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MS3 trying to Decide. ENT, GI, Interventional Cards

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  • #16


    ENT docs? I have heard some attending complain about wage stagnation and MGMA 2015 and one I saw from 2012 seem to say compensation has stayed around 400, any concerns? Overall ENT has so many procedures that people do that it seems like it would be more insulated from cuts? Any fellowships out of ENT worth the extra year as far as compensation?
    Click to expand...


    I agree with the advice thus far regarding a) deciding between surgery and medicine, and b) not picking something based on income.  The residencies for these fields (ENT vs IM) are really quite different.  While a small number of years in the grand scheme of things, you do have to ask yourself if you want to spend 5 years in a surgical residency vs 3 years in an IM residency (and THEN apply to another fellowship...or two).  Perhaps additional rotations or shadowing residents more might help?  If you have down time on specialties in your end of third year rotations and can get away to round with or see specific procedures if going late in the day or weekends that not only speaks volumes about your commitment but gives you a better idea of how the specialty operates during the odd hours.  Don't sacrifice your 3rd year grades to do so - making AOA is likely more important, for example.

    As for ENT and fellowships, I don't know of any data showing declining compensation, and I wouldn't base your decision off one attending complaining about 2015 data.  Salaries have been reasonably high (median around the $430k's), but this will vary depending on academic vs private or rural vs city.  Ancillary income can be a significant advantage, and there are plenty of ENTs out there making $600k+.  A paper came out a few years back that showed that fellowships in ENT didn't confer any economic advantage over being a generalist (provided you trust their assumptions and methods).  This has been shown in other fields as well, but not in IM-->Cards or GI I'm guessing.

    Also take the 30,000 ft view of healthcare and technology.  A lot of what ENT does is quality of life based with endpoints that aren't as easy to measure.  GI does a lot of important cancer screening for everyone, and cards has more endpoints that are life or death and involves a disease (atherosclerosis) that is in the crosshairs in terms of disruption and spending.  You are less diversified in interventional cards IMO, in terms of diseases providing for your livelihood.  Any technological disruption affects you significantly more than in a given field in ENT, for example.  The same risks apply for someone who has decided to get a fellowship in ENT, but those disease processes fly under the radar a lot more than the #1 killer in the US.

    The biggest threat to income in all these fields, aside from idiosyncratic disruption, is single payer.  Which do you think will be affected by cuts (which will be substantial under single payer) or more regulation - the specialty that involves recommended screening for all or #1 healthcare cost expenditure, or one that is primarily based in quality of life concerns with comparatively little economic impact?  I'm inherently biased in saying I think ENT is more well protected; however, this is not the reason I chose ENT.  I chose ENT because of the diversity of cases, the people, and the interesting disease processes that can manifest in a complex region of the body.  Hopefully you have an ah-ha moment.  I can't help but think more and more exposure will show you the light.  Best of luck!

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    • #17
      You're looking too much at procedures and compensation and not also at the patient population, breadth, diseases managed, etc. These are all very different between the 3 specialties. And any sub-branch of cardiology except purely outpatient clinic or imaging should not be perceived as lifestyle in any way. EP, advanced heart failure, IC - none of this is exactly lifestyle. Also, surgery specialties and proceduralists out of medicine is something different. As a (good) cardiologist you still have to be an internist, you have to appreciate and maintain basic knowledge of other systems (heme, renal, pulm, etc.) and how they play into what you are doing. So make sure IM is something you can deal with if you are planning on doing any IM subspecialty.

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      • #18





        ENT docs? I have heard some attending complain about wage stagnation and MGMA 2015 and one I saw from 2012 seem to say compensation has stayed around 400, any concerns? Overall ENT has so many procedures that people do that it seems like it would be more insulated from cuts? Any fellowships out of ENT worth the extra year as far as compensation? 
        Click to expand…


        I agree with the advice thus far regarding a) deciding between surgery and medicine, and b) not picking something based on income.  The residencies for these fields (ENT vs IM) are really quite different.  While a small number of years in the grand scheme of things, you do have to ask yourself if you want to spend 5 years in a surgical residency vs 3 years in an IM residency (and THEN apply to another fellowship…or two).  Perhaps additional rotations or shadowing residents more might help?  If you have down time on specialties in your end of third year rotations and can get away to round with or see specific procedures if going late in the day or weekends that not only speaks volumes about your commitment but gives you a better idea of how the specialty operates during the odd hours.  Don’t sacrifice your 3rd year grades to do so – making AOA is likely more important, for example.

        As for ENT and fellowships, I don’t know of any data showing declining compensation, and I wouldn’t base your decision off one attending complaining about 2015 data.  Salaries have been reasonably high (median around the $430k’s), but this will vary depending on academic vs private or rural vs city.  Ancillary income can be a significant advantage, and there are plenty of ENTs out there making $600k+.  A paper came out a few years back that showed that fellowships in ENT didn’t confer any economic advantage over being a generalist (provided you trust their assumptions and methods).  This has been shown in other fields as well, but not in IM–>Cards or GI I’m guessing.

        Also take the 30,000 ft view of healthcare and technology.  A lot of what ENT does is quality of life based with endpoints that aren’t as easy to measure.  GI does a lot of important cancer screening for everyone, and cards has more endpoints that are life or death and involves a disease (atherosclerosis) that is in the crosshairs in terms of disruption and spending.  You are less diversified in interventional cards IMO, in terms of diseases providing for your livelihood.  Any technological disruption affects you significantly more than in a given field in ENT, for example.  The same risks apply for someone who has decided to get a fellowship in ENT, but those disease processes fly under the radar a lot more than the #1 killer in the US.

        The biggest threat to income in all these fields, aside from idiosyncratic disruption, is single payer.  Which do you think will be affected by cuts (which will be substantial under single payer) or more regulation – the specialty that involves recommended screening for all or #1 healthcare cost expenditure, or one that is primarily based in quality of life concerns with comparatively little economic impact?  I’m inherently biased in saying I think ENT is more well protected; however, this is not the reason I chose ENT.  I chose ENT because of the diversity of cases, the people, and the interesting disease processes that can manifest in a complex region of the body.  Hopefully you have an ah-ha moment.  I can’t help but think more and more exposure will show you the light.  Best of luck!
        Click to expand...


        yes but regarding future incomes,  there are a lot of ways compensation could flow.  reimbursements could move away from fee for service and heavily into value based.   by then, everyone could be insured and physicians could be employed and bundled payments may be the rage.  in those settings, it is at least conceivable that the heavy volume and historically highly profitable areas will negotiate for the lions share of the bundled payment and the specialty with soft outcomes and QOL would have a harder time maintaining income.

        i'm not saying this will happen, just that the future is hard to predict.

        everyone is inherently biased with regards to discussions of future incomes. 

        having said that, i have heard the sky is falling with regards to incomes for twenty years.  incomes have steadily gone up for me, but i think more of that is due to partners having savvy business partners and making good decisions with regards to mandates and business expenditures.  the only years where income went down were self inflicted--when we hired a new partner.  new compensation models will develop in response to changes.

        as the primary consideration when choosing a career.  most people eventually find a few specialties more interesting than the others for a variety of reasons (income, being the 'man', lifestyle, intellectual satisfaction, flexibility, control of schedule, opportunities for research, administration, etc).  even if they have to change in residency one time, they usually do find the answer.  ymmv.

        as always, i am enjoying the healthy conversation and diversity of opinions.

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        • #19




          You should decide surgery or medicine first. If you decide medicine then you have a few more years to pick if you wanna subspecialize. Like why would you need to pick between interventional cards and gi now? Either way you should try to go to a solid medicine program and kick butt
          Click to expand...


          Agree 100%. Don't pick your specialty based on a planned fellowship.

          It's one thing to be decided between uro and ENT. But ENT and IM makes me think you need to spend more time with first principles and life discernment.

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          • #20







            I’m a CCM fellow currently. Honestly, if I liked all 3 of those equally – I would go for ENT. It’s a surgical subspecialty, you will be well respected, low midlevel threat, and shorter training path – especially in comparison to interventional cards.
            Click to expand…


            The frequency with which I call these specialities is

            1) Cardiology

            2) Cardiology

            3) Cardiology

            4) GI

            8) ENT

            There are a few ENT emergencies, but they’re pretty rare compared to STEMIs and steaks in esophagi. (esophaguses?)
            Click to expand...


            Not only that but I would say that most calls I make to ENT are "can you see this tomorrow?"

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            • #21
              Whichever one has the thing you do the most that you can tolerate, do that. Even cool things in subspecialties become routine. From an AI standpoint, I would gather that ENT is the least at risk in your lifetime.

              And don't pick what you want based on money or lifestyle. Do what you love.

              Did I mention I'm a radiologist?

               

              In all seriousness... see the monotony in a subspecialty and pick which one you like the most. As you may have gathered if you've read enough posts. The key to building wealth and retiring is not making a million dollars, it's making good financial decisions.

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              • #22
                thank you everyone for the advice. I am trying to figure things out based on what I like and have fourth year Sub I rotations ready on ENT and GI but everyone tells us that private practice is much different then academic so trying to piece together the full picture.

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                • #23
                  The travesty of our academic programs is that the students don’t get to rotate with anyone in the community. Try to see how the private side operates if you can.

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                  • #24
                    @ENT Doc,
                    “The travesty of our academic programs is that the students don’t get to rotate with anyone in the community. Try to see how the private side operates if you can.”

                    Confirmation bias is unavoidable. Surrounded by skilled, dedicated guardians of knowledge that serve as role models for years, it’s intimidating to actually exit the academic environment if one is comfortable.
                    But at what cost? When you come to the fork in the road, take it! One looks so familiar and the other has unfamiliar challenges in building a successful practice.

                    Some choices are made for you and others are self selected. It’s a travesty all right.

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                    • #25
                      I appreciate everyones advice. I always like updates so I thought Id post one and let you all know I decided to apply for ENT. Hopefully I can match back on the west coast close to my SO but regardless I'm happy with my decision (by the grace of God as long as I match).

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                      • #26
                        Thanks for coming back with an update, good luck!

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                        • #27
                          good luck!

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                          • #28
                            Why did you make a new username?

                            Comment


                            • #29
                              Best of luck!

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