Thinking about sub-fellowship after PCCM - Need Advise

[Smashingdude]

Hey everyone,

Its been a longtime since I posted something here. I am a 2nd year PCCM fellow and I have been contemplating what to do after fellowship. There are basically four routes as I can see it : start practice; IP fellowship; PH fellowship; advanced lung disease/lung transplant fellowship. I've also seen ECMO fellowships here and there.

I am looking to get more insight on these fellowships, especially from someone who has done one of these and can share their experience. I've googled program description and they all seem nice but someone who has completed these fellowships can offer a much better advice. If they can help answer:
1- Average Salary
2- Job market/demands/feasibility of finding a job
3- Work/life balance
4- Was it worth it?

One of the main reasons I am considering sub-fellowship is dissatisfaction with the field as a whole - ICU becomes a drag, autopilot and repetitive, general pulmonary is depressing as many diseases we don't have good treatments and we refer them out. I do like procedures a lot so that's why I was considering IP. I also have debts so have to weigh in the financial aspect as well. Finally, my attendings always tell me to think how will be the field/demand in 10-15 years and then make your decision.

Any tips/comments/advise is greatly appreciated!

Thanks.

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[IMResApplicant]

Can anyone respond? I am curious about this as well.

 

[Bobblehead]

Sleep. None of the other things you've listed will get you away from general pulmonary medicine.

 

[Green Man]

To assess practical market supply and demand, look up job postings for pulmonary and critical care. (Practice Match, practice link, etc) See how many you can find for subspecialties. Very few.. Even in big academic centers, it's hard to maintain your productivity/patient load for one subspecialty only. Any subspecialty you pursue, just keep in mind that you will still have to do a large portion of general Pulmonary and Critical care.

 

[deleted547339]

Dude. Life is 1000x better as an attending. I was so burned out in fellowship (didn’t do pccm; I’m EM->CCM). Turns out when you don’t spend 100 hours/week in the icu and get paid a lot, it’s actually pretty fun.

 

[FireMedic4]

Sleep. None of the other things you've listed will get you away from general pulmonary medicine.

This is the right answer. Source: Doing sleep medicine now after PCCM and life is FANTASTIC. Highly recommend it to help break up the rigor of CC blocks and mental fatigue of pulmonary.

*EDIT*
To expand a bit since OP didn't have this as an option. Sleep will increase your salary overall. With the 2021 outpatient E/M changes, you can easily see lots of sleep patients and get paid more based on the changes (can code most follow up by time). Reading sleep studies is easy once you get the hang of it and while the reimbursement isn't what it used to be, it's straightforward and can increase RVU generation without adding liability. Having sleep will make you more marketable in non academic position and you're not working as hard as general PCCM to generate similar, if not more, RVUs. If you end up doing more sleep in your practice, the work life balance is amazing since it is all outpatient.

 

[CaliPCCSM]

After almost 3 decades in the ICU, is nice to have Sleep certification to transition into an office based practice.

 

[deleted547339]

After almost 3 decades in the ICU, is nice to have Sleep certification to transition into an office based practice.

After almost 3 decades of icu, why don’t you transition to golf?

 

[CaliPCCSM]

I hate golf. Was lucky enough to have great partners and we all work 12 days on and 9 days off. 7 days in the ICU and 5 days in clinic then 9 days off. Piece of cake. You better plan on working 30 years if you start working in your 30s

 

[spacegun]

This is the right answer. Source: Doing sleep medicine now after PCCM and life is FANTASTIC. Highly recommend it to help break up the rigor of CC blocks and mental fatigue of pulmonary.

*EDIT*
To expand a bit since OP didn't have this as an option. Sleep will increase your salary overall. With the 2021 outpatient E/M changes, you can easily see lots of sleep patients and get paid more based on the changes (can code most follow up by time). Reading sleep studies is easy once you get the hang of it and while the reimbursement isn't what it used to be, it's straightforward and can increase RVU generation without adding liability. Having sleep will make you more marketable in non academic position and you're not working as hard as general PCCM to generate similar, if not more, RVUs. If you end up doing more sleep in your practice, the work life balance is amazing since it is all outpatient.

I guess another option for someone from IM is to do pulm/sleep? No ICU. I love ccm so I want to do the traditional pulm/ccm, but maybe someone who loves outpatient and/or dislikes the ICU could consider pulm/sleep? Not that money should be the main focus, but it seems like pulm/sleep could be financially lucrative and have a relatively good life/work balance too.

 

[FireMedic4]

How much does adding sleep to PCCM compare to adding IP? 350k vs 400k?

Short answer is that PCCM + sleep will make more than general PCCM by being able to increase wRVU easily by reading sleep studies and seeing more 'simple' follow ups. By how much really varies based on how your schedule is made and how you divide your time.

The 2021 changes to E/M reimbursement have hurt procedural based specialties because CMS has to maintain budget-neutrality. I'm not sure we know exactly by how much this is affecting IP yet, it can be inferred that the reimbursement per IP procedure will go down.

 

[FireMedic4]

I guess another option for someone from IM is to do pulm/sleep? No ICU. I love ccm so I want to do the traditional pulm/ccm, but maybe someone who loves outpatient and/or dislikes the ICU could consider pulm/sleep? Not that money should be the main focus, but it seems like pulm/sleep could be financially lucrative and have a relatively good life/work balance too.

I don't think 'lucrative' is the right word for this.

You will be grinding daily seeing patients if you do just pulm/sleep. Pulm patients, as a whole, are usually fairly complicated and require a lot of close attention and care. OSA patients, not so much, but other sleep patients are equally as complicated (think narcolepsy, insomnia). While the bulk of sleep medicine is certainly OSA, I'm not sure someone who does PCCM would find just seeing OSA day in and day out fulfilling. What I do think is that is seeing those patients would help to lighten the 'mental burden' of more complex pulmonary patients.

I think there are other disciplines of medicine which could be considered 'lucrative' but pulm/sleep is not part of that.

 

[spacegun]

I don't think 'lucrative' is the right word for this.

You will be grinding daily seeing patients if you do just pulm/sleep. Pulm patients, as a whole, are usually fairly complicated and require a lot of close attention and care. OSA patients, not so much, but other sleep patients are equally as complicated (think narcolepsy, insomnia). While the bulk of sleep medicine is certainly OSA, I'm not sure someone who does PCCM would find just seeing OSA day in and day out fulfilling. What I do think is that is seeing those patients would help to lighten the 'mental burden' of more complex pulmonary patients.

I think there are other disciplines of medicine which could be considered 'lucrative' but pulm/sleep is not part of that.

Thanks this is helpful information! Just to clarify or elaborate (I should've done this initially sorry about that) by "lucrative" I just had in mind a pulm/ccm attending who told me he could make ~$350k doing outpatient pulm only (no sleep, no ICU, no pulm consults). This is in a smaller or medium sized Midwest town though so maybe (or probably) he's not representative. But I had thought (maybe wrongly) that reading sleep studies could add more compensation to pulm only. But maybe sleep doesn't add much in terms of compensation even though it is valuable in other ways like you said because it helps in "lightening the mental burden of more complex pulmonary patients."

 

[FireMedic4]

Thanks this is helpful information! Just to clarify or elaborate (I should've done this initially sorry about that) by "lucrative" I just had in mind a pulm/ccm attending who told me he could make ~$350k doing outpatient pulm only (no sleep, no ICU, no pulm consults). This is in a smaller or medium sized Midwest town though so maybe (or probably) he's not representative. But I had thought (maybe wrongly) that reading sleep studies could add more compensation to pulm only. But maybe sleep doesn't add much in terms of compensation even though it is valuable in other ways like you said because it helps in "lightening the mental burden of more complex pulmonary patients."

No worries, happy to provide insight where I can.

Making 350k outpatient pulm only is possible but you're REALLY working hard for that money because it is all new/follow up patients with likely some (low reimbursing) procedures interspersed. It is also probably a bit higher risk in terms of lung cancer/nodule follow ups and intensive for chronically sick pulmonary patients.

To put it in perspective, I got the following numbers from a recent job offer. To make 350k in the Northeast, with this particular job, you would need 5,793 wRVU annually compensated at $60.53/wRVU. Now 5793 wRVU is quite easy if you are mixing ICU blocks and billing 4.5 wRVU/critically ill patient as well as mixing sleep study readings and is very challenging if you're grinding it all in pulmonary outpatient. Reading sleep studies can definitely increase your compensation but you need to be boarded (or eligible) in sleep to get paid to do that. Home studies pay crap but they are easy. In labs pay a little more and require a bit more work but again, are fairly straightforward.

I think we're saying the same thing here. Pulm + sleep is definitely 'easier' with higher revenue potential than pulm alone. That being said, it is still challenging to do day-in and day-out and there are definitely other IM outpatient specialties which would be 'easier' in terms of patient complexity IMO.

In the end, it all depends on what you like to do. Salary is part of that equation but does not tell the whole story. If you enjoy pulmonary and ICU, do PCCM. Pulm only is a tough life, generally speaking. My contention is that sleep medicine is a bridge from pulmonary and can help in the long run in combatting burnout and improves QoL for the doctor.

 

[deleted547339]

I hate golf. Was lucky enough to have great partners and we all work 12 days on and 9 days off. 7 days in the ICU and 5 days in clinic then 9 days off. Piece of cake. You better plan on working 30 years if you start working in your 30s

Heck no. My goal is be 100% financial independent at 15 years out of training. I will almost certainly keep working after that in some capacity, but I’m not going to be doing 12 days straight, 12 hour shifts, nights or holidays when I have a paid off house and enough money in the bank to punch out.

 

[jdh71]

The guys who do PCCM plus sleep in my group make the most and have the better outpatient mix because of easy OSA new and follow ups plus the sleep studies.