$400K a year hospitalist gig or pulmonary / critical care fellowship

[IM.MD]

Hi everyone! I realize this is a very individual decision but would still appreciate your input. From a mainly financial perspective, is it worth doing a Pulm/CCM fellowship if I'm currently making $400K a year as a hospitalist? I enjoy critical care and pulmonology more than hospital medicine. Let's say 25% more but I also don't mind being a hospitalist and I get some fulfillment out of it. I was the de facto intensivist at my first hospitalist job out of residency and kinda wished I could spend all of my time in the ICU but did not feel adequately trained to do that (hence, I left that job). I like my current gig. 7 on / 7 off, 12 hour in house shifts (tiring but cool staff to chat with), one week PTO, 90K population, fun Midwestern town (local women seem to like my euro accent and sports car ), about 18 patient encounters a shift with the PA seeing 10 of them, open ICU with 24/7 intensivist coverage, most sub-specialties available. I'm getting $320K yearly base salary + $30K yearly if meeting quality metrics + $20K a year retention bonus x 5 years + $200 per hour for extra shifts, $5K for CME, good benefits (403b + 457b, etc.), only 14 overnight shifts required yearly. I make $400K a year with ~ 192 twelve hour shifts. I'm 37 years old and completed IM residency in 2017 (had a late academic start in the US). I'm not married, have $390K student loan debt (hoping PSLF goes through), renting. I feel like I may get bored being a hospitalist in 5-10 years and perhaps I should preemptively do the fellowship before marriage, kids, buying a house, etc. Should I spend 2-3 years (open to CCM only too) in fellowship at $60K a year in the pursuit of higher job satisfaction or focus on the positives of hospital medicine, learn to love it and continue getting paid handsomely without the pay cut during fellowship? Thanks!

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[thumbz]

My gut reaction was to say "keep doing it, you're living the dream" but after reading more of your post I can't. It sounds like you love CCM. The 192 shifts a year is going to wear on you, and burnout will set in at some point if you don't love what you do. I see it in my colleagues. As they get deeper into being a hospitalist all they want to do is cut back on number of shifts and try to get out of the hospital as soon as possible.

I'm saying this because of the "learn to love it" in your post. I don't know that you'll learn to love it. A CCM fellowship may show you the grass isn't truly greener, but again you don't want to wake up in 10 years full of regrets.

Disclosure - I'm an academic hospitalist. I adore my job and couldn't imagine doing anything else. I pick up extra shifts because I love doing what I do, the extra money is literally a secondary. That's what I want for you!

 

[psychbender]

How much do the intensivists at your shop make and do they work similar hours? That's some pretty crazy pay right now, so your opportunity cost is going to be rather high, unless the CC folk are making significantly more than you are now.

Also, while going back into training with a wife and kids can be stressful, it is doable, and it's only two more years for CC. I was four years out of residency when I went back, and started fellowship with a two year old and a six month old. Granted, my fellowship was just a year, but several of my Pulm/CC colleagues also had small kids at the time.

 

[CCM-MD]

From a purely financial perspective, if you are making 400k right now, it’s not worth going to a 3 year fellowship in a specialty that has a median pay of what you are making now.

The opportunity cost is high, and in addition you have to account for the time-value of money (money today is worth much more than future money).

Bottom line, do it only if you love it.

 

[deleted941485]

Opportunity cost seems a bit on the high side but if you really like pulmcc or you think you can make the same money with less work then perhaps?

 

[IM.MD]

How much do the intensivists at your shop make and do they work similar hours? That's some pretty crazy pay right now, so your opportunity cost is going to be rather high, unless the CC folk are making significantly more than you are now.

Also, while going back into training with a wife and kids can be stressful, it is doable, and it's only two more years for CC. I was four years out of residency when I went back, and started fellowship with a two year old and a six month old. Granted, my fellowship was just a year, but several of my Pulm/CC colleagues also had small kids at the time.

I don't know how much the CC folks make at my hospital. I recently started there, so I don't feel comfortable asking them just yet I would assume $400K+ base. They work 7 days on / 7 days off, 7 am to 7 pm in house and being on call 7 pm to 7 am with a CC NP in the unit.

 

[tartesos]

I don't know how much the CC folks make at my hospital. I recently started there, so I don't feel comfortable asking them just yet I would assume $400K+ base. They work 7 days on / 7 days off, 7 am to 7 pm in house and being on call 7 pm to 7 am with a CC NP in the unit.

The fact that they remain on call after their shift probably means they are making 400+.
If you love ccm and have the opportunity to do it, I say go for it( I did and have no regrets).

 

[IM.MD]

My gut reaction was to say "keep doing it, you're living the dream" but after reading more of your post I can't. It sounds like you love CCM. The 192 shifts a year is going to wear on you, and burnout will set in at some point if you don't love what you do. I see it in my colleagues. As they get deeper into being a hospitalist all they want to do is cut back on number of shifts and try to get out of the hospital as soon as possible.

I'm saying this because of the "learn to love it" in your post. I don't know that you'll learn to love it. A CCM fellowship may show you the grass isn't truly greener, but again you don't want to wake up in 10 years full of regrets.

Disclosure - I'm an academic hospitalist. I adore my job and couldn't imagine doing anything else. I pick up extra shifts because I love doing what I do, the extra money is literally a secondary. That's what I want for you!

Thank you for the thoughtful reply. If I decide to stick with hospital medicine I'll definitely switch to a more sustainable 5 on / 5 off schedule which is an option at my hospital.

 

[DeadCactus]

I find it unlikely that the quality of your life will be noticeably different due to a $1-1.5million change in lifetime earnings. I would personally acknowledge that it will be a financial hit and then move on and focus on deciding whether the job change is worth the time away from family and recreation in fellowship.

 

[Splenda88]

My gut reaction was to say "keep doing it, you're living the dream" but after reading more of your post I can't. It sounds like you love CCM. The 192 shifts a year is going to wear on you, and burnout will set in at some point if you don't love what you do. I see it in my colleagues. As they get deeper into being a hospitalist all they want to do is cut back on number of shifts and try to get out of the hospital as soon as possible.

I'm saying this because of the "learn to love it" in your post. I don't know that you'll learn to love it. A CCM fellowship may show you the grass isn't truly greener, but again you don't want to wake up in 10 years full of regrets.

Disclosure - I'm an academic hospitalist. I adore my job and couldn't imagine doing anything else. I pick up extra shifts because I love doing what I do, the extra money is literally a secondary. That's what I want for you!

If OP can't be somewhat financial independent after 10 yrs living in the midwest while making that kind of salary, then something is wrong. OP can probably semi retire after 10 yrs if he wants...

I am kind of conflicted about OP's situation. If you are ok with what you are doing now, you should think hard about the opportunity cost.

 

[deleted941485]

I thought about it again. I’m firmly in the no change camp. Too many changes in medicine. If M4A passes in one form or another then you’ll lose on both ends.

You will make resident money for more years when you retrain and then graduate only to make less than you thought or work harder.

Stay where you are

 

[spacegun]

Hi everyone! I realize this is a very individual decision but would still appreciate your input. From a mainly financial perspective, is it worth doing a Pulm/CCM fellowship if I'm currently making $400K a year as a hospitalist? I enjoy critical care and pulmonology more than hospital medicine. Let's say 25% more but I also don't mind being a hospitalist and I get some fulfillment out of it. I was the de facto intensivist at my first hospitalist job out of residency and kinda wished I could spend all of my time in the ICU but did not feel adequately trained to do that (hence, I left that job). I like my current gig. 7 on / 7 off, 12 hour in house shifts (tiring but cool staff to chat with), one week PTO, 90K population, fun Midwestern town (local women seem to like my euro accent and sports car ), about 18 patient encounters a shift with the PA seeing 10 of them, open ICU with 24/7 intensivist coverage, most sub-specialties available. I'm getting $320K yearly base salary + $30K yearly if meeting quality metrics + $20K a year retention bonus x 5 years + $200 per hour for extra shifts, $5K for CME, good benefits (403b + 457b, etc.), only 14 overnight shifts required yearly. I make $400K a year with ~ 192 twelve hour shifts. I'm 38 years old, completed IM residency in 2018 (had a late academic start). I'm not married, have $390K student loan debt (hoping PSLF goes through), renting. I feel like I may get bored being a hospitalist in 5-10 years and perhaps I should preemptively do the fellowship before marriage, kids, buying a house, etc. Should I spend 2-3 years (open to CCM only too) in fellowship at $60K a year in the pursuit of higher job satisfaction or focus on the positives of hospital medicine, learn to love it and continue getting paid handsomely without the pay cut during fellowship? Thanks!

I don't know if these numbers are realistic for pulm/CCM, just throwing it out there for now:

Hospitalist
Year 1 $400
Year 2 $400
Year 3 $400
Year 4 $400
Year 5 $400
Year 6 $400
Year 7 $400
Year 8 $400
Year 9 $400
Year 10 $400
$4 million

Pulm/CCM
Year 1 $60
Year 2 $60
Year 3 $60
Year 4 $500
Year 5 $500
Year 6 $500
Year 7 $500
Year 8 $500
Year 9 $500
Year 10 $500
$3,680,000

Given these numbers (which again might not be realistic), it wouldn't be until year 11 that you'd surpass your current hospitalist salary. I guess it depends if you are okay with that?

However, that said, some benefits of doing pulm/CCM now:
-Unlike hospitalist or CCM only, you could scale back to pulm only as you get older probably without as much of a hit to your income. Probably still at least $350 maybe $400 after building a pulm practice.
-You could scale back from hospitalist to outpatient only too, but then it'd probably be a lot less money than hospitalist, maybe $250?
-But even if it's not about the money, you'd be doing primary care, but it doesn't sound like you'd like doing primary care very much.
-I don't know the future of hospitalist or pulm/CCM, but don't most people say the future of being a hospitalist is less certain than pulm/CCM? At least it seems like you're less likely to be "replaceable" as a subspecialist.

Or like @Splenda88 astutely mentioned above, after 10 years as a hospitalist, you could just semi-retire!

 

[chocomorsel]

If OP can't be somewhat financial independent after 10 yrs living in the midwest while making that kind of salary, then something is wrong. OP can probably semi retire after 10 yrs if he wants...

I am kind of conflicted about OP's situation. If you are ok with what you are doing now, you should think hard about the opportunity cost.

I wish I was financially independent after working for 6 years. Not making that kind of salary more in the 3s but still. Where did it all go?

 

[IM.MD]

I thought about it again. I’m firmly in the no change camp. Too many changes in medicine. If M4A passes in one form or another then you’ll lose on both ends.

You will make resident money for more years when you retrain and then graduate only to make less than you thought or work harder.

Stay where you are

But don't you think, despite any potential changes in reimbursement, CCM will always make more per hour than hospital medicine?

 

[IM.MD]

I don't know if these numbers are realistic for pulm/CCM, just throwing it out there for now:

Hospitalist
Year 1 $400
Year 2 $400
Year 3 $400
Year 4 $400
Year 5 $400
Year 6 $400
Year 7 $400
Year 8 $400
Year 9 $400
Year 10 $400
$4 million

Pulm/CCM
Year 1 $60
Year 2 $60
Year 3 $60
Year 4 $500
Year 5 $500
Year 6 $500
Year 7 $500
Year 8 $500
Year 9 $500
Year 10 $500
$3,680,000

Given these numbers (which again might not be realistic), it wouldn't be until year 11 that you'd surpass your current hospitalist salary. I guess it depends if you are okay with that?

However, that said, some benefits of doing pulm/CCM now:
-Unlike hospitalist or CCM only, you could scale back to pulm only as you get older probably without as much of a hit to your income. Probably still at least $350 maybe $400 after building a pulm practice.
-You could scale back from hospitalist to outpatient only too, but then it'd probably be a lot less money than hospitalist, maybe $250?
-But even if it's not about the money, you'd be doing primary care, but it doesn't sound like you'd like doing primary care very much.
-I don't know the future of hospitalist or pulm/CCM, but don't most people say the future of being a hospitalist is less certain than pulm/CCM? At least it seems like you're less likely to be "replaceable" as a subspecialist.

Or like @Splenda88 astutely mentioned above, after 10 years as a hospitalist, you could just semi-retire!

Like CCM-MD wrote above, "you have to also account for the time-value of money (money today is worth much more than future money)". I think it is difficult to predict the future job security for most specialties but business in hospital medicine seems to be booming since everyone else "dumps on us" which is not necessarily a bad thing in regards to patient care and the growth of the specialty. I would not be happy in outpatient primary care. If I decide against doing a fellowship and down the line I feel I'm getting burned out doing 7 on / 7 off, I'll switch to 5 on / 5 off schedule which is an option at my hospital. If I still feel burned out, I'll go to 0.75 or 0.50 FTE +/- an attempt to move up in administration. The same scaling back strategy applies if I do CCM without pulmonology. I'm not a huge fan of pulmonology clinic but much prefer it over primary care.

 

[IM.MD]

I wish I was financially independent after working for 6 years. Not making that kind of salary more in the 3s but still. Where did it all go?

Haha. I need to change my ways if I'm to semi retire in 10 years. ~ 40% total income tax, buying a $49K car 9 months out of residency (at least I bought it 3 years old, not brand new), Caribbean island hopping almost monthly (winters are cold and long where I'm working) and paying $1,200 a month rent for one bedroom apartment (very few reasonably nice apartment buildings around here so rent is relatively high). I can hear Dave Ramsey yelling at me.

 

[chocomorsel]

Haha. I need to change my ways if I'm to semi retire in 10 years. ~ 40% total income tax, buying a $49K car 9 months out of residency (at least I bought it 3 years old, not brand new), Caribbean island hopping almost monthly (winters are cold and long where I'm working) and paying $1,200 a month rent for one bedroom apartment (very few reasonably nice apartment buildings around here so rent is relatively high). I can hear Dave Ramsey yelling at me.

Well, mine was marrying the wrong person. Hopefully I can now make Dave Ramsey proud since I got rid of the leech. But it was expensive.

 

[deleted941485]

But don't you think, despite any potential changes in reimbursement, CCM will always make more per hour than hospital medicine?

It might but the differences won’t be worth the added effort.

Aggressive Cost cutting measures across the system will also likely put a crimp on hiring too so even if you say the hell with it and retrain you will have the added burden of having a harder time finding a job.

Just stay where you are for now.

 

[deleted171991]

Hi everyone! I realize this is a very individual decision but would still appreciate your input. From a mainly financial perspective, is it worth doing a Pulm/CCM fellowship if I'm currently making $400K a year as a hospitalist? I enjoy critical care and pulmonology more than hospital medicine. Let's say 25% more but I also don't mind being a hospitalist and I get some fulfillment out of it. I was the de facto intensivist at my first hospitalist job out of residency and kinda wished I could spend all of my time in the ICU but did not feel adequately trained to do that (hence, I left that job). I like my current gig. 7 on / 7 off, 12 hour in house shifts (tiring but cool staff to chat with), one week PTO, 90K population, fun Midwestern town (local women seem to like my euro accent and sports car ), about 18 patient encounters a shift with the PA seeing 10 of them, open ICU with 24/7 intensivist coverage, most sub-specialties available. I'm getting $320K yearly base salary + $30K yearly if meeting quality metrics + $20K a year retention bonus x 5 years + $200 per hour for extra shifts, $5K for CME, good benefits (403b + 457b, etc.), only 14 overnight shifts required yearly. I make $400K a year with ~ 192 twelve hour shifts. I'm 38 years old, completed IM residency in 2018 (had a late academic start). I'm not married, have $390K student loan debt (hoping PSLF goes through), renting. I feel like I may get bored being a hospitalist in 5-10 years and perhaps I should preemptively do the fellowship before marriage, kids, buying a house, etc. Should I spend 2-3 years (open to CCM only too) in fellowship at $60K a year in the pursuit of higher job satisfaction or focus on the positives of hospital medicine, learn to love it and continue getting paid handsomely without the pay cut during fellowship? Thanks!

Is it worth $600K AFTER-TAX to you? And that doesn't include the growth of that money in your investment account for 30 years. That would make it about $1.2M in today's money, conservatively.

People burn out in every specialty, including CCM. One can't spend one's life working for the man and not burn out.