Tuesday, March 14, 2006

Reality Check (Ruthlessly Candid)

I am looking for a job.

After three years of residency in Internal Medicine I have decided to forgo fellowship and go into Primary Care/Internist or Hospitalist work. I thought it would be interesting to share with you some of the offers as well as my thought process.

I think this can be interesting because due to my anonymity I can afford to be ruthlessly candid. The other reason is that as some have stated you would like to read about the true experience of being a resident, look no further.

In the past, I have done my share of complaining: about the job, the hours, the pay, the future etc. etc. I’ve stopped all that. Not because I don’t still have those same concerns but because I realize that some of my audience likely make a fraction of what an internist makes these days and so my complaining seems kind of “funny”. So please don't view anything I write here as complaining, just my honest thoughts.

And, since I always believe that two, or two hundred, heads are better than one I would certainly welcome any tips that my readership can provide, maybe something I haven’t thought about.

Before I do, I think I have to be candidly honest about my goals and current situation, so that all of you can give me the best advice:

Overall, this is the plan: My wife and I would like to be able to return to Israel to live there within 5-10 years. Since doctors make roughly $30-40,000 in Israel I do not think that I will be able to pay my medical school loans there, this is the reason why I returned to the U.S. after attending medical school in Haifa. I would also like to be able to purchase the apartment/house I will live in there, since that can be very expensive. The plan is to pay off the private loans before I go back and make enough investments in the U.S. so that I can have income that can pay off the rest of the loans by itself. Currently, we are hoping to finally purchase a home and stop renting. Preferably in a good community with good schools so that Jordan can be safe.

Current financial situation:
1. Private Student Loans: $80,000 at 6.25% variable interest. Current monthly payment can vary but minimum is rough $600.
2. Stafford Student Loans: $96,000 at 3.25% locked, monthly payments $400 over 30 years.
3. Savings: $40,000
4. Currently renting but hell-bent on buying something soon. I currently live in a major urban city and the housing prices here are on the level of prohibitive.

Thus Far: I have been to 5 primary care interviews and 3 Hospitalist interviews here is what I have come up with: I have multiple offers, here they are:

Primary Care Positions:
1. $120,000 a year. No bonus. Partnership, maybe, after two years. Housing reasonably priced.
2. $115,000 a year. Bonus once surpassing three times your income. Partnership after 3 years. Opening Concierge service possible. Housing extremely expensive.
3. $80,000 a year. No bonus. 10% of whatever you bring in. Housing extremely expensive.

Funniest trend: The more expensive housing is in the area the smaller the salary.

Hospitalist Positions:
1. $110,000 no bonus, known to be a hard hospital to work in with lots of hours of work. Housing in area extremely expensive.
2. $125,000 no bonus. Work hard. Housing expensive.
3. $140,000 with bonus. Two hours away from family and outside current city. Housing cheap. Good community. Work hard.

My current inclination is to take the third Hospitalist position since I will likely be able to save the most there. The wife and I think it is our best chance at achieving our goals even though we will have to leave the family behind.

I had intended to go into clinic based medicine but will likely hold off until I move to Israel. It is an unfortunate truth which I simply have to confront and that is that currently I cannot allow myself to enter primary care and achieve my short term goals. When I listen to my friends who entered other specialties and the offers they are getting I am extremely jealous and if I had to make the same decision again I would have chosen differently.


Blogger shadowfax said...

I don't understand -- you went to Med School in Israel but you have Stafford loans?

Funniest trend: The more expensive housing is in the area the smaller the salary.

Common. For ER docs it's the same. The more rural the location or undesirable the location, the better the pay. The suburban sites pay better too, based on better payor mixes, and tend to be cheaper to live in. Urban sites have high living costs and poor payor mixes, so you get hosed both ways.

FWIW, I would take the last offer and move the family there. IMHO, no amount of money is worth four hours of your life every day. If you can't move, calculate the hourly compensation based on hours worked + hours commuting and see how it stacks up aganist the more local offers.

2:32 PM  
Blogger Kelly said...

Dear Doctor,

I agree with you (if it's any consolation)....the last offer seems to be able to put you where you want to be. And take it from one who has kids and family far away (10 hrs): 2 hours is nothing when you have what you want in life. And it seems like your child is a top priority (not just your future plans), so the better community will be priceless for her and your wife.

I DO have a question that you don't have to answer: What effect will moving to Isreal in potentially 10 years have on your daughter? Would it be possible to achieve your goal sooner, when she is not so tied to the culture here? Just a thought. 11 year olds can be obnoxious about such things!

All the best in whatever you do!

4:08 PM  
Blogger Internal Medicine Doctor said...

Shadowfax: I agree about the trend and it's reasoning. Over here though I see that some locations are undesirable but still pay very little. If you want specifics you can email me. and BTW...what does FWIW and IMHO mean? I can't figure them out.

Kelly: great question about jordan. I am hoping to achieve my goals within five to seven years and probably continue doing some locum tenens three or four months a year if i have to finish while the family is already is israel. I moved to the US at 10 years old and adjusted wonderfully. I think that is probably the limit though.

5:35 PM  
Anonymous Anonymous said...

Hospitalist #3 sounds like a good idea. Will you live apart from your family or are you planning to commute?

BTW, I know this is a little tangential, but if you have the time, could you write more about your last comment? The one that goes "...if I had to make the same decision again I would have chosen differently."

Good luck with your plans. I hope things work out for you and your family.


12:16 AM  
Anonymous Ali said...

FWIW = For What It's Worth
IMHO = In My Humble Opinion

Although I have very little to offer in the way of advice, I just wanted to thank you for this post. This is the kind of information I don't really get elsewhere, and it's the kind of information someone like me (non-traditional [read:older, changing careers] premed) really needs.

The last option does seem the best, though.

9:22 AM  
Anonymous Ali said...

Oops - forgot to post this handy site:


The one that always confused me was IANAL.

9:23 AM  
Blogger shadowfax said...


Geez, now that's an obscure acronym!

Over here though I see that some locations are undesirable but still pay very little.

Yeah, probably an effect of payor mix. The medical market is weird, not like any other employment market I am aware of. If a 'regular' company wants to pay a person to go work somewhere expensive or undesirable, there is usually a salary premium required to recruit people. OTOH, desirable locations do not need this premium. In the medical field, the market is often driven largely by payor mixes and other regional factors, like the state's regulatory environment (i.e. how easy is it for insurance companies to deny payment). So the pacific NW, for example, is an incredibly desirable place to work, but pay tends to be high, compared to national averages. It really makes little sense.

10:24 AM  
Blogger Internal Medicine Doctor said...

dear anonymous: if i had to choose again i would probably think to go into the higher paying residencies. many require a lot less knowledge and hard work than internal medicine and pay a lot more.

i just want to make this real to you so that you understand that these numbers people are throwing at you are actual numbers that will likely make a large difference later on.

ali: thanks for the acronym finder man. feel free to email me if you really want any other infor. i would be gald if i now the answers.

shadowfax: i really need to sit with you and have you explain all these things to me. seriously!

6:14 PM  
Blogger Echo Mouse said...

#3 Hospitalist position. And I agree with others who say move the family there to avoid the commute. I spent years commuting. It's hell on the body and the vehicle and you end up spending the same as if you just lived there (for car maintenance, health maintenance etc.). Not to mention loss of time with family and friends. That stuff is invaluable to beat stress and ensure quality of life.

A lesson I learned the hard way is that money is more important when you're starting out. And solid offers are better than "maybe a bonus" or any other maybes. Go with what's assured and the most pay.

11:56 AM  
Anonymous Kel said...

4. Cardiology fellowship.

Seriously, I would probably say PCP 1 vs. Hospitalist 3.

Is the family you are leaving 2 hours away the wife and future intern, or your inlaws/parents. If you are bringing the wife and 'tern with you 2 hours is no biggie, leaving them there, thats tough. I moved 1000 miles from my mom and 1150 from my inlaws bringing my wife. My daughter is now a southerner (born here during the fellowship). We're staying put as I am joining the faculty (research mostly). My mom is probably going to relocate to spent time with "future senior resident".

I think that the decision would be how much can you save/year after cost of living in the $120K vs $140K jobs and whether clinic or hospital based medicine would more likely make you put a bullet in your brain.

8:22 PM  
Blogger shrinkette said...

Be very careful when evaluating hospitalist positions. How often is call, how are night shifts and vacation coverage handled, how is the department organized? Are you expected to take on every ER admission from a particular medical group practice? Who takes care of patients with no PCP and no insurance? How are consults handled? Are there any limits on the numbers of inpatients and consult patients that you'd be following? Residents have some built-in limits on those numbers, but what are the rules for hospitalists? And do all of your prospective employers have residents and internship programs, too?

Some hospitalists are functioning like sixth and seventh year IM residents. Those calls don't get easier as you get older. It takes longer to recover. A poorly managed, poorly staffed and poorly organized hospitalist program, in which you are basically an intern forever...well, a million dollars isn't enough compensation, in my opinion.

4:50 PM  
Blogger shrinkette said...

Oh, and this is so obvious that you probably don't need to hear it, but: talk to a financial planner and find out what your actual take-home pay will be, for each of those jobs. You will not see $140,000, or $120,000. You will pay state and federal taxes that will take your breath away, at first. You will pay for insurance for yourself and your family. You will pay Medicare taxes. As your income goes up, you will lose access to many deductions, and it looks like you still don't have a mortgage deduction.

My salary is above $140,000 per year. But my take-home paychecks total less than $80,000 per year, because I live in America, and I live in a high-tax state.

5:01 PM  
Anonymous Jay said...

Funny IANAL came up. When I saw the post and thought about commenting, I was thinking I could write "IANAD, but..." to paraphrase all the replies you see online that relate to legal issues, when non-lawyers respond and supply the caveat up front.

To me the third hospitalist position sounds like it makes the most sense if it's all about optimizing revenue to realize your longer term goals soonest without being completely miserable in the process.

7:43 AM  
Anonymous Anonymous said...

Find yourself a specialty or super special procedure that will make you marketable in Eretz Yisroel. The other alternative is emergency room commuting back and forth one or two months at a time. The rest of the time in E.Y. sit and learn in a Yeshiva-Kollel and don't become a self-employed target for the tax authorities.

2:12 PM  
Anonymous Anonymous said...

A word about your loans. After you buy a house, keep track of the market in your area. If appreciation brings you some equity consider taking out a second mortgage to pay off your student loans. Why? The interest on home loans is tax-deductible, the interest on student loans is not (or it will not be at your new, higher level of income)

8:37 AM  
Blogger Charity Doc said...

Don't do it!! Spend the extra 2 years and do a fellowship. Here are some ideas:

Cardiology - you will work like a dog and be consulted every time a patient c/o chest pain (which is roughly 30%+ of all ER visits). You'll cath every middle aged and old people that have a femoral pulse. If they don't, you put a pacemaker in. If they're also dizzy, make it a pacemaker/ICD combo. But on the other hand, you'll be stinkin' rich and paid very handsomely. As far as hospital politics go, you'll be coveted and treated like a god, while us lowly, replaceable ER docs wish we have your clout with the hospital administrators and other medical staffs. I've been at this hospital for over 5 years now and the CEO, COO and CFO of the hospital still don't know who the heck I am every time I see them at the staff meetings.

Nephrology - you'll work like an ox and get consulted for every Creatinine level above 1.5 But you'll make money out the wazoo because every dialysis patient is fully funded so your reimbursement rate is...CHACHING. You'll even volunteer to dialyze road kill if it has an AV shunt in. But somehow, and for some stinkin' reason, you'll moan and groan every time you look at your census list which takes up a whole page, front and back, single spaced. Those damn dialysis patients sure have a lot of medical problems. DM, CHF, PVD, HTN, CAD...the list is endless. You'll find yourself arguing with the cardiologist whether CHF is a disease of the heart or a disease of the kidneys.

Hem/Onc - You may find it too depressing. Consult the Happy Oncologist blog for this one.

Rheumatology - No pt. seems to get any better do they? Another depressing discipline.

Endocrine - how many endocrine consult have you done? As an ER doc, I've never had to called one. Maybe you should forget this one. The chaching bell ain't ringing here.

Pulmonary/Critical Care - I'm just not feeling the big chaching factor here either. They seem to bronch everybody and scan everyone's chest. Vent management ain't that much of a mystery. It just seems that way. They're the only ones that get all excited about sputum. Sloogy docs. Everyone gets PFT's. What would you do without the cigarette industry?

GI - Oh my God! While the rest of the world upchucks and toss their cookies whenever a GI bleeder shows up, the GI guys sniffs it all in and says..."Can you smell the money??!!!" Poopy docs and Golytely pushers. They do make a very decent salary though, scoping from above and below all day long.

Neurology - Every since the NIH touts tPA for ischemic strokes, these guys are consulted all the time now from the ER. They're all over the TV and radios being spokepersons as every hospital compete to get that Stroke Center designation. What a load of crap, heh? Stroke Center. The standard of care, the 3 hours window for thrombolytic from onset of symptoms is the flipping same at every hospital. Every hospital has a OT/PT department, too. So why should any "stroke center" be any different from any other hospital? Yet, they're all over the newspaper and radio touting so.

Don't get me wrong, we need primary care providers. But why be one, work just as hard as the other guys and get pay less? Do the extra 2-3 years fellowship. It's all worth it. If I had to do it all over again, and if someone were to point a gun at me and force me to, I'd choose cardiology and nephrology as a second choice.

Just my thoughts. Good luck on your decisions.


8:59 PM  
Blogger Kim said...

Wow, I'd take Hosp #3, live as frugally and as cheaply as possible, pay the student loans off ASAP and get over to Israel.

But hey! I'm just a nurse who likes the thought of working with someone like you as the hospitalist! : )

1:34 AM  
Anonymous amka said...

A little late on the uptake, but let me give you a reason a hospitalist position might be better as well. In a clinic setting, you will gain patients who you will get to know very well and come to appreciate. You may have patients that will come to trust you, and then when you leave, it will take them a long time to find another doctor. We had this happen when our family doctor quit for urgent care. The reason was understandable, and in fact it was one of the factors that made me like him so much. The clinic was taking up too many of his hours. He wanted more time with his family, so he switched to urgent care only, at the same facility, where he didn't have to take calls in the middle of the night and cover urgent care several nights a week on top of his regular clinic hours.

But we didn't like any other doctor at that clinic. While we've found a ped for our kids, and I have an ob/gyn, we still don't have a regular doctor that we like as much as that first doctor.

6:38 PM  
Anonymous Anonymous said...

What area do you live in? The salaries offered seem to be on the low side. I'm in the Southwest, and most hospitalist positions start at around $150,000, plus bonus.

8:30 PM  
Anonymous emmy said...

OK...here it goes. I understand that you can't go home right now. And I'm kind of pissed because of your stafford loans. My son who should max out on them can't because of people like you. He'll be ok and so will you, but go for what ever senario leads you to where you want to be. I lived too many of my years away from "home". Do me a favor please? Take a trip over the sea of Galilee and try to imagine stepping out of the boat. It was my lifes ambition and now I know I won't make it.

6:41 PM  
Anonymous Anonymous said...

Welcome to America! I hope you like it here, because I can't see how you will ever be able to leave financially. With $176,000 of student debt, and wanting to take on a mortgage (likely another $150,000 or more) and with a family to raise, I just don't see how you can expect to have enough income on a primary care level to pay off all this debt and save enough to achieve your goals in Israel. Especially when your income levels, like those of every other doctor, will be steadily declining over the next 7-10 years as a result of Medicare cuts and penalty-for-nonperformance, oops, "pay-4-performance". I am a practicing general internist in Texas for the last 11 years and I have some experience in this matter.

11:52 AM  
Anonymous Willis Vandalay said...

I would disregard everything that Charity Doc had to say....calculating the "cha-ching" is no way to choose a specialty. It is a sure-fire way to become a bitter, miserable doctor over 10 or 15 years. You need to factor everything into the decision, but most of all choose the work that you will likely find most rewardng (or, more cynically, the most tolerable). And if no one specialty really grabs you, and you can imagine being a Generalist, do NOT do a fellowship.

Oh, also, if Charity Doc can find a 2 year cardiology, GI, or Pulm/CCM fellowship in the U.S., I would love to hear about it. Those fellowships are all 3 (or 4) years long.

4:57 PM  
Blogger dr_ghost said...

I think I am too late, you must have finished your residency 3 months ago, but still let me write
what do you think about the positions you interviewed and my hospital offering - starting with $180,000 a year and 2 weeks on and 2 weeks off working hours that includes 2 weeks night duty - once every three months (2 weeks from your regular weeks -not extra!!), ya and you work as an hospitalist!

your options:

(I think you shouldn't worry much about student loans - its over 30 years, presuming that you will not pay it off earlier, even if you have to pay interest its not going to be much may be 20-30 k interest = bottom line is this loans should not change your decisions)

1) If you love big city and your primary goal (including $) is achieved then go to 3rd hospital.

2) If you think you might want to do fellowship or you might have other opportunities (law/business/partner of big time hospital - medical or non medical bla bla bla) in some place, I would take this even if I am getting less pay.

Good luck.

11:57 PM  
Anonymous Anonymous said...

Are you sure about the wages for Israeli doctors? Because according to this(http://www.haaretz.com/hasen/spages/863371.html) the average wage for Israeli doctors is $60,000 a year. And if they get their raise it will jump to $80,000 a year.

8:02 PM  
Anonymous Anonymous said...

Have a question. I work for a healthcare corporation and we've been recruiting an IM doc or two for over a year. Pay is good (base + bonus), really nice small town in Virginia (pop of 20K & 40K for county), low cost of living, great schools. Not a single applicant in 3 months. Full insurance coverage. Little or no hospital coverage. What gives?

7:12 AM  
Anonymous Anonymous said...

I have a question for all of the physicians on this board. (I'll get to that in a second) I understand that using recruiters is an annoying process. Recruiters work for the hospital and try to fill whatever position the hospital is trying to fill (usually for a rip of $25K). Under this model, it is in the recruiter's best interest to call every resident/physician in the country until they find somebody to take the job. If I was a physician, I would be turned off by this strategy. Not to mention most recruiters are salespeople with limited knowledge of the world you live in.

To my question... Why don't more of you guys/girls use Agents. I am a Physician Agent have worked on behalf of numerous physicians. I work on your behalf. I don't get paid by the employer so your interests are my primary concern. In addition since this is what I do for a living, I am up to speed on all issues which impact your life which respectfully you are too busy to do. I know what the MD across the street at the competior is making. I know why there is an opening (why did the previous MD quit etcc.) I understand Mapractice Insurance and know when you're getting a deal. I know about the technology the hospital has and how that stacks up to other facilities etc..

My partner is an attorney and handles the legal review of all contracts.

Now the catch. We charge 5% of your first year comp. salary + signing bonus. If I negotiate a $300K package, the MD pays me $12K. In YR 2 you pay me nothing and still make $300K (this number is for example purposes only). If you could have received the same comp. without my assistance it's a bad deal for you. If my assistance increased your negotiated comp. by 5% it's a win for the MD (assuming you stay longer than 12 months)

I am not posting on here for leads or to get you to use my services. I just want to understand why I have 100 clients and not 5,000?

Thanks in advance

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3:52 PM  

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