Have the lucrative specialties changed?

[Strider_91]

As an incoming M1 I get the advice to do what you love because who knows what the future holds but I know I can enjoy many specialties and given the choice I'm taking the one that pays more with a better lifestyle every time. My interest seems to be leaning towards a surgical sub-specialty, EM or Anes because I want to do procedures.

 

When you were in school what were the top paying specialties and how have they changed? When did you graduate? What are the "odds" ortho, urology, or ENT just start paying less than other specialties in the future? What is the chance that FM or pediatrics starts to become compensated more than other specialties?

[janettebournes]

Pick derm, you will never go wrong with derm.

[Craigy]

You can be sure revenue and lifestyle will fluctuate up and down but typically if one field is lucrative now, it'll be lucrative later.  If something makes a lot now, even if things changed and they trended down for awhile, took a cut, it'd still be higher than many others.  Same for the flipside.  Even if a low paying specialty is on the upswing, it has a long way to go to surpass the traditionally high paying specialties.

Keep in mind that physician compensation is driven directly by market demand and supply and what the market places value upon.  Some of this market value is influenced by 3rd party payors which can change due to policy or things outside of your control.  Ultimately it's all set by what someone is willing to pay, either 3rd party or patient himself.  People probably won't suddenly decide they are willing to pay double or triple for checkups and chats.

And yeah you don't have to make this choice for awhile.

[VagabondMD]

As a first year student, it will be very difficult to project what will reimburse well 8-10 years from now, when you are finished training. That said, try to pick a specialty that you think you will enjoy doing, and try to enjoy doing ortho or derm .

[Strider_91]

Appreciate the advice and I certainly will focus on my studies and try my hardest. I just find it easier to work hard when I am working towards something specific and have a vision for what my life may look like; it's just something I've always done when times got hard studying.

I wanted to hear people's advice on the "just do what you like" advice because it kind of sounds dumb to me. I know I can like more than one specialty and after 10-12 years I'm sure compensation will matter a lot more to me than the day to day work does because basically anything gets boring after doing it for that long.

Obviously I wouldn't choose something I hated for the money...this is why I am not really considering Derm. It just does nothing for me and I find old peoples skin and rashes to be less than appealing. Even in that field tho I'm sure I can find a practice model I enjoy enough.

[VagabondMD]

Craigy wrote:

You can be sure revenue and lifestyle will fluctuate up and down but typically if one field is lucrative now, it’ll be lucrative later.  If something makes a lot now, even if things changed and they trended down for awhile, took a cut, it’d still be higher than many others.  Same for the flipside.  Even if a low paying specialty is on the upswing, it has a long way to go to surpass the traditionally high paying specialties.

Keep in mind that physician compensation is driven directly by market demand and supply and what the market places value upon.  Some of this market value is influenced by 3rd party payors which can change due to policy or things outside of your control.  Ultimately it’s all set by what someone is willing to pay, either 3rd party or patient himself.

Click to expand...

I am going to disagree with this. The government (CMS) can unilaterally and suddenly change (usually drop) reimbursement for specialties and subspecialties, and I have seen numerous examples of this in my post-residency career. The trend toward reimbursement is downward, but who knows who is going to take the next hit?

My subspecialty, IR, was once a cash cow for private practice groups and now is a loss leader. Ophthalmology was once one of the highest paying specialties and now tends to be more middle of the pack (still great lifestyle).

Additionally, the way we do things is constantly upended by technology. If there is a successful breast cancer blood test (which is being actively researched), suddenly half or more of the mammograms will go away. What will happen to all of the subspecialty mammographers? And so forth...

[Strider_91]

I currently work in a PMR/ pain practice and their lifestyle is pretty good, although kind of boring. I think boring can be good when you're 50. There a few issues that turn me off from the field (shady patients, poor outcomes, people in litigation that are incentivized not to get better) but I know more about this field than others; I'm sure every field has issues.

There are ortho guys who sublet our office and they let me in on some of their cases. It is definitely something I can see myself doing but obviously it's super competitive and an ex athlete doing ortho is just so cliche lol. Seems like they do 30% more work for like double to triple the reimbursement tho.

[Craigy]

Vagabond MD wrote:

Craigy wrote:

You can be sure revenue and lifestyle will fluctuate up and down but typically if one field is lucrative now, it’ll be lucrative later.  If something makes a lot now, even if things changed and they trended down for awhile, took a cut, it’d still be higher than many others.  Same for the flipside.  Even if a low paying specialty is on the upswing, it has a long way to go to surpass the traditionally high paying specialties.

Keep in mind that physician compensation is driven directly by market demand and supply and what the market places value upon.  Some of this market value is influenced by 3rd party payors which can change due to policy or things outside of your control.  Ultimately it’s all set by what someone is willing to pay, either 3rd party or patient himself.

Click to expand…

I am going to disagree with this. The government (CMS) can unilaterally and suddenly change (usually drop) reimbursement for specialties and subspecialties, and I have seen numerous examples of this in my post-residency career. The trend toward reimbursement is downward, but who knows who is going to take the next hit?

My subspecialty, IR, was once a cash cow for private practice groups and now is a loss leader. Ophthalmology was once one of the highest paying specialties and now tends to be more middle of the pack (still great lifestyle).

Additionally, the way we do things is constantly upended by technology. If there is a successful breast cancer blood test (which is being actively researched), suddenly half or more of the mammograms will go away. What will happen to all of the subspecialty mammographers? And so forth…

Click to expand...

Optho is a good example that I believe fits my argument.  Sure they've trended down substantially, but they're still solidly in the top half of compensation.  It's possible this could slide further, but if you started in optho 20-25 years ago when the money was gushing out of patients eyes, you're still doing well today, probably making double what your shrink and peds neighbors are pulling in.  Same if you picked ortho today.  It's definitely going to trail off at some point, but it'll still be a high paying field.

I don't believe there has been a top paying specialty that has suddenly found themselves at the bottom of the field.  Perhaps deep subspecialties hinged on one or two treatments might come and go but that's the nature of medicine, and people adapt.  However I'd love to know if I'm wrong here.

[VagabondMD]

Craigy wrote:

Vagabond MD wrote:

Craigy wrote:

You can be sure revenue and lifestyle will fluctuate up and down but typically if one field is lucrative now, it’ll be lucrative later.  If something makes a lot now, even if things changed and they trended down for awhile, took a cut, it’d still be higher than many others.  Same for the flipside.  Even if a low paying specialty is on the upswing, it has a long way to go to surpass the traditionally high paying specialties.

Keep in mind that physician compensation is driven directly by market demand and supply and what the market places value upon.  Some of this market value is influenced by 3rd party payors which can change due to policy or things outside of your control.  Ultimately it’s all set by what someone is willing to pay, either 3rd party or patient himself.

Click to expand…

I am going to disagree with this. The government (CMS) can unilaterally and suddenly change (usually drop) reimbursement for specialties and subspecialties, and I have seen numerous examples of this in my post-residency career. The trend toward reimbursement is downward, but who knows who is going to take the next hit?

My subspecialty, IR, was once a cash cow for private practice groups and now is a loss leader. Ophthalmology was once one of the highest paying specialties and now tends to be more middle of the pack (still great lifestyle).

Additionally, the way we do things is constantly upended by technology. If there is a successful breast cancer blood test (which is being actively researched), suddenly half or more of the mammograms will go away. What will happen to all of the subspecialty mammographers? And so forth…

Click to expand…

Optho is a good example that I believe fits my argument.  Sure they’ve trended down substantially, but they’re still solidly in the top half of compensation.  It’s possible this could slide further, but if you started in optho 20-25 years ago when the money was gushing out of patients eyes, you’re still doing well today, probably making double what your shrink and peds neighbors are pulling in.  Same if you picked ortho today.  It’s definitely going to trail off at some point, but it’ll still be a high paying field.

I don’t believe there has been a top paying specialty that has suddenly found themselves at the bottom of the field.  Perhaps deep subspecialties hinged on one or two treatments might come and go but that’s the nature of medicine, and people adapt.  However I’d love to know if I’m wrong here.

Click to expand...

What you do not hear about is the fields where the compensation has been reduced, and as a result, people shift their practices or retire early. We once had four cardiac surgeons in our hospital. Now, we have two, both earning what the four earned ten years ago. The other two have moved on--one does thoracic somewhere else (lower paying) and one was forced into an early retirement. The salary figures will reflect stability, while the real life experience is much different.

[Strider_91]

Hi vagabond,

I see what your saying but according to RSNA.org which is a radiology org. The median compensation of IR was 518k in 2014. I am not sure if this is entirely accurate, but even if it were 100k that still seems to me like a very well paying specialty.

I am pretty sure I have also seen you say in a comment that you are able to stash away 1mm every 3 years. It seems to me, although I don't have any money yet or a very real sense of what the world costs, that you would need to be in a very high paying specialty to accomplish such a feet.

I guess my memory could be serving me wrong and it was a different IR who said that but idk I have a pretty photographic memory for things I read.

[SValleyMD]

My take:

1. Nail step 1 to keep options open

2. Agree- can't go wrong with derm

3. High paying specialties that take a lot of call or hospital based are probably more protected financially but you'll have to earn it.

4. Rads to me seems to be the biggest change over my ten year run

5. Anesthesia would make me nervous

6. I agree it's the "golden age " of ER. Will be interesting to see if that holds up. ER is the one specialty I would perhaps do if I had to do it over.

7. Procedure or surgery based specialties in general should be more protected from midlevel invasion.

8. Doom and gloom rarely happens. Incomes have generally been stable or rising for over three decades. I make more in cards now than my father ever did who cranked it back in the day of high reimbursement and broad indications.

[VagabondMD]

Hi, Strider,

Radiology is still one of the better paying specialties, but IR, as a subspecialty, has been on a downward compensation trend, due to loss of good turf and a decrease in reimbursement per procedure. In order to keep the salary up, most groups subsidize from DR, IRs work harder/longer, IRs do not add people to group to replace those who have left, and or do more general radiology.

Your memory is pretty accurate, but my nest egg was built on the backs of two hard-working professionals. My wife works as an attorney an average of 55 hours per week, and I have been on call for every other weekend for 21 years. I had no student loans, and my wife had minimal loans from law school.

None of this, of course, is the point of this thread, which is that you should pick something you like and excel in it because you can do very well in anything, and if $100k is your benchmark of being well paid, you will be living like a king no matter what field you pick. But let's talk again in 20 years... ?

[Strider_91]

Married to a lawyer....you deserve a medal!!

Thanks for the insight and I think you misinterpreted my "100k" remark. I just meant if the median of 500k was off by 100k, lowering it to 400k/ yr that would still be considering a well compensated specialty.

My "benchmark" is to make over 300k as an attending because I will need to go 200k in debt to get there and that seems to be a good investment. Obviously I wouldn't be upset with making more and would try my best to do so..

According to salary surveys and people on this website that doesn't take too many specialties off the table except for FM and Peds and possibly psych.

[SValleyMD]

Remember that location often matters more than specialty when taking about income.

At my hospital >90% of all docs make more than 300k including all PCPs. Our Hospitalists are over 400k and I imagine >70% of all specialists are over 500k

So keeping an open mind on where you live can make more of a difference at times

[ENT Doc]

SValleyMD wrote:

Remember that location often matters more than specialty when taking about income.

At my hospital >90% of all docs make more than 300k including all PCPs. Our Hospitalists are over 400k and I imagine >70% of all specialists are over 500k

So keeping an open mind on where you live can make more of a difference at times

Click to expand...

Where do you work?  Haha.

As for your specialty, Strider91, you don't seem to know right now and you won't know until you start shadowing more and doing rotations in various fields.  But you won't be at that point until 3rd year, unless you're committed to doing time on the side, which will take you away from what should be your focus right now - killing your classes and step 1.  Your time is better spent knowing that you gave these goals all you could.  The doors will open after that, assuming you know how to be a good M3/4 on rotations.  I didn't have a clue that I wanted to do ENT until the end of my 3rd year (and I didn't do it because of the money).  But the only reason that was an option was because I had buried my face in the books for 2 years straight and studied for 1 month of 10 hour days for step 1 (using a stop watch to not count chat time, food or bathroom breaks).  Work hard, be willing to help others and explain things, stay later than anyone studying, put in time on the weekends, and in your second year start spending additional time consolidating materials in preparation for Step 1 studying.  Last thing you want is to waste your Step 1 studying time getting organized.  Good luck.