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Starting M4 Year – Seeking Some Advice on Residency for Career Goals

Home General/Welcome Starting M4 Year – Seeking Some Advice on Residency for Career Goals

  • Avatar SandorClegane 
    Participant
    Status: Student
    Posts: 5
    Joined: 05/25/2019

    Greeting WCI community,

     

    A little background: I graduated college with a degree in Economics, worked in business development (sales, account management, marketing) for a few years in the software industry, then decided to pursue medical school. I will graduate in May 2020 at age 35 as a bachelor with approximately $100,000 in overall debt (thank you mom and dad!).

     

    My question is about what career path to choose for what I want in life. What sounds great to me now, is initially working 10-20% of my time doing inpatient medicine (med, peds, psych, whatever), and to spend 40-50% doing outpatient/private practice medicine, and the remaining time traveling and becoming an entrepreneur.

    When I say entrepreneur, I mean I would be happy owning my own psychiatry practice and hiring other docs/NPs/PAs and spending several months a year abroad or traveling and keeping up with patients via telepsychiatry/telemedicine. OR, going into a primary care field and using capital from friends and family to start a clinic and hire NPs/PAs to see patients, have PTs/OTs for rehab, in-house pharmacy etc.

    At the end of the day, what I really want is to have enough money and flexibility to live a nice life, travel alot, and take care of my parents and disabled sister. I want to shoot for the stars (become a multimillionaire, start foundations, etc.) but I would be happy with being wealthy enough to live a comfortable abundant life for me and my family.

     

    So my questions please are:

     

    1. Is this type of career path realistic? How hard is it to open a PP psychiatry practice and transition to mainly doing admin type work and telemedicine from abroad? How feasible is it to be a Pediatrician or IM doc and own a multi-million dollar clinic with NPs doing my scut work? I don’t have rich parents or family, so I would be taking out business loans or asking friends and family to invest.

    2. What residency path is most conducive to my desired life of good income/wealth building, lifestyle, travel? (Of course, I am still very interested in patient care and helping patients!)?  Right now, I am considering combined training in Peds-Psych-Child psych fellowship (aka Triple Board), combined Med-Psych, and considering straight Psychiatry. Things I have also considered are Anesthesiology (but I like talking too much), PMR (missed “medicine”), IM+Critical care/Onc (I’m old and don’t want to go thru 2 matches, knowing that I maybe won’t even try to match again bc I’ll be tired).

    3. A bit out of scope, I feel like combined training would give me the most versatility in terms of business opportunities; but if that doesn’t work out, as an employed physician, there would be no point to maintaining multiple board certs. The chair of psychiatry at my school said I should continue to do away rotations in these fields, but be mindful that the vast majority of combined training grads only do psychiatry.

    4. Any other wisdom or career advice for me? I have about 3 months before ERAS opens…..

     

    Thank you very much!

     

     

     

     

    #216860 Reply
    Avatar Peds 
    Moderator
    Status: Physician
    Posts: 4440
    Joined: 01/08/2016
    1. Is this type of career path realistic?

    Click to expand…

    i dont see your vision

    be a Pediatrician or IM doc and own a multi-million dollar clinic with NPs doing my scut work?

    Click to expand…

    um….wow.

    2. What residency path is most conducive to my desired life of good income/wealth building, lifestyle, travel?

    Click to expand…

    i mean, you shouldnt have transitioned INTO medicine.

     

    #216867 Reply
    Avatar jacoavlu 
    Moderator
    Status: Physician, Small Business Owner
    Posts: 2381
    Joined: 03/01/2018

    There are lots of paths in medicine to make money.
    There are lots of paths in medicine to have time off and flexibility.
    There’s not very many paths to have a lot of both.

    It’s like a scatter plot. X axis is money. Y axis is time working. The general trend will be up and to the right. To be far out right and low on the Y axis is really rare.

    I would challenge you to support a conclusion that multi specialty certification affords more business opportunities. I think lots of those folks end up on the wrong side of the best fit time-money curve.

    The Finance Buff's solo 401k contribution spreadsheet: https://goo.gl/6cZKVA

    #216878 Reply
    Avatar nephron 
    Participant
    Status: Physician
    Posts: 227
    Joined: 05/09/2019
    Earnest refinancing bonus

    It’s actually hard work to start a practice and build a large enough referral base to the point where you can hire an employee physician or nurse practitioner. If i were you and wanted to get rich quick, I would move out in the Midwest, do a lot of moonlighting as an inpt psych in addition to your day job, then you can figure out what to do with your assets to make them grow. Right now you have a negative net worth, it is much easier to get rich if you are already rich. I don’t think that it’s easy to open a multi doctor practice, I imagine that there are easier and shorter ways to build up wealth, but most do require some initial capital.

    #216883 Reply
    Avatar Outdoors 
    Participant
    Status: Resident
    Posts: 27
    Joined: 08/12/2017

    I’m just starting residency, so take my comments with a grain of salt.  I agree that it’s difficult to build up a large practice business like you described, and it will probably require a lot of work to start up.  But is it impossible? No.  Some physicians have built large practices where they can make tremendous profits, and of course also take on the added risks as a business owner.

    If I was in your shoes, I’d do psychiatry only.  I don’t know enough about the field to know whether you’d need a child psych fellowship, but I suspect the demand is so great in places that you might not.  There’s great moonlighting opportunities in residency (and more free time to do the moonlighting than a lot of other specialties).  As an attending the demand is sky-high for psychiatrists. There was a post on here a while back about a psychiatrist who made incredible money setting up moonighting that you might want look up.

    Your business ideas you mentioned may or may not come to fruition.  So much depends on the future of medicine and health insurance in the US, who controls Congress, competing businesses, etc.  As a psychiatrist you can definitely make very good money and have a comfortable lifestyle.  If you just wanted to travel like you said, you could even just pick and choose among locums jobs and travel when you’re off.

     

    #216894 Reply
    Liked by SandorClegane
    Vagabond MD Vagabond MD 
    Participant
    Status: Physician
    Posts: 3475
    Joined: 01/21/2016

    I love your screen name. It made me open the thread and read your post. He may have been my favorite non-Stark character in the series, and the acting performance was consistently outstanding.

    Basically, you want it all, and I do not blame you for it. The actual blocking and tackling of doctor work is quite grueling. Yes, you can do all of the things that you suggest in the OP, but you will have to really work your ass off to get to that point: building a practice, cultivating a professional network, and having top line clinical skills. Most docs cannot do all three, but I think you can.

    Good luck!

    "Wealth is the slave of the wise man and the master of the fool.” -Seneca the Younger

    #216898 Reply
    Avatar BCBiker 
    Participant
    Status: Physician
    Posts: 235
    Joined: 01/10/2016

    I agree with general sentiment so far on this thread. Medicine is a good hourly rate but multimillionaire status making a good hourly rate takes many years and the more you prioritize lifestyle it is at the expense of hours at that hourly rate. If your goal is to build a business you should spend all of your time when you are not learning medicine to learn about businesses. Find a business mentor with experience in healthcare. Find some volunteer consulting opportunities where you can see the struggles of a real healthcare business. It might not be as glamorous as you think. With your goals, the sooner you can get into active practice the better because when you are in training, you are not building your business.

    Your concept of your future career seems a bit whimsical.  I’m going to own a practice and hire people to do the work while I travel the world.  When I feel like seeing patients I can have them Skype me as long as I’m not climbing Mt. Fuji at the moment. I don’t want to crush your hopes and dreams but those seem like fairly unrealistic expectations in the short term. It is not impossible in the long term though. Getting to that point will take a lot of work.

    #216899 Reply
    Avatar Tim 
    Participant
    Status: Accountant
    Posts: 3067
    Joined: 09/18/2018

    “ (sales, account management, marketing)”!
    If you wish to “run” a healthcare practice, that admirable. If you wish to practice in a healthcare field, that is admirable too.
    It sounds like 1/3 medicine, 1/3 business, 1/3 leisure.
    Almost everyone finds it extremely challenging becoming fabulously wealthy devoting 100% effort in any one of the areas. Personally, I would pick leisure. Unfortunately, start with medicine, then the business, and then the leisure.
    The psych guys story involved extremely long hours 7 days per week. The key is developing the revenue stream, needing help to fill the hours, and grow omg the business. Doable, but the leisure part depends on how successful you are on the first two goals. Then you cut back and enjoy the fruits of your labors.
    It’s called part time or retirement (some sooner than later).
    Good luck.

    #216904 Reply
    wonka31 wonka31 
    Participant
    Status: Physician
    Posts: 701
    Joined: 03/24/2018

    I think you need to figure out what you want to do, then learn that field well, then build up a practice and then become the mogul you set out to be. As discussed above, this doesn’t happen overnight. The wealthiest people I know also work as hard as anyone I know and are true grinders. If you have it in you, go for it, but you have to crawl before you sprint.

    #216907 Reply
    Avatar Brains428 
    Participant
    Status: Physician
    Posts: 398
    Joined: 11/09/2017

    Add pediatric to anything and you generally take a pay cut.

    While you may have big dreams about lifestyle and money, I would keep some of those sentiments to yourself during interview season. It’s not to say that you didn’t factor that in when picking a subspecialty, but no amount of money will make you enjoy that job. Residency offers little flexibility in time and money, and the last thing anyone wants is a resident who is difficult to work with. I would see a few med students who would pursue radiology because of the lifestyle possibilities, and many of them failed to remember that they still had to be a radiologist and enjoy that.

    Most people who made a ton of money in medicine didn’t do it traveling and not working their butts off.

    Be weary of saying NPs/extenders do scut work. You may feel that way, but… maybe keep that to yourself.

    Don’t get dual boarded unless it’s something you really want to do. Extra time training and more tests all just to do the same job as the person who has a single certification (as I understand and have seen, but feel free to correct me).

    Sometimes I feel like I’m speaking out of both sides of my mouth because I will criticize the decision to go into a typically lower paid specialty because it seems like a poor decision financially, but I will equally criticize you for thinking of the financial aspect first and the medicine second. It’s a difficult decision and there are few perfect situations that will satisfy all your desires of time/money/career fulfillment.

    Although it may be very anti-WCI geo arbritrage, you may want to consider going to one of the larger cities to have the opportunities to obtain connections. Also, you may try to prioritize a program that has already built tele-medicine into training so you can take that knowledge wherever you go. If it’s not established already, it may not be worth it unless you really want to get your hands dirty trying to build such a program at a university (personal experience, and it was only a small arm of a larger moderately established system).

    No matter what you choose, good luck. 4th year is enjoyable and interview season is fun (and expensive).

     

    #216912 Reply
    Avatar Anne 
    Participant
    Status: Physician
    Posts: 1172
    Joined: 11/07/2017

    It’s not clear reading your post what your career goals really are. Do you want to be an entrepreneur because you have that entrepreneurial spirit or because you see it as a way to keep the income coming in while you travel?

    If the former, then work towards building your own business. But expect to work a lot doing it, for many years before it’s on auto-pilot enough that you can leave for any significant amount of time.

    Leaving mid levels alone to run your business without much onsite supervision sounds like a big liability risk to me. Personally I would never be comfortable doing that. Plus you will really need to trust the people who are doing the onsite work while you are away. That kind of trust takes years to build, plus skill and luck in attracting the right people. You will be at least 38/39 when graduating residency, then a few years to really feel strong clinically on your own, then a few more years to build up the business…you’re talking mid to late 40s at the earliest before you have a chance of really reaching this dream lifestyle. If you don’t have an internal mandate to become an entrepreneur, I think the same goal could be achieved in the same time frame by working as hard as you can upon completion of residency, saving like crazy so you have at least a couple million by mid-late forties (do you have any head start on retirement funds from your prior career? How much do you need to live happily?) and then traveling alternating with locums. Then when you are traveling you are truly off and not trying to run a business from the other side of the globe. Psych seems like it would be very amenable to intermittent locums with an inpatient/outpatient mix, but I don’t know for sure.

    If you do start a business i would recommend against hitting up friends/family for starting capital, especially if they are non-wealthy and it could really hurt them if the business fails.

    Also keep in mind that goals change as you get older. I had similar goals of spending months at a time abroad when I was mid 30s. I’m not that far away (early 40s) but already have built up social commitments and roots in my community and the thought of leaving them for months at a time every year is becoming less appealing. I still like to travel, but my desired time frame has shrunk a bit. So many things impact this as you get older–whether you get married and what your spouse wants to/can do, children, hobbies, parents’ (and siblings) health, etc.

    TLDR: all dreams are possible, but many are not probable. Dreams change with time. Choosing the right specialty imo makes a big difference in long term work satisfaction.

    Avatar SandorClegane 
    Participant
    Status: Student
    Posts: 5
    Joined: 05/25/2019
    1. Is this type of career path realistic? 

    Click to expand…

    i dont see your vision

    be a Pediatrician or IM doc and own a multi-million dollar clinic with NPs doing my scut work? 

    Click to expand…

    um….wow.

    2. What residency path is most conducive to my desired life of good income/wealth building, lifestyle, travel? 

    Click to expand…

    i mean, you shouldnt have transitioned INTO medicine.

     

    Click to expand…

    Per for the forum rules, I would appreciate if you didn’t make judgments about me without knowing me.

    #217211 Reply
    Avatar Peds 
    Moderator
    Status: Physician
    Posts: 4440
    Joined: 01/08/2016

    The code is more what you’d call “guidelines” than actual rules….

     

    or as an alternative:

     

    Smoky, this is not ‘nam. This is bowling. There are rules…
    #217216 Reply
    Avatar SandorClegane 
    Participant
    Status: Student
    Posts: 5
    Joined: 05/25/2019

    There are lots of paths in medicine to make money.
    There are lots of paths in medicine to have time off and flexibility.
    There’s not very many paths to have a lot of both.

    It’s like a scatter plot. X axis is money. Y axis is time working. The general trend will be up and to the right. To be far out right and low on the Y axis is really rare.

    I would challenge you to support a conclusion that multi specialty certification affords more business opportunities. I think lots of those folks end up on the wrong side of the best fit time-money curve.

    Click to expand…

    It’s actually hard work to start a practice and build a large enough referral base to the point where you can hire an employee physician or nurse practitioner. If i were you and wanted to get rich quick, I would move out in the Midwest, do a lot of moonlighting as an inpt psych in addition to your day job, then you can figure out what to do with your assets to make them grow. Right now you have a negative net worth, it is much easier to get rich if you are already rich. I don’t think that it’s easy to open a multi doctor practice, I imagine that there are easier and shorter ways to build up wealth, but most do require some initial capital.

    Click to expand…

    It’s actually hard work to start a practice and build a large enough referral base to the point where you can hire an employee physician or nurse practitioner. If i were you and wanted to get rich quick, I would move out in the Midwest, do a lot of moonlighting as an inpt psych in addition to your day job, then you can figure out what to do with your assets to make them grow. Right now you have a negative net worth, it is much easier to get rich if you are already rich. I don’t think that it’s easy to open a multi doctor practice, I imagine that there are easier and shorter ways to build up wealth, but most do require some initial capital.

    Click to expand…

    I love your screen name. It made me open the thread and read your post. He may have been my favorite non-Stark character in the series, and the acting performance was consistently outstanding.

    Basically, you want it all, and I do not blame you for it. The actual blocking and tackling of doctor work is quite grueling. Yes, you can do all of the things that you suggest in the OP, but you will have to really work your ass off to get to that point: building a practice, cultivating a professional network, and having top line clinical skills. Most docs cannot do all three, but I think you can.

    Good luck!BCBiker wrote:

    I agree with general sentiment so far on this thread. Medicine is a good hourly rate but multimillionaire status making a good hourly rate takes many years and the more you prioritize lifestyle it is at the expense of hours at that hourly rate. If your goal is to build a business you should spend all of your time when you are not learning medicine to learn about businesses. Find a business mentor with experience in healthcare. Find some volunteer consulting opportunities where you can see the struggles of a real healthcare business. It might not be as glamorous as you think. With your goals, the sooner you can get into active practice the better because when you are in training, you are not building your business.

    Your concept of your future career seems a bit whimsical.  I’m going to own a practice and hire people to do the work while I travel the world.  When I feel like seeing patients I can have them Skype me as long as I’m not climbing Mt. Fuji at the moment. I don’t want to crush your hopes and dreams but those seem like fairly unrealistic expectations in the short term. It is not impossible in the long term though. Getting to that point will take a lot of work.

    Click to expand…

    “ (sales, account management, marketing)”!
    If you wish to “run” a healthcare practice, that admirable. If you wish to practice in a healthcare field, that is admirable too.
    It sounds like 1/3 medicine, 1/3 business, 1/3 leisure.
    Almost everyone finds it extremely challenging becoming fabulously wealthy devoting 100% effort in any one of the areas. Personally, I would pick leisure. Unfortunately, start with medicine, then the business, and then the leisure.
    The psych guys story involved extremely long hours 7 days per week. The key is developing the revenue stream, needing help to fill the hours, and grow omg the business. Doable, but the leisure part depends on how successful you are on the first two goals. Then you cut back and enjoy the fruits of your labors.
    It’s called part time or retirement (some sooner than later).
    Good luck.

    Click to expand…

    I think you need to figure out what you want to do, then learn that field well, then build up a practice and then become the mogul you set out to be. As discussed above, this doesn’t happen overnight. The wealthiest people I know also work as hard as anyone I know and are true grinders. If you have it in you, go for it, but you have to crawl before you sprint.

    Click to expand…

    Add pediatric to anything and you generally take a pay cut.

    While you may have big dreams about lifestyle and money, I would keep some of those sentiments to yourself during interview season. It’s not to say that you didn’t factor that in when picking a subspecialty, but no amount of money will make you enjoy that job. Residency offers little flexibility in time and money, and the last thing anyone wants is a resident who is difficult to work with. I would see a few med students who would pursue radiology because of the lifestyle possibilities, and many of them failed to remember that they still had to be a radiologist and enjoy that.

    Most people who made a ton of money in medicine didn’t do it traveling and not working their butts off.

    Be weary of saying NPs/extenders do scut work. You may feel that way, but… maybe keep that to yourself.

    Don’t get dual boarded unless it’s something you really want to do. Extra time training and more tests all just to do the same job as the person who has a single certification (as I understand and have seen, but feel free to correct me).

    Sometimes I feel like I’m speaking out of both sides of my mouth because I will criticize the decision to go into a typically lower paid specialty because it seems like a poor decision financially, but I will equally criticize you for thinking of the financial aspect first and the medicine second. It’s a difficult decision and there are few perfect situations that will satisfy all your desires of time/money/career fulfillment.

    Although it may be very anti-WCI geo arbritrage, you may want to consider going to one of the larger cities to have the opportunities to obtain connections. Also, you may try to prioritize a program that has already built tele-medicine into training so you can take that knowledge wherever you go. If it’s not established already, it may not be worth it unless you really want to get your hands dirty trying to build such a program at a university (personal experience, and it was only a small arm of a larger moderately established system).

    No matter what you choose, good luck. 4th year is enjoyable and interview season is fun (and expensive).

     

    Click to expand…

    It’s not clear reading your post what your career goals really are. Do you want to be an entrepreneur because you have that entrepreneurial spirit or because you see it as a way to keep the income coming in while you travel?

    If the former, then work towards building your own business. But expect to work a lot doing it, for many years before it’s on auto-pilot enough that you can leave for any significant amount of time.

    Leaving mid levels alone to run your business without much onsite supervision sounds like a big liability risk to me. Personally I would never be comfortable doing that. Plus you will really need to trust the people who are doing the onsite work while you are away. That kind of trust takes years to build, plus skill and luck in attracting the right people. You will be at least 38/39 when graduating residency, then a few years to really feel strong clinically on your own, then a few more years to build up the business…you’re talking mid to late 40s at the earliest before you have a chance of really reaching this dream lifestyle. If you don’t have an internal mandate to become an entrepreneur, I think the same goal could be achieved in the same time frame by working as hard as you can upon completion of residency, saving like crazy so you have at least a couple million by mid-late forties (do you have any head start on retirement funds from your prior career? How much do you need to live happily?) and then traveling alternating with locums. Then when you are traveling you are truly off and not trying to run a business from the other side of the globe. Psych seems like it would be very amenable to intermittent locums with an inpatient/outpatient mix, but I don’t know for sure.

    If you do start a business i would recommend against hitting up friends/family for starting capital, especially if they are non-wealthy and it could really hurt them if the business fails.

    Also keep in mind that goals change as you get older. I had similar goals of spending months at a time abroad when I was mid 30s. I’m not that far away (early 40s) but already have built up social commitments and roots in my community and the thought of leaving them for months at a time every year is becoming less appealing. I still like to travel, but my desired time frame has shrunk a bit. So many things impact this as you get older–whether you get married and what your spouse wants to/can do, children, hobbies, parents’ (and siblings) health, etc.

    TLDR: all dreams are possible, but many are not probable. Dreams change with time. Choosing the right specialty imo makes a big difference in long term work satisfaction.

    Click to expand…

    Hey everyone, thank you VERY much for the proptips and sage advice.

     

    It seems the general consensus is that my dream/vision is possible but will be very hard to do. Some of the take home messages I have received are that to achieve a lifestyle of business ownership while traveling/leisure and relying on telemedicine is fairly fantastical. I understand this, and unless telemedecine changes drastically in the next decade or so my best bet would be to do locums work to get my travel bug itched.

    Further I understand that the best strategy for myself to get wealthy is to work hard, save, save, and invest wisely. To answer a previous poster, I have about $40k in assets in various wealth management funds (again thanks mom and dad), and about $25k in my roth IRA. To add some more context to my whimsical dream, my previous career started working for a very successful family member who is an entrepreneur in software and health IT. I got my chops cold-calling physicians and trying to sell them e-prescribing, practice management, and EMR software that my family member’s company sold. I also did this while working for a congressman and built some political connections leading to various business/networking positions and local political appointed positions. Because I was good, this helped me work up into working with high dollar clients and bigger software implementation deals in hospital systems and stuff. This was all maybe 7-10 years ago now, but the seed of entrepreneurship/leadership has been inside me for a long time. In fact this same family member has been talking to me about opening up a clinic and how he’d just need a doctor (*hint, hint) who would oversee stuff and sign prescriptions. He made some comments about having physician friends who had multimillion dollar clinics and how every doctor must be doing medicare fraud.

    To be honest, while I totally believe this family member could help me get rick quicker in this regard, I don’t ethically believe in working with someone who is ok with any sort of medicare fraud even if they are a multimillionaire with tons of connections. Not to mention I’ve worked way too hard to do anything illegal anyway.

    It also seems that I should probably decide on one field and stick with it. Financially, it sounds like psych would be the best for more time off to moonlight and make money, and for lifestyle, and for demand in the midwest/rural.

    I appreciate the positivity of how it will be hard but possible, I guess step 1 is figuring out my specialty choice and going from there. It sucks because I really do love psych, and general inpatient peds, and all sorts of adult medicine (but not general IM/hospitalist).

    ….Yeah, Sandor Clegane has definitely been one of the best characters in the books and defnitely the show. His one liners this season have been the only highlights in otherwise garbage writing IMO. The scene from season 4 with him and Arya and the chickens still gets me everytime hahaha.

    #217218 Reply
    Liked by Vagabond MD
    q-school q-school 
    Participant
    Status: Physician
    Posts: 2629
    Joined: 05/07/2017

    If you are agnostic to specialty, and your goals are as simple as you outline, it’s easy.

    I’m still not convinced you shouldn’t be a Hospitalist with one week one and one week off.  Pick an underserved area to work since you will be traveling half the year and you can be a multimillionaire by 45 easily.  You will have 26 weeks of the year to travel.  If you want to work less, those jobs typically allow part time work even.  If you want to be a multimillionaire by 43 do nighttime hospitalist.  Easy.

    to scratch the entrepreneurial side, do a non medical side hustle that you can run from the internet anywhere.  Problems solved.

    Not getting why you don’t want to do adult medicine.  What specifically is turning you off to it?   But it doesn’t matter if i get it or not.  Pick ED then.  This shift work is what will allow you to run out the door and travel when you want.  If you have long term relationships with patients, it gets harder and harder to do that as the years go by.

    i’m not sure whether you are trolling us.  Why would you ever write that your wealthy family member thinks physicians are frauds and then say he wants you to open a clinic with your medical license?  So you can commit said fraud and s/he can get rich?

     

    #217222 Reply
    Liked by Anne, CM, octopus85, wonka31

Reply To: Starting M4 Year – Seeking Some Advice on Residency for Career Goals

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