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$400K a year hospitalist gig or pulmonary / critical care fellowship

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  • $400K a year hospitalist gig or pulmonary / critical care fellowship

    Hi everyone! I realize this is a very individual decision but would still appreciate your input. From a mainly financial perspective, is it worth doing a Pulm/CCM fellowship if I'm currently making $400K a year as a hospitalist? I enjoy critical care and pulmonology more than hospital medicine. Let's say 25% more but I also don't mind being a hospitalist and I get some fulfillment out of it. I was the de facto intensivist at my first hospitalist job out of residency and kinda wished I could spend all of my time in the ICU but did not feel adequately trained to do that (hence, I left that job). I like my current gig. 7 on / 7 off, 12 hour in house shifts (tiring but cool staff to chat with), one week PTO, 90K population, fun Midwestern town (local women seem to like my euro accent and sports car ), about 18 patient encounters a shift with the PA seeing 10 of them, open ICU with 24/7 intensivist coverage, most sub-specialties available. I'm getting $320K yearly base salary + $30K yearly if meeting quality metrics + $20K a year retention bonus x 5 years + $200 per hour for extra shifts, $5K for CME, good benefits (403b + 457b, etc.), only 14 overnight shifts required yearly. I make $400K a year with ~ 192 twelve hour shifts.
    I'm 37 years old and completed IM residency in 2017 (had a late academic start in the US). I'm not married, have $390K student loan debt (hoping PSLF goes through), renting. I feel like I may get bored being a hospitalist in 5-10 years and perhaps I should preemptively do the fellowship before marriage, kids, buying a house, etc. Should I spend 2-3 years (open to CCM only too) in fellowship at $60K a year in the pursuit of higher job satisfaction or focus on the positives of hospital medicine, learn to love it and continue getting paid handsomely without the pay cut during fellowship? Thanks!
    Last edited by IMMD; 02-20-2020, 03:46 PM.

  • #2

    I realize this is a very individual decision but would still appreciate your input.
    Click to expand...

    You said it correctly here. Is being a hospitalist something you can see yourself doing long term and being happy? If not, you need a better plan (which may or may not include a fellowship).


    • #3
      You have found yourself a very lucrative hospitalist position.  A lot of people can't see themselves being a hospitalist forever due to the shift work, nights, etc, but I personally think that critical care shift work is even harder then hospitalist.   At least with hospitalist, you are more likely to have a nocturnist to do more of the nights, a late person to stay late, etc.  Critical care, the places that I go, I feel like they are there all the time and they have trouble covering their nights with anyone other then tele-icu work or hospitalists doing admissions which are less then ideal.   Obviously the work load is different and you may enjoy not having to deal with the social issues, snf placement pain management, etc you see as a hospitalist.  If you are going to go back into doing a fellowship, I agree that doing so before you get settled with a spouse and kids is easier. It may not look like it makes a lot of financial sense to go back and o a fellowship, but it may end up making financial sense if you can see yourself having a longer career in ccm then hospitalist.


      • #4
        It would be interesting to crunch the numbers regarding ibr for PSLF if you do fellowship— it seems in your current situation you may well pay off a large chunk of your loans before getting any forgiven assuming you stay at a 501 3c. If you go back to fellowship it may make pslf more worth it. No where near enough to make up for loss in salary but it’s something. That’s also assuming post fellowship job remains eligible.

        I’d think more about those loans and do the math of what gets forgiven (if anything) with no fellowship vs fellowship then 5013c job (which may pay much less than a non eligible job and also may not be worth whatever forgiveness you get).

        What ibr plan are you in?
        How many qualifying payments are logged in your fed loans gateway as of today?

        If you refi now the entire sum now with a great rate you will not be able to afford the monthly payments on fellowship or it will be way too tight.

        Maybe think about staying in this gig and killing the loans with massive savings over 2 years before fellowship? Betting on forgiveness requires a lot of thought and a lot because I’m sure your paying the crazy high 5-7% government interest rates. It may force you to take a job you don’t want because of sunk cost or pay a bunch of extra interest with minimal forgiveness.

        There’s a lot more to this choice than loans but you whatever you decide you should make sure you optimize your loan situation for that choice


        • #5
          Also as a side point I’m planning on leaving hospital medicine and applying to fellowship. I’m also older approaching 34. I don’t get paid as much as you but i feel the same that I could do this (there are a million worse jobs out there) but honestly I’m not that happy and I think for career satisfaction and longevity it’s worth it for me to get more training. I have research and clinical interests beyond what I’m doing now or what I could do without additional training.

          I feel like if I stuck with it in 5 years time I would either have to be doing admin or education stuff I’m not passionate about or just looking at it solely as a job that facilitates a certain lifestyle instead of a career that I am developing or growing in (ie clinical work then go home). I know all medicine is a job and grass is not always greener, but I think if you have a reason and a plan for the training. you’re picking up what I’m throwing down. Can’t tell you if it’ll be a good choice for me till it’s over and done with though


          • #6
            I would stay put. Spend as much time as possible in the icu to satisfy the itch ... you can figure a lot of it out over time if you’re motivated.


            • #7
              My IBR plan is revised pay as you earn. I've made about 48 PSLF eligible monthly payments to FedLoans out of the 120 required. I started making payments as a PGY1. Interest is 7.1 %. I've been submitting the employment certification form yearly to FedLoans and they have always said my employers qualify and I'm on the right track, so hopefully my application for loan forgiveness doesn't get denied after 6 years.

              What fellowship are you applying to?

              "Can’t tell you if it’ll be a good choice for me till it’s over and done with though" --- completely agree; there is no guarantee you will enjoy the new specialty that much more than hospital medicine for the time, $ and energy investment to be worth it.


              • #8
                Financially, skip the fellowship.

                Also, switch to PAYE.


                • #9
                  The rational thing is of course given your age to continue on this path as You sort of have a great set up in terms of compensation and it is financially sound future—gigs like this are hard to find it seems which can lock you into the job. I have no idea though how typical this job is for your geographic area.

                  A cynic would say however you could find something similar if needed plus How much more joy will you get for more work, more studying at your age with less pay for several years and only to again finish as a wet behind the ears attending in your new specialty settling into practice pattern in their 40s? You’re definitely introducing more work, more stress, without the guarantee of much more money. A relationship and/or kids wil demand more of your time and could make you happier than any job plus they they have their costs, own needs for possible relocation for SOs career, better schools, be near family etc. all your doing is switching the evil you know for novelty and then you’ll probably view your new job just like your old job more or less. Crit care has its own osh bombs, gomers, etc that can be fodder for burn out. Pulm Clinic can be full of chronic cough, unexplained Dyspnsa (ie obesity), gerd/aspiration you can’t fix, copd that you will never make better

                  On the other hand, yolo. You didn’t come this far and work this hard to stop short of where you want to be. You don’t want to continually wonder what if. If work is going to be a big part of your life regardless for the next 20/30 years why not learn to do what you want? It may be hard to find a better gig but life events could force you into another hospitalist job that’s much more painful. You may be one of those docs who keeps working even when they don’t have to. You will have new skills you didn’t before and be able to help people in new ways. You can also still moonlight in fellowship so it’s not just 60k each year.

                  7 on 7 off could be tough on a relationship and could get old. So can icu shifts. With Pulm you have the option of transitioning more towards OP if you desired which may be better for longevity. Pulm is tough with a lot to learn— to be good takes a lot of effort that can either invigorate you or may be exhausting in that you’re comfortable with hospital medicine and you’d have to again leave your comfort zone to learn a specialty . I Imagine you’d be general pulm ie not ild or phtn, cf, transplant focused? Are you open to OP work?

                  Back to loans... If you stay in your current job have you calculated how much will be forgiven with your current payments? I forget if REPAYE has caps on monthly payments.


                  • #10
                    I think I'd consider riding this hospitalist gravy train as long as possible.  It sounds like you have a great thing going.  Save hard, pay off debts.  The grass may not be greener and you may not find as nice of a pulm-crit job, don't like it as much as you thought, lesser pay, less desirable area, etc.  I'd imagine you could still pursue fellowship later, I don't think it's that competitive, and if you have a hefty portfolio at that point the financial hit won't be so bad.


                    • #11
                      I would tackle those student loans first and continue to work as a hospitalist for now.  You're still in the honeymoon phase of hospitalist work (you just got out of residency so it seems a lot better than your residency schedule...this is why hospitalist groups prefer new grads).  You haven't gotten burnt out yet, but with that shift burden, you'll get there eventually.  You're being paid higher than most for a full time hospitalist gig.  So, I would take this opportunity to get rid of your loans.  Once you've accomplished this, step back and see how you feel.  With no student loans, you'd be in a better position to pursue a fellowship at that point.

                      For now, enjoy your lady friends, work hard, pay off debt, and save what you can.  In a few years time, you'll be in much better shape.


                      • #12
                        Financially, it's going to be very difficult for a 3 year pulm/CC fellowship to pull ahead of a $400k/year hospitalist position. I work a hybrid intensivist/part time clinic model, and if I didn't do the clinic on top of my ICU shifts I'd be in the same ballpark from a comp standpoint. I still make 85-90% of my income from my ICU work, however. Even if you make $100k/year during fellowship with moonlighting, that's ~$900k lost income over 3 years to try and make up, which will be very hard.


                        • #13
                          If you know you want to do critical care then I would skip the pulmonary portion. I’m a hospitalist and our critical care docs are critical care only. Our Pulmonary docs are critical care trained but don’t do it because they’re not always in the building like the Intensivists. 12 hours in house is not sustainable with a family. Imagine not having dinner with your family or seeing your kids for a week. Where I’m at every other day we get to leave at 3:30 but still have to answer our pager. Maybe that’s why the pay is so high. I’ve been doing this 11 years and it’s sustainable because I can have somewhat of a life during my week on. Just something to think about.


                          • #14
                            Not to minimize your decision and the choices you’re comparing in any way, as I obviously can’t give you a physician’s perspective, but what you have asked violates my (personal) rec. for tax planning. I think it may also apply here.

                            Never make an impactful decision based upon what “might” happen or what you “feel” may change in the future (cause you have no idea what else might also happen or how your feelings may change in the meantime). In regard to taxes, don’t do something now based on what Congress, the IRS, or your wealthy grandfather “may” do (hint - your wealthy grandfather’s decision is far more predictable than Congress - even the IRS is more predictable). Base your decision upon what you know right now rather than trying to predict (not only the future, but) the impact of what could change in the future. That’s the only truth. Otherwise, you are just trying to get lucky and, yes, a few people get lucky!

                            Have you ever considered how many investors have been “sitting on the sidelines” for years because they were waiting for another big market drop ? (You’ll have to go back to 2009). Or how many homeowners have sold/purchased a home based on what they “feel” interest rates will fall? I have a pretty good idea of these answers because we’ve talked a good number of clients out of acting on inappropriate ‘feelings’ that are unreasonable. And these are people we have worked to educate and who say they agree with what we have discussed.

                            This is, again, seriously JMPO but I hope it helps.
                            Our passion is protecting clients and others from predatory and ignorant advisors. Fox & Co CPAs, Fox & Co Wealth Mgmt. 270-247-6087


                            • #15

                              Financially, skip the fellowship.

                              Also, switch to PAYE.
                              Click to expand...

                              Why is PAYE better than revised PAYE?