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MS4 Trying to Figure out Life - Cards? Heme/Onc? PCP?

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  • MS4 Trying to Figure out Life - Cards? Heme/Onc? PCP?

    Hey y'all,

    Post-match MS4 here, matched IM and trying to figure out what direction I want my life to go in. I really enjoyed the pathology of Cards and Heme Onc, so right now its definitely cards = heme onc > PCP, with PCP mainly an option because of not having to do years of fellowship and little to no call. Lifestyle wise, I'm seeing that heme/onc seems to be better then cardiology; does this remain true in private practice/hospital employed? Those of y'all who are in general cardiology, how bad is the weekly workload/call burden and is it possible to maintain good work/life balance?

    Although I know this decision should be minimally financially motivated, I'm assuming that either fellowship should be an overall long-term income gain, although the WCI article primarly discussed cards/GI for financial benefit. Would y'all know how salaries are in saturated markets (More like Dallas/Houston/Atlanta, not NYC/SF/LA)? Is it still a financial benefit over PCP?

  • #2
    Originally posted by medstudent18732 View Post
    Although I know this decision should be minimally financially motivated
    I’d reevaluate this thought.

    It should be financially motivated to the extent that you are financially motivated, compared to other factors—lifestyle, call, training length, ability to do procedures, etc.

    You’re not going to be poor either way, but different things matter to different people so I’d try to spend your intern and PGY-2 years with that in mind.

    Comment


    • #3
      Originally posted by medstudent18732 View Post
      Hey y'all,

      Post-match MS4 here, matched IM and trying to figure out what direction I want my life to go in. I really enjoyed the pathology of Cards and Heme Onc, so right now its definitely cards = heme onc > PCP, with PCP mainly an option because of not having to do years of fellowship and little to no call. Lifestyle wise, I'm seeing that heme/onc seems to be better then cardiology; does this remain true in private practice/hospital employed? Those of y'all who are in general cardiology, how bad is the weekly workload/call burden and is it possible to maintain good work/life balance?

      Although I know this decision should be minimally financially motivated, I'm assuming that either fellowship should be an overall long-term income gain, although the WCI article primarly discussed cards/GI for financial benefit. Would y'all know how salaries are in saturated markets (More like Dallas/Houston/Atlanta, not NYC/SF/LA)? Is it still a financial benefit over PCP?
      Welcome to the forum. Congrats on matching. Good luck.

      Comment


      • #4
        Dude. You got time. Relax. Congrats on matching.

        Comment


        • #5
          When I was making specialty decisions, the internet did not exist. We tried to get guidance from the older docs who were our mentors. EM was in its infancy when I graduated. I really liked EM but the mentors acted like EM was for students that didn’t have the smarts to do something “more meaningful”. This attitude toward EM reflected the past at that moment, not the future, but mentors often have backward looking biases. I also considered ophthalmology, which I also loved, but I ended up feeling it was too narrow, too specialized.

          As med students, most of us had no idea about the financial implications of our choices. A few who had physician parents got steered in one direction or another, but no one spoke at all about the financial implications of these choices. Doctors and money were topics that together were taboo. You didn’t talk about these things in polite company. At one point I also considered peds, but again, we had no idea about the pay differentials for different specialties. Fortunately, the loan situation in those days was nothing like it is today. I graduated with a total of $10,000 in student loans.

          After much deliberation, I decided to do internal medicine. As a resident, however, I still liked the ED. Many of us did moonlighting in those days, so as a PGY2 I started moonlighting in the ED. I liked the acute resuscitation kind of thing, and I liked being on the Wild West front line of medicine, so I went on to a pulmonary fellowship, and those were the years when critical care was just becoming a new specialty. So the pulmonary fellowship also gave me critical care experience. When I finished, I became a Pulm/CritCare attending and I also worked in the ED. My academic hospital wanted to get in on this newfangled specialty of EM, so a group of us started an EM residency. As academic EM physicians who were contributing to the growth of our new specialty, we were allowed to sit for the ABEM board exams in EM.

          Mine was a meandering path. Along the way, I picked up 4 board certifications. I worked in an academic hospital, primarily in the ICU and the ED, but I also did rounds on the pulmonary consult service and on the pulmonary team on the medical service. It was a very interesting career. The amount of knowledge I gained from the cross pollination of my varied specialties made life very interesting.

          From a financial perspective, I also valued being financially successful. I earned more of a typical salary for a successful academic physician, but I somehow found my path to a high level of financial success. I ended up doing things like moonlighting in the early years, and I studied investing on my own. As time progressed, I developed an entrepreneurial bent and beyond stock and mutual fund investing, I also did real estate investing and I started some side ventures that over time became increasingly successful.

          My point in sharing all of this is that our life path with choice of specialties can be a meandering one. Mine certainly was. But somehow, despite the various influences that led me one direction or another, somehow I found my way to where I needed to go.

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          • #6
            If it’s truly an either/or in your mind than always choose the specialty with less call/nights imo… so clearly heme/onc.

            Cardiology has the worse call burden of any specialty. Ask any ER doc who they call the most or see the most in the middle of the night (not including the shift based specialties like Hospitalists). It’s also the specialty to get the least amount of Hospitslist support from what I’ve seen as well.

            Granted some general cards spots can be reasonable and not require a lot of coming in but you’re still taking a lot of phone calls from multiple sources (er, icu, floor, transfers) for critically sick patients on issues (chest pain) that very few feel comfortable handling.

            Unfortunately students choosing specialties have no clue what heavy call burden specialties (on call, work the next day) can do to you over a lifetime.

            personally I would never choose any specialty that was shift based and required nights (cc, em) or ones that required heavy call burden (Gen surgery, cards). It’s not worth it to your own health and other relationships.

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            • #7
              I think you have to choose what you actually like to do, and that is a tough call when you are a student and even during residency. I went into IM, I did traditional for 10 years with admissions and office. I absolutely hated getting the 2 am call and driving to the hospital. I was miseable for years. I used to be in the hospital then the office the next day on 2 hours of sleep.

              Now with hospitalists times have changed. Now my life style is good, I make more than I need, I have been FI since 50, call is non existant as are weekends and nights. The downside, at least for myself is the mental stimulation. I would love to go back to the times of acute medicine and more procedures, but right now at least I would not trade that for my lifestyle.

              Comment


              • #8
                Congrats on matching! I'm a resident in a different specialty, so I can't give too many specifics on your field. But just some general thoughts:

                Try to talk with physicians in private practice who are out of training, like many of the physicians here. See if you can meet some docs at your local medical society or through other connections. It helps a lot to hear from people outside the academic bubble what their practice is like.

                Look up the MGMA salary data (not Medscape or others) if you want to know more details on compensation. My general knowledge is Cardiology > Heme/Onc >> PCP. It's almost always better to go for private practice partnership if you want to maximize compensation. There can be huge variability within the same specialty. For example, a physician partnership that owns their medical office building or procedure center and collects all the technical fees on procedures will make a very high income.

                Income can all change with the stroke of a pen in Washington. So be sure you actually enjoy what you do in case the big money gets taken away.

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                • #9
                  I'm gen cards and my lifestyle is fine, but it's VERY job-dependent. For me it's <50hrs/wk, light call 1x/wk. But take your time, do some rotations and keep an open mind to figure out your interests. Hem-onc has some good gigs out there, and hospitalists/PCPs can make decent money too. Someplace like Houston is still somewhat desirable so I wouldn't expect huge advantages there.

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                  • #10
                    firstly. Do you want to do procedures? If so->cards subspecialty
                    If not, gen cards/onc/pcp. I really like onc and with Biden's plan to throw so much $$ into "curing cancer", onc is a really exciting future looking specialty right now(think Car T cell).

                    However, my onc colleagues in my major city get ABUSED. So much work for embarrassing amounts of pay(think low 300s for 40-50 complicated pt/day. PCP in my major city get good pay for way less work.

                    Outside of major citys, onc makes like 4-500k with a pretty decent lifestyle

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                    • #11
                      I am ambulatory FM. You cant beat the lifestyle compared to any other specialty except maybe Derm. Of course, I do not get paid like some of the surgical specialties but as WCI has said before, there is more diversity in salary within a specialty then comparing them to other specialties. Every situation will be unique, but dont underestimate the burden of call and procedures.

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                      • #12
                        Originally posted by Random1 View Post
                        I think you have to choose what you actually like to do, and that is a tough call when you are a student and even during residency. I went into IM, I did traditional for 10 years with admissions and office. I absolutely hated getting the 2 am call and driving to the hospital. I was miserable for years. I used to be in the hospital then the office the next day on 2 hours of sleep.

                        Now with hospitalists times have changed. Now my life style is good, I make more than I need, I have been FI since 50, call is non existent as are weekends and nights. The downside, at least for myself is the mental stimulation. I would love to go back to the times of acute medicine and more procedures, but right now at least I would not trade that for my lifestyle.
                        That for me is another thing with my decision. With the way private clinics I've shadowed have been run, I didn't feel like I had time for deeply diving in with the PCP environment, and am worried about that possible lack of mental stimulation over time. I considered hospitalist, but the number of weekend shifts seemed like it would also get tough over time, and again, in many private environments, there were so many patients it seemed like specialists were running the show.

                        What you are discussing with hospital and night and office the next day is what scares me with cardiology; it does seem like it is pretty hard to ease the call burden, and cardiologists will forever be busy with consults. Hopefully the next year or two will give me some more exposure to decide.

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                        • #13
                          Originally posted by Bdoc View Post
                          firstly. Do you want to do procedures? If so->cards subspecialty
                          If not, gen cards/onc/pcp. I really like onc and with Biden's plan to throw so much $$ into "curing cancer", onc is a really exciting future looking specialty right now(think Car T cell).

                          However, my onc colleagues in my major city get ABUSED. So much work for embarrassing amounts of pay(think low 300s for 40-50 complicated pt/day. PCP in my major city get good pay for way less work.

                          Outside of major citys, onc makes like 4-500k with a pretty decent lifestyle
                          Procedures are okay to me, don't care that much either way. I'm seeing the same thing with oncology; in Houston, talking to seniors, pay seems shockingly low. I'm unsure if that is because MD Anderson creates too much competition for oncology, but I have no idea how people hit the MGMA median for oncology or even close to it in this area. Graduating fellows in Houston are getting packages starting at 240,000 with only 35/rvu bonus after passing 4700 RVUs, which seems like quite a lot. To me, it seems like this package is barely more than primary care, which makes me a little hesitant about fellowship, but I do think I would enjoy the stimulation from heme/onc a lot.

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                          • #14
                            Originally posted by cards67 View Post
                            I'm gen cards and my lifestyle is fine, but it's VERY job-dependent. For me it's <50hrs/wk, light call 1x/wk. But take your time, do some rotations and keep an open mind to figure out your interests. Hem-onc has some good gigs out there, and hospitalists/PCPs can make decent money too. Someplace like Houston is still somewhat desirable so I wouldn't expect huge advantages there.
                            To be honest, I think of the three cardiology has been the most interesting to me and I was very happy with the balance of acuity and clinic during rotations I've seen so far. However, all of it has been in the academic environment, and most of the teaching faculty only have call 1-2x a month. How often are you working weekends/inpatient and how much does the call burden affect your life?

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                            • #15
                              "in Houston, talking to seniors, pay seems shockingly low. I'm unsure if that is because MD Anderson creates too much competition for oncology,"

                              You have two major academic structures (Baylor and UT Houston) that basically cover the majority of the big hospital systems. Hermann Memorial and Methodist along with MD Anderson, all partner with each university system. Referrals are tough for private practices. I am sure some exist and have privileges but a number have also been bought out. That is what you run into in Cards as well although likely to a lesser degree. You are not employed by the hospital system, you affiliate with academic or private practice that affiliates with the hospital systems.

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