Can't decide between Cards and GI

[Tollats]

IM intern here. I went into residency wanting GI since I enjoyed the pathology and learning about it in med school. I published 2 papers so far and currently working on multiple others, but I felt a little disappointed after my GI rotation this year- I found the content to be a little dry and the majority of consults boiled down to a decision about scoping. The people were also kinda toxic, badmouthing colleagues and other residents, and I think that soured my experience but I realize that's a program-dependent factor.

I went into my Cards rotation afterwards with low expectations and I thought the cases were ++ interesting and more relevant to my IM training. I liked that the consultant role in Cards was more "cerebral" (not to say that GI is not cerebral), putting together labs/EKG/echo to come to a diagnosis. I also liked that most things were not dependent on one diagnostic modality alone such as scoping.

My main concern at this point is the tough fellowship in Cards. As much as I liked the content I'm afraid that the hours and frequent high-stress situations in fellowship will burn me out. From what I've heard, GI can also be very busy/hectic, but it doesn't seem nearly as bad as Cards at my shop. I've spoken with some cards fellows who felt their first year of fellowship was worse than intern year, which sounds awful.

Changing to cards would also mean having to start new research from square one, build new connections, etc. which isn't impossible but I guess I would be disadvantaged from that perspective compared to other applicants.

I know the age old advice is to do what you like/the field where you can tolerate the bread and butter cases. I'm just not sure if the intense fellowship would still allow me to enjoy the field. Would love to hear your thoughts especially if you were in a similar scenario.

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[CatFactorial]

The first year of most (many) IM fellowships is usually worse than intern year, not unique to cardiology.

Yes, you will have to start over. Too bad you only have the pretty much the entirety of your residency to do so.

 

[mszzeta]

Every medical specialty has a "cerebral" component. Compared to other specialties including GI, the degree of "cerebral" in cardiology is really modest at best......

 

[NewYorkDoctors]

Hepatology is "cerebral."
Pulmonology (outside MICU) is also "cerebral"
Rheumatology is "cerebral"
ID is "cerebral."
Nephrology is "cerebral."
A/I is "cerebral."
Hematology is "cerebral."

all the subspecialties have you teasing out the history, using available basic IM ordered tests, ordering specialized tests , perhaps doing an invasive procedure, then putting it all together








let's not beat around the bush now....

both GI and cardiology make a lot of money and General Cardiology can avoid doing invasive procedures and stay in the office and do all kinds of noninvasive testing.
maybe private GIs in the community do not really do hepatology and turf to academic GI/hep once it gets too complex.

but the fellowship itself is tough due to CCU , STEMI calls, high patient loads, etc...

 

[Gastrapathy]

So you prefer cards but are thinking GI because F1 is easier? Thats pretty silly. They both will suck and it’s a year. Do cards

 

[DrMetal]

It's interesting how both (Cards and GI) now have a plethora of sub-fellowships. You're somehow admonished if you're just a general GI or general cardiologist. Why they can't seem to incorporate said sub-fellowships into an already-long 3-year fellowship is beyond me. Lest we be PGY9++ before we can practice.

 

[chessknt]

I have yet to ever see GI contribute anything in the inpatient setting besides scoping. They won't follow up or write recs or essentially do anything except decide whether or not to scope, then do that and sign off or never write a note again. I assume they do more things in the outpatient setting but as inpatient providers they are as cerebral as IR.

 

[cards67]

Fellowship difficulty can vary more by the program itself vs specialty. GI can be rough too. Don't use your one internal program to make a career decision. My pgy4 was tough, not as bad as intern year though, but the following years were easy and chill. Do what you're interested in, you have plenty of time to catch up on publishing and such.

 

[timpview]

GI is the no brainer choice in todays climate but obviously hard to know if that holds in 5-10 years.

Low-risk, high volume procedures that can be performed in an ASC (in an easier fashion than cards).. less direct hospital employment.. less high acuity patients.. less burdensome call (can be mitigated if you did ep, general)

 

[shouldigomd]

Pretty much everything you mentioned in your initial post is program / hospital specific. The demands on fellows is extremely variable across programs / hospitals for both GI and Cards. If you are at a big liver TXP center dealing with crashing cirrhotic bleeds... that can lead to a very busy consult / ICU fellow. If you are at a big heart TXP / ECMO center ... that can lead to a busy cards ICU fellow. How much IM support does the program get? When I was an IM resident we did all the notes / orders / lines for the ICU patients and the fellow just answered questions essentially. That being said I think the vast majority of fellows will say life is so much better than IM even at its busiest. Also there are many rotations that are not stressful. Im a IC cards fellow so at least at my program unless you are running the consults / floors life is good. Most programs are 1st year heavy and then 2nd/3rd year is much more elective based.

GI and Cards are very different. GI is much more outpatient oriented and less "procedural" without much critical care. Obviously I am biased but I find that cards is much more dynamic with more toys and specialization potential. If you like the "cerebral" stuff you can be a critical care cardiologist or if procedures are your jam you can be a cath monkey like me. Or if you want that good life you can do imaging and sip your coffee reading scans all day.

You are just an intern... it will come just enjoy the ride and don't let 1st impressions influence you. Politics / drama is everywhere and the bane of medicine in my opinion. That varies from place to place so don't let that jade your decision either.

Cheers

 

[Gastrapathy]

GI is less procedural? Umm...what?

 

[Splenda88]

Our hospital hired a few months ago 2 GI docs to do ONLY outpatient Mon-Fr.

Someone who was in a leadership position told me that these guys get paid 820k/yr

A fellow hospitalist who is close to one of them told us that the GI guy said all he does is scoping all day (12-15/day).

Can 12-15 scopes per day support that kind of salary?

GI >>>> Cardio

 

[NewYorkDoctors]

looks about right with the basic arithmetic

anyone can search up the CPT codes to get an idea of what money value is associated with it (rather than just RVUs)

let's juse a nice number of $350 a scope * 15 a day * 5 days a week * 48 weeks a month (i'm just throwing that out there. vacation and holidays and all that might make that lower) = $1,260,000

throw in the office visits for H pylori, HBV, IBS for some more 99202-99215 action as well.

seems to be in the right ballpark.

other GIs can correct my math. my next door GI doctor runs a "scope mill." He hired an Internist (not any old PA or NP but an actual Internist) to see all consults for him and follow up on IBS lol. he gives the final say but the Internist manages it for him. good times. internist keeps a portion of office visit billings while the GI just scopes all day long. he has three scope rooms and flows from one room to the next. i think he does like 40 scope a day up and down

too bad he won't help me get a Bravo study done but i digress.

 

[timpview]

Throw in the facility fees (and overall autonomy) in a GI owned ASC

 

[NewYorkDoctors]

Throw in the facility fees (and overall autonomy) in a GI owned ASC

which is pretty much a thriving private practice GI office which has the ASC pretty much built in

 

[NYknicks44]

I am an interventional cardiologist in a community setting. I am four years out. I am on call more and make less than my residency friends who did GI.

 

[NewYorkDoctors]

I am an interventional cardiologist in a community setting. I am four years out. I am on call more and make less than my residency friends who did GI.

do you do any General cardiology as well? the local community EP and interventional guys all do general as well.

 

[chessknt]

I am an interventional cardiologist in a community setting. I am four years out. I am on call more and make less than my residency friends who did GI.

You need to just do more TAVR and youll be good. Everyone over the age of 40 needs a TAVR, ideally weeks to months before death from what I have seen in my community. Morbidly obese and non-ambulatory with a decub ulcer--->TAVR, get sepsis and die 4 months later. Advanced dementia needs help feeding self--->TAVR, die of aspiration pneumonia in 2 months. End-stage lung disease with dyspnea on standing-->TAVR, die 2 weeks after the procedure on a vent.

TAVRs for everyone! I can't wait for mine after I get metastatic brain cancer and am actively herniating.

 

[Splenda88]

do you do any General cardiology as well? the local community EP and interventional guys all do general as well.

I don't know about interventional. For instance, GI locum at my shop got ~5k/day while general card got only 3k.

It seems like GI docs these days have money printing machine.

 

[NewYorkDoctors]

I don't know about interventional. For instance, GI locum at my shop got ~5k/shift while general card got only 3k.

It seems like GI docs these days have money printing machine.

the local interventional cardiologist (in NYC "local" simply means someone who has a physical office in one neighborhood and services the patients of the PCPs who are in the general vicinity of a few zip codes but anyone all over the city can go to any local doctor) I like to refer to (for RHC for PH or when I workup dyspnea first with CPET / EKG Stress test and get some positive stress test findings and cardiovascular limitation. In fact I have worked up a few patients referred for COPD evaluation but do not actually have COPD but I do a CPET and get chest pain and ST depressions > 1mm in multiple leads on the EKG stress test - send to interventional and get cath'ed right away. I get to play the role of a general cardiologist. not that I think about it, there is no "hard stop" reason why a cardiologist does not buy a PFT machine and do those too. PFts are not that hard) does general and interventional.

He is on call for STEMI call in the local tertiary care hospital. He does hospital consults. He also has office hours in which he would do what the general cardiologist does working up dyspnea/chest pain with the usual EKG, treadmill EKG stress test, echo, and vascular ultrasou studies. He does not seem to do nuclear though as he orders CTCAs for the lower pretest probabilities and then just takes the higher presto probabilities straight to cath. makes sense. but it seems that he is making some extra money doing the general cardiology procedures.

but yeah the local GI doctors all have ASCs within their office building itself and they make the big bank. everyone need a screen colonoscopy. everyone needs multiple colonoscopies and EGDs as well for their tubular adenomas and intestinal metaplasias.

addendum:
while a cardiologist (or Internist for that matter) can call up a PFT machine company, buy a machine, get studies done in the office, and can bill for them (one does not need to be a pulmologist to actually do PFTs and bill for them successfully), the issue comes from needing to hire a respiratory therapist to do it. some pulmonologists have nurses, medical assistants, and even secretaries learn how to do it.... right how hospitals are mandated by joint commission to make sure they have RTs doing the PFTs or a doctor. but this does not apply to private offices... it's really cutting corners lol... I use RTs because they can do other things like do sleep studies, do CPAP / biapp mask fits and education, do in office ABGs (i need it sometimes and sometimes I will draw it pre and post CPET in that rare situation in which I am trying to discern V/Q mismatch from shunt doing the 100% FiO2 NRB post), etc....
but nothing stopping a cardiologist from doing a basic spirometry with or without bronchodilator and a 6MWT

cardiology colleagues, consider buying a spirometer and getting some 94010 and 94060 action in for about $20-$40 a blow when you work up dyspnea. also do a 6MWT for 94618 and get paid about $35 for it. hey you need a 6MWT for CHF right?

 

[NYknicks44]

Yes, I do general cardiology. I would say about 70% of my job is general cardiology (echoes, nuclear, office patients and hospital consults) Most EP and interventional guys in community (at least northeast) do general cardiology.

High volume interventional only guys are found in academics or unicorn practices

 

[NYknicks44]

You need to just do more TAVR and youll be good. Everyone over the age of 40 needs a TAVR, ideally weeks to months before death from what I have seen in my community. Morbidly obese and non-ambulatory with a decub ulcer--->TAVR, get sepsis and die 4 months later. Advanced dementia needs help feeding self--->TAVR, die of aspiration pneumonia in 2 months. End-stage lung disease with dyspnea on standing-->TAVR, die 2 weeks after the procedure on a vent.

TAVRs for everyone! I can't wait for mine after I get metastatic brain cancer and am actively herniating.

Believe it or not… TAVR is heavily regulated. All TAVR outcomes are tracked by the state (at least in NY). CT surgery is heavily involved. Hospital administration is involved to make sure outcomes are good for US news rankings.

The Wild West is peripheral angioplasty. You can do it in your OBL (office based lab). There is no regulation and no tracking.

 

[chessknt]

Believe it or not… TAVR is heavily regulated. All TAVR outcomes are tracked by the state (at least in NY). CT surgery is heavily involved. Hospital administration is involved to make sure outcomes are good for US news rankings.

The Wild West is peripheral angioplasty. You can do it in your OBL (office based lab). There is no regulation and no tracking.

I don't believe it. Regulated in what way lol? Like if someone in the country manages to die without one installed there is a board sanction issued?

 

[Nocturnist]

Believe it or not… TAVR is heavily regulated. All TAVR outcomes are tracked by the state (at least in NY). CT surgery is heavily involved. Hospital administration is involved to make sure outcomes are good for US news rankings.

The Wild West is peripheral angioplasty. You can do it in your OBL (office based lab). There is no regulation and no tracking.

Don't feed the troll.

I referred a close family friend to a TAVR at the age of 95 when he started developing heart failure from his AS. A year out and he's doing great, active, lives independently. Obviously no surgeon would have ever done an open repair and he'd be dead by now without it. I'm thankful for the geniuses and visionaries that looked at one of the most complex, delicate, and dangerous surgeries known to man and thought "hey can't we just float that valve 3 feet up and pop it open instead?" We may not have flying cars yet, but at least we have TAVRs.

 

[shouldigomd]

GI is less procedural? Umm...what?

Ummm yes?

 

[shouldigomd]

There is too much variation in salary to get caught up comparing apples to oranges. I am an IC so I won't speak on behalf of GI but there are IC's making 400K/yr and IC's making 2.5 million/yr.

 

[shouldigomd]

Yes, I do general cardiology. I would say about 70% of my job is general cardiology (echoes, nuclear, office patients and hospital consults) Most EP and interventional guys in community (at least northeast) do general cardiology.

High volume interventional only guys are found in academics or unicorn practices

Thats because you are in the northeast perhaps? Plenty of high IC volume positions out there if you aren't going to a saturated market.

 

[NYknicks44]

Thats because you are in the northeast perhaps? Plenty of high IC volume positions out there if you aren't going to a saturated market.

That’s fair. I can only comment on IC market in northeast suburbs.

 

[aafisahar]

whenever i hear someone debating between cards and GI, the only thing they actually care about is money.

 

[anonperson]

whenever i hear someone debating between cards and GI, the only thing they actually care about is money.

What's your point?

 

[HemeOncHopeful19]

What's your point?

They forgot about Onc!

 

[IM_to_ortho_hopeful]

Our hospital hired a few months ago 2 GI docs to do ONLY outpatient Mon-Fr.

Someone who was in a leadership position told me that these guys get paid 820k/yr

A fellow hospitalist who is close to one of them told us that the GI guy said all he does is scoping all day (12-15/day).

I don't know about interventional. For instance, GI locum at my shop got ~5k/day while general card got only 3k.

It seems like GI docs these days have money printing machine.

Can 12-15 scopes per day support that kind of salary?

GI >>>> Cardio

I don’t believe your rates for GI. 800k hospital employed, you don’t see any jobs like that on practice link. 5k/day locums? I see 3k/day as going rate… and that’s in the Midwest

 

[Nocturnist]

I don’t believe your rates for GI. 800k hospital employed, you don’t see any jobs like that on practice link. 5k/day locums? I see 3k/day as going rate… and that’s in the Midwest

When was the last time you saw an advertisement for Ferrari? Enough said.

 

[NewYorkDoctors]

the lower the google rating for a GI doctor, the more money he/she is making!

no time to talk about your IBS. gotta keep rotating to the next scope room!

if you are a GI PP doctor with your own ASC, then you WANT the lower google rating! you dont want functional patients with IBS and other issues seeing your 5 stars and wanting to talk to you for 5 horus

 

[Splenda88]

I don’t believe your rates for GI. 800k hospital employed, you don’t see any jobs like that on practice link. 5k/day locums? I see 3k/day as going rate… and that’s in the Midwest

I got the 820k from someone who was in the leadership (former chief of medicine). It's a small city and these people have been here for > 30 yrs so they usually know what's going on.

I have seen the 5k/day. He was a new GI grad who was doing locum and waiting for his academic job to credential him. He even made a joke about making more in 2 wks locum than what he made in his last year of fellowship in Vermont.

 

[Splenda88]

They are also trying to recruit 2 GI inpatient docs 7 days on/off

One of the hospitalist who does locum here told me they interviewed his cousin and the offer was 650k/yr. Not sure why there is a big discrepancy between inpatient vs. outpatient. Though I am sure that guy can negotiate to get 700k/yr because we have been using locum since I have been here for 2+ yrs.

 

[IM_to_ortho_hopeful]

When was the last time you saw an advertisement for Ferrari? Enough said.

I guess this applies to all fields so then how do people find the jobs that are > 1 SD over mean?

 

[IM_to_ortho_hopeful]

They are also trying to recruit 2 GI inpatient docs 7 days on/off

One of the hospitalist who does locum here told me they interviewed his cousin and the offer was 650k/yr. Not sure why there is a big discrepancy between inpatient vs. outpatient. Though I am sure that guy can negotiate to get 700k/yr because we have been using locum since I have been here for 2+ yrs.

These hospitalist GI jobs can be tough you’re on call for 24/7 often. Also interesting, there’s an MGMA thread in the GI forum where a guy with same geography as you mentioned is getting overworked for 600

 

[Splenda88]

These hospitalist GI jobs can be tough you’re on call for 24/7 often. Also interesting, there’s an MGMA thread in the GI forum where a guy with same geography as you mentioned is getting overworked for 600

It's not for me. But I guess they have to overwork you for that kind of money.

 

[Nocturnist]

I guess this applies to all fields so then how do people find the jobs that are > 1 SD over mean?

Just like any other great job in life- Nepotism, word of mouth, networking, favoritism, a little bit of luck or they just never open up until someone dies or retires so are rarely if ever advertised and not for long. All I know is if a job is so great, you probably wouldn't need to advertise it.

 

[coroner]

the lower the google rating for a GI doctor, the more money he/she is making!

no time to talk about your IBS. gotta keep rotating to the next scope room!

if you are a GI PP doctor with your own ASC, then you WANT the lower google rating! you dont want functional patients with IBS and other issues seeing your 5 stars and wanting to talk to you for 5 horus

That could backfire. If a pt. sees a low rating and thinks you're so dysfunctional, they won't trust you to scope them out of fear 😧. Fewer patients = fewer dollars

 

[NewYorkDoctors]

That could backfire. If a pt. sees a low rating and thinks you're so dysfunctional, they won't trust you to scope them out of fear 😧. Fewer patients = fewer dollars

until someone calls the 5 star tertiary care center and finds out 3 month wait time!!?!??!

somethings gotta give now

 

[NewYorkDoctors]

Just like any other great job in life- Nepotism, word of mouth, networking, favoritism, a little bit of luck or they just never open up until someone dies or retires so are rarely if ever advertised and not for long. All I know is if a job is so great, you probably wouldn't need to advertise it.

yep i opened a satellite office branch I installed my friend fresh out of residency to be the Internist and "regional manager." Got him into the same IPA and now he bills top rates and living the good life right out of residency. he's a qualified doctor so in this case its not nepotism. it's just connections and friends/family deal.

his wife is the "Assistant Regional manager' or "Assistant to the Regional manager." unclear which

 

[InternistDO]

until someone calls the 5 star tertiary care center and finds out 3 month wait time!!?!??!

somethings gotta give now

Try 6 months at certain Manhattan tertiary centers...