Thinking about doing a Endocrine vs Rheumatology fellowship vs just starting PCP practice. Soon to be PGY2 IM Resident.

[crigglernajjar11345]

So I'm an IM PGY2 soon to be PGY3 resident... I am thinking about doing an Endocrine vs Rheumatology fellowship.
I don't have a ton of research but I have good Step 1 and 2 Scores as a DO resident.
I like the Endocrine system and Rheum is cool as well, but pondering whether its a good idea to delay making decent
money for another 2 years before I can start earning.
After PGY3 I could make 220k+ in outpatient PCP... But I'd be settling for having to do with every single organ system
for the rest of my life and never being able to specialize...
Financially, is it worth it to do an endocrine or rheumatology fellowship instead of just working PCP.
Thanks.

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[voxveritatisetlucis]

Financially, not at all.

 

[PugsAndHugs]

Starting my Endocrine fellowship next month, here is my advice.

Endocrine and Rheum are similar in the sense of lifestyle and salary, but VERY different in actual practice. In medical school I thought rheumatology was very interesting, I did research, got a publication, but when I did an actual month long rotation in it I actually hated it. So my advice to you is do rotations in both fields (outpatient AND inpatient) to see what the clinical practice is actually like and see which one you enjoy more.

As far as if it is worth it to do fellowship vs PCP? That is a personal question only you can answer. I personally was miserable doing PCP work and happy in endocrine clinic, so to me an extra 2 years is undoubtably worth it. The extra 2 years of fellowship is not to make more money, it is to not be miserable in my work life, which is honestly worth more than any bump in salary I can ask for.

Don’t specialize just to specialize. Specialize if you enjoy the field/work. If you don’t enjoy any field, pick the one you hate the least, that will ultimately make you the happiest.

TLDR: do clinical rotations/electives in any field you may be interested in to see what its really like

 

[NewYorkDoctors]

As far as if it is worth it to do fellowship vs PCP? That is a personal question only you can answer. I personally was miserable doing PCP work and happy in endocrine clinic, so to me an extra 2 years is undoubtably worth it. The extra 2 years of fellowship is not to make more money, it is to not be miserable in my work life, which is honestly worth more than any bump in salary I can ask for.

I agree with this sentiment wholeheartedly.

I practice PCP for some "legacy patients" (some patients I was PCP for before I finished fellowship) and for some of the patients who primarily have rather serious chronic lung diseases (because things get messed up inevitably when these patients are floating around with a PMD who has my notes and phone # but just cannot be bothered to do anything besides order a Zpak).

I will say if I had to just deal with the same "not easily fixed" (i won't say unfixable) complaints all day long ("bloating which is really obesity, lumbar radiculopathy, MDD/bipolar, etc). patients asking about quack treatments they read online, patients wanting an "instant cure" like the Pokemon Center (do-do-dodo-do) and not wanting to do the hard work (like losing weight... which isnt that hard these days with pharmacotherapy), chasing BIRADS3 and tubular adenomas that have not been followed up on for years, dealing with pain seekers, etc... all day long... I would want to stop doing medicine all together.

if you like those two subspecialties, then by all means pursue them

you can always do primary care as a specialist. You cannot do specialty care as a PCP.

 

[rokshana]

Both are good fields, but people go into these fields because they truly enjoy the subject… not to make money… at least for endocrine, you will make less than you can as a pcp or hospitalist.

As has been suggested, do a rotation in both and see which is a better fit for you… and if neither are then go be a pcp. If you find after a few years, you aren’t happy as a pcp, you can then reconsider doing fellowship … these 2 are not crazy competitive and a few years out isn’t going to keep from doing fellowship later…program dependent, but it’s not like cards or gi where you are the most competitive coming out of residency.

 

[Drrrrrr. Celty]

I agree wholeheartedly with the doing fellowship to not be miserable in your job. I like being a specialist. I actually find myself deeply nerding out on stuff like growth hormone, insulin pumps, etc. I think my job is far more interesting than what I could do as a PCP where half of my job would be spent doing stuff I am uninterested.

 

[Splenda88]

Both are good fields, but people go into these fields because they truly enjoy the subject… not to make money… at least for endocrine, you will make less than you can as a pcp or hospitalist.

As has been suggested, do a rotation in both and see which is a better fit for you… and if neither are then go be a pcp. If you find after a few years, you aren’t happy as a pcp, you can then reconsider doing fellowship … these 2 are not crazy competitive and a few years out isn’t going to keep from doing fellowship later…program dependent, but it’s not like cards or gi where you are the most competitive coming out of residency.

I thought rheum was somewhat competitive.

Anyway, that was the advice I got when I wanted to do ID fellowship. An ID doc told me to try hospital medicine first and if I don't like it, I can always do ID fellowship since it's not competitive. It was a great advice given that I really like what I do as a hospitalist.

 

[rokshana]

I thought rheum was somewhat competitive.

Anyway, that was the advice I got when I wanted to do ID fellowship. An ID doc told me to try hospital medicine first and if I don't like it, I can always do ID fellowship since it's not competitive. It was a great advice given that I really like what I do as a hospitalist.

Rheum is more competitive than ID and nephrology and less competitive than hem/onc and pccm.

In groupings, endo and rheum are about the same…both have relatively the same number of spots and a decent candidate can get some place… with the upper tier programs being more competitive. Neither requires a significant amount of research to be competitive. ( though it of course doesn’t hurt).
Rheum makes a bit more, mostly related to the biologics, but still not the big money maker of IM sub specialties.
Most people who go into either rheum or endo do it because they like the subject.

 

[Residentdoc86]

Rheum fellow here:

I was in the same boat as a resident. Choose Rheum after spending time in both clinics. I almost fell asleep during one of my outpatient endo clinics. Maybe I was tired after seeing 7 T2DM cases in a row. My mentor in Rheum was wicked smart, always wanted to teach, and I saw a lot of cool cases.

Here's the kicker, I ended up taking a PCP job after residency for 4 years and I agree with the statement below + COVID.

"I will say if I had to just deal with the same "not easily fixed" (i won't say unfixable) complaints all day long ("bloating which is really obesity, lumbar radiculopathy, MDD/bipolar, etc). patients asking about quack treatments they read online, patients wanting an "instant cure" like the Pokemon Center (do-do-dodo-do) and not wanting to do the hard work (like losing weight... which isn't that hard these days with pharmacotherapy), chasing BIRADS3 and tubular adenomas that have not been followed up on for years, dealing with pain seekers, etc... all day long... I would want to stop doing medicine altogether."

 

[berenjena89]

It is worth it believe me, you ll decrease the amount of paperwork and take care of less issues. Salaries in rheum, endo or pcp are similar however i think that endo/ rheum are in general better compensated if you take into consideration that you ll be taking care of less issues compared with pcp/ hospitalist ( so realistically, less work or less headaches)

 

[VA Hopeful Dr]

I'm FM so take this with a grain of salt..

I was having trouble deciding between IM and FM in med school so I asked myself: would I be happy never seeing another pediatric patient for the rest of my career. The answer was no, so I did FM.

You could do something similar here. Ask yourself if you would be OK never managing blood pressure, COPD, a fib, or doing preventative medicine ever again for outpatient work. Also OK with never doing inpatient medicine again for hospital medicine.

If you're not going to miss any of those things, then fellowship in one of those 2 areas might be a good idea for you.

 

[rokshana]

I'm FM so take this with a grain of salt..

I was having trouble deciding between IM and FM in med school so I asked myself: would I be happy never seeing another pediatric patient for the rest of my career. The answer was no, so I did FM.

You could do something similar here. Ask yourself if you would be OK never managing blood pressure, COPD, a fib, or doing preventative medicine ever again for outpatient work. Also OK with never doing inpatient medicine again for hospital medicine.

If you're not going to miss any of those things, then fellowship in one of those 2 areas might be a good idea for you.

I agree with asking those questions, but I do a significant amount of inpt consults and while uncommon, there are endocrinologists that do just inpt…but most endocrinologists don’t want to do inpt medicine.

 

[collegestud2013]

So I'm an IM PGY2 soon to be PGY3 resident... I am thinking about doing an Endocrine vs Rheumatology fellowship.
I don't have a ton of research but I have good Step 1 and 2 Scores as a DO resident.
I like the Endocrine system and Rheum is cool as well, but pondering whether its a good idea to delay making decent
money for another 2 years before I can start earning.
After PGY3 I could make 220k+ in outpatient PCP... But I'd be settling for having to do with every single organ system
for the rest of my life and never being able to specialize...
Financially, is it worth it to do an endocrine or rheumatology fellowship instead of just working PCP.
Thanks.

Financially not really sensible once you consider the additional 2 year training time. Rheumatology may be able to make a bit more than general IM (either outpatient or hospitalist) in private practice if you're a partner/owner and can profit by buying and billing biologics, but the employed rheumatologists don't make much more than general IM.. Endocrinology makes similar to PCP. Also in 2023 you should be making way more than just $220k working full time doing PCP or hospitalist ($300k+ should be easily doable nowadays in most markets).

 

[rokshana]

Financially not really sensible once you consider the additional 2 year training time. Rheumatology may be able to make a bit more than general IM (either outpatient or hospitalist) in private practice if you're a partner/owner and can profit by buying and billing biologics, but the employed rheumatologists don't make much more than general IM.. Endocrinology makes similar to PCP. Also in 2023 you should be making way more than just $220k working full time doing PCP or hospitalist ($300k+ should be easily doable nowadays in most markets).

Realize that most people who go into subspecialties such as endocrine and rheum aren’t looking at the money per se… it’s the subject matter and not having to do pcp work.
I am amazed and appreciate all those that do pcp work( unless you order reverse t3…then you are the enemy 😊), but I would rather poke my eye out than be a pcp.
Been a hospitalist and for me, that wasn’t a long term plan.

 

[berenjena89]

Realize that most people who go into subspecialties such as endocrine and rheum aren’t looking at the money per se… it’s the subject matter and not having to do pcp work.
I am amazed and appreciate all those that do pcp work( unless you order reverse t3…then you are the enemy 😊), but I would rather poke my eye out than be a pcp.
Been a hospitalist and for me, that wasn’t a long term plan

If I might ask you, why hospitalist wasn’t a long term plan? I know hospitalist that are happy with their income and lifestyle ( week on and off)

And did you ever consider a more lucrative field? Than endocrine ( cardio/GI?) do you have regrets? ( financially speaking)

 

[Splenda88]

Realize that most people who go into subspecialties such as endocrine and rheum aren’t looking at the money per se… it’s the subject matter and not having to do pcp work.
I am amazed and appreciate all those that do pcp work( unless you order reverse t3…then you are the enemy 😊), but I would rather poke my eye out than be a pcp.
Been a hospitalist and for me, that wasn’t a long term plan.

I wonder of the percentage of DM, thyroid disorders makes up the panel of the typical outpatient endocrinologist.

 

[sloh]

Financially not really sensible once you consider the additional 2 year training time. Rheumatology may be able to make a bit more than general IM (either outpatient or hospitalist) in private practice if you're a partner/owner and can profit by buying and billing biologics, but the employed rheumatologists don't make much more than general IM.. Endocrinology makes similar to PCP. Also in 2023 you should be making way more than just $220k working full time doing PCP or hospitalist ($300k+ should be easily doable nowadays in most markets).

Do you find 300k+ to be easily doable in SoCal/LA?

 

[rokshana]

I wonder of the percentage of DM, thyroid disorders makes up the panel of the typical outpatient endocrinologist.

Depends…a general endocrinologist, is probably 50-75% diabetes… depends on what part of the country…obesity/diabetes belt of the country, it’s probably closer to 75%. But these are generally not the run of the mill diabetes, since they are generally managed by pcps.
Thyroid…typically graves is managed by endocrine… stable hypothyroidism is managed by pcp…it’s again the more difficult to control that come and stay with endocrine. Thyroid probably makes up to 25% of the general endocrine panel. But there are thyroidologists that do only thyroid and typically see more complex pts with thyroid disease/cancer.
Also in some endocrinology clinic that utilize midlevels, many times the bulk of the diabetes and hypothyroidism are seem by them, freeing up the schedule for the endocrinologist to see the more complex cases in endocrinology.
For those that specialize, say thyroid cancer, osteoporosis, calcium metabolism, they generally will see little to no diabetes.
Where I trained, we had a division of endocrinology and a separate division of diabetes…those that were in the endocrinology section, saw no diabetes at the mothership and only saw some diabetes at their satellite clinics once or twice a month.

 

[rokshana]

If I might ask you, why hospitalist wasn’t a long term plan? I know hospitalist that are happy with their income and lifestyle ( week on and off)

And did you ever consider a more lucrative field? Than endocrine ( cardio/GI?) do you have regrets? ( financially speaking)

For me, the hospitalist lifestyle was not really something I could do now…basically 7-12s was doable when was younger…and do occasionally when needed( was Covid hospitalist to help and could do it), but not what I see for the next 10,15,20 years.

No…I considered radiology as a med student, but it was pretty competitive when I was applying and was told I could get a community program…but I was considering an academic career and felt that would not be as beneficial for me. I was competitive for a university IM , so went that route after doing a gen endocrinology elective at the end of 3rd yr.
When I came into med school, I was thinking REI…my graduate degree is in reproductive biology and thought that would be my goal…until I did my ob/gyn rotation and in considering whether I would be happy as a gen ob/gyn if I didn’t get the REI fellowship ( which is crazy competitive) …I decided I would not be.
And no…no regrets… I make a really decent amount of money and work basically 2 weeks/month…the ability to have flexibility and free time is more of a priority… and make pretty much full time amount for part time work as locums.

 

[dozitgetchahi]

If I might ask you, why hospitalist wasn’t a long term plan? I know hospitalist that are happy with their income and lifestyle ( week on and off)

And did you ever consider a more lucrative field? Than endocrine ( cardio/GI?) do you have regrets? ( financially speaking)

I’m rheumatology. I’ve talked about all of these things quite a bit recently here and in the IM specialty forum (just search) but I’m going to rehash the highlights here:

- I’m 100% outpatient rheumatology and I love it. I love the clinic, dread the hospital, and ultimately decided that outpatient primary care seemed to have too much BS associated with it to be satisfying in the long term (I definitely thought about it, though). I also have no desire whatsoever to be a hospitalist. My priority was also lifestyle, and for me that meant no weekends, no nights, no call, and no hospital rounding. Rheumatology has delivered beautifully on this.

- Income in PP rheum can be very, very good. My base salary at my current job is $325k. With bonuses in year one, I’m on track to make about $400k in total this year. My partner, who is well established, makes $700-800k on average. It’s not always easy to find the “right” PP rheum job that will make money like this (it took me 4 tries), but if you do, you can blow rheum MGMA out of the water. So I have no “regrets” from a financial standpoint whatsoever. Plus, I generally dislike procedures and there’s no way I’d be happy scoping all day, or doing caths, or whatever. I considered radiology back as a medical student - I liked it - but I ultimately decided I didn’t want to be a human slide reader all day long. Plus I think that specialty is one of the first that will be rendered irrelevant by AI. Glad I dodged that bullet (at least to some extent - AI is eventually coming for all of us IMO).

- I currently work 4.5 days a week. My partner works 4 days a week. Neither of us goes to the hospital.

 

[sloh]

I’m rheumatology. I’ve talked about all of these things quite a bit recently here and in the IM specialty forum (just search) but I’m going to rehash the highlights here:

- I’m 100% outpatient rheumatology and I love it. I love the clinic, dread the hospital, and ultimately decided that outpatient primary care seemed to have too much BS associated with it to be satisfying in the long term (I definitely thought about it, though). I also have no desire whatsoever to be a hospitalist. My priority was also lifestyle, and for me that meant no weekends, no nights, no call, and no hospital rounding. Rheumatology has delivered beautifully on this.

- Income in PP rheum can be very, very good. My base salary at my current job is $325k. With bonuses in year one, I’m on track to make about $400k in total this year. My partner, who is well established, makes $700-800k on average. It’s not always easy to find the “right” PP rheum job that will make money like this (it took me 4 tries), but if you do, you can blow rheum MGMA out of the water. So I have no “regrets” from a financial standpoint whatsoever. Plus, I generally dislike procedures and there’s no way I’d be happy scoping all day, or doing caths, or whatever. I considered radiology back as a medical student - I liked it - but I ultimately decided I didn’t want to be a human slide reader all day long. Plus I think that specialty is one of the first that will be rendered irrelevant by AI. Glad I dodged that bullet (at least to some extent - AI is eventually coming for all of us IMO).

- I currently work 4.5 days a week. My partner works 4 days a week. Neither of us goes to the hospital.

What does your partner do?

 

[collegestud2013]

What does your partner do?

I’m rheumatology. I’ve talked about all of these things quite a bit recently here and in the IM specialty forum (just search) but I’m going to rehash the highlights here:

- I’m 100% outpatient rheumatology and I love it. I love the clinic, dread the hospital, and ultimately decided that outpatient primary care seemed to have too much BS associated with it to be satisfying in the long term (I definitely thought about it, though). I also have no desire whatsoever to be a hospitalist. My priority was also lifestyle, and for me that meant no weekends, no nights, no call, and no hospital rounding. Rheumatology has delivered beautifully on this.

- Income in PP rheum can be very, very good. My base salary at my current job is $325k. With bonuses in year one, I’m on track to make about $400k in total this year. My partner, who is well established, makes $700-800k on average. It’s not always easy to find the “right” PP rheum job that will make money like this (it took me 4 tries), but if you do, you can blow rheum MGMA out of the water. So I have no “regrets” from a financial standpoint whatsoever. Plus, I generally dislike procedures and there’s no way I’d be happy scoping all day, or doing caths, or whatever. I considered radiology back as a medical student - I liked it - but I ultimately decided I didn’t want to be a human slide reader all day long. Plus I think that specialty is one of the first that will be rendered irrelevant by AI. Glad I dodged that bullet (at least to some extent - AI is eventually coming for all of us IMO).

- I currently work 4.5 days a week. My partner works 4 days a week. Neither of us goes to the hospital.

$700-800k is well beyond the 90th percentile for rheum compensation according to MGMA. Nearly impossible to make that much in a non-procedural specialty only taking insurance and only through E&M alone. Especially if one only works 4 days a week. Would almost certainly need to have additional ancillary revenue. Does he make a profit from buy and bill for biologics? Assuming he can buy at low enough price, that seems to be a way for some non-surgical specialties like rheum or heme/onc to tap into additional income stream.

 

[dozitgetchahi]

$700-800k is well beyond the 90th percentile for rheum compensation according to MGMA. Nearly impossible to make that much in a non-procedural specialty only taking insurance and only through E&M alone. Especially if one only works 4 days a week. Would almost certainly need to have additional ancillary revenue. Does he make a profit from buy and bill for biologics? Assuming he can buy at low enough price, that seems to be a way for some non-surgical specialties like rheum or heme/onc to tap into additional income stream.

Yes, a significant fraction of this is buy and bill for infusions as well as other ancillaries. Ancillaries are the name of the game for significant revenue in these specialties. Our large multispecialty clinic has a well oiled infusion practice and you retain a significant portion of ancillaries for whatever you infuse there.

 

[AlbinoHawk DO]

So I'm an IM PGY2 soon to be PGY3 resident... I am thinking about doing an Endocrine vs Rheumatology fellowship.
I don't have a ton of research but I have good Step 1 and 2 Scores as a DO resident.
I like the Endocrine system and Rheum is cool as well, but pondering whether its a good idea to delay making decent
money for another 2 years before I can start earning.
After PGY3 I could make 220k+ in outpatient PCP... But I'd be settling for having to do with every single organ system
for the rest of my life and never being able to specialize...
Financially, is it worth it to do an endocrine or rheumatology fellowship instead of just working PCP.
Thanks.

I don't see the point of doing PCP unless you truly enjoy PCP. The same is true with doing a fellowship. Overall, I think fellowships are a better path to success and happiness. You get to be an expert and you get to work less intensely and deal with much less BS than a PCP unless you're one of these "save the world" types that will go do inner city endo for medicaid patients. The sacrifice for fellowship is the 2 extra years, but in the grand scheme of things, it's better than PCP. That is, unless you really enjoy PCP and don't mind dealing with the BS it brings

 

[collegestud2013]

I don't see the point of doing PCP unless you truly enjoy PCP. The same is true with doing a fellowship. Overall, I think fellowships are a better path to success and happiness. You get to be an expert and you get to work less intensely and deal with much less BS than a PCP unless you're one of these "save the world" types that will go do inner city endo for medicaid patients. The sacrifice for fellowship is the 2 extra years, but in the grand scheme of things, it's better than PCP. That is, unless you really enjoy PCP and don't mind dealing with the BS it brings

Depends on the practice setting as well. It seems like the PCPs that are happiest and burn out the least are those with their own practices or partners on a smaller physician-owned, and who have a full panel of cash paying patients (eg direct primary care, concierge). Profit overheads usually a lot higher in these cash-based set-ups so the their patient panels and patient volumes are smaller, and you rarely have to deal with insurance. Probably the worst setting the health system employed PCPs, where you have have have to deal with the usual BS of being a PCP, usually see large patient volumes, and deal with the BS of being an employee in a system.

 

[VA Hopeful Dr]

Depends on the practice setting as well. It seems like the PCPs that are happiest and burn out the least are those with their own practices or partners on a smaller physician-owned, and who have a full panel of cash paying patients (eg direct primary care, concierge). Profit overheads usually a lot higher in these cash-based set-ups so the their patient panels and patient volumes are smaller, and you rarely have to deal with insurance. Probably the worst setting the health system employed PCPs, where you have have have to deal with the usual BS of being a PCP, usually see large patient volumes, and deal with the BS of being an employee in a system.

I was way more burned out doing DPC than I am as a hospital-employed PCP.

To enjoy DPC you have to enjoy the running a business aspect of the practice. That's not for everyone.

 

[dozitgetchahi]

Do you feel that this setup is feasible or realistic to find in the next decade for someone in training, or mostly a thing of the past?

I eventually managed to find a job like this after switching jobs 3 times. If I had known this was possible, I would have pursued PP jobs fresh out of fellowship rather than spending my first job with a hospital system (horrible experience).

Part of the problem was that on my first job search, I interviewed with a poorly run local PP whose starting salary was about 50% lower than MGMA, gave no sign on bonus, etc etc. I avoided PP after this until I started searching to get out of my crappy hospital job, at which point I realized that some of these jobs actually pay way better. So there are good PP jobs, but there are also a lot of bad PP rheum jobs run by greedy senior partners who want to keep as much money for themselves as possible. That said, you can still find the good ones.

 

[Prehealth1011]

I was way more burned out doing DPC than I am as a hospital-employed PCP.

To enjoy DPC you have to enjoy the running a business aspect of the practice. That's not for everyone.

I forgot if I asked you this before. Did being on call all the time play a part in your burnout with DPC?

 

[VA Hopeful Dr]

I forgot if I asked you this before. Did being on call all the time play a part in your burnout with DPC?

A bit,. though that part wasn't too bad most of the time.

It was the business and constant marketing that I truly hated.