By Dr. James M. Dahle, WCI Founder
One of the funnest parts of running The White Coat Investor is the opportunity to peer into the nitty-gritty details of the financial lives of other doctors. It's a little bit like practicing emergency medicine that way—a bit voyeuristic but often entertaining and always interesting. People always want to know how much doctors make, but one of the things I have noticed, that no one ever seems to talk about, is that intraspecialty pay variation is higher than interspecialty pay variation. Let me explain what I mean.
How Much Does a Family Doctor Make?
Take a look at this salary survey from Medscape on the medical specialties broken down by salary(and show it to your med students, apparently 3/4 of docs are never shown something like this in med school):
The casual viewer looks at this and says, “Cardiologists make almost twice as much as family practice docs. I want to be a cardiologist.” But once you've been in my shoes, you look at this and say, “Wow, some family practitioners make more than the average cardiologist. I wonder how they do that?” Look at the variation here: the difference between an orthopedist and a pediatrician is $279K a year.
Compensation Ranges for Emergency Medicine Doctors
Now check out a specialty-specific salary survey, from my specialty of Emergency Medicine. This one is from 2015, so not quite up to date but it will work to illustrate my point:
Look at the 10th percentile for employees—$213K. Now, look at the 90th percentile for partners—$510K. Difference? $297K. GREATER than the difference between the average pediatrician and the average plastic surgeon!
The ability to increase pay, and increase it substantially, solves a ton of financial problems that real doctors run into and email me about all the time. It's way easier to pay off your student loans or mortgage on twice the income. Even after-tax, it's much easier to become financially independent or have a dignified retirement or send your kids to the college of their choice when you can double your income. The bigger the hole you are in, the more interested you should be in this topic.
So today I thought I would do a post all about intraspecialty pay differences. But frankly, none of you readers are interested in hearing about the average earner in your specialty, much less the low earners. You want to know how those who are really killing it are doing it.
I trolled around in the WCI Facebook Group until I got a few nibbles. Then I reeled them in with some emailed questions. I considered doing this on the podcast, and maybe still will, but it was a bit tricky to get people willing to come on the podcast and give us the straight scoop without the anonymity I can provide in this blog post.
Before we get into their comments, though, let's discuss a few ways to increase your physician income.
How to Make More Money as Family Medicine Physician
In January 2020, we ran a guest post from Gerardo Bonilla, a family medicine physician in Woodland, California. Dr. Bonilla is the founder of StatNote and author of StatNote: Dot Phrases to Expedite Your Medical Documentation. His company provides tools that facilitate medical documentation so doctors can enjoy seeing patients and get fair compensation while doing so. We have no financial relationship. Here's what he wrote about how to increase your primary care physician income.
#1 Preventive Medicine
The annual physical is falling out of style, at least in adult medicine. But insurance companies pay for preventive care for a reason. An ounce of prevention is worth a pound of cure. Some doctors sprinkle health maintenance throughout their patient’s visits, but an annual physical ensures that your patients get all the evidence-based screening and disease prevention recommendations.
According to the AAFP, the average payment for the preventive visit is 25-percent higher than for the problem-oriented visit.
Just by doing preventive medicine, and billing for it, you could see about a $70,000 annual increase in revenue in your practice while ensuring better patient care. (Take a look at the comparison of Physician A and B in this article from the FPM (Family Practice Management) Journal and calculated revenue on the table below.) You don’t need to see more patients. The patients are already coming to your clinic. You just need to spend more time with them.
However, spending more time with each patient and providing more services means more documentation. Having templates or using dot phrases in your electronic health record (EHR) will help you effectively chart all the onerous documentation requirements. This is especially true if you want to meet the ones required to bill for a Medicare Wellness visit.
Conduct a wellness visit and, when appropriate, conduct a problem-oriented visit at the same time. Most patients have chronic problems to discuss at their wellness visits. CMS allows physicians to report both the problem-oriented visit and the wellness visit at the same time, and the revenue implications of reporting both services are significant. [Editor's Note: Note that patients on a high deductible plan who thought their visit was going to be free even though they also talked about their problems might not be so pleased, however.]
The burden of medical documentation is the main cause not only of physician burnout, but also of frustrated patients who only get five-minute visits with their doctors. That is why optimizing your documentation is strongly encouraged.
This is where your dot phrases come in handy. They enable you to expedite your medical documentation and spend less time in front of the computer. Therefore, you can spend more quality time with your patient. Your patients will love it. They will think you are an old-school doctor with good bedside manners.
By using dot phrases and templates, physicians can capture the essentials of the visit with minimal effort. You can document what actually goes on in the exam room instead of selectively picking from the laundry list of problems the patient presents at the visit.
#2 Practice Full-Spectrum Medicine
Have you thought about doing some inpatient shifts or working at an urgent care? Maybe being the medical director for a nursing home or being on-call coverage for OB? Having work outside of the clinic obviously increases your income, but it is also a nice change of pace that might give you some sanity and time away from the never-ending inbox.
Practicing full-spectrum family medicine is rare now, but there is no reason why you shouldn’t practice at the top of your license, spending less time doing clerical work and more time taking care of the patient. You can practice at the top of your license by using your training and expertise to take care of patients.
This is sometimes limited by time. We often don’t have the time to do that joint injection or remove that mole, so we end up referring the patient to a specialist, adding to the fragmentation of care and the burden of healthcare cost—not to mention wasting the patient’s time.
By carving out some time to make room for these and other minor surgical procedures, you will see an increase in your practice revenue. Using dot phrases and templates helps you by giving you more time to do this. Check out this study that found that for every hour of direct clinical facetime with patients, doctors typically spend two additional hours on EHR and desk work within the clinic day.
#3 Know Your Coding
If you want to get better at billing, you need to get better at coding. Know the rules of the game inside out. Read the AAFP’s FPM Journal and the FPM’s Blog Getting Paid. They are a great starting point.
Other good resources are Optum360 EncoderPro and the AMA CPT Professional book. They are good reference tools when you want to get the right CPT code for your procedure. You can also have favorites saved in your EMR for your most frequently used E&M and CPT codes used for billing. It will save you time.
Physicians routinely undervalue services they are already providing. Taking a coding training course might help you become more confident in the worth of the work that you are doing.
There are many courses available out there. For example, the E&M CodeRight® course by MediSync can help you gain a clear understanding of the key components needed to calculate the level of coding. [Also consider the WCI partner Medical Coding and Billing Course.-ed]
As part of the quality strategy to reform how healthcare is delivered and paid for, CMS is implementing initiatives to assure quality healthcare. These value-based programs reward healthcare providers with incentive payments for the quality of care they give to their patients. Your group may receive annual incentive payments from insurers based on quality measures that are used to calculate that pay.
It’s important to pay attention to any quality incentive measures that you may have in your office, as this might represent a bonus in your salary. This might mean documenting or clicking the right box for your diabetic foot exam and ordering an annual microalbumin lab, recording in the EHR that controlled blood pressure reading from home, and making sure you don’t prescribe an antibiotic if your ICD-10 code is acute bronchitis. If these ensure you a $30,000 quality bonus in your paycheck, for example, suddenly it doesn’t become an annoyance anymore.
#4 Optimize Your Medical Documentation
Being more efficient at documenting your progress notes can have a huge impact on your time and therefore could potentially enable you to increase your income. Practicing at the top of your license, doing preventive care, minor procedures, or work outside the clinic are ways to maximize that revenue.
By reducing time in front of the computer, you can spend more time with your patient. For example, you can take the time to do Advance Care Planning with your senior patients, counseling on tobacco and alcohol use, or even do psychotherapy with your depressed and anxious patients. All of these counseling services should typically be reimbursed if they are properly documented.
Comprehensive care and doing what is best for your patient and for the healthcare system will also be the best for you. This will ultimately increase the joy of practicing medicine and enable you to be a Rockstar Doctor!
How These Doctors Made More Money
OK, back to our volunteers from the Facebook group. I have four docs from three specialties—family practice, pediatrics, and med-peds, all of whom are making 2X+ the average for their specialty. I asked them all the same questions and, with minor edits, I'm posting the answers they sent me. If you are a doc or other high-income professional in what is supposed to be a poorly paid field and are making 2X+ the average, please post your tips in the comments section after the post
#1 Pediatrician Making $430K
and you can play along at home!
No, I haven't verified any of this, and no, I cannot promise they will answer the additional questions about their lives that I'm sure you'll post in the comm
ents section. But this I can tell you—these people exist in every specialty. If you want to have an income like theirs, I would suggest doing at least some of what they do that is different from what you are doing now.
Our first volunteer is Mike, a pediatrician who made $430,000 (>2X the average above) in 2018. He averages 8-9 hours a day, four days a week, 50 weeks a year. Like many pediatricians, he works longer in winter than in the summer and takes q13 call plus 8 Saturday mornings a year. No inpatient work. He came out of residency in 2013 with $65K in student loans (actually paid them off the day before responding to my email).
Mike is a partner in a 10-doc partnership with three part-time MD employees and four NPs. Seventy people total work in the practice, many part-time. About 20-25% of patients are Medicaid (no cap), the rest private insurance. Mike does not do many procedures, mostly circumcisions and ear piercings which are all cash pay, but he feels that really doesn't make a big difference in his income. He sees 25-35 patients a day.
What Have You Done to Increase Your Physician Income?
“For me personally, I bought into the private practice. This allowed me to increase my income from an employed physician to a partner receiving partner salary and taking part in the profit sharing.
We as a practice own the properties, as well, so I collect rent on the properties. I think we are a very efficiently run practice and a busy practice. I see 4-6 patients per hour. I see 2-3 well visits an hour. My billing is good and my documentation supports my billing. We do a developmental or mental health screening at every single well visit starting at 2 months old through 18 years old. We check hearing and vision at every single well visit. We are part of purchasing groups which help us negotiate vaccine prices. We have a partner who is very good at making sure that we are achieving PCHM level 3, and other metrics to prove that we are good at what we do which in turn allow us to go to the insurance companies and negotiate better payment for our work. Our A/R is good, we keep credit cards on file, are very good at collecting copays at time of visit.
Our biggest expense is staff. We pay fair rates for our staff, but also demand that they work hard for their money. We do not have excess staff and think very hard before hiring another person or creating another job to be sure that the roles that are needed cannot be completed by another staff member. When we add another service we ensure that it will be revenue generating. We invested time and money into a new system for appointment reminders so that we are sending text and email reminders frequently to decrease our no-show rate by over 1% in the past year going from 4.5% to 3.5% (which is a huge amount of money). We bring patients back for rechecks frequently (I don’t think excessively or inappropriately, though). The key is to keep our schedule full. If it is full, then we are doing well. During the summer if there isn’t as much sick, then we get creative and add more well visits.
Partners are paid solely based on their RVU’s so I am very incentivized to be busy. Other partners are not as busy as me, so they don’t get paid as well. There are other partners that are more busy than me and make maybe $30-40K more per year.”
#2 Pediatrician Making $450K
Our second volunteer wishes to remain anonymous but is also a primary care pediatrician who makes $450,000 working 32 hours per week over four days and 47 weeks a year. He also takes call 4-5 times a month. He is 22 years out of residency and paid off his $40,000 in student loans over 3 years.
He owns his practice with three physician partners and has two doctor employees, two NP employees, and 35 others. He sees 50% Medicaid, 45% HMO/Private Insurance, and 5% self-pay, but feels no control over that mix as they are the largest practice in the county. They attend high-risk deliveries at two hospitals and stabilize critically ill newborns prior to transfer, but their office procedure mix is pretty standard among pediatricians. He sees 25-30 patients per day.
Why Is Your Income Higher Than Average?
“One main reason my income is higher than the average pediatrician in the region is because of the high risk deliveries we attend. We have a contract with the 2 hospitals that pay us (as independent contractors) in addition to our office reimbursement.”
#3 Family Practice Doc Making $415K
This anonymous family practitioner came out of residency in 2016 owing $375,000 in student loans. He is an employee of a 501(c)(3) hospital and made $343,000 in 2018 and expects to make $415,000 in 2019 working 42 hours per week over four days and refuses to sign into his EMR on his weekday off. He works 44-45 weeks/year and takes phone call every weeknight for his 2,700-patient panel, then rotates weekends for group call every 5-6 weekends. That usually works out to 2-3 phone calls during the week and 5-10 on weekends.
He is on an RVU compensation model but thinks the payor mix is 60% private and 40% Medicare/Medicaid. He accepts all new patients into the group of patients he inherited from a prior doc. He averages 23 patients per day and does “more procedures than average. I perform a lot of derm procedures (biopsies, cyst, and lipoma removals), cryotherapy, joint injections (subacromial, knees, trochanteric bursa, carpal tunnel, trigger point), ganglion cysts. I also perform vasectomies.”
What Have You Done to Increase Your Physician Income?
“I have spent a lot of time learning my EMR (Epic) and how to make my day as efficient as possible. I use MModal to dictate. This has really helped with work after hours. I start at 7:30 each day and my last patient is at 4:30. I am out the door heading home with all my charts closed and paperwork completed by 5:15 pm. My partners and I have monthly meetings to discuss issues with our staff and how to become more efficient. From the front office staff, phone staff, and clinical staff, we identify gaps in care. Our goal is to have everyone practice at the top of their license. If a nurse is doing something an MA is capable of doing, we take that responsibility and give it to the MA. If a physician is doing something a RN is capable of doing, again, we take that off the doc and assign that to RNs. This helps keep us physicians busy seeing patients and doing procedures and not get bogged down in prior authorizations, FMLA/disability paperwork, phone calls and other things.
I think the main thing that has helped my income is developing the mindset that when I am at work, I have come to work. I love my job and love seeing patients, but if I'm spending time away from my family I am not there to waste time. I want to see patients. My template is 15 minutes for follow-ups and 30 minutes for new patients and annual physicals/medicare wellness visits.
I realized early on that one of the most annoying and interrupting things in my day was when patients would show up late. I would still try to squeeze them into my schedule so I wouldn't miss out on the RVU and to avoid inconveniencing them. After a while I realized by working late patients into the schedule I was making all my other patients that day upset because I was then running behind. They were upset; I was upset. It was causing a lot of stress trying to please everyone. I then realized that if I set a ‘late policy' and held to it, patients would eventually get on board and realize the importance of being punctual. I set my policy at 10 minutes. If they arrive after 10 minutes, they have to reschedule. If they arrive before 10 minutes, I'll agree to see them but they have to be willing to wait until I have time. I see the patients who arrive on time first. Managing my schedule has been very important for me to increase my efficiency.
I think the other main factor is learning how to bill. I think a lot of PCP's underbill. I'm not sure if it's because they don't take the time to learn the difference between a level 3 vs 4 vs 5 or if they are just nervous that they will be audited so they bill everything a 3. My hospital does a voluntary audit every year and my audit passes every year. I know the difference between office visit levels and I document accordingly. There is no award for seeing a complex patient and then billing a level 3. If you do the work, get paid for it. It's not easy to manage 3-4 chronic medical problems and address 2-3 new complaints in 15 minutes. I think providers don't necessarily need to document more, they just need to document smarter.
Combining E&M visits with procedures makes a huge difference as well. A level 3 office visit for an established patient is 0.97 RVUs. A level 4 is 1.5 RVUs. A joint injection/biopsy/cryotherapy is about the same RVU as a level 3 visit but takes just an extra minute or two of my time. I have established protocols with my staff so when I want to do a procedure, I just tell them what I plan to do and then go in to see my next patient while they get everything set up as I've instructed. I can then just pop back in to do the procedure and wrap everything up. EMR's then make it convenient to add the appropriate procedure template to the office note which completes the documentation.”
#4 Internist Makes Half a Million
“Dr. Solo” is a med-peds doc who made $500,000 in 2018 working 35-40 hours/week, 45 weeks/year. He is “always on call” with the solo practice he owns but never goes to the hospital. Call is about three after-hours calls per month. He is 12 years out of residency and still owes $50,000 of his original $150,000 3.25% student loans.
He employs no APCs, and is down to two employees from the 4-5 he had before transitioning to a subscription-based practice. His patients are 85% private, 10% Medicare, and 5% Medicaid, but he hasn't actually taken insurance since 2011. The patients who stayed with his practice generally have PPO-type plans and he is out of network on those. He does no procedures and sees 5-6 patients per day. No, there is no typo in the previous sentence.
Why Is Your Income Higher Than Average?
“I transitioned out of accepting insurance, acquired knowledge in integrative medicine and nutrition to develop a niche, changed to a membership-based practice, and cut overhead, i.e. from five employees down to two. I am passionate about spending the appropriate amount of time with each patient, enough time to allow me to best understand and treat not only their physical/medical problem(s) but the interdependent psycho-social and lifestyle choices (i.e. diet, exercise, sleep habits)—and I keep this tenet at the forefront of every decision to optimize the practice.”
As you can see, it is entirely possible to go into a primary care specialty AND make a lot of money. The key is the same as with any business—those who own a well-run business make more money than those who own a poorly-run business and those who are employed. So rather than crying “woe is me, I can't get rich because I'm a pediatrician” or worse, not going into family practice because you think you can't make enough to pay back your student loans doing so, do what these docs did and create your own destiny.
What do you think? If you are in primary care, what have you done to increase your income? What are your tips for your peers to go from the 25th percentile to the 75th percentile for your specialty? Comment below!
Hi WCI readers!
As a longtime reader of this blog, this is a great article! I am an FM medicine trained Hospitalist. 5 years out of residency, my income for 2019 will exceed $400k maybe closer to $450k.
Here’s how I do it:
1. My ‘main job’ gives me about $275k with bonuses and rvu’s- I’m an above average biller and work for a private group. I might even make more this year depending on bonuses.
2. I’m a ‘supervising physician’ for mid levels at various companies- pays another $50k per year, all remote, no clinical time. Just backup and support for NP’s
3. I moonlight at hospitals throughout the year, sometimes traveling to neighboring states but mainly stay in the PA, NY, NJ region. I don’t take a shift unless it pays $2k minimum. I make over $100k annually doing an extra 4-6 shifts per month.
I typically work 18-20 days every month, have no call, and get paid in both 1099 and w2—- there you have it! Good luck!
That’s impressive for the northeast. Can I pm you ? Have some questions regarding Hospitalist jobs in northeast.
Wow.
I supervise mid-levels for no extra comp.
Could you share more about the remote supervision options?
About NP supervision. The reality is that yiu are putting your license on the line to supervise practitioners that have frequently completed an online education and only 500 clinical hours. The NP schools have no standardization. You need to seriously look into this. They have also been very open about their goal to be independent from physicians and this is exactly the behavior that they tell our legislators. You maybe making money but the patients suffer and PCPs, ER docs, Anesthesiologist etc are literally losing their jobs to these people. A physician’s oath is to do no harm And that is the opposite of this.
I agree
In the past two years I’ve seen an uptick in lawsuits for my medical expert work where physicians were being a little too loose working with pa/NPs
This us not to say that I do not see the value in the model, just that the risk is real for lawsuits.
Justsayin
This is a financial site first so I do think it’s helpful for people to share how they supplement their income, but this point is a valid one. I’ll keep it focused on the finances to avoid a flame war: I have decided for me personally I’m not willing to take on the liability risk associated with supervising midlevels. Nothing against midlevels, but I wouldn’t personally feel comfortable taking on liability risk for anyone other than myself. In my field it’s worth an extra $20,000 a year. That at my marginal tax rate isn’t worth it to me. But everyone has different values/risk tolerance.
To clarify actual pay off for the partners, how much did their practice buy in cost? Does that factor decrease their actual annual ‘salary’- can we discount their take by the 5% that’s just a return on their practice buy in if they had put it somewhere else to get a more accurate number or are they already paid off with lower earning years? (and what did that cost them)
Thanks!
valid points.
Presumably their practice is an investment that will pay them back when they retire/sell. I think it’s more likely that you can ADD 5%/yr or so in appreciation of the basis in their practice ownership.
Outstanding post. It proves that by becoming more efficient and smarter with billing you can achieve the top quintile of your specialty for income. A common theme seems to be that these types of physicians are partners/owners of their practice. That is where the best return of money is for your time. If you are salaried, it is likely that your employer is making a profit off of you, keeping the difference between accounts received and what is paid to you. I would love to see the intraspecialty range for radiology. Based on the average salaries typically listed, I feel confident that I am in the top 20% if not 10% of my specialty and again that is due to being a full partner in my multispecialty medical practice.
This comment rings true with me. Employed pain doc. 80th percentile production getting less than 25th percentile $/wrvu valuation whereas my colleagues in my practice at 30th percentile making greater than 75th percentile $/wRVU valuation. Pays to be lazy apparently. We have a decreasing $/wRVU valuation as you produce more.
Wow this is really inspiring. Thanks!
What resources do new attendings use to learn more about coding appropriately? I notice most of these stories involve docs who say they bill higher than their peers. I believe them – I do think most people underbill – but where do you learn the nuances so that you can bill 99214s and stay confident that your documentation holds up in an audit?
Would be interested to see buy-in numbers and practice loan numbers considering how many on this list are partners.
Would also love to learn more about the last doc’s model. An article on direct primary care finances would be fascinating. Do the patients pay subscription + at each visit or just the annual fee? What’s reasonable to charge for an annual subscription? Are procedures free or at additional cost? How many patients make up his/her total base? And does he or she practice in a wealthy area?
80% of my salary is RVU based. I’m very aggressive in coding in my FM practice, but our practice self audits and I’ve never had any trouble. The difference in 99213 and 99214 is really pretty small. Especially using an EMR. Now, going from a 99214 to a 99215 is a much bigger leap.
As for resources to learn…I’m betting most of us aggressive coders are self taught. Read the definitions. Get over the idea that MC is going to throw us in jail for fraud. There’s a ton of “grey area” in medical coding. If you aren’t blatant, you’ll just blend in with the tens of thousands of other docs coding well. Also keep in mind that there are close to a BILLION patient visits per year in the US. Auditors really can only look for the malicious ones that are charging level 5 visits 25 times a day or the equivalent
I have a table with the MDM criteria for outpatient E/M codes (I took a screen shot from a powerpoint my employer put together when the rules changed for 2021). It’s printed out and lives on my desk. For a while I looked at the table for EVERY SINGLE E/M visit I performed to make sure I had the coding right. Now I’ve looked at it enough that I usually don’t need it. But it’s still on my desk just in case.
If any of the docs are not already it would be great if they joined the WCI Forum. You can remain anonymous there and it would be great to pick your brains on your success. I am particularly interested in the family physician since I too am an employed FP. I came up with the same late policy which helped more then I thought it would.
I agree that you need to code correctly. A lot of docs code too many 99213s and not enough 4s. Capturing an E/M code with a procedure or wellness code together really helps as well.
I run into trouble with scheduling and office efficiency and it would be great to have more people on the forum to bounce ideas off of rather then reinvent the wheel.
Thanks for the great post!
I really enjoyed reading this. It seems there is a lot of hate when whenever the average income chart is brought out. It’s like it’s a criticism of the lower paid specialties.
This post shows there’s more to the story besides the “average” compensation number.
I’m most impressed at the doc listed at the end who makes $500,000 seeing 6 patients per day. It seems that if a doc is worth the money, patient will recognize that and pay for the service, even out of pocket.
Jim, any insight on where “Dr. Solo” practices? I wonder if this is in an affluent area.
Thanks,
— TDD
Yes, I have insight, but I’m also preserving anonymity here.
I definitely understand that concern, thanks!
— TDD
I’ve heard of these types of “concerige” medicine practices becoming more popular. The patient number is low, which sounds enticing at first, but clearly the type of patients that can afford and prefer this kind of physician service likely expects not only time but likely lot of knowledge and accessibility to you after-hours for any quick questions or concerns since they are paying a good penny for this level of service. So while it sounds cushy I wonder how different the stress level is.
And I would presume this is in a more affluent city or area of a mid to large sized city.
I have always been very suspicious of those salary surveys and think they are grossly under-reported. It used to be felt there was bias because those surveys are mostly employed positions? Does anyone really think there is a plastic surgeon only making 500k?
FP here – entering 16th year of practice. Over last 5 years have averaged between 400-500k per year. I am in the office 3 day per week from 8a-5p and round at 6 Nursing Homes on Thursday and every other Friday. I am medical director/co-medical director at all 6 facilities. Medical direction at each facility varies from $1000-$2000/ month – depending on co vs full medical director positions. Project around $100,000 in 1099 work as Medical Director this year.
1. Learn how to code/bill for your work. I CANNOT STRESS this enough. I used the following book when I was in residency and early in my career- it was published in 1997 (I know it is old but the concepts are still true):
https://www.amazon.com/Getting-Paid-What-You-Reimbursement/dp/1570660670 . If you work for an organization see if they have certified coders and work with them on improving your documentation to meet higher level codes (this does not mean make stuff up – but document and code appropriately).
2. If able leverage mid levels for office and other work options. Very few things in Medicine can you get paid for without actually seeing the patient. This can be one of those places.
3. Use scribes if able for documentation. If not available learn how to use templates/shortcuts in your EMR, learn to use voice recognition software for documentation. YOU NEED TO INVEST THE TIME to learn your EMR- it will save you time in the long run.
4. If you have interest do Nursing Home work. In some areas there are NOT enough doctors to care for these patients. If you find you like it there may be Medical Director positions available. The visit wRVUs are almost equal to inpatient wRVUs. My organization has a great process to help with the day to day issues, phone calls, faxes. We use embedded NPs in our high volume facilities to help prevent readmissions, perform acute visits and regulatory visits.
Hi aCMD, would you be willing to talk further about your experiences working in the nursing homes? I too am a family medicine trained physician who will be working at a local nursing home full time. My income is salary based only, and I will earn near the 10th percentile for employees total salary in the table above. I want to increase my income but have read that full time work at nursing homes is not the best way to do this, rather it’s better as a supplement to other full time work in an outpatient practice or hospital. However, I have no desire to work in the hospital or the outpatient setting. If you’d be willing to discuss further it would be great, please let me know!
I am in a salaried position working with midlevels without extra compensation. How can I use the midlevels to my advantage? I had been using them to see the patient first and start charting, but are there other roles for optimization of my time and charting?
I recently switched jobs and definitely need to be more efficient with my time and charting (ie templates and getting to know my EMR better as you suggested)
Thanks so much!
Sounds like you’re using them as Medical assistant by having them start charting and then you see the patient? APPs can do everything from beginning to end. Maximizing them at the top of their license include letting them see their own patient, billing and coding, thus giving you more time to see more patients. Some states just require you to cosign their chart. Allowing them to practice at their top of their license also entail paying them the salary that they are worth.
The more they do, the more “efficient” you become with your time. The risk? That the patients are being cared for by someone with less training. That’s both a patient care risk to the patients as well as financial risk to your job if it is just given to the APCs instead of you.
Levels of APC supervision range from the comical “just sign the charts a week later” when you’re not even available when the patient is seen to physically laying eyes on and talking to every patient the APC sees.
Great post: simple but CRITICAL for all young readers (med students, residents) to understand. The last paragraph says it all, “those who own a well-run business make more money than those who own a poorly-run business and those who are employed.” This is not limited to primary care specialties, and is just as true for the plastic surgeons, orthopedists, and dermatologists of the world who still make +2x the “mean income” in well run private practices.
Residents are being lured into employed positions with “high” starting salaries that are typically just marginally higher than comparative job offers with private practice groups, but much less risk due to their employed nature. Read through the forums here for plenty of examples of private practices gone “bad.” And yet, those cases are relatively rare while the benefit of private practice is on the range of DOUBLE in regards to income. Combine that with increased control, autonomy, quality of life, opportunities for ancillary income and flexibility for future changes and you have a recipe for financial success and burnout prevention. My advice to young readers: don’t fear private practice. Sure it has risks, but the rewards are FAR greater.
The other take-home point here is that while “being a good coder” was mentioned a few times – don’t get caught up in that. Sure, improving your coding (ethically) can increase your collections – but perhaps only on the order of 10%. In an employed or RVU-based situation, that translates to a 10% increase in income. However, in a PRIVATE setting assuming a 50% overhead, that translates to a 20% increase in income (overhead stays the same, so your “half” of the pot increased by 20%). Then throw in the ability to control your efficiency by appropriately utilizing physician extenders and office staff (also mentioned in the post) to increase your productivity another 10-20%. Add in the potential to own your building and pay rent to yourself…. moonlight…. start other interesting businesses or blogs…. contract with a hospital for unique services…. and each of these can add 5-10% to your income. All combined, this type of practice set up has massive potential for success and increased risk is off-set by multiple income streams and flexibility to shift course when necessary (it’s like investment diversification).
Of course, I’m biased because I’m in private practice. But I remember when looking for jobs a lot of people were saying “private practice is on the way out.” Maybe it is, maybe it isn’t – but that depends entirely on how future doctors choose to practice. And my sincere hope is that students and residents will recognize the personal benefits to private practice and continue to thrive in that setting.
2 common things I see in these physicians which allow them to make money equivalent to their worth.
#1. They own their business. This part is probably the most important part, as it means some extra work (even though this is downplayed in the post), but significant increase in compensation.
#2. They value themselves as physicians. They accept what they feel is right for their pay and have not allowed themselves to become commodities valued by market forces and other outside people.
Coming from a physician who makes 4-5x what the average compensation for someone in my specialty makes, I have seen these forces hard at work in generating extra income for myself.
I hope the next generation of physicians will take a hard look at this post and use it wisely for their own benefit.
Thanks,
Not sure how much more I could have upplayed the ownership aspect.
Agree…my comment was not a critique. Just agreeing with what was stated. Ownership is huge and if physicians want to be “just employees” going forward, then they will become just that. Unfortunately from both a financial and “happyness” aspect, I believe ownership is the better course to achieve both of these.
Thanks,
Would you ever have time to talk to a medical student about your diversified income streams?
Unfortunate to see so many people deep in their careers showing the obvious- ‘work more make more.’
Do you enjoy it?
Heck by 50 I’ll make 2x+, but 1x of it will be from passive income. Better strategy IMHO
How about roll your money into something that pays you so you don’t have to moonlight to make more money?
Night shifts lose their appeal in the 6th & 7th decades
JustSayin
Yes, the best way to make money is the old-fashioned way.
Hard work, strategy, efficiency, and business ownership.
Some people seem to be able to get rich in any job or specialty. Many of the skills can be learned.
There is no denying that it is a lot easier to get rich in the consistently high-paying specialties.
I know an anesthesiologist who works part-time and makes $300K. Making $300K as a family doctor takes an extraordinary person, workload, or business setup.
Some runners can go fast in any conditions, but it is always easier to run fast when the wind is at your back rather than a headwind.
So for those in training, consider a higher-income specialty. Don’t do it just for the money. But realize your medical career will be hard and challenging no matter what. You might as well boost your return by choosing your specialty wisely from the start.
As someone in a high income, surgical/procedure based specialty, I’d be interested to see a post discussing the upper range of what those specialties can earn and how they did it?
How can you get in the 90th+ percentile in surgical/procedure based specialties? Having a similar post with that topic would be very fascinating. Interested to see what similarities and differences there are between ways of maximizing income between “low” vs “high” paying specialties.
Thank you!
I agree, but a small part of me worries that as we highlight the high earning procedural fields – and then highlight even the outliers in that group – that it draws attention to those fields in a negative light (in terms of the RUC). I know my old school attendings always used to tell me to be careful about that sort of stuff, because of the fear of reimbursement cuts in the future. Now that may be a complete myth and have no basis in reality, but with a site like this one (with such a wide audience) you wonder if such an article could have a negative impact down the line.
But yes, as someone in such a field, I would be interested in finding opportunities as clearly I’m being outearned by all the PCPs on this list.
While I cannot provide specifics, I’ve read something that is very very similar to the WCI post.
I frequent car forums and have came across 2 situations that can illustrate surgical specialty fields and their earning potential. I do not have actual annual compensation numbers but proxy signs that may point to the level of potential earnings:
Example 1: Ophthalmologist in a private practice group in a large city, doing lot of vision correction surgery. Very comfortably able to afford an exotic european sports car costing 300k+
Example 2: Orthopod in a private practice group with 10+ orthopods + support staff. He is one of the original 1 or 2 physician partners that was there when the group started. Very comfortably able to own MULTIPLE european exotic vehicles costing 300k++
Both docs are easily in the 7-figure range and the orthopod likely is close to 8-figures, if not more….
You forgot the most telling detail….did they pay cash or take out a loan?
Lot’s of “credit card millionaires” out there, doctors and non-doctors alike.
Regards to #1: Refractive surgery is all cash and can be lucrative, but competition is absolutely fierce! Lots of practices bought lasers back in the book of the 2000s (break even is 5-10/month) and are struggling to even get that many. Practices that focus on it have a boutique atmosphere which requires higher building costs and more FTE/patients seen. Refractive ophthalmologists doing enough volume to make 7 figures are a minority.
I am 2 years out of family medicine training. Current gross income of $375,000 with student loan burden of $330,000. I am an employed doc, work 8-5 M-F. No weekends, 1 week of phone call per year. I work an avg of 47 wks per yr. I am able to supplement my clinic income by working one 12 hour ER night shift a week at a small local critical access hospital which makes me over a $100,000 per yr. I also review APN charts for an urgent care that pays $1000 a month. That only takes about 2 hours a month of my time. I hope to one day cut way back on ER and start my own clinic but I’m waiting until my loans are paid off to do that. Currently going for PSLF, 5 years left to go on that.
@BE87 Could I pick your brain about PSLF? Would over email be best?
I am a rising MS4 looking to pursue FM.
3x surgical sub specialty ave:
—extra year for fellowship
—private practice
—cut overhead by 30%
—own our buildings
Jim…did you forget our podcast?
https://www.whitecoatinvestor.com/increasing-your-primary-care-income-an-interview-with-doc-g-of-diversefi-podcast-75/
How could I forget you! But yes, I probably should have linked to it!
It would be amazing if you could do a similar episode for EM. As a recent EM graduate who works for a CMG, in an area where there are few SDGs, I feel I’m essentially a cog in a giant machine paid by the hour, and partnership opportunities are limited.
There’s a reason it feels that way…..:)
Your options are:
1) Work more shifts/better paying shifts
2) Negotiate a higher salary
3) Take on more responsibility that pays better (medical director)
4) Go do locums somewhere else a few days a month
5) Move and get a partner job
Or I suppose you could also figure out a way to spend less. Penny saved is two pennies earned and all that.
Payer mix is key. The first pediatrician takes 20-25% Medicaid I think average is 25-30%. One thing to note is that just over 50% of kids are on medicaid. (Which means that for there are others taking 75% medicaid.)
I think that’s where a lot of the “whining” from pediatricians comes from. We want to see sicker and more complex kids and be an academic environment but still get paid “fairly”. Yes life is a trade off. I doubt there are pediatricians in academic centers or private practice pediatricians in medicaid rich environments making this type of money. Also Mike is averaging about 15 mins a patient. That works for well visits and easy sick visits. The medically complex kid with a med list that rivals an adult nursing home patient who sees 3 subspecialists is a 30 min visit.
For the second pediatrician who does the high risk DR coverage. You just have to be careful from medicolegal standpoint. If there’s a precipitous delivery and a bad outcome you could be in trouble. Someone could make the argument that it would have gone better with a neonatologist present.
I will be graduating family medicine residency in 2020, and started my job search. This post has been inspiring and emphasized the importance of seeing patients and coding, except for the concierge medicine at the end. After doing the math for “family doc making 415k” based on his 343k salary in 2018, 23pts/day, 4 days/wk, and 45wks/yr. Using $47/RVU as a conversion factor, based on Average FP salary $230k / average 4900 RVU/yr in 2015, He is averaging 1.76 RVU/pt or 7298 RVU/yr. That’s some excellent coding/billing, especially since the average is around 1.3 RVU/pt. To get 340k, I can see working 5days/wk, 23pts/day, and working 45wks/yr, at $47/RVU = 1.4 RVU/pt which shouldn’t be too bad.
Disclaimer: forgive me for any typos or mathematical error, I was reading this post at 2am because I couldn’t sleep.
I am an employed family doctor 10 years out of residency in the Northeast.
Working Mondays, Tuesdays and Wednesdays only at a Community Health Center. About 24 hours clinical time. Rest of the time is precepting/admin time/medical director time. Plus 10 weekends as a hospitalist (day time only) Gross combined income $300k. If I worked an 8 hour day on Thursdays and saw 14 patients, I would earn an additional $60,000 in salary plus productivity for the year. If I did he same on Friday, then another $60,000! Total could be $400-420k! (Maybe I should start working more ). At this point, I am content with the 300k and enjoy the 4 day weekend most weeks.
Sounds like a nice set up.
Totally agree… great job
Which state /city
Meriden / Middletown Connecticut. Fairly urban / suburban area. By no means is this an easy job, very challenging. Less demanding primary care jobs are available in a non community health center set up. Co workers are great. Strong team environment. Full spectrum family medicine practice. Administrators are fairly reasonable.
This is such a great article. It’s actually more common that many primary care providers do not know how to capitalize on their skills to increase their revenue. Journal Solutions is a practice management company working with practices, specifically pediatrics, to help find ways to maximize their potential and increase revenue. Feel free to check us out https://journalsolutionsllc.com/home
It is fascinating to know that a pediatrician who owns a personal family medical practice makes more than the usual physicians. My cousin is studying for a medical degree and I will suggest this to him. If ever, we will need a medical expert for more useful tips on his career.
Great article. I’ll be researching private practice once my H1b visa is done and I have a green card. My only critique is that any income after 40 hours should not be included. In any study it’s important to control for confounding variables. Such as those high risk deliveries if they are after hours work. Any employed physician could also work extra hours, so it should not be included.
Secondly some credit should be given to employee benefits like 401k match and health insurance. having $0 copay for two newborns saves alot of money. no bill from the maternity and delivery.
Unprofessional White Coat Investor… Forum Moderator “ACN” is cussing people out in the weekly political ranting! Thought you had rules and standards. Terrible branding for you and judgment.
Being addressed.
[Complaint about WCI forum removed and email sent to commenter]