the flip side, the vibe on the cards side at my program is totally different. Every attending seems obsessed with the field. I also do enjoy Cards, I'd say as a single organ system it's been my favorite. EP especially has caught my attention with some of the coolest procedures I've got to experience in medicine, and I'm certainly an individual who loves to be hands on (almost went surgery if not for my love of pure physiology and medicine)

So now I keep asking mysely am I considering cards just because our specific cards department just seems more gung-ho about their jobs or do I think I'd actually prefer it 5, 10, 15 years down the road. I'll say this, every year a decent handful of people enter our program with thoughts of PCCM, and only 0 to 2 a year actually wind up applying (usually jumping to cards).


I guess I’m looking for input from people who’ve seriously considered both, how did you decide? I try to think of the future but I've never been good at that. I tell myself "which subject would I prefer to teach," which would be critical care but I'm unsure if that's enough


Appreciate any thoughts.

 

[tartesos]

Came into residency planning to do PCCM. I genuinely love the MICU and all it has to offer (vent management, navigating shock, diversity of pathophysiology, other interesting support devices). It’s the kind of stuff that makes me feel like I’m really practicing medicine. That said, I’ve noticed that a lot of our attendings seem a little jaded, not necessarily burned out, but definitely more ambivalent about their career choice than I expected. However it it's difficult to tease that from the individuals, most are pulm researchers with an ICU obligation so ofc they'd maybe not be having the best time there.

On the flip side, the vibe on the cards side at my program is totally different. Every attending seems obsessed with the field. I also do enjoy Cards, I'd say as a single organ system it's been my favorite. EP especially has caught my attention with some of the coolest procedures I've got to experience in medicine, and I'm certainly an individual who loves to be hands on (almost went surgery if not for my love of pure physiology and medicine)

So now I keep asking mysely am I considering cards just because our specific cards department just seems more gung-ho about their jobs or do I think I'd actually prefer it 5, 10, 15 years down the road. I'll say this, every year a decent handful of people enter our program with thoughts of PCCM, and only 0 to 2 a year actually wind up applying (usually jumping to cards).


I guess I’m looking for input from people who’ve seriously considered both, how did you decide? I try to think of the future but I've never been good at that. I tell myself "which subject would I prefer to teach," which would be critical care but I'm unsure if that's enough


Appreciate any thoughts.

Cardiologists should be happy. A non interventional cardiologist makes 900k here.

I’d be happy too 🤣

 

[AnonymousDoctorGuyPerson]

Cardiologists should be happy. A non interventional cardiologist makes 900k here.

I’d be happy too 🤣

Sure money is a factor, and a big one for many people, doesn't mean the job (and particular the lifestyle of IC) begets happiness.

Given your above comment why didn't you just do cards then?

 

[chessknt]

Sure money is a factor, and a big one for many people, doesn't mean the job (and particular the lifestyle of IC) begets happiness.

Given your above comment why didn't you just do cards then?

Because we were dumb enough to believe your first sentence.

I absolutely guarantee your cardiology attendings would be much less happy if they made pccm money. So would H/O. Just go with the highest paying field you won't care about how excited you are when you make 2-3x as much for the same (or less) work. Reimbursement in medicine is a scam, those fields are at the top.

 

[AnonymousDoctorGuyPerson]

Because we were dumb enough to believe your first sentence.

I absolutely guarantee your cardiology attendings would be much less happy if they made pccm money. So would H/O. Just go with the highest paying field you won't care about how excited you are when you make 2-3x as much for the same (or less) work. Reimbursement in medicine is a scam, those fields are at the top.

Well then I wouldn't have even gone into IM if thats truly all that matter. If I, today, stopped contributing to my retirement accounts, with an estimated aROR of 7%, in 30 years I'd have 3.3 mil. Sure not enoug to retire on with the lifestlye I plan on living but I'd hit my goal no matter the specialty, especially since dual income, no kids; the difference in salary isn't going to be as impactful as the satisfaction I derive from the day-to-day work. Hence my initial question.

And in your example, if I chose say IC, sure I'd make more, but I'd also want to retire 30 years earlier after my 3rd STEMI call.

 

[tartesos]

Sure money is a factor, and a big one for many people, doesn't mean the job (and particular the lifestyle of IC) begets happiness.

Given your above comment why didn't you just do cards then?

Because I don’t like it.

I’d do the same thing again if I had to.

 

[tartesos]

Well then I wouldn't have even gone into IM if thats truly all that matter. If I, today, stopped contributing to my retirement accounts, with an estimated aROR of 7%, in 30 years I'd have 3.3 mil. Sure not enoug to retire on with the lifestlye I plan on living but I'd hit my goal no matter the specialty, especially since dual income, no kids; the difference in salary isn't going to be as impactful as the satisfaction I derive from the day-to-day work. Hence my initial question.

And in your example, if I chose say IC, sure I'd make more, but I'd also want to retire 30 years earlier after my 3rd STEMI call.

Some people would prefer being able to retire in 10-15 years or sooner than 30.

Everyone is different. You have to do what works for you.

 

[AnonymousDoctorGuyPerson]

Because I don’t like it.

I’d do the same thing again if I had to.

Thanks for the response, this answers my main question - whether you'd still do PCCM again.

What keeps you enjoying it? What did you initially enjoy that you no longer do?

 

[chessknt]

Well then I wouldn't have even gone into IM if thats truly all that matter. If I, today, stopped contributing to my retirement accounts, with an estimated aROR of 7%, in 30 years I'd have 3.3 mil. Sure not enoug to retire on with the lifestlye I plan on living but I'd hit my goal no matter the specialty, especially since dual income, no kids; the difference in salary isn't going to be as impactful as the satisfaction I derive from the day-to-day work. Hence my initial question.

And in your example, if I chose say IC, sure I'd make more, but I'd also want to retire 30 years earlier after my 3rd STEMI call.

The thing is you haven't worked as a real doctor long enough to actually say that.

Try working 12 grueling hours in the covid ward with maga spewing vitriol at you and half your patients guaranteed to die with nothing you can do about it while the heme onc sold chemo to people for 2/3 the amount of time got to go home on time for dinner and made 12x what you did. Or the GI who did mindless scopes in their ASC they own and made 3k every 45 mins while their NP does all the clinic work and can retire after 5 years if they can keep their scope numbers up with 2x your number in 30.

Meanwhile clipboard nurse manager RNccndnp is messaging you about trying to take a Foley out of someone on 4 pressors and the hospital won't up your stipend because they have to pay this useless parasite instead of you the same year CMS changes the rules so CC time always rounds down to decrease your productivity because you're a hero.

 

[gulmohr]

Came into residency planning to do PCCM. I genuinely love the MICU and all it has to offer (vent management, navigating shock, diversity of pathophysiology, other interesting support devices). It’s the kind of stuff that makes me feel like I’m really practicing medicine. That said, I’ve noticed that a lot of our attendings seem a little jaded, not necessarily burned out, but definitely more ambivalent about their career choice than I expected. However it it's difficult to tease that from the individuals, most are pulm researchers with an ICU obligation so ofc they'd maybe not be having the best time there.

On the flip side, the vibe on the cards side at my program is totally different. Every attending seems obsessed with the field. I also do enjoy Cards, I'd say as a single organ system it's been my favorite. EP especially has caught my attention with some of the coolest procedures I've got to experience in medicine, and I'm certainly an individual who loves to be hands on (almost went surgery if not for my love of pure physiology and medicine)

So now I keep asking mysely am I considering cards just because our specific cards department just seems more gung-ho about their jobs or do I think I'd actually prefer it 5, 10, 15 years down the road. I'll say this, every year a decent handful of people enter our program with thoughts of PCCM, and only 0 to 2 a year actually wind up applying (usually jumping to cards).


I guess I’m looking for input from people who’ve seriously considered both, how did you decide? I try to think of the future but I've never been good at that. I tell myself "which subject would I prefer to teach," which would be critical care but I'm unsure if that's enough


Appreciate any thoughts.

I think the answer you're looking for is already in the question you have asked. Do cardiology.

 

[AnonymousDoctorGuyPerson]

I think the answer you're looking for is already in the question you have asked. Do cardiology.

Not catching it haha 😅, how so?

 

[gulmohr]

Came into residency planning to do PCCM. I genuinely love the MICU and all it has to offer (vent management, navigating shock, diversity of pathophysiology, other interesting support devices). It’s the kind of stuff that makes me feel like I’m really practicing medicine. That said, I’ve noticed that a lot of our attendings seem a little jaded, not necessarily burned out, but definitely more ambivalent about their career choice than I expected. However it it's difficult to tease that from the individuals, most are pulm researchers with an ICU obligation so ofc they'd maybe not be having the best time there.

On the flip side, the vibe on the cards side at my program is totally different. Every attending seems obsessed with the field. I also do enjoy Cards, I'd say as a single organ system it's been my favorite. EP especially has caught my attention with some of the coolest procedures I've got to experience in medicine, and I'm certainly an individual who loves to be hands on (almost went surgery if not for my love of pure physiology and medicine)

So now I keep asking mysely am I considering cards just because our specific cards department just seems more gung-ho about their jobs or do I think I'd actually prefer it 5, 10, 15 years down the road. I'll say this, every year a decent handful of people enter our program with thoughts of PCCM, and only 0 to 2 a year actually wind up applying (usually jumping to cards).


I guess I’m looking for input from people who’ve seriously considered both, how did you decide? I try to think of the future but I've never been good at that. I tell myself "which subject would I prefer to teach," which would be critical care but I'm unsure if that's enough


Appreciate any thoughts

I think you have to let go of the bias you came into residency with and go with what feels more appealing after actual exposure. That is the point of residency after all. Also, everything chessknt said.

 

[CCM-MD]

Do cardiology if you like both equally, specifically IC or EP.

The financial argument is there for IC and EP but not so much for gen cards. One could make the lifestyle argument for gen cards but you have to like clinic… which many like myself have a strong distaste for. The strongest argument for cardiology is that IC and EP are much more protected from midlevel encroachment than critical care.

 

[AnonymousDoctorGuyPerson]

Do cardiology if you like both equally, specifically IC or EP.

The financial argument is there for IC and EP but not so much for gen cards. One could make the lifestyle argument for gen cards but you have to like clinic… which many like myself have a strong distaste for. The strongest argument for cardiology is that IC and EP are much more protected from midlevel encroachment than critical care.

Yeah, it's hard to say which I like more or if they're equal

Id say crit care takes the edge, but it's possible they even out further into my career. The midlevel encroachment was one of the initial reasons I was even looking deeper into proceduralists subspecialties

How do you think this will shake out for jobs and compensation in crit care going forward?

 

[CCM-MD]

Yeah, it's hard to say which I like more or if they're equal

Id say crit care takes the edge, but it's possible they even out further into my career. The midlevel encroachment was one of the initial reasons I was even looking deeper into proceduralists subspecialties

How do you think this will shake out for jobs and compensation in crit care going forward?

Impossible to predict how things will shake out. I think IC or EP are much better/safer options.

 

[chessknt]

Do cardiology if you like both equally, specifically IC or EP.

The financial argument is there for IC and EP but not so much for gen cards. One could make the lifestyle argument for gen cards but you have to like clinic… which many like myself have a strong distaste for. The strongest argument for cardiology is that IC and EP are much more protected from midlevel encroachment than critical care.

This is a fundamental misunderstanding by people who don't understand outpatient. Ownership of ancillary services is critical--gen cards owns echo, mri, coronary ct, exercise testing, stress testing, pet imaging etc. They do an e/m code and generate 2-6 ancillary tests off a new patient that pay the e/m code multiple times over--each private referral is worth 4-10k for a single visit + ancillary tests. Gen cards is the god of ancillary testing and IMO the most protected from political pressures. H/O and GI are highly dependent on a single aspect of income but cards is so diverse it they lose one aspect (eg mri) it doesn't impact the bottom line much.

 

[AnonymousDoctorGuyPerson]

This is a fundamental misunderstanding by people who don't understand outpatient. Ownership of ancillary services is critical--gen cards owns echo, mri, coronary ct, exercise testing, stress testing, pet imaging etc. They do an e/m code and generate 2-6 ancillary tests off a new patient that pay the e/m code multiple times over--each private referral is worth 4-10k for a single visit + ancillary tests. Gen cards is the god of ancillary testing and IMO the most protected from political pressures. H/O and GI are highly dependent on a single aspect of income but cards is so diverse it they lose one aspect (eg mri) it doesn't impact the bottom line much.

I know this wasn't responding to me but I just want to reiterate once again my initial post has nothing to do with financials between Cards and PCCM, which is plain to anyone which comes out on top. My partner is also a physician. They make around 450k. We will not be having kids. The income potential between cards and PCCM is essentially a non factor.

 

[chessknt]

And again, as you haven't done it yet, you don't know that it is a non factor. The income disparity between the fields is a factor of 3-4x depending on how you configure it. You aren't going to feel that difference is a non-factor in year 7 of your career while people you graduated with scale back to part time or simply just retire while you are still slogging away working double their hours for half the pay.

Being tied to hospital subsidies has huge downside potential as well. As healthcare systems collapse under the Medicaid changes we will see enormous downward pressure on hospital dependent specialists that generate no revenue. How fulfilled will you be when you have to fight for your existence to a bottom quartile MBA grad paid 3x as much as you as to why they can't just replace your with a robot or super nurse?

I know this sounds jaded and you are going dismiss it but talk to people who have done pp for 10+ years. See what is actually happening.

 

[AnonymousDoctorGuyPerson]

And again, as you haven't done it yet, you don't know that it is a non factor. The income disparity between the fields is a factor of 3-4x depending on how you configure it. You aren't going to feel that difference is a non-factor in year 7 of your career while people you graduated with scale back to part time or simply just retire while you are still slogging away working double their hours for half the pay.

Being tied to hospital subsidies has huge downside potential as well. As healthcare systems collapse under the Medicaid changes we will see enormous downward pressure on hospital dependent specialists that generate no revenue. How fulfilled will you be when you have to fight for your existence to a bottom quartile MBA grad paid 3x as much as you as to why they can't just replace your with a robot or super nurse?

I know this sounds jaded and you are going dismiss it but talk to people who have done pp for 10+ years. See what is actually happening.

It is jaded, but rightfully so, and I know part of me is not listening because I have not experienced it. With that I still have to degree on one point
> scale back to part time
If I can't do that in 7 years if I wanted/needed to
on dual physician income then that's completely on me and would be a marker of a failure of my own financial decisions and not my specialty choice.

However, to your other point, that’s a fair argument and worsening of tjose pressures would certainly make hospital-employed physicians far more prone to burnout compared to those in PP

 

[CCM-MD]

This is a fundamental misunderstanding by people who don't understand outpatient. Ownership of ancillary services is critical--gen cards owns echo, mri, coronary ct, exercise testing, stress testing, pet imaging etc. They do an e/m code and generate 2-6 ancillary tests off a new patient that pay the e/m code multiple times over--each private referral is worth 4-10k for a single visit + ancillary tests. Gen cards is the god of ancillary testing and IMO the most protected from political pressures. H/O and GI are highly dependent on a single aspect of income but cards is so diverse it they lose one aspect (eg mri) it doesn't impact the bottom line much.

I can’t speak for private practice, except for the fact that it’s disappearing and if the trend continues physicians are all eventually going to be employees. Given the trend, I think it’s silly to sell the idea of practice ownership to anyone in training right now. And in an employed setting, gen cards and critical care can make very similar money.

Midlevels can generate all of that downstream revenue and ancillary testing you mentioned. In fact primary care ultimately generates a massive amount downstream revenue but are still paid trash l, so in an employed setting there is little protection provided from that alone.

 

[chessknt]

I can’t speak for private practice, except for the fact that it’s disappearing and if the trend continues physicians are all eventually going to be employees. Given the trend, I think it’s silly to sell the idea of practice ownership to anyone in training right now. And in an employed setting, gen cards and critical care can make very similar money.

Midlevels can generate all of that downstream revenue and ancillary testing you mentioned. In fact primary care ultimately generates a massive amount downstream revenue but are still paid trash l, so in an employed setting there is little protection provided from that alone.

Did you bother to look for PP at all or were you region bound?

PP still thrives in certain parts of the country where corporate medicine has not been able to infiltrate and destroy the medical community. You are correct that it is less common but it isn't extinct by any stretch and the autonomy/pay differential is substantial compared to hospital employment. It is something that a majority of grads never see because pp generally steers clear of training programs.

It isn't about generating revenue as much as owning the revenue source you generate. A PCP isn't going to own a MRI/CT scanner/lab because they aren't qualified to interpret all those tests--a cardiologist can.

 

[CCM-MD]

Hate to break it to you, private practice isn’t thriving. I personally know so many that have sold or closed doors due to the simple economics of massive increases in overhead due to inflation and simultaneous reduction in CMS reimbursement (forget about keeping up with inflation, they are actually cutting).

Trying to sell to a current intern/resident that they should pick X specialty because of the boatload of cash that is to be made from technical fees of ancillary testing is bordering on delusion given the trend.

 

[chessknt]

View attachment 411525
Hate to break it to you, private practice isn’t thriving. I personally know so many that have sold or closed doors due to the simple economics of massive increases in overhead due to inflation and simultaneous reduction in CMS reimbursement (forget about keeping up with inflation, they are actually cutting).

Trying to sell to a current intern/resident that they should pick X specialty because of the boatload of cash that is to be made from technical fees of ancillary testing is bordering on delusion given the trend.

Again I get the feeling you dont actually have any familiarity with this topic. There are headwinds but several specialties remain very well poised to maintain independence and in IM that is cards, HO, and, to a lesser extent, GI.

Even disregarding PP look at the HO employee unit rate compared to pulmonary--its almost double, even at an employed level. They still count as 2x the lesser specialties. Are you telling me if you had the option you would chose to work for half your pay if you 'liked' the work more?

 

[CCM-MD]

Talk about shifting goalposts, somehow we have gotten to talking about heme onc. I’ll agree to your point: if given a binary choice yes I will take more money for less work. But decisions about this sort of thing have other factors at play.

 

[sloh]

And again, as you haven't done it yet, you don't know that it is a non factor. The income disparity between the fields is a factor of 3-4x depending on how you configure it. You aren't going to feel that difference is a non-factor in year 7 of your career while people you graduated with scale back to part time or simply just retire while you are still slogging away working double their hours for half the pay.

Being tied to hospital subsidies has huge downside potential as well. As healthcare systems collapse under the Medicaid changes we will see enormous downward pressure on hospital dependent specialists that generate no revenue. How fulfilled will you be when you have to fight for your existence to a bottom quartile MBA grad paid 3x as much as you as to why they can't just replace your with a robot or super nurse?

I know this sounds jaded and you are going dismiss it but talk to people who have done pp for 10+ years. See what is actually happening.

Already happening with hospitalist getting laid off

https://www.reddit.com/r/hospitalist/s/F4ZuPzZOec

 

[Espressso]

Soooo.. as a soon to be pccm grad.... looking at job options, i'm really favoring trying to find a PP position. Is this a mistake long term?

 

[chessknt]

Soooo.. as a soon to be pccm grad.... looking at job options, i'm really favoring trying to find a PP position. Is this a mistake long term?

I don't think so. Find the right market you will do much better and be less subject to hospital bull****. Need to make sure the practice is actually viable though--how is the competition? How are the insurance contracts? Are they dependent on a hospital subsidy? Etc

 

[CCM-MD]

Soooo.. as a soon to be pccm grad.... looking at job options, i'm really favoring trying to find a PP position. Is this a mistake long term?

The trend of decreased private practice is expected to continue. The general private practice job involves a partnership track with low salary for X number of years prior to making partner pay. I know enough folks that have been in situations where they never became partner or the practice sold before they became partner… don’t be one of those.

 

[TexasMed22]

The thing is you haven't worked as a real doctor long enough to actually say that.

Try working 12 grueling hours in the covid ward with maga spewing vitriol at you and half your patients guaranteed to die with nothing you can do about it while the heme onc sold chemo to people for 2/3 the amount of time got to go home on time for dinner and made 12x what you did. Or the GI who did mindless scopes in their ASC they own and made 3k every 45 mins while their NP does all the clinic work and can retire after 5 years if they can keep their scope numbers up with 2x your number in 30.

Meanwhile clipboard nurse manager RNccndnp is messaging you about trying to take a Foley out of someone on 4 pressors and the hospital won't up your stipend because they have to pay this useless parasite instead of you the same year CMS changes the rules so CC time always rounds down to decrease your productivity because you're a hero.

Does heme onc really make much more than pulm crit? I thought the averages were always pretty similar.

 

[chessknt]

Does heme onc really make much more than pulm crit? I thought the averages were always pretty similar.

They have a thread in their forum with real world data. The pp HO near me clear 2 mil/yr since they own their infusion centers and have ironclad pp contracts.