Today's Q&A comes from an ongoing Bogleheads thread.
Q.
I am a medical student and will be picking a specialty in the near future. I think I already have a few ideas in mind but I want to talk about them from a financial stand point. My main question being… Is it worth doing one of these long residency/fellowships or is it better to just finish as soon as possible? I expect to have minimal debt when finishing which does change things. I realize anything can happen in the future of medicine too.
It seems to me that higher paid specialists actually do work very hard despite what some may think. So in the end you are working harder/more stress anyways to get the extra money. Also the specialists are slowly but surely getting nuked on reimbursement and who knows to what extent that will continue to happen.
It seems to me that just finishing as soon as possible and making money earlier is the better option and I might be able to work a less stressful/demanding job which is always a plus. I do have some options on both sides of the playing field but I don't think I want to be in training forever. Any insight?
A.
The most common response on the thread aligned with my initial “short and sweet” advice:
Perhaps if there are two specialties you like equally choose the one that pays better. But mostly pick what you want to spend A LOT of time doing.
But the more I think about it, the more interesting this question becomes. We can all readily remember the angst that accompanied us from that first lunch-time “specialty discussion” as an MSI to the required third year rotations to choosing SubIs as an MSIV before we finally figured out what we wanted to do with our lives. Even then, lots of people still changed their mind mid-internship or even later. Should finances have carried greater weight in that initial decision? I applaud the thread's OP for even considering the topic- I don't recall that I did at all. I was halfway through my intern year before I ever gave any financially-related topic more than a passing glance.
It is well-known in my specialty that pretty much no fellowship is worth it financially. One of the longest and most popular- becoming a pediatric emergency physician, requires two more years of training in order to make less money than a run-of-the-mill emergency physician. Toxicology, EMS, Wilderness Medicine, Ultrasound, International Medicine etc. They might help you get an academic position easier, but that would probably also come with a pay cut compared to a community emergency medicine job. Critical care might be worth it, but only if you spent a significant portion of your career working as an intensivist instead of an emergency doc, which seems to defeat the purpose of an EM residency in the first place.
Pediatrics finds itself in a similar boat. Lobon, a poster on the thread, cites a study from Pediatrics that notes that only Pediatric cardiology, Pediatric Critical Care, and Neonatology seem to command salaries that justify the additional years of training. I imagine a similar study done on internal medicine subspecialties would yield similar results.
The problem comes when you consider the logical consequences of what happens when medical students actually do consider the financial implications of their specialty choice. Now that medical students are getting hit with the triple whammy of increased tuition costs, worsening loan terms (no subsidized loans and rates now 3-4% higher than mortgage rates), and decreasing compensation once in practice, more and more of them will consider the financial impact of this already difficulty choice. Even when I matriculated to medical school over a decade ago it was well-known that if you couldn't get in to your state school that you might not be able to afford to do primary care. This process will lead to a worsening shortage of important specialties that require a lot of “uncompensated training.” An editorial accompanying the Pediatrics study notes that 13 states have zero pediatric rheumatologists. A family member of mine recently developing a difficult to diagnose rheumatologic condition. It took several months and a 3000 mile plane flight to get him in to see an ADULT rheumatologist. I wonder how many rheumatologists there would be if it paid as well as invasive cardiology. Too bad you can't stent fibromyalgia.
At the end of the day though, medical students shouldn't make finances a top consideration in their choice of specialty. Even a poorly paid physician usually makes 2-3 times the average American household income. Living like a resident for a few years can wipe out the student loans. But medical training and the practice of medicine itself is too long and hard to do just for the money. You've got to love it, and that goes for each specialty as well.
A couple other comments from the thread worth quoting:
From staythecourse:
Perfect example of picking what you like, because of not knowing what will happen in the future with reimbursement is that radiation oncology. Always considered a high paying and relaxed speciality is facing a whopping 16% medicare cut that is being proposed while everyone esle is between 1-3%.
Pick what you like because medicine, like any other job, the happiness does not come from the money, but from your interest in the field.
From am-
Tough to be “interested” in the field after working 13 days straight with one day off when I do weekend shifts every month. Just a grueling marathon that leaves you burned out. Only thing keeping me going is the still nice paycheck and the hope for early retirement one day. Kinda sad. If only the committee that admitted me to med school could hear me now…
Do not believe many docs who work outside of maybe academics really like their job or have much interest in their field as it becomes so routine and numbing after years of practice.
What say you? How much should a medical student consider the financial implications of his specialty choice? Comment below!
financial considerations SHOULD be prominently included in any rational thought process involving specialty choice by med students. i think it is as hard to predict the short-medium term behavior of the medical marketplace as it is to predict the stock or bond market. all we know is how things are now, and the uncertainty involving any future predictions is immense. what they told me when i started med school in ’96, that “specialist pay will be much lower, primary care pay will be much higher, and specialists will have relative trouble finding jobs” just has not panned out thus far. i am very glad that i did not take that advice to heart, and instead chose a specialty that i thought would hold my interest for years, that allowed for a good amount of flexibility in terms of schedule and work venue, and had the best ratio of $/work hour among the specialties that i was considering.
It depends on the person.
For me, I would never have gone through the 8 years (more if you count college) of unpleasantness were it not for the nice pay and good lifestyle waiting at the end of the tunnel. I don’t think I’m in the minority here. Look at the residency match statistics for the most competitive specialties every year: I have a hard time believing that that many people discover within themselves, either before or during medical school, an unquenchable passion for treating skin. Come on. We all know why derm has a 50% match rate, and if my grades and step 1 score had been slightly better, I’d probably have tried for it too.
I picked a specialty that I do enjoy relative to all the other options, but above all else I limited my choices to fields of medicine known for decent pay and good lifestyle. I learned early on in my training that I can not be a happy person, regardless of what job I have, if I am working 60 hours a week with little free time. That’s just me though. One of my best friends is a trauma surgeon and he loves being in the hospital all the time. To each his own. My satisfaction in life is derived from what I do in the evenings, weekends, and time off. What I do during the day… it’s a job.
i think a lot of the disenchantment we hear stems from an incorrect assumption when starting medical school that doctors either spent a lot of time playing golf or made tons of money.
the simple and sad fact is that neither of those are true for any specialty or primary care doctor, with the above noted exceptions in the other posts. financial considerations are important in any major life decision, there is no question about that. however, given that all training in medicine or surgery is hard, and the lifestyle afterwards is even harder, you need to pick something that you truly love. but even more important than that, you need to understand that it will not love you back. as the Fat Man says “they can always hurt you more.”
i picked a surgical specialty that even most surgeons even think is painful, vascular surgery, and i love it, not everyday, but just about. i know not everyone is lucky enough to find a job they love, even in medicine, but remember that no matter how much a job pays, it won’t make you like it more.
and in the end, if you find that you end up hating whatever you do, stop doing it.
This comment was emailed in:
I would tell a medical student who asked about this that there are two ways to make more money practicing medicine, doing procedures and employing mid-level staff. The most lucrative approach is to choose a specialty that allows a lot of procedures, since they pay far more per hour than evaluation and management work. Surgical specialties, ophthalmology, dermatology, cardiology, radiology and GI come to mind in this regard. Specialties like internal medicine, pediatrics, psychiatry, neurology, rhemumatology and endocrinology rarely generate the big bucks.
The second approach, which is less reliable, is to have a lot of people working for you. An office with several PAs or NPs may generate enough income that the supervising MD does very well. The best situation of all is supervising mid-levels who do procedures, like a neurosurgeon’s PA adjusting shunts or brain stimulators.
But I agree with those who say that the money is not everything. If you hate your work, they cannot pay you enough to keep doing it for years. Pick a field you enjoy, where you feel you are making a contribution to the world, and don’t envy the people who chose to do procedures or run an empire. Research says that beyond $75,000 a year, more money does not correlate with more happiness. Unless you feel your circumstances require a really high income for some reason, you don’t need to choose your life’s work in medicine based on making the most money. It’s OK to choose a lower-stress field, invest wisely, and small the roses as life goes by.
Neurologist, 62
Great post – also a topic that I didn’t really consider as a medical student.
It also seems that these posts are overwhelmingly represented by non-surgeons. I’m a plastic surgery resident in my last year (PGY7) and am starting a fellowship in hand/microsurgery next summer. I have $250k in student loan debt, two kids, a house that is under water (thanks to housing market crash) – all in all a terrible financial situation. That said, I love my job (mostly), and derive great satisfaction from the constant technical and mental challenges as well as the ability to work with incredibly smart people daily. I anticipate doing well financially in the future (no guarantee), owing at least partially to my broad-based training.
As stated previously, money is not everything. It certainly helps, but I would encourage medical students to avoid making this the sole determinant of your specialty choice. Find something you enjoy and are/will be good at and try to be great at what you do.
I also chose my specialty (Pediatrics) based on what I had enjoyed most. I knew about the financial “downside”, but for me it was not as if I was equally torn between Peds and a more highly compensated specialty. That said, I do love my job and almost every day when i am driving in I look forward to working. I am not sure that an additional $100k (or even $300k) would be enough to overcome that if I were burnt out or did not like my job. Of course when you do not come from a background of a lot of money even your residency stipend can make you feel “rich”.
Thanks for the blog; I have learned a lot from it.
Its really hard to pick a specialty. there is such limited time to make that decision and your view of it is always so skewed. few doctors practice whatever specialty in the same teaching hospital situation that they learned about the specialty. Understanding the money side is just as complicated with the additional problems of uncertainty and even propaganda (im sure many of us have been told that primary specialties are going to be paid much better in the future and while that may be true, there isnt any evidence for it). Fortunately even the worst paid specialties make reasonable money.
While I think it would be foolish to chose a field SOLELY on money, I think it would be equally as foolish to ignore the money. While being an MD is a consuming profession, there is more to life than being a doctor. Whatever your outside interests are, having more cash helps you enjoy those interests.
Also, with in a given field the salaries paid can vary greatly irrespective of workload. I’ve seen some intensivists who make in the mid 100s but work in a prestigious academic organization, to those who make in the mid 300s in more remote areas for the same amount of work.
I think what is clear is that primary care is getting the raw end of the deal since there are times where you can subspecialize for a few extra years of training and almost double your salary. There are few opportunities like that outside of medicine. I posted more about this a while ago on my blog: http://www.picumd.com/2011/04/physician-salaries-and-loan-debt-is-it.html
In a nutshell do what you like, but realize that if your goal is to drive a ferrari, you’re not going to do that on a primary care MD’s salary.
I’m currently a PGY-I. My opinion is that medical students pick residencies during a time of their life that does not remotely represent what their next 30-40 yrs working will be like. Most are single, or at least without children. To them being in the hospital for long hours is not as troublesome since there is not much going on in their life outside work. Things become very different once children are born. I had my son during MS4, and I specifically avoided fields with long hours and those that would keep me away from family.
Furthermore medical students are sold this idea that primary care and IM are somehow good fields to go into. Especially family medicine tries to recruit med students in a misleading way (med students get treated very well on these rotations). In reality, doctors in these fields are overworked and under paid. Yes, they are easy to get into, but not easy to work in.
And finally $. Yes, salary is very important. I can’t stand arguments “its OK to work in primary care and make slightly more than a physician assistant/nurse anesthetist (and sometimes less) because “its where my heart is/”its what I enjoy most”. Come on now. There are many lifestyle specialties that are stimulating and interesting. I do not see any reason to go into primary care (overworked, underpaid, dumped on by all specialists; mountain of paperwork). So why would anyone graduating today (with most student loans in history) go into these fields?
The decision making of most medical students are not driven by reality, but by faculty and teachers around them. Their perspectives are guided by reasons that are not always in best interest of students (such as “our graduates choose primary care, we are diverse, etc…”. Similar situation is in undergrad institutions where students choose fields such as “anthropology, English writing, etc.” based on advise from their counselors (who have little out-of-academia experience). Often times they are told “choose what you love”, and nothing else is explained or put in perspective (i.e. quality of work-life, salary, ability to get a job; low-tier-providers, work-life balance).
I advise students to choose specialty fields and look hard at future implications of their choices. Not just what their academic advisers think is a good fit for them.
In the nearly 20 years I’ve been in radiology, the market has gone through cycles of job availability. (Currently the market is tight for job-seekers.) In tight markets, residents usually do a fellowship, but when good jobs were plentiful, many residents skipped fellowship to get a paying position (now some are going back for additional training).
Most rad fellowships are 1 year in length (neuro is usually 2), so not a huge additional time investment, but fellowship does not generally increase our income, as groups typically split profits (but may give bonuses based on volume or revenue generated.) Fellowship is mostly useful in finding the position you want in the first place.
Currently mammography and interventional are in highest demand. Residents often choose fellowship based on market factors, but how much time you spend in your specialty vs. doing general radiology is a function of the specific practice you join. (And interventional radiology tends to be extremely demanding call-wise.)
I would echo the ‘short and sweet’ advice: all things being equal, give financial situation greater weight, but any specialty is stressful enough without the added burden of hating what you do.
Given current economic /health care situation, no one knows exactly what the future will bring (although I don’t see much optimism) but I suggest that a medical student spend some time asking questions, either of their attendings or on forums, asking about pros and cons of their top choices, and what the economic outlook is. One thing to consider is whether a specialty has sideline or cash-only opportunities. E.g., if I was considering ID, I would think about working for a group with a nice travel clinic.
Sent in by email:
I am a Physiatrist. Another name: Physical Medicine and Rehabilitation.
I bet not too many medical students know about this field. I went into in 1987. At that time, this was an unknown field. Most of the residents in the field were FMG’s because the residencies could not fill the openings with American trained medical students.
Now it is one of those fields where only US medical school- trained students get accepted into residencies. How times have changed.
Private practice doctors in our field can have a lucrative income, especially if they located in a town where they are the only ones available for consults/treatments. Some are very, very well compensated, if you know what I mean.
I’m a first year EM attending.
I see the light financially. I have a total of about $250k in debt which is equal almost exactly to one year compensation (academic job with good retirement match).
It is very manageable. I don’t love paying $1800 in loans every month but there is a whole hell of a lot left over even after that.
I max out contributions to my retirement accounts, have a 22% savings rate, and even on a 10 year loan repayment plan have about an extra 3k/mo to play around with than I did as a resident. Let me repeat: that is AFTER an aggressive savings plan that should allow me on time if not early retirement.
I live in a huge city and pay for rent and parking at a rate much higher than I would if I lived in Des Moines.
The people who are going to be in trouble are those who have loan burdens that are much more than 100% one year gross salary. I spoke with a fairly irresponsible student recently who has over 600k in med school and undergrad debt. He has screwed around in med school, taken time off, maxed out loans, etc. The MINIMUM payment on this would be over 3k/month and that would probably amortize the loan in 30 years. He’s nontrad which means that he may carry the debt into retirement. He is is deep s*** unless he goes into a really high paying field.
And just FYI I’m playing around with my extra money by putting it towards my debt. Living like a resident is actually pretty easy. It’s all about priorities. I would rather forgo the luxuries now and have a nice house in 10 years than buy all the trinkets now and have PUD when I’m 45.
no need to consider ‘pay’ when choosing specialty. just follow your heart. aim to attain financial freedom by meeting your ‘goal’ asap by saving and investing. once you attain your ‘number’ you will find that you are willing to even work for a very low pay to do what you actually like. hence the need to ‘ follow your heart’