The Hospitalist medicine profession was almost unheard of 20 years ago. Today it is one of the most popular jobs for physicians, simply due to the demand for hospital medicine and the evolution of healthcare.
Most doctors well into their tenure of medical already have a general idea about how other specialists spend their days (except for radiation oncologists, where NO ONE else knows what they do). However, as a medical student I had incredibly limited insight on the variety of means to practice medicine. Even as an attending physician, I am still discovering how creative some medical specialties allow one to be. For instance, how many of you guys knew that you could be a cash-only neuromuscular neurologist?
Fortunately all medical school rotations will include some exposure to pediatrics, but this doesn’t mean that one or two months of rotation is actually adequate to inform students on the merits of pediatrics. This article will serve as an overview for those students considering a career in medicine or those medical students who are in their MS3 rotations considering what specialty to choose.
The medical aspects of pediatrics
Pediatricians take care of children, who are not small adults! This ranges from well visits to intensive care hospitalizations. One can also opt to take of children as sub specialists who train in a separate fellowship, like pediatric cardiology. There are too many pathways to take care of kids than I can keep track of. A rough diagram can be summed up as such:
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Pediatrics residency spans three years, with some programs adding a year of research if you choose. Fellowships can also span anywhere from one year to as long as one desires, although at some point you have to realize that the only way to truly master your profession is to get out and practice medicine. After training, there are a few common venues to practice pediatrics.
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The daily grind
Outpatient pediatric medicine is the more common approach to practice, and it is exactly what you think it is. Patients are scheduled perhaps every twenty minutes throughout the day, along with space for add-on emergencies. Some are well visits. Others are sick visits. Kids also get sick during winter months, so pediatricians are typically busier during those months. A pediatrician’s clinic schedule may range from twenty to thirty patients a day. It’s also common for most doctors to spend at least an hour after clinic tidying up notes or calling patients/parents about lab or test results. With the mandate of electronic health systems, we can all expect to spend some time after clinic to finish charting.
Years ago, most outpatient doctors also took care of their own patients while hospitalized. It’s more common that there are some pediatricians who work strictly on the inpatient services to take care of hospitalized kids. What that means is that you could become a pediatrics hospitalist. All newborns need to have a physicians in order to be discharged from the hospital.
Unfortunately as important as our next generation is, society has decided to reimburse “pediatrics” anything at only insulting to mediocre levels. We all have to realize that none of us should ever consider going into medicine for the sake of money, but many medical students that have rotated with me have boldly commented on physician salaries. The bottom line is that you’re not going to starve if you become a doctor who takes care of kids. Don’t expect to own any McMansions.
There are also options to go against the grain. Concierge medicine is becoming more popular in affluent areas, where the patients pay a certain retainer to obtain better “access” to the doctor. It is more common for internists to become a concierge practice, although the same can theoretically be done in pediatrics.
Other possibilities simply include working outside of clinical practice: consulting, health insurance reviewer, or even medical officer within a corporate health system. The sky is the limit.
What other aspects of pediatrics should medical students understand before choosing to enter the field?
Moh’s surgeons typically focus their careers on removal of cancers on the skin. They are dermatologists by training, but have completed a fellowship (often lasting one year) on microscopic removal of cancerous lesions. The Moh’s fellowship society tends to limit the number of trainees in their field for various reasons, so availability is scarce. Competition into the field is fierce, since there are already a limited number of dermatology spots and only a handful of Moh’s fellowship positions yearly.
Full-time clinical Moh’s surgeons are either in the office or in the procedure room on most days. Clinical days are spent seeing referrals for skin lesion removals. Most of these referrals come from dermatologists or internists. I would say that a high number of referrals end up requiring surgery. The clinical volume of a Moh’s surgeon runs around 20+ patients a day. This is significantly less than what a general dermatologist will see.
Surgery days (or half days) are spent removing skin lesions, waiting for histology to assess clean margins (if possible), and closing up the skin lesions. These procedures are tedious, but the RVUs generated are very high. Very busy Moh’s surgeons can have 8-10 procedures a day.
The overall lifestyle of this profession is relatively good. There are very few emergencies. Most of the procedures are planned. Many Moh’s surgeons can structure a 4-day workweek, simply because there are sometimes limited number of cases that need to be performed and revenue rate per procedure is very high. Some Moh’s surgeons starting out in their practice will also see general dermatological cases.
Many starting salaries for Moh’s surgeons being around $300,000. I’ve seen salaries around $250,000 in highly competitive markets. A well-established Moh’s surgeon who also owns a histology department can earn serious amounts of money. I once met a Moh’s surgeon who worked 4 days a week and took 2 months of vacation per year tell me that she made approximately $1.5 million (pretax)!
The ability of a Moh’s surgeon to generate high income comes from multiple revenue sources. The professional fees for the surgery itself are relatively high given the complexity of the procedure. However, I would estimate that the revenue stream coming from a histology lab (charges insurance for analysis) would more than double the income of an efficient surgeon.
Sounds great being a Moh’s surgeon, right? The truth is that there are still stresses with the job. You are mostly dealing with cancer. There is limited room for mistakes given that clinical management will change depending on surgical outcome.
Would you want to be a Moh’s surgeon?
(Photo courtesy of Flickr)
The family practitioner represents the stereotypical doctor—a generalist who helps maintain the well-being of people. This includes well-patient visits to upset stomachs to respiratory illnesses. Classically, these doctors also performed in-house visits before offices existed.
Daily Clinical Lifestyle
Family medicine physicians typically train for three years of residency after medical school. Afterward, clinical practice typically involves outpatient care. Hours worked are relatively reasonable in the 9am-5pm range, or 8am to 5pm five days a week. A family practitioner typically sees approximately 15-25 patients per day. Many of these are well-patient visits to sick visits. Illnesses treated include hypercholesterolemia, hypertension, diabetes, upper respiratory illnesses, sinusitis, and musculoskeletal issues.
Stress levels are relatively low, except for the occasional hospital-bound sick patient. Even then, most family practitioners opt not to have hospital privileges. In these cases, Hospitalists take care of inpatients and offer a buffer to a more sanitary lifestyle of an outpatient based family practitioner.
Documentation and increasing requirements for patient volume tend to be the common stressors in this field. Overall, the lifestyle of a family medicine practitioner is very manageable in the spectrum of physician specialties.
One of the advantages of a family medical practice is that equipment needs are relatively low. This allows the doctor to have increased flexibility to perform exams both in the office and even at the patient’s residence. One possible venue to combat against the ever increasing number of clinic patients as governed by insurance companies is to care for patients on a per subscription basis. This allows patients to have more exclusive access to their doctor while allowing the doctor to personalize care to a smaller number of patients. Does this translate to a higher income? Likely, but the compromise is that the stakes will be higher and the clientele will likely be more demanding. Expect to see more family medicine doctors transitioning to concierge medicine in the future.
Perils of being a family practitioner.
Healthcare will always continue to become more complex. Increasing regulations, increasing number of administrators, and increasing healthcare costs will continue to squeeze all doctors. “Physician extenders” have become a more common term these days to describe adjunct nursing staff to assist with healthcare. Some of these physician assistant and nursing positions have frighteningly similar daily tasks as a family practitioner. Will the role of a family practitioner be obviated in the future? Who knows, but I would assume that there should be distinguishing between someone with a medical degree and that of everyone else.
Are you a family practitioner? Are there other aspects of your field that you would like to add?
(Photo courtesy of Flickr).
Ambulance sirens. Gunshot wounds. Broken bones and bloodied faces accompanied by security guards. That’s the sensational portrayal of the life in the emergency room. For those of us who are either aspiring to become an emergency room physician or are practicing emergency room medicine, you’d better pray that not every one of your shifts will be as action-packed as what we see on television.
The truth is that most emergency room physicians aren’t exposed to a constant barrage of high acuity illnesses. If you are, then you must either love it or are insane. Either way, I hope that you are compensated appropriately.
The Daily Clinical Aspects of Emergency Medicine Are Repetitive.
Just like most careers and jobs, emergency medicine medical practice typically consists of a standard routine. Most full-time ER doctors work in shifts ranging from 6 to 12 hours long. On average, a full-time ER job may include 10 twelve-hour shift per month. I have a friend working 8 twelve hour shifts a month and is still considered full-time! As you a can see, one of the perks of this field is that you do have the opportunity to work fewer hours than most other doctors.
Essentially the duties of an ER physician during that shift is to take care of the patients that roll into the ER and create a disposition for them: treatment and discharge, consultation with specialists, or admission to the hospital. If you can get everyone accounted for, you are done. Depending on the acuity of the clientele, you might have broken bones that need to be splinted, pneumonias, COPD exacerbations, trauma, heart attacks, or strokes—you do have to retain a breadth of knowledge as an ER physician and to identify what conditions need immediate attention. Some ER’s are going to be busier than others—an ER doctor might see anywhere from one to four+ patients an hour. Multiply that by a twelve-hour shift, and you’ve got some hurting.
The Income of An Emergency Room Physician is Good.
ER physicians can make good money. Income is something we don’t often discuss openly, but you can easily find an entry-level position that commands at least $250,000. More often, I see ER docs in the $300,000+ range on a normal schedule. If you like to add on extra shifts, you can go even higher. This is not bad for a typical three or four year residency. You get the most bang for the buck in terms of indentured servitude during residency. In fact, an ER doc’s income/work time is probably one of the highest in medicine.
Emergency Medicine is High Stress.
There is no free lunch unfortunately. A high income in anything rarely comes easily. Whether you are working at a Level 1 Trauma Center or a sleepy urgent care facility, you still have to be relatively vigilant during your shift. While it is unfair to say that a family practitioner has a less stressful job than an urgent care emergency physician, it is most definitely true in most cases. An otherwise well-appearing emergency room patient complaining of some difficulty breathing may actually have a collapsed lung. It is commonly said that an hour’s worth of work in an emergency room is equivalent to that of approximately 1.5 hours of outpatient medicine. Combine the intensity with unpredictable hours during shifts, and you get a relatively stressful job. Perhaps that is why ER docs command serious coin.
Emergency Medicine Is Not For Everyone.
In any career, you have to make a balance among income, stress, and time. Emergency medicine has a unique compromise with income and stress. Many ER physicians tend to have many hobbies outside of medicine; I’m not sure if the specialty lends itself to doing so or that it attracts those who already have extracurricular activities.
With high intensity during the work hours, there often is a higher burn-out rate among ER physicians. However, options do exist to work in lower acuity settings.
The television perception of doctors is often skewed toward drama, sex, and a rockstar lifestyle. Take Grey’s Anatomy, Mistresses (plastic surgeon character), Scrubs, or Dr. 90201. Even reality medicine shows like NY Med or Boston Med portray a more sensational view of a doctor’s life. Our lives are both exciting and boring at the same time. Exciting in that most specialties involve troubleshooting symptoms and boring in that there is quite a bit of repetition.
To help the general layperson get a broad sense of an average doctor’s routine, I will detail the daily life of a dermatologist. Note: I am not a Dermatologist, but have spent considerable time working with them and have colleagues in the field.
The average workday of a Dermatologist is not easy by any stretch of the imagination, but it is also a very manageable day. A typical day runs about 8-10 hours including some amount of time to use the restroom and eat lunch (10 minutes – 1 hour). Most of the workday for a clinician dermatologist involves patient care. An average Dermatology office will have its doctor see about 40-50 patients a day, although I have seen numbers up to 100 a day! What this means is that you haul ass, as a Dermatologist! Minimal chit-chatting, and a lot of spot diagnoses and treatments. Our reimbursements have dwindled over the years, and many offices are often forces to pile on our patients. Nonetheless, the brief time the Dermatologist spends with her patients is quite sufficient for accurate diagnosis.
Rinse and repeat for each of the days the doctor is in clinic. Some Dermatologists may have certain half days dedicated to biopsies or particular skin treatments in order to operate more efficiently. Most doctors will also have administrative duties like business meetings that often add on 5-10 hours a month to the work schedule.
There’s no loitering around. On an average 20-day month, a Dermatologist seeing 50 patients per day will see 1000 people!
An academic Dermatologist will have more dedicated time to research, teaching, administration, or writing. Many university-based doctors will have perhaps two half-day clinics of patient care with perhaps two days a week of research time. One day of the week may even be dedicated to administrative duties. Revenue generated by the academic Dermatologist is minimal and likely insufficient to even cover the doctor’s salary. Income thus comes from donations (appointed chairs), state/governmental funding, and grants to perform research. The perks of academic medicine include the fact that you can be removed from the financial considerations of medical practice. You involve yourself with interesting technology and are given the opportunity to work with thought leaders (and become one) of your field. You can’t really put a price on fame. And what you do daily really shouldn’t be boring. You can immerse yourself in the cutting edge of medicine. Most academic physicians I know bring their paper-writing home and spend a lot of their free time on their careers. Not necessarily a bad thing to do, but it really shows that you love your career.
One of the downsides of the academic lifestyle is that you are removed from many of the practical matters of medical practice (read: finances). Most doctors I know in academia are quite ignorant of finances and actually think that their one-day a week clinic actually covers their salary. There is no free lunch. You really aren’t generating your worth in cold, hard, cash but rather intrinsically through your research, teaching, and innovations to the field.
Dermatologists Are Busy
You can basically substitute in any medical specialty in the sentence above (except for maybe rehab medicine—j/k). Dermatologists are no different. The clinician routine is quite repetitive. Imagine spending your entire 20’s training to see thousands of patients a month for your entire career! It is not an easy task. Maybe that’s why we often seen doctors with those fancy cars, homes, and yachts….
Do you have any comments to add regarding the lifestyle of a Dermatologist? Sound out below!
Those of you who are interested about the life of a Moh’s surgeon, see our post on this specialty.