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Should I pursue additional training?

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  • Avatar CCM 
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    Status: Physician
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    Joined: 07/17/2018

    I completed my residency in IM and am currently a fellow in a 2 year CCM fellowship, I will be completing my fellowship July 2019 and my wife will be completing endocrinology fellowship at that time also.

    I am considering starting work as an attending intensivist vs. further training in cardiology. Obviously there are many aspects to this, but for argument’s sake, I wanted to conduct an analysis from a purely financial perspective. Below is an analysis based purely on income – numbers are approximates for my region from the most recent MGMA compensation survey.

    Option 1 – start work as an intensivist.

    Annual aggregate post-tax household income: 388k (Pre-Tax = 650k – mine 400k, wife 250k)

    Option 2 – 3 year cardiology fellowship

    During 3 years of fellowship, annual aggregate post-tax household income: 200k (Pre-Tax 310k – mine 60k, wife 250k)

    After fellowship, annual aggregate post-tax house hold income: 442k (Pre-Tax 750k – mine 500k, wife 250k)

    Option 3 – 3 year cardiology fellowship + 1 year interventional

    During 4 years of fellowship, annual aggregate post-tax household income: 200k (Pre-Tax 310k – mine 60k, wife 250k)

    After fellowship, annual aggregate post-tax house hold income: 524k (Pre-Tax 900k – mine 650k, wife 250k)

     

    30 Year Projection: https://docs.google.com/spreadsheets/d/11aGR_75J498ovRBrk9CRBZZedbzUF59OvQ4mZRx_C9s/edit?usp=sharing

     

    I am on the fence about pursuing additional training and am trying to convince myself that it is a bad financial decision. What else should I be considering from a financial standpoint? More early investments if I become an attending sooner, resulting in more growth over time? What else? Any other thoughts?

     

    Thank you.

     

    #137313 Reply
    CordMcNally CordMcNally 
    Participant
    Status: Physician
    Posts: 2806
    Joined: 01/03/2017

    I would do whatever you think you’d be the happiest doing for the next 30 years. Incomes in medicine will likely change in the next 30 years, especially in regards to each other. No matter which way you go, the game has been won as long as you make good financial decisions.

    “But investing isn’t about beating others at their game. It’s about controlling yourself at your own game.”
    ― Benjamin Graham, The Intelligent Investor

    #137373 Reply
    ENT Doc ENT Doc 
    Participant
    Status: Physician
    Posts: 3500
    Joined: 01/14/2017

    I can’t see the underlying calculations on your spreadsheet but it appears you haven’t taken into account the time value of money.  What discount rate are you planning on using?  Are you going to assume a certain rate of growth in wages?  You’re a year out from potentially having a job – isn’t now the time to be looking anyway?  Seems like a more imminent decision given that you’re less than a year away from a potential fellowship spot, if not missed the window, no?  My latter point is that you and your wife should probably have reasonable estimates of Option 1 already based on a potential job search, not MGMA averages.

    Most NPV analysis that I’ve seen regarding fellowship show that it’s a bad decision.  I would ignore that for now; however, and focus on the more imminent job search issue and doing what you love – you’ll make plenty either way.  You need to be happy at the end of the day.

    #137378 Reply
    Avatar DCdoc 
    Participant
    Status: Physician
    Posts: 553
    Joined: 06/14/2016

    Agree with above. This is not purely a financial decision. You can’t project happiness based on spreadsheets if potential future earnings. Those could change. CCM vs cardiology are very different, especially if you do EP. what do you WANT to do? What career will make you happy working day in abd day out for the next 25 years? Once you answer that, you have your answer.

    #137379 Reply
    Avatar Kamban 
    Participant
    Status: Physician
    Posts: 2484
    Joined: 08/01/2016

    There is no way to know what the incomes and job prospects will be for the 2 fields you are considering over the next 30 years. So do what makes you happy.

    If you also do cardiology there is a 99% chance that critical care will go by the wayside and that will be 2 years of wasted fellowship. I see people doing pulm + critical care or nephrology + crtical care who do not use the critical care aspect of medicine. But if cardiology makes you happy, pursue it.

    My only thought is at age 55-60, would you still like to be doing critical care at 2 AM. Or be in bed with a good night rest.

    #137380 Reply
    q-school q-school 
    Participant
    Status: Physician
    Posts: 2629
    Joined: 05/07/2017

    wow, where to start.

    the things you like when you are young may not seem so awesome after doing them for twenty years.  it’s hard to remain expert at all things.  by the time you finish cardiology, interventional may well be two.  you are looking at maintaining critical care boards, cardiology boards, interventional boards.  possibly nuclear and echo and vascular as well, if you choose to maintain those certifications.   that’s a lot of studying.  I think these financial projections are impossible to rely on long term.  with two physicians, the average salaries almost don’t matter.  you can tailor the income to your needs.  in the future, your health may preclude one or both from working.  wife may stay home with kids.  you may choose to be in academics or not.  range of incomes can double depending on call schedule and geographic variances.  so if you want to make more to make up for lost time, you can.  however, I would encourage you to NOT do so, focus on the long game.

    it is way easier to go part time in critical care medicine than in cardiology.  with two physicians, if you ever have kids, you will need to be clear on how you run your family.  if you want to share time off when kids get sick, interventional cardiology is least forgiving in terms of cultural understanding.  if you want a month of paternity leave, ditto.  if your wife is comfortable that she owns the majority of family time, her practice is going to be understanding of a lot of early departures and sick days and other things potentially.  lots of cancelled clinic appointments that will go on her permanent record.  or maybe none of these things matter.  you could get a nanny.  there are many solutions, but being on same page with spouse is so so important.

    with both in medicine, and one in a very challenging timewise and energywise field, I think flexibility is important.  unless you love cardiology and can’t live without it, I would forego.  if you do, then pursue, but realize it’s at the expense of personal/family time.  I did nine years of clinical training with three fellowships, and my wife is a physician, so I may know a little of what I speak.

    as always

    ymmv

    jmo

     

     

    Avatar CCM 
    Participant
    Status: Physician
    Posts: 9
    Joined: 07/17/2018

    There is no way to know what the incomes and job prospects will be for the 2 fields you are considering over the next 30 years. So do what makes you happy.

    If you also do cardiology there is a 99% chance that critical care will go by the wayside and that will be 2 years of wasted fellowship. I see people doing pulm + critical care or nephrology + crtical care who do not use the critical care aspect of medicine. But if cardiology makes you happy, pursue it.

    My only thought is at age 55-60, would you still like to be doing critical care at 2 AM. Or be in bed with a good night rest.

    Click to expand…

    Agree that if I do cardiology, CCM would probably be a wasted fellowship. I’m not sure if I understood the rest of what you said correctly – from my experience, majority of people who end up doing CCM after nephro or ID end up practicing full time CCM because it generally pays more with better lifestyle. More shift work, lack of “call”, more time off etc. The pulm folk seem to transition to less CCM and more pulm as they age.

    I would do whatever you think you’d be the happiest doing for the next 30 years. Incomes in medicine will likely change in the next 30 years, especially in regards to each other. No matter which way you go, the game has been won as long as you make good financial decisions.

    Click to expand…

    Thank you.

    I can’t see the underlying calculations on your spreadsheet but it appears you haven’t taken into account the time value of money.  What discount rate are you planning on using?  Are you going to assume a certain rate of growth in wages?  You’re a year out from potentially having a job – isn’t now the time to be looking anyway?  Seems like a more imminent decision given that you’re less than a year away from a potential fellowship spot, if not missed the window, no?  My latter point is that you and your wife should probably have reasonable estimates of Option 1 already based on a potential job search, not MGMA averages.

    Most NPV analysis that I’ve seen regarding fellowship show that it’s a bad decision.  I would ignore that for now; however, and focus on the more imminent job search issue and doing what you love – you’ll make plenty either way.  You need to be happy at the end of the day.

    Click to expand…

    I literally added the post tax dollar value as the years progressed. I did not account for a discount rate or rate of growth in wages – how do you think this would impact the analysis? More in favor of CCM, as I would start earning attending money sooner?

    Job search is ongoing for the both of us and we are seeing similar or higher numbers than what I have mentioned in my original post.

    wow, where to start.

    the things you like when you are young may not seem so awesome after doing them for twenty years.  it’s hard to remain expert at all things.  by the time you finish cardiology, interventional may well be two.  you are looking at maintaining critical care boards, cardiology boards, interventional boards.  possibly nuclear and echo and vascular as well, if you choose to maintain those certifications.   that’s a lot of studying.  I think these financial projections are impossible to rely on long term.  with two physicians, the average salaries almost don’t matter.  you can tailor the income to your needs.  in the future, your health may preclude one or both from working.  wife may stay home with kids.  you may choose to be in academics or not.  range of incomes can double depending on call schedule and geographic variances.  so if you want to make more to make up for lost time, you can.  however, I would encourage you to NOT do so, focus on the long game.

    it is way easier to go part time in critical care medicine than in cardiology.  with two physicians, if you ever have kids, you will need to be clear on how you run your family.  if you want to share time off when kids get sick, interventional cardiology is least forgiving in terms of cultural understanding.  if you want a month of paternity leave, ditto.  if your wife is comfortable that she owns the majority of family time, her practice is going to understand a lot of early departures and sick days and other things potentially.  lots of cancelled clinic appointments that will go on her permanent record.  or maybe none of these things matter.

    with both in medicine, and one in a very challenging timewise and energywise field, I think flexibility is important.  unless you love cardiology and can’t live without it, I would forego.  if you do, then pursue, but realize it’s at the expense of personal/family time.  I did nine years of clinical training with three fellowships, and my wife is a physician, so I may know a little of what I speak.

    as always

    ymmv

    jmo

     

     

    Click to expand…

    Thank you. Your post was extremely helpful. I really needed to hear this. My wife is very against me pursuing additional training but will support me if I really want to.

     

     

    #137397 Reply
    Avatar Kamban 
    Participant
    Status: Physician
    Posts: 2484
    Joined: 08/01/2016
    from my experience, majority of people who end up doing CCM after nephro or ID end up practicing full time CCM because it generally pays more with better lifestyle.

    Click to expand…

    Maybe if they did it after an interval of time post nephrology they might do CCM full time. The ones I know did 2 years nephro + 1 year critical care in one straight shot. Those people go into nephro and they end up with office nephrology, dialysis, medical directorships of dialysis centers and hosp work. They don’t do critical care since it reduces nephrology referrals from pulmonary and other inteventionists. But I suppose it depends on who their referring sources are and if there is competing nephrology group in town that can be played against them.

    #137420 Reply
    q-school q-school 
    Participant
    Status: Physician
    Posts: 2629
    Joined: 05/07/2017

    in case it was lost in the discussion, I wanted to congratulate both you and your wife on approaching (a?) finish line.  it’s really amazing.   I hope you both take some time to celebrate the milestone at the end of the year.  most of us who had lengthy training are kind of indoctrinated into the lifestyle of training.  there is a whole another world available to you.

    I remember when I went on my first job interview.  they asked me what my hobbies were.  I had to think about it because I didn’t have any.  I worked and did research and in between wrote articles and ghost wrote book chapters for attendings (what an honor right?).  but they were just trying to converse about the region and conduct informal non-academic interviews.  now I laugh at how absurd the lifestyle during training was.

    best wishes for whatever you decide.

     

    #137428 Reply
    ENT Doc ENT Doc 
    Participant
    Status: Physician
    Posts: 3500
    Joined: 01/14/2017

    There is no way to know what the incomes and job prospects will be for the 2 fields you are considering over the next 30 years. So do what makes you happy.

    If you also do cardiology there is a 99% chance that critical care will go by the wayside and that will be 2 years of wasted fellowship. I see people doing pulm + critical care or nephrology + crtical care who do not use the critical care aspect of medicine. But if cardiology makes you happy, pursue it.

    My only thought is at age 55-60, would you still like to be doing critical care at 2 AM. Or be in bed with a good night rest.

    Click to expand…

    Agree that if I do cardiology, CCM would probably be a wasted fellowship. I’m not sure if I understood the rest of what you said correctly – from my experience, majority of people who end up doing CCM after nephro or ID end up practicing full time CCM because it generally pays more with better lifestyle. More shift work, lack of “call”, more time off etc. The pulm folk seem to transition to less CCM and more pulm as they age.

    I would do whatever you think you’d be the happiest doing for the next 30 years. Incomes in medicine will likely change in the next 30 years, especially in regards to each other. No matter which way you go, the game has been won as long as you make good financial decisions.

    Click to expand…

    Thank you.

    I can’t see the underlying calculations on your spreadsheet but it appears you haven’t taken into account the time value of money.  What discount rate are you planning on using?  Are you going to assume a certain rate of growth in wages?  You’re a year out from potentially having a job – isn’t now the time to be looking anyway?  Seems like a more imminent decision given that you’re less than a year away from a potential fellowship spot, if not missed the window, no?  My latter point is that you and your wife should probably have reasonable estimates of Option 1 already based on a potential job search, not MGMA averages.

    Most NPV analysis that I’ve seen regarding fellowship show that it’s a bad decision.  I would ignore that for now; however, and focus on the more imminent job search issue and doing what you love – you’ll make plenty either way.  You need to be happy at the end of the day.

    Click to expand…

    I literally added the post tax dollar value as the years progressed. I did not account for a discount rate or rate of growth in wages – how do you think this would impact the analysis? More in favor of CCM, as I would start earning attending money sooner?

    Job search is ongoing for the both of us and we are seeing similar or higher numbers than what I have mentioned in my original post.

    wow, where to start.

    the things you like when you are young may not seem so awesome after doing them for twenty years.  it’s hard to remain expert at all things.  by the time you finish cardiology, interventional may well be two.  you are looking at maintaining critical care boards, cardiology boards, interventional boards.  possibly nuclear and echo and vascular as well, if you choose to maintain those certifications.   that’s a lot of studying.  I think these financial projections are impossible to rely on long term.  with two physicians, the average salaries almost don’t matter.  you can tailor the income to your needs.  in the future, your health may preclude one or both from working.  wife may stay home with kids.  you may choose to be in academics or not.  range of incomes can double depending on call schedule and geographic variances.  so if you want to make more to make up for lost time, you can.  however, I would encourage you to NOT do so, focus on the long game.

    it is way easier to go part time in critical care medicine than in cardiology.  with two physicians, if you ever have kids, you will need to be clear on how you run your family.  if you want to share time off when kids get sick, interventional cardiology is least forgiving in terms of cultural understanding.  if you want a month of paternity leave, ditto.  if your wife is comfortable that she owns the majority of family time, her practice is going to understand a lot of early departures and sick days and other things potentially.  lots of cancelled clinic appointments that will go on her permanent record.  or maybe none of these things matter.

    with both in medicine, and one in a very challenging timewise and energywise field, I think flexibility is important.  unless you love cardiology and can’t live without it, I would forego.  if you do, then pursue, but realize it’s at the expense of personal/family time.  I did nine years of clinical training with three fellowships, and my wife is a physician, so I may know a little of what I speak.

    as always

    ymmv

    jmo

     

     

    Click to expand…

    Thank you. Your post was extremely helpful. I really needed to hear this. My wife is very against me pursuing additional training but will support me if I really want to.

     

     

    Click to expand…

    Hard to say how things will turn out, but suffice it to say having an extra (presumed) $188k in post-tax money every year for 4 years will make that increased salary have to work a bit harder on the back end.  Without doing a big spreadsheet I’d say there’s bound to be crossover at some point, where your added 4 years of fellowship win out, but again I think this is the last thing I’d focus on given your dual income household.  You must have done a CCM fellowship for a reason – why not give that a test drive for a few years before making a decision?

    #137433 Reply
    Liked by Zaphod, CCM
    Avatar Kamban 
    Participant
    Status: Physician
    Posts: 2484
    Joined: 08/01/2016
    I am on the fence about pursuing additional training and am trying to convince myself that it is a bad financial decision. What else should I be considering from a financial standpoint? More early investments if I become an attending sooner, resulting in more growth over time? What else? Any other thoughts?

    Click to expand…

    You have projected earnings from age 32 to 60. After 20+ years of the same job, whether they be CCM or Card or Int cardiology you are going to have a bit of burnout. You will need to make lifestyle changes. One of the easiest is to cut back the hours. That is easier in CCM than in cardiology.

    If you are employed you will need to maintain certifications and all the crap like MOC etc. That is easier to do with just one field like CCM. Finally if your wife gets a good job at a different place or you want a change of location, it is quicker to get a job as CCM.

    #137447 Reply
    Avatar G 
    Participant
    Status: Physician, Small Business Owner
    Posts: 1799
    Joined: 01/08/2016
    My wife is very against me pursuing additional training

    Click to expand…

    I suspect the non-economic factors weigh more heavily than financial ones, as most everyone else has suggested.

    FWIW, I have had two friends that were attendings for awhile and then went back to do fellowships.  Although I couldn’t imagine the (temporary) downgrade in lifestyle and income, it seemed to work out great for them.

    Good luck!

    #137453 Reply
    Liked by CCM
    Craigy Craigy 
    Participant
    Status: Spouse
    Posts: 2049
    Joined: 09/16/2016

    A few extra thoughts/platitudes 😆  focusing pure-salary:

    1. Yeah you should absolutely apply a discount to give yourself a present value.  Just a 3% or 5% discount will make the numbers a lot more realistic and apples to apples.  Money you get today is worth more than money you get tomorrow, compound interest, uncertainty, etc.
    2. From a real-world perspective, and not just economic theory, money today is going to be worth much more to you now vs years out, too.  Bird in the hand, make hay while sun shines.  Right now you can use the money to start your life, buy yourself additional security and freedoms, buy a house, move, be in a better position to change jobs, get a jump start on your retirement savings, you name it.  Later, it’s just extra money on your pile of money.  It also becomes less certain the farther out you go.
    3. From an income tax standpoint, it’s better to spread your earnings over a longer period of years due to the nature of the progressive tax system.  If you’re planning on working 28 years, spreading your income over four fewer years may be significant.  Taxes tend only to go up and not down, and if you can stretch your income over a longer period you’ll probably realize more of your money.
    4. Pushing back the start of your career even further means you get that much of a later start, and it really incentivizes/necessitates working many more years to get that return on your investment.  Docs already get a late start as it is.  If you plan to retire early, you’re cutting off the tail of your table and the part where the deltas grow the largest.
    5. Finally, as others said above, you really can’t count on those projected salaries being accurate so far out.  The market will be very different in five or ten years, let alone 20.  High-paying specialties tend to drift down and the low-paying specialties tend to drift up.  That said, picking a field that’s more lucrative today will likely be more lucrative tomorrow as well.  Interventional cards will probably always make more money for the foreseeable future.

    Looking at your table, assuming the numbers are relatively accurate (I have no idea), you don’t hit break even on the other training options until about year 9 of 28.  It will be even longer once you factor a present value discount.  IMO, based off the table alone, it doesn’t look like the 3-year cards fellowship is worth it unless you put in that 4th year.  But you have to listen to the actual docs and not just the numbers here.

    LEVEL 1 WCI FORUM MEMBER.

    #137463 Reply
    CM CM 
    Participant
    Status: Physician
    Posts: 1168
    Joined: 01/14/2017

    FWIW, I have had two friends that were attendings for awhile and then went back to do fellowships.  Although I couldn’t imagine the (temporary) downgrade in lifestyle and income, it seemed to work out great for them.

    Click to expand…

    .

    Erstwhile Dance Theatre of Dayton performer cum bellhop. Carried bags for Cyd Charisse (gracious). Hosted epic company parties after Friday night rehearsals.

    #137577 Reply
    Avatar CCM 
    Participant
    Status: Physician
    Posts: 9
    Joined: 07/17/2018

    If you are willing to take a critical care job in a less popular area and work extra shifts you’ll probably come out way ahead in critical care, at least over the first 15 years. Who knows what will happen to compensation beyond 10 years?

    Click to expand…

    Thank you. Agree 100%!

    #137581 Reply
    Liked by EDDOCMOM

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