Is outpatient really that bad?

[PikminOC]

I'm a PGY5 now. I honestly love what I do.
It took a long time to get here though. And I will still admit that I am more cynical and more lonely. And I think that's how a lot of physicians feel. Their jobs become part of their family. Their connection to something meaningful.

That being said as I mentioned above here. My goal is to buy a nice house in the next 12 months. And that's pretty reasonable. A lot of my high school friends won't be able to do that in the next 10 years.

Yes. How many of your high school classmates found a job where demand is higher than supply

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[VA Hopeful Dr]

IM pgy-2. Perhaps much too early in my career to state an opinion like this, but I am really not sure if I would choose this path again. I simply don’t think it’s worth the amount of time, sacrifice, energy, and commitment. I really can’t imagine anyone enjoying medicine THAT much to put up with everything we have to deal with. If a person is smart and motivated enough to become a doctor, there are many things he can do to earn a similar income, which requires nowhere near the amount of time and sacrifice. So far I’ve experienced very little reward in this career.

There's not many jobs that make what I do who have a better work life balance, and I'm just an outpatient FP.

You're a resident so of course you haven't experienced much reward yet. The job gets much better when a) your income goes up by a factor of 4-5 b) you aren't working 80 hour weeks regularly and c) you're not at the beck and call of a gaggle of attendings. The complete lack of control in residency was one of the things that I enjoyed the least.

 

[NewYorkDoctors]

There's not many jobs that make what I do who have a better work life balance, and I'm just an outpatient FP.

You're a resident so of course you haven't experienced much reward yet. The job gets much better when a) your income goes up by a factor of 4-5 b) you aren't working 80 hour weeks regularly and c) you're not at the beck and call of a gaggle of attendings. The complete lack of control in residency was one of the things that I enjoyed the least.

I second this wholeheartedly. While residency / fellowship are necessary in order to gain the knowledge, skill, and discipline to be independent, once you are out you can work in any capacity you see fit.

Personally I enjoy the grind so I work crazy hours. I get dopamine rush from successfully getting better at the grind. This might be a byproduct from my earlier years when I was into playing action RPG games that require a lot of grinding to "get better."

But others may find more joy finding out working far fewer hours than in residency and being able to "enjoy life."

To each one's own.



And for the few patients who have listened to me (on the PCP side of things or the OSA side of things), when I get people to stop eating processed junk, get to 10,000 + steps on the pedometer a day, possibly eat something like a "clean keto diet" (as in prior posts at the patient's discretion not at my urging), and get onto the CPAP or dental appliance, they all magically feel so much better in so many ways.
naturally these patients NEVER EVER come tell me "hey thanks you were right and my life is better now."
nope nope nope i always find out when I ask them later on hey btw...

but you can bet your mortgage that patients will be running at the first sign something is "NOT GETTING BETTER"

 

[Splenda88]

There's not many jobs that make what I do who have a better work life balance, and I'm just an outpatient FP.

You're a resident so of course you haven't experienced much reward yet. The job gets much better when a) your income goes up by a factor of 4-5 b) you aren't working 80 hour weeks regularly and c) you're not at the beck and call of a gaggle of attendings. The complete lack of control in residency was one of the things that I enjoyed the least.

Always amazed when some in SDN think there are people out there making 300k-500k/yr working 30hrs/wk. Who are these people? What do they do?

 

[NewYorkDoctors]

Always amazed when some in SDN think there are people out there making 300k-500k/yr working 30hrs/wk. Who are these people? What do they do?

Professors of Medicine Directors of Divisions / Departments. 80+ year old. minimal clinical duties. lots of sancitmonious preaching.
possibly still signing off on research as senior author.
collecting big pharma stipends.
lecturing to fellows/residents about how they suck.
possibly friends with the washington DC 80+ year old fossils who refuse to retire.

do I sound ageist? perhaps. but I only direct this to elderly people who still hog the limelight and resources from the next generation

when I am older, I will fade into the background and do my own thing and not bother others

 

[NewYorkDoctors]

one thing about outpatient management among private practices is the lack of communication
As I am not part of a health system, I do not have an integrated EMR so I cannot see other physician notes.
Usually this is not a big problem as other physician notes (aside from other subspecialists with whom I am comanaging a complex case such as med onc and thoracic surgery for lung cancer or rheum for a CVD-ILD or cardiology notes for dyspnea) are not that important for me.

But when I do PCP, i SELDOM ever get any notes from other consultants. when my office requests it, I realize why... those notes are empty notes that are for billing also. no substance whatsoever

but I make it a big point to send the consult note as soon as I am done and check out the chart. I personally send it to ensure I attach the appropriate studies (like a CTC report or a PFT) and I hit the EMR's efax button. I have my staff check the next day to ensure there was no fax failure.

whether or not the PCP reads my notes is another matter... I tend to write my notes very matter of fact and explain my rationale and also explain my backup plans for certain things that involve a branch point. this helps matters because many patients go back to their PCP to ask the PCP to confirm the subspecialist's input.

everytime my PCP patients come to me and say "specialist said this. what do you think?"
my first impression is "gosh i am not that subspeciailist thats why I sent you to that doctor. jeez"
i end up fake smiling and saying "oh that sounds right. that is a very good doctor I referred you to. please listen to him/her."

I also be certain to put every little complaint and whine that a patient said so the PCP knows what's going on so no patient slanders me. a common one is "HPI: The patient was scheduled at 11AM and arrived and checked in at 1150AM. The patient was informed by the front desk that he/she was late but that the doctor has to see the patient who is on time right now. However, the doctor will gladly forego his lunch time and bathroom break to see you.
At the start the visit, the patient is exasperated and complains about waiting so long. I remind the patient of the current scenario and inform the patient that the patient can either work with me here or can re-schedule. I wanted the PCP to be aware of this."

I

 

[dozitgetchahi]

I'm a PGY5 now. I honestly love what I do.
It took a long time to get here though. And I will still admit that I am more cynical and more lonely. And I think that's how a lot of physicians feel. Their jobs become part of their family. Their connection to something meaningful.

That being said as I mentioned above here. My goal is to buy a nice house in the next 12 months. And that's pretty reasonable. A lot of my high school friends won't be able to do that in the next 10 years.

That “medicine is my meaning in life” bit is what I’ve tried hard to get away from in my own personal life as a doctor.

It really is just a job. I have a life too, and I want the two to be separate. I think a lot of docs would do well to broaden their horizons and find satisfaction outside of medicine.

Professors of Medicine Directors of Divisions / Departments. 80+ year old. minimal clinical duties. lots of sancitmonious preaching.
possibly still signing off on research as senior author.
collecting big pharma stipends.
lecturing to fellows/residents about how they suck.
possibly friends with the washington DC 80+ year old fossils who refuse to retire.

do I sound ageist? perhaps. but I only direct this to elderly people who still hog the limelight and resources from the next generation

when I am older, I will fade into the background and do my own thing and not bother others

What nobody talks about is that you only get to that point in academia after many many long hard years of getting grossly underpaid. Some never get there. But as Max Plank famously said, “science advances one funeral at a time”.

The only people getting paid $500k for 30 hours a week in any industry are probably getting kickbacks and/or have special connections or are due favors etc. Everyone else in that income bracket is working their asses off.

 

[Drrrrrr. Celty]

That “medicine is my meaning in life” bit is what I’ve tried hard to get away from in my own personal life as a doctor.

It really is just a job. I have a life too, and I want the two to be separate. I think a lot of docs would do well to broaden their horizons and find satisfaction outside of medicine.


What nobody talks about is that you only get to that point in academia after many many long hard years of getting grossly underpaid. Some never get there. But as Max Plank famously said, “science advances one funeral at a time”.

The only people getting paid $500k for 30 hours a week in any industry are probably getting kickbacks and/or have special connections or are due favors etc. Everyone else in that income bracket is working their asses off.

Being able to be free to actually live life outside of work was why I chose Endo tbh. I want a chill life where I can do something I like where I can be good at it, and satisfied with outcomes.

I like the game. But it can't be my whole life.

 

[chessknt]

Always amazed when some in SDN think there are people out there making 300k-500k/yr working 30hrs/wk. Who are these people? What do they do?

Anesthesia bros are making 300+ an hour which is well in that range. There is a pain guy near me who sells a bull**** interventional procedure to cure every ailment for 600 cash (bills insurance 2-3x that) and takes him 10 minutes to do. His entire schedule is booked all week with this ****--he makes over 5k/hr.

 

[Splenda88]

Anesthesia bros are making 300+ an hour which is well in that range. There is a pain guy near me who sells a bull**** interventional procedure to cure every ailment for 600 cash (bills insurance 2-3x that) and takes him 10 minutes to do. His entire schedule is booked all week with this ****--he makes over 5k/hr.

I was talking about careers outside of medicine.

People in medicine don't understand how privilege they are in term of salary and most importantly, job security.

 

[PikminOC]

Anesthesia bros are making 300+ an hour which is well in that range. There is a pain guy near me who sells a bull**** interventional procedure to cure every ailment for 600 cash (bills insurance 2-3x that) and takes him 10 minutes to do. His entire schedule is booked all week with this ****--he makes over 5k/hr.

What's the interventional procedure he does ?

 

[aafisahar]

What's the interventional procedure he does ?

Percutaneous wallet biopsy

 

[NewYorkDoctors]

I was talking about careers outside of medicine.

People in medicine don't understand how privilege they are in term of salary and most importantly, job security.

definitely. security is the most important part of being a health care provider (and especially a physician)
at the end of the day, no administrator will exist without physician to mooch off of (or commensalism at best).
they can try to create a midlevel only hospital or clinic. Good luck to them .

healthcare will always be required.

I also take pride in knowing that being a physician is one of the jobs in which one "legitimately" makes money. (I am discounting billing fraud and sellin snake oil).

Most other "finance" jobs that make it big are done with lobbying, corruption, politicking, and selling political influence. (not meant to be a political jab but I am sure some can read through the lines). Not my cup of tea.

 

[VA Hopeful Dr]

What's the interventional procedure he does ?

I would assume something stem cell related.

 

[chessknt]

I would assume something stem cell related.

Bingo

 

[PikminOC]

I would assume something stem cell related.

A sucker is born every minute. I don't know how they fill the schedule with that. People are freaking out about money. And the boards don't care.

 

[Drrrrrr. Celty]

definitely. security is the most important part of being a health care provider (and especially a physician)
at the end of the day, no administrator will exist without physician to mooch off of (or commensalism at best).
they can try to create a midlevel only hospital or clinic. Good luck to them .

healthcare will always be required.

I also take pride in knowing that being a physician is one of the jobs in which one "legitimately" makes money. (I am discounting billing fraud and sellin snake oil).

Most other "finance" jobs that make it big are done with lobbying, corruption, politicking, and selling political influence. (not meant to be a political jab but I am sure some can read through the lines). Not my cup of tea.

Security is a big pro to the game.

That being said, medical payments have not real kept up with other careers. A guy out of engineering school making 100 start and hitting 150k within 10 years with minimal debt is better off than a lot of doctors. My dad in many cases these days keeps on harping about how 250-300k a year after taking 9 extra years of training and accruing a lot of debt probably means I won't even break even with some of his company's starting engineers for at least 20 years.

This is not to dismiss that debt for the average med graduate is only going to go up. My med school's is now 8-10k more per year. Reviewing their budgeting guide they're recommending you be ready to spend 80-90k for total COL/Tuition a year. Add in another year of lost time as most MD applicants on average taking a gap year and fundamentally you're looking at a rough start.

I'm not going to deny that I'm certainly happier as a physician than as an engineer. But I also think that as far as a pathway to significant economic prosperity, we're really heading towards something somewhat mid for the 50% of physicians who aren't in procedural fields.

 

[Drrrrrr. Celty]

A sucker is born every minute. I don't know how they fill the schedule with that. People are freaking out about money. And the boards don't care.

Tbh if there is a how then there is a way.

Side ways money is a helpful venture. I already know I'll probably so some concierge like dabbling. I also am not afraid to drug rep. I can speak well and I'm loud enough that I think I'd be good enough at it to do it once in a while.

 

[VA Hopeful Dr]

Security is a big pro to the game.

That being said, medical payments have not real kept up with other careers. A guy out of engineering school making 100 start and hitting 150k within 10 years with minimal debt is better off than a lot of doctors. My dad in many cases these days keeps on harping about how 250-300k a year after taking 9 extra years of training and accruing a lot of debt probably means I won't even break even with some of his company's starting engineers for at least 20 years.

This is not to dismiss that debt for the average med graduate is only going to go up. My med school's is now 8-10k more per year. Reviewing their budgeting guide they're recommending you be ready to spend 80-90k for total COL/Tuition a year. Add in another year of lost time as most MD applicants on average taking a gap year and fundamentally you're looking at a rough start.

I'm not going to deny that I'm certainly happier as a physician than as an engineer. But I also think that as far as a pathway to significant economic prosperity, we're really heading towards something somewhat mid for the 50% of physicians who aren't in procedural fields.

I think people underestimate how much the majority of doctors make.

 

[Osteoth]

I think people underestimate how much the majority of doctors make.

Average is around $280k I believe.

 

[VA Hopeful Dr]

Average is around $280k I believe.

Average reported. I haven't ever received or filled out an income survey.

Many times that also includes part-time and academic doctors.

 

[sloh]

Medians for each specialty are more informative

 

[PikminOC]

Average is around $280k I believe.

Yes and to the average worker, that's a lot of 💰

 

[dozitgetchahi]

Medians for each specialty are more informative

But again, it all depends on who’s filling out the surveys and what the motives are of the institutions coming up with the numbers. I’ve never filled out a survey either.

MGMA numbers are notoriously low - but the data is usually being bought by hospital systems who want to keep salaries low. There’s an incentive there. Plus iirc MGMA sample sizes are super low, like much less than 50 docs in many situations, which IMHO is so small as to be meaningless.

 

[sloh]

But again, it all depends on who’s filling out the surveys and what the motives are of the institutions coming up with the numbers. I’ve never filled out a survey either.

MGMA numbers are notoriously low - but the data is usually being bought by hospital systems who want to keep salaries low. There’s an incentive there. Plus iirc MGMA sample sizes are super low, like much less than 50 docs in many situations, which IMHO is so small as to be meaningless.

True true. Can't pay you more because of "FMV."

 

[PikminOC]

True true. Can't pay you more because of "FMV."

What's fmv?

 

[sloh]

What's fmv?

Fair market value

 

[PikminOC]

In 2012 I was at a hospital system making 240 a year as a psych

 

[Osteoth]

For all the PCPs on this thread, what’s your average reimbursement for a 99214?

 

[NewYorkDoctors]

For all the PCPs on this thread, what’s your average reimbursement for a 99214?

I bill 99214 for someone with multiple chronic complex issues every 3-4 months they come to visit . Here in nyc the allowed amount is about $140 .

 

[Osteoth]

I bill 99214 for someone with multiple chronic complex issues every 3-4 months they come to visit . Here in nyc the allowed amount is about $140 .

Medicare or private?

You’ll have to forgive me I’m a new attending but is Medicare usually higher or lower than private?

And any tips on these “modifiers” people keep talking about? What are they and do they meaningfully add compensation?

 

[NewYorkDoctors]

Medicare or private?

You’ll have to forgive me I’m a new attending but is Medicare usually higher or lower than private?

And any tips on these “modifiers” people keep talking about? What are they and do they meaningfully add compensation?

other billing gurus can correct or add to what I have to say as I am not a billing expert. I just do my own billing since i run a small business I cannot and will not trust a stranger to learn my financial situation.

but all of these CPT codes are assigned a fee amount and also an RVU amount.

Search the Physician Fee Schedule | CMS

Downloads Physician Fee Schedule Guide (PDF)

www.cms.gov

I just typed in 99214

while this is a rather busy slide, I like to just use this to get a rough idea what to expect. what the insurances actually pay me depends on the individual insurance and what their fee schedules are.

 

[Osteoth]

other billing gurus can correct or add to what I have to say as I am not a billing expert. I just do my own billing since i run a small business I cannot and will not trust a stranger to learn my financial situation.

but all of these CPT codes are assigned a fee amount and also an RVU amount.

Search the Physician Fee Schedule | CMS

Downloads Physician Fee Schedule Guide (PDF)

www.cms.gov

I just typed in 99214

while this is a rather busy slide, I like to just use this to get a rough idea what to expect. what the insurances actually pay me depends on the individual insurance and what their fee schedules are.


View attachment 375948

So if you own your clinic do you charge both the facility and non facility fee?

 

[chessknt]

So if you own your clinic do you charge both the facility and non facility fee?

RVU has 3 components--work, malpractice (negligible), and practice expense. When you own the location/equipment where a RVU is being billed you also collect the practice expense component (which is included in the figure above).

Medicare is the absolute floor of all payments--nothing pays worse than it except medicaid.

 

[NewYorkDoctors]

So if you own your clinic do you charge both the facility and non facility fee?

I just put in the codes and the insurance pays ne a certain amount . Perhaps the facility and non facility fees are a suggested way to distribute earnings ?

Certain procedures have clearly defined facility and non facility fees like the various ekg stress test codes 93015-8 . Not so for office codes so I’m unclear

 

[NewYorkDoctors]

RVU has 3 components--work, malpractice (negligible), and practice expense. When you own the location/equipment where a RVU is being billed you also collect the practice expense component (which is included in the figure above).

Medicare is the absolute floor of all payments--nothing pays worse than it except medicaid.

certain lower tiered commercial insurances pay worse . Some patients who have a low cost commercial insurance (a few patients with empire bcbs come to mind ) have 99213s that pay me $37 only .

 

[hotsaws]

It's tough not to get grass in greener syndrome with other careers. I have friends my age that make good money in sales or who have started businesses. They do well. They work for it though. They don't have the same security as a physician. They also don't have the same level of debt and opportunity cost. Many of them started making money at a younger age and have already started investing and seeing those gains. Many newly minted attendings aren't making the same money as an established private practice doc who is 5+ years into a career. My brother in law and his wife have college degrees, one with a masters, and no student debt. They both probably earn in the low six figures (i'm guessing because I don't ask directly, but I'd say probably 100-150 each). However, they have no debt and both of their jobs allow pretty much entirely remote working. They are not even 30 yet and are doing quite well in a nice city and now have a small second home in a nice area outside of the city that they can spend weeks at a time at because of the remote work option. Save for a few fields (maybe psych and rads) most of us docs will always work in a brick-and-mortar setting.

I think inflation and the current economy has done us dirty. Physician salaries don't seem to have moved much whereas other fields (tech, engineering, banking, general corporate stuff) has moved up with it to remain competitive. If you made 200k a year in say 2005, you were in a very different position than you are making 200k now. Physicians back then also had loans at like 2% instead of nearly 6%. So you're getting pounded on both ends. At the end of the day, we all make enough to be comfortable, but I don't think comparable jobs are as over exaggerated as some may imply. I think alot has changed in the last 15 years and a ton has changed even in the last 3 years (if you finished training prior to 2020 and bought your first home, your mortgage payment is probably half or even less than a new grad buying the home next door to you this August). Jobs outside of medicine making 150-250k a year with minimal education are not that uncommon but it's obviously not a cakewalk.

Those of you who didn't put yourself through school on loans can stfu for real though. If you had parents fund your education and then walked straight into a 200k+ job, you're doing just fine.

 

[Splenda88]

It's Jobs outside of medicine making 150-250k a year with minimal education are not that uncommon but it's obviously not a cakewalk.

Those of you who didn't put yourself through school on loans can stfu for real though. If you had parents fund your education and then walked straight into a 200k+ job, you're doing just fine.

Statistics alone tell you it's not common

Average income of the top 10% is 173k (bottom half of that 133.5k). A lot of these people are in the healthcare industry

How Much Income Puts You in the Top 1%, 5%, 10%?

To count yourself among the nation's top earners, it takes an income of at least six figures. Here's how the numbers break down for each group.

www.investopedia.com

How much do I need to make to be in the top 1%, 5%, and 10% in the US? It's probably less than you think

Are you on the upper rungs of the class ladder?

www.yahoo.com

We are biased because of the people we know and the ones we surround ourselves with.

Yes, there are jobs out there that few people have that pay 150k+/yr without accumulating 300k in debt and spending 11 yrs in school. However, 97%+ of college grad dont start making that kind of money at the age of 22-23. It takes them a few years (5+) to start making that money.

 

[Nocturnist]

It's tough not to get grass in greener syndrome with other careers. I have friends my age that make good money in sales or who have started businesses. They do well. They work for it though. They don't have the same security as a physician. They also don't have the same level of debt and opportunity cost. Many of them started making money at a younger age and have already started investing and seeing those gains. Many newly minted attendings aren't making the same money as an established private practice doc who is 5+ years into a career. My brother in law and his wife have college degrees, one with a masters, and no student debt. They both probably earn in the low six figures (i'm guessing because I don't ask directly, but I'd say probably 100-150 each). However, they have no debt and both of their jobs allow pretty much entirely remote working. They are not even 30 yet and are doing quite well in a nice city and now have a small second home in a nice area outside of the city that they can spend weeks at a time at because of the remote work option. Save for a few fields (maybe psych and rads) most of us docs will always work in a brick-and-mortar setting.

I think inflation and the current economy has done us dirty. Physician salaries don't seem to have moved much whereas other fields (tech, engineering, banking, general corporate stuff) has moved up with it to remain competitive. If you made 200k a year in say 2005, you were in a very different position than you are making 200k now. Physicians back then also had loans at like 2% instead of nearly 6%. So you're getting pounded on both ends. At the end of the day, we all make enough to be comfortable, but I don't think comparable jobs are as over exaggerated as some may imply. I think alot has changed in the last 15 years and a ton has changed even in the last 3 years (if you finished training prior to 2020 and bought your first home, your mortgage payment is probably half or even less than a new grad buying the home next door to you this August). Jobs outside of medicine making 150-250k a year with minimal education are not that uncommon but it's obviously not a cakewalk.

Those of you who didn't put yourself through school on loans can stfu for real though. If you had parents fund your education and then walked straight into a 200k+ job, you're doing just fine.

I dont have my finger to the pulse of other specialties, but at least with regards to hospital medicine- you can take any salary survey across any 10-20 year range since the 90s and you'll find that our salaries have risen by close to double the rate of inflation. 200k in 2005 is 313k today, which happens to be right around the nation wide average total compensation. Obviously I don't think this that rate is sustainable. I also do think that trend has decelerated since 2020 and future surveys will probably show some flattening, but for now it's tough to argue with these strong numbers.

I do think that comparison is the thief of joy.
It was particularly frustrating in March 2020 when my spouse who is in health care was the only one of their friend group to have been furloughed. The rest are in sales, marketing, business, finance, tech, law. Most of them are in the 150-250k range. They've been making 6 figures since their mid 20s. They were all thriving working from home spending all the time in the world with their kids while I was changing in the garage and took a full shower before I could even see mine. But it doesn't take more than looking at the wide layoffs in tech this past year to appreciate the utter rock solid job security. My dad's a software engineer, his salary is probably on par with a hospitalist except he only had to get a bachelor's degree to make it. But every single year since I've known him, it's always been "this is the year I'll be laid off". Ageism is also a huge issue in tech, and he's always mentioned how difficult to impossible it would be to find a job at his age. Ask your older non medical friends what is was like to live through 2008-2010 and youll get some perspective. I feel fortunate that layoffs in medicine are virtually unheard of and age/experience aren't a liability.

I will say what I appreciate financially about this job is the ability to dial in exactly what I want to make. If I want to make an extra 100k, all I have to do is pick up 3-4 extra shifts a month. want to make an extra 100k in any of those other fields? you'll need to switch jobs or get a promotion.

 

[end stage fibro]

RVU has 3 components--work, malpractice (negligible), and practice expense. When you own the location/equipment where a RVU is being billed you also collect the practice expense component (which is included in the figure above).

Medicare is the absolute floor of all payments--nothing pays worse than it except medicaid.

Just to add a little to this...

Everyone here uses CPT codes: 99223, 99291, 99205, etc. Many CPT codes have a facility and non facility value (facility meaning a hospital, SNF, ASC, LTACH, etc. NOT the office). If something is done in a facility, the practice expense RVU is much lower and gets replaced with a facility fee. What facility a service takes place in is determined by the place of service (POS) code. you can see all the codes here. What makes some people jaded is that rendering the same service utilizing the same resources can have WILDLY different payments depending on the POS code. A common example that you may have seen in the news is a private PCP who gets bought out by the local hospital system. The PCP's office can now be converted to POS 22, hospital outpatient department (HOPD). This results in a much higher reimbursement and probably a higher cost to the patient. there is no way you can access this extra money without being a hospital, even though nothing has changed in the PCP's clinic. For similar reasons, some hospital employed physicians can get a much higher salary than is otherwise possible grinding out FFS.

This isn't fair you might mutter to yourself. Damn right it isn't.


Managed care insurance (i.e. private insurance) is usually expressed as % of Medicare. Usually it is 100+%, but if you are an individual physician it can be even 80% medicare, which sucks. pays to be part of a group, especially a multispecialty group. Finally, medicaid payment is embarrassingly bad. In the 4 states where I know the rate, you literally lose money by seeing medicaid patients. doesn't even cover overhead.

 

[Splenda88]

I dont have my finger to the pulse of other specialties, but at least with regards to hospital medicine- you can take any salary survey across any 10-20 year range since the 90s and you'll find that our salaries have risen by close to double the rate of inflation. 200k in 2005 is 313k today, which happens to be right around the nation wide average total compensation. Obviously I don't think this that rate is sustainable. I also do think that trend has decelerated since 2020 and future surveys will probably show some flattening, but for now it's tough to argue with these strong numbers.

I do think that comparison is the thief of joy.
It was particularly frustrating in March 2020 when my spouse who is in health care was the only one of their friend group to have been furloughed. The rest are in sales, marketing, business, finance, tech, law. Most of them are in the 150-250k range. They've been making 6 figures since their mid 20s. They were all thriving working from home spending all the time in the world with their kids while I was changing in the garage and took a full shower before I could even see mine. But it doesn't take more than looking at the wide layoffs in tech this past year to appreciate the utter rock solid job security. My dad's a software engineer, his salary is probably on par with a hospitalist except he only had to get a bachelor's degree to make it. But every single year since I've known him, it's always been "this is the year I'll be laid off". Ageism is also a huge issue in tech, and he's always mentioned how difficult to impossible it would be to find a job at his age. Ask your older non medical friends what is was like to live through 2008-2010 and youll get some perspective. I feel fortunate that layoffs in medicine are virtually unheard of and age/experience aren't a liability.

I will say what I appreciate financially about this job is the ability to dial in exactly what I want to make. If I want to make an extra 100k, all I have to do is pick up 3-4 extra shifts a month. want to make an extra 100k in any of those other fields? you'll need to switch jobs or get a promotion.

Well, I got a 20k raise in May. I tried to "strong arm" my company last month in giving another 20K. Lol

 

[NewYorkDoctors]

Managed care insurance (i.e. private insurance) is usually expressed as % of Medicare. Usually it is 100+%, but if you are an individual physician it can be even 80% medicare, which sucks. pays to be part of a group, especially a multispecialty group. Finally, medicaid payment is embarrassingly bad. In the 4 states where I know the rate, you literally lose money by seeing medicaid patients. doesn't even cover overhead.

right on. the Managed Medicaid or Medicare usually pays 100%+ for me but that's only because I am part of a large IPA that negotiated top rates for serving the "underserved communities."

but for some physicians who do not have such collective bargaining power and "went at it alone" they may get far less than the Medicare rate for the "private" insurances

here in NYS (though I am sure this must be the same in all stats), straight Medicaid pays $70 or so for 99213 while Medicare will allow $106 or something for 99213 (along with the 20% copay)

but the straight Medicaid used to be $30 for 99213 last year. I am not exactly sure why it increased by more than double. but one can see how straight medicaid paid peanuts before.

 

[Osteoth]

Just to add a little to this...

Everyone here uses CPT codes: 99223, 99291, 99205, etc. Many CPT codes have a facility and non facility value (facility meaning a hospital, SNF, ASC, LTACH, etc. NOT the office). If something is done in a facility, the practice expense RVU is much lower and gets replaced with a facility fee. What facility a service takes place in is determined by the place of service (POS) code. you can see all the codes here. What makes some people jaded is that rendering the same service utilizing the same resources can have WILDLY different payments depending on the POS code. A common example that you may have seen in the news is a private PCP who gets bought out by the local hospital system. The PCP's office can now be converted to POS 22, hospital outpatient department (HOPD). This results in a much higher reimbursement and probably a higher cost to the patient. there is no way you can access this extra money without being a hospital, even though nothing has changed in the PCP's clinic. For similar reasons, some hospital employed physicians can get a much higher salary than is otherwise possible grinding out FFS.

This isn't fair you might mutter to yourself. Damn right it isn't.


Managed care insurance (i.e. private insurance) is usually expressed as % of Medicare. Usually it is 100+%, but if you are an individual physician it can be even 80% medicare, which sucks. pays to be part of a group, especially a multispecialty group. Finally, medicaid payment is embarrassingly bad. In the 4 states where I know the rate, you literally lose money by seeing medicaid patients. doesn't even cover overhead.

So I assume someone has brought this up. What does CMS say? Trying to kill private practice?

 

[hotsaws]

Statistics alone tell you it's not common

Average income of the top 10% is 173k (bottom half of that 133.5k). A lot of these people are in the healthcare industry

How Much Income Puts You in the Top 1%, 5%, 10%?

To count yourself among the nation's top earners, it takes an income of at least six figures. Here's how the numbers break down for each group.

www.investopedia.com

How much do I need to make to be in the top 1%, 5%, and 10% in the US? It's probably less than you think

Are you on the upper rungs of the class ladder?

www.yahoo.com

We are bias because of the people we know and the ones we surround ourselves with.

Yes, there are jobs out there that few people have that pay 150k+/yr without accumulating 300k in debt and spending 11 yrs in school. However, 97%+ of college grad dont start making that kind of money at the age of 22-23. It takes them a few years (5+) to start making that money.

You're probably right and I need to remember to keep this perspective. I am pretty much surrounded by a friend group of hard working guys and they are probably a very disproportionate sample. I also am probably very biased in who I compare myself to. My response was from a downer perspective, probably driven by the dreadful student debt looming over my wife and I. It's all about perspective. It's also important to know that all of those guys making good money think they need to make MORE money to be happy and suffer from the same worries and doubts that I do. Hey the upside is that I really love being an allergist. Like I genuinely enjoy what I do every day.

I dont have my finger to the pulse of other specialties, but at least with regards to hospital medicine- you can take any salary survey across any 10-20 year range since the 90s and you'll find that our salaries have risen by close to double the rate of inflation. 200k in 2005 is 313k today, which happens to be right around the nation wide average total compensation. Obviously I don't think this that rate is sustainable. I also do think that trend has decelerated since 2020 and future surveys will probably show some flattening, but for now it's tough to argue with these strong numbers.

I do think that comparison is the thief of joy.
It was particularly frustrating in March 2020 when my spouse who is in health care was the only one of their friend group to have been furloughed. The rest are in sales, marketing, business, finance, tech, law. Most of them are in the 150-250k range. They've been making 6 figures since their mid 20s. They were all thriving working from home spending all the time in the world with their kids while I was changing in the garage and took a full shower before I could even see mine. But it doesn't take more than looking at the wide layoffs in tech this past year to appreciate the utter rock solid job security. My dad's a software engineer, his salary is probably on par with a hospitalist except he only had to get a bachelor's degree to make it. But every single year since I've known him, it's always been "this is the year I'll be laid off". Ageism is also a huge issue in tech, and he's always mentioned how difficult to impossible it would be to find a job at his age. Ask your older non medical friends what is was like to live through 2008-2010 and youll get some perspective. I feel fortunate that layoffs in medicine are virtually unheard of and age/experience aren't a liability.

I will say what I appreciate financially about this job is the ability to dial in exactly what I want to make. If I want to make an extra 100k, all I have to do is pick up 3-4 extra shifts a month. want to make an extra 100k in any of those other fields? you'll need to switch jobs or get a promotion.

You make a good point. I haven't really dove into the statistics of it all. I do think comparing student loan rates mitigates some salary gains over that time. My comparisons are more simplistic, although still relevant but perhaps more a reflection of our current economy and not medicine as a career choice. You are absolutely on point about the job security. I can't imagine the stress of my friends in sales. It's like they go from quarter to quarter wondering whether they are getting a fat bonus or losing their job. The stress is immense and I do not think they get nearly the fulfillment that I do. Being an allergist, I don't have the same ability to dial up my compensation. I can't just work more to make more money (aside from say moonlighting as a hospitalist or something...which is not practical given that I have a family and a wife who works and childcare etc.). However, if and when I make partner, my income would jump dramatically.

I'm not sure medicine is the ideal career choice from a purely financial standpoint but overall we have it pretty good. I live in a nice neighborhood, my kid is in a nice day care, I don't worry about most purchases, and I have landscapers, a pool guy, and cleaning people. I can afford to pay my loans even though it pains me.

Anyways, thanks guys, good points. I'll shut up now. I have it good and I think y'all have made me just a little more grateful.

....still bitter about the not being able to work remotely from my future second home though.

 

[PikminOC]

Statistics alone tell you it's not common

Average income of the top 10% is 173k (bottom half of that 133.5k). A lot of these people are in the healthcare industry

How Much Income Puts You in the Top 1%, 5%, 10%?

To count yourself among the nation's top earners, it takes an income of at least six figures. Here's how the numbers break down for each group.

www.investopedia.com

How much do I need to make to be in the top 1%, 5%, and 10% in the US? It's probably less than you think

Are you on the upper rungs of the class ladder?

www.yahoo.com

We are biased because of the people we know and the ones we surround ourselves with.

Yes, there are jobs out there that few people have that pay 150k+/yr without accumulating 300k in debt and spending 11 yrs in school. However, 97%+ of college grad dont start making that kind of money at the age of 22-23. It takes them a few years (5+) to start making that money.

My brother is a gi and got laid off during covid. They said he could work in the er instead. He did do that.

 

[Nocturnist]

My brother is a gi and got laid off during covid. They said he could work in the er instead. He did do that.

A GI MD? That might truly be the first lay off in medicine I've heard of. I know several subspecialists that got furloughed or their hours cut temporarily. The hospitalist department offered to train any willing hand on deck, many took us up on it including a dermatologist. No layoffs I've ever heard of though.

 

[hotsaws]

Would love to see a GI doc in the ED. Let them triage the crowd that they condemn to hospital purgatory...pt is too sick to scope or not sick enough to scope -- they may be bleeding from their whatever but either way GI can't scope any time soon.

 

[MD46]

Mid levels as physician extenders : do ancillary supportive things for example for us in Onc , chemotherapy education/ consent, followup on some patient calls to triage their need to be seen in clinic, see simple anemia followups to make space in our schedule for new cancer patients that need to be seen asap, as we nor the patients (with cancer) have a luxury to wait as they do for other specialist with 6-9 months wait times, to see a rheum for positive ANA or neuro for headache etc

Mid levels as physician replacement: nope, not happening, cant compete.

They have their role, need to be utilized in a way that makes your life easier as a physician while providing better and more comprehensive care for the patient.

My 2 cents…

 

[dozitgetchahi]

And my employer would much rather me see 3 or 4 patients who want chemo than wasting that same amount of time on the patient they're only getting the visit fee for. And IME, these folks tend to be the uninsured/medicaid population, not the commercially insured.

Isn't it interesting how this works?

In the beginning at my current job, I was taking some Medicaid patients to help fill the slots. What a headache on so many levels. At least in rheumatology, that patient population by far are the ones who are most likely to come in with kooky, off the wall complaints that don’t make sense (and that largely turn out to be somatic/functional etc). A lot of them have obnoxious, overbearing personalities. They dump 30 years of unresolved issues on you and expect you to solve them all at once. Then they don’t follow up to appointments, and disappear for months with their phone service shut off and any mailings to them returned to sender. Then they mysteriously reappear out of nowhere, and try to rip you a new one for not getting them better despite the fact that they haven’t seen you in months and haven’t been taking meds etc.

The “BS factor” in my clinic declined by at least 95% when I stopped seeing these patients. My staff was so much happier that they weren’t having to keep dealing with all the BS these patients were throwing at them every day. We have a few “real characters” left in the patient panel among the insured folks, but the overwhelming majority of them came from the Medicaid crowd. When you take into account that you basically lose money every time you see someone on Medicaid, it’s no wonder that very very few physicians out there will see these people.

 

[NewYorkDoctors]

Isn't it interesting how this works?

In the beginning at my current job, I was taking some Medicaid patients to help fill the slots in the beginning. What a headache on so many levels. At least in rheumatology, that patient population by far are the ones who are most likely to come in with kooky, off the wall complaints that don’t make sense (and that largely turn out to be somatic/functional etc). A lot of them have obnoxious, overbearing personalities. They dump 30 years of unresolved issues on you and expect you to solve them all at once. Then they don’t follow up to appointments, and disappear for months with their phone service shut off and any mailings to them returned to sender. Then they mysteriously reappear out of nowhere, and try to rip you a new one for not getting them better despite the fact that they haven’t seen you in months and haven’t been taking meds etc.

The “BS factor” in my clinic declined by at least 95% when I stopped seeing these patients. My staff was so much happier that they weren’t having to keep dealing with all the BS these patients were throwing at them every day. We have a few “real characters” left in the patient panel among the insured folks, but the overwhelming majority of them came from the Medicaid crowd. When you take into account that you basically lose money every time you see someone on Medicaid, it’s no wonder that very very few physicians out there will see these people.

I see these Bs patients also for cpet proven anxiety dyspnea whose pmd keep gaslighting then to come back to see me . If I decline they got nuts and threaten to review bomb me (to which I said I’ll just community note review you back try it lol ) .

But rather than be antagonistic I tell them let’s email all the time in my hipaa secure email server. Then I bombard them with “helpful update patient education,” YouTube links , joe Rogan links (lol) until I thoroughly exhaust them . I have gotten some people to stop bothering me as a result

This is what the step 1 usmle board question answer of “establish frequent visits “ means lol