[Rice Brah]

I'm currently a medical student in the US and will have to decide which specialty I will go into. This is obviously a multifactorial decision, but for the purposes of this thread I'll focus solely on the "lifestyle/money" component.

I've narrowed down my choices to two vastly different options: orthopedic surgery and emergency medicine. These fields are pretty self explanatory: orthopedic surgeons operate on bones and joints, emergency medicine docs work in ERs.

The big conundrum is this: emergency medicine residency is 3 years long while ortho residency is 5 or 6 years long post medical school. On the other hand, orthos make much more money. The median salary for a spine surgeon is $750k, but you can easily exceed this median by working outside of popular metro areas. The 90th percentile salary is not far from $2m a year so I figure that with my preference for living outside of the big cities I can expect to at least break 7 figures. However, orthos work 60-70 hour weeks and it is a real pain in the ass to take extended time off, much as in a corporate job.

The pay in emergency medicine isn't too shabby, either. You can make around $250/hour, so technically if you work 12 hours a day every single day of the year you could make $1m. Realistically, the shifts are murderously stressful and full time is considered 12-15 shifts a month. Making $400k is on the high side for EM, so much less money than ortho.

On the other hand, EM is amazingly flexible. Many people work as independent contractors and pick up shifts only when they feel like it. If I go into it, my plan is to work 1 month on/1 month off. With an entire month off to rest after each month of work, I think I could force myself to pull 25 shifts and gross 75k every other month. In my months off I would travel around and probably set up a sweet little home base in Latin America or Asia where the money would go a long way.

I realize this has been long and bored most of you to sleep, so here is the TLDR part:
I can have the EM lifestyle I just described in my early/mid 30s, or I can wait until my mid/late thirties and make 7 figures working like a dog in ortho. In your opinion, would the extra money make any difference to the type of life you can lead and would it be worth keeping my life "on hold" for an additional 3 to attain it? Keep in mind that I'm single with no kids and have no plans to change any of that in the foreseeable future. I'm curious what you guys think, whether you have first or second hand experience with this kind of scenario or just a gut feeling for what you would do in my position.

[Sonoma]

There's also the factor of which type of work do you prefer- Ortho or ER?

Ortho sounds much more relaxed in terms of the actual work being completed, even if the hours are insane. Also note you could probably do like 5-10 years in Ortho and retire, versus 15 or so in ER. The lifestyle of ER sounds much more enjoyable though in terms of taking time off, as well as getting paid sooner

[Akwesi]

Seems some research a few years back showed that beyond around $75 k more money doesn't create greater happiness for most people. I've never made 400 k a year, but it seems to me that if I was making 400 k with freedom and flexibility I wouldn't start working my ass off just to make 1m. Retiring a few years earlier with a bigger nest egg might be nice, but all the money in the world won't recover the experiences you lost out on in your younger years. Value your time and your freedom.

[Cattle Rustler]

Which one do you like more?

Which one has debt that can be paid off sooner?

There's no point in working something you won't like, no matter the amount of money. You work will show it.

[scubadude]

Like everyone else has said, which do you want to do more? You will make a great living in either.

Don't forget you have to actually get accepted into the residency you want first followed by a spine fellowship. There are many that do not get the specialty they want and even end up scrambling for a family practice residency. Also remember that you do get paid during residency and can moonlight for extra $$ so the difference in those couple years between when the two residencies would end is not as great as you think.

The idea of doing 30 days on then 30 off sounds nice. About a week into the 30 on you will want to eat a bullet. Not a chance that is sustainable for very long. You will be burnt out within a year.

With EM when you leave, your day is over and you can do whatever you want. Ortho, you will be paged 24/7 and never be "off" unless you have someone covering for you. I've known plenty that do both specialties and those in EM are almost always much happier. Either way, neither is a ROAD as far as lifestyle etc.

Also consider that specialty pay varies over time. A few major insurers and medicare start reducing the reimbursement rates and you could very easily drop down to EM pay as an orthopod. It's happened before, i.e. cardio.

Then again, after some time in med school you may decide to go a completely different way.

[Digimata]

Without knowing what you want from life, your age, personality, it will be very hard to give an informed answer.

[Araveug]

Fair to assume some things about OP - he is posting on RVF.

Outside of a metro area, $400k will go a looong way. Plus, once you build some cashflow (after your first shift), there are other, less time-consuming, ways to make more $$$ outside of medical.

ER doc, no brainer in my book. Good luck.

[Cattle Rustler]

Also, if you're going to take BFE america into consideration don't forget the following things:

State income tax
Sales taxes
Property taxes
Rent
Alcohol laws
Logistics (can you flow out to a hub?)
Sanity (Will you want to kill yourself?)

Example: Pokelahoma (Oklahoma)

State income tax is 5% non-progressive flat. So if you're pulling 400K, you will pay 20K on top of your federal taxes.
Sales taxes are in the 8.5-9% range and there are no exclusions for food or clothing.
Property and auto insurance rates are among the highest in the country.
Outside of OKC and Tulsa, you will probably have to use a toll road for the highway. Srsly brah, check the OK road map...toll roads everywhere.
Rent for a "prime" apartment is expensive. I've seen apartments in OKC/Kansas City that rent for the same prices in Houston but no additional benefits. They're just both centrally located and considered "luxury apts".
The Pokelahoma educational system sucks so bad that companies don't want to establish themselves there.


So when you think about it, BFE America is not that cheap.

[scubadude]

(07-07-2017 04:22 AM)Cattle Rustler Wrote:  

Also, if you're going to take BFE america into consideration don't forget the following things:

State income tax
Sales taxes
Property taxes
Rent
Alcohol laws
Logistics (can you flow out to a hub?)
Sanity (Will you want to kill yourself?)

Example: Pokelahoma (Oklahoma)

State income tax is 5% non-progressive flat. So if you're pulling 400K, you will pay 20K on top of your federal taxes.
Sales taxes are in the 8.5-9% range and there are no exclusions for food or clothing.
Property and auto insurance rates are among the highest in the country.
Outside of OKC and Tulsa, you will probably have to use a toll road for the highway. Srsly brah, check the OK road map...toll roads everywhere.
Rent for a "prime" apartment is expensive. I've seen apartments in OKC/Kansas City that rent for the same prices in Houston but no additional benefits. They're just both centrally located and considered "luxury apts".
The Pokelahoma educational system sucks so bad that companies don't want to establish themselves there.


So when you think about it, BFE America is not that cheap.

Don't forget places like Oklahoma also have things like higher than national rates of obesity, single mothers etc.

[Rice Brah]

Thanks for the feedback. I didn't mention which field I like more because each has their pros and cons and right now it's basically a wash.

(07-06-2017 07:09 PM)scubadude Wrote:  

Don't forget you have to actually get accepted into the residency you want first followed by a spine fellowship. There are many that do not get the specialty they want and even end up scrambling for a family practice residency. Also remember that you do get paid during residency and can moonlight for extra $$ so the difference in those couple years between when the two residencies would end is not as great as you think.

For sure, ortho is arguably one of the 2 or 3 hardest specialties to match into. The spine fellowship itself is surprisingly not as competitive as people might think despite being the most lucrative because a large chunk of patients are "back pain" for which there is only so much you can do, and so dealing with them is more hassle than the money is worth to a lot of people.

(07-06-2017 07:09 PM)scubadude Wrote:  

Also consider that specialty pay varies over time. A few major insurers and medicare start reducing the reimbursement rates and you could very easily drop down to EM pay as an orthopod. It's happened before, i.e. cardio.

Oh man have I considered it! Lots of money is riding on this so I've gone so far as to put together a model of demographic changes in swing states and other crazy neurotic stuff. The short version is, I think ortho is less susceptible to salary falls than EM in the medium run because the supply is unaffected by midlevels and residency expansion. The problem with ortho is that it would take me 3 extra years of training, and who is to say how much longer financial system collapse and/or socialized healthcare can be kept at bay? Could be 20 years could be 5, so a part of me just wants to take the shortest possible route to make hay while the sun still shines.

(07-06-2017 10:13 PM)Digimata Wrote:  

Without knowing what you want from life, your age, personality, it will be very hard to give an informed answer.

I'm currently in medical school and by the time I'd finish EM residency I would be in my early/mid thirties. I don't think anyone can answer exactly what it is they want from life, which is part of the problem with making this decision. With that said, the way I want to set up my life right now is definitely more compatible with EM than ortho.

Basically, the way I envision my lifestyle after I finish training is to initially work my ass off for a year to pay off my loans and stash away $100k or so. Once that is done, I'd like to enjoy life for a bit, could be as short as a year or as long as the rest of my thirties and beyond, who can say in advance.

When I say enjoy my life, I mean work hard play hard. If I do EM I could work 20 or 25 shifts and make upwards of $70k in a single month (granted as an independent contractor that's gonna be closer to 45k after taxes). The beauty is that you can pick up shifts whenever you want, so you're not tied down to a specific schedule. You can work 2 months and take 1 month off, or work 1 month and take 3 months off, as you like. Some EM dudes I know work less than 2 months a year, and that "much" only to keep their certs up and remain marketable and the rest of the time they travel.

As to what I'd do with the time and money, I'm sure it's not very different from what most guys on this forum would do in that position. One thing I'd definitely do is buy a legit sailing catamaran and park it in either SEA or Latin America. I'd outfit it with an air compressor for scuba diving and that's already 70% of what I want out of life haha. After each stint working in the US is done I'd immediately hop on a flight and get to my yacht, then either sail it around with my friends or park it in a downtown marina and use as bait for latina or Asian chicks.

Some of the time I'd switch it up and go stay at the swankiest Tokyo hotels for a few weeks or go hiking in Alaska. I know I'm sounding douchy as hell but fuck it, I grew up poor and want to enjoy the fruits of my labor after suffering through delayed gratification for so long. Besides, since I'm single and not spending the money on a McMansion for the wife and private school for the kids the free cashflow has to go somewhere.

Why am I even asking this question then, seems like EM is the obvious choice? At some point I will either get bored of the above lifestyle or simply age out of it. At that point I'll have to shift gears and get my kicks from something else, which I figure is going to be business. Ortho is more conducive to this as it not only generates much more cashflow for potential investments but also provides organic investment opportunities related to your day to day work. You an open up Ambulatory Surgery Centers, hire physical therapists, collaborate with medical device companies on new generation artificial joints and other implants, etc.

The length is getting excessive so I'm going to stop here, but the gist of it is that EM is likely to be awesome for the first 5 to 10 years, but ortho provides the opportunity for taking things to the next level for the 20-30 year duration of my career.

PS it goes without saying I will only work in states without state income tax

[Cattle Rustler]

Are you asian or do you go to Rice?

[Hypno]

I would get into a type of medicine that lends itself towards life extension. An example might be an endocrinologist. They also treat diabetes. The diabetes will fill your plate and allow you to easily start your own practice - no hustling for clients like dentists and lawyers. The life extension part allows you to bill at non-insurance rates.

There are some alternative therapies in ortho using placental tissues, stem cells, etc. so its not without it opportunities.

[scenicway]

Without question EM unless you really like Ortho.

It sounds cliche, but you really have to do what you enjoy, as you will be well off either way. I think the shiftwork in EM would be a dream. No call, don't have to be the face of a business. Just punch in and get a nice paycheck. $400k is solid. Can pick up and move whenever. Really does it get much better?

If you go ortho it will consume you and become your identity, which is great if that's your "passion" (you cannot fake your way through a surgery residency). And you want to be a big swinging dick in your little town etc. And want a boat and Ferrari and all that bullshit.

Once you spend some time in the OR, things will become more clear.

[Kona]

Emergency room doctors I know wind up burning out.

You work at the wrong hospital you see all kinds of nasty shit. Don't desensitize yourself to it. It will make you mean.

You should vomit like a normal person when you see cockroaches inside a homeless woman's yeasty vagina. That's just another day for some er doctors.

Plus, no one in their right mind enjoys going to the emergency room. Everyone there is mad or upset about something. You want people yelling at you when you don't revive a heroin addict? Eventually you will just think everybody hates you.

And don't get me started on the smells.

Aloha!

[Cattle Rustler]

(07-08-2017 05:05 PM)Kona Wrote:  

...When you see cockroaches inside a homeless woman's yeasty vagina.

Aloha!

[djk100]

The plus side being an EM is the flexibility or working fulll/part time and moving to another states to find work.

[Hypno]

When you are making $300K, your needs are met (provided you don't have other obligations, like debt, children, alimony, etc.)

What then becomes important is not the difference between $300 or $600, but your time, freedom, and fulfillment. Some people find this in relationships and family. Some people find it in in their career, either by doing interesting work (orthopedics is likely to be reshaped by biotechnology; ER less so), interesting research, serving the community or a calling (ER), or building a company. Some people find it in outside hobbies like having the free time to play sports, travel, perform music, etc. Only you can answer which is most important to you, and your answer will change over time as you experience life. (Consider that a lot of the recommendations above - including my own - are influenced by the poster's experiences and priorities, which may be different from yours.)

What I would tell you is don't sweat it because either choice is sufficiently financially lucrative, provided you don't blow it on alimony or some other disaster like gambling, drugs, or poor investments (happens to a lot of M.D.s). Give some thought to what motivates you, what drives your passion. For me, its things like new technology, business success, connecting my work to a purpose. I would want to kill myself if my job in the ER involved patching up gunshot wounds for criminals, but I could see how someone with a more charitable disposition would find that the ultimate calling. (If I was a school teacher, I would want to teach gifted students while others would want to teach kids with learning disabilities; both are noble, neither is better than the other, but one is better for you.)

Also, often times the humblest career paths have opportunities to be the most lucrative. In medical diagnostics, routine blood tests like blood type and blood grouping are performed a few million times a year, and exotic blood tests like for Aids or the Zika virus perhaps no more than 100K a year. The business opportunities for the former are far greater than the latter. In law, simple accidents don't require Harvard-trained lawyers, but the guys who build firms around volume are the guys who get rich, more so than the fancy Harvard trained lawyers.

[Digimata]

Go EM. You are young and by your own admission not from a wealthy background, which means you haven't gone balls out overseas or stateside. EM will give the cashflow and flexibility to do so.

You have already articulated your points, they key is knowing when to jump ship from EM to something else. You aren't going to want to be in EM after 10+ years working those kinds of shifts unless you only want to work 3 months of the year at 40.

[OptimusDude]

I'm a specialist making about $400k incl bonus for 4 days a week - roughly 32 clinic hours. Been out three years. It's good money but by no means enough to retire super early on realistically. I'd like to live with a retirement income of about 150k a year and that will still take me 25-30 years of investments to achieve. My next move is either work for the same place, move to a less desirable area for $625k a year, or risk opening up shop.

To your predicament: I have friends in both fields, and it seems like the EM guys have a better schedule and are happier because there is no annoying follow up for their shitty patients. Both friend groups are driving luxury cars, have nice houses, etc. Total joint friend of mine is living the high life but he admits it's very boring. Overall go with what you like to do - and I totally agree to not replace your youth with extra years of 24/7 residency work if possible.

[billyb]

I'm a specialist at the 90% level in my specialty, pulling down high 6 figures. I work like a dog though.

spine the median salary I agree is probably around 750k but remember you also need to do a spine fellowship post ortho residency, so another 1 year for that. you also have to be a superstar if you want to be in spine because you're competing against neurosurgeons and the best orthopods. anyway it's not typical to make 7 figures even in spine. I think the 2sd range is probably 400-1200. especially 7-8 years from now the way things are going. your figures for er are about right.

if your main discriminatory criteria is money, I'd probably go with er. things are changing rapidly in medicine and I'd probably lean toward getting out faster and starting to cash checks and pay back those loans. remember the government takes half anyway so it reduces the difference between a 1000k and 400k income.

[Rice Brah]

Thanks for the feedback, seems EM is the prevailing opinion and that is what I was strongly leaning towards myself. The main thing holding me back from pulling the trigger on it relates to this:

Quote:

if your main discriminatory criteria is money, I'd probably go with er. things are changing rapidly in medicine and I'd probably lean toward getting out faster and starting to cash checks and pay back those loans.

This has been really bothering me ever since I started med school. There is a feeling of impending doom and gloom in the physician community that I find well justified after looking at the numerous and independent trends that have the potential to mess with our $$.

EM is really fucking sweet right now but I have serious doubts on how sustainable that is beyond the next 5 to at most 10 years. It's a very new specialty and they've been churning out residents like crazy. Those $250/hr rates are at least somewhat a function of the current undersupply of BE/BC EM docs and according to projections that shortage is closing at a rate of ~1200 docs a year and will be entirely gone within 5-10 years:
https://www.ncbi.nlm.nih.gov/pubmed/26823136

That's not even considering the explosion in the number of midlevels and their increasing utilization in EDs.

Ortho is a specialty I consider very safe from oversupply and midlevels. Big chunk of them are over 60, their residency spots have not been growing, and the idea you will have midlevels independently doing joint replacements and spine work is still far fetched at this point, vs the EM world where they are already independently seeing patients as we speak. But waiting to get paid in ortho brings us even further into the future where anything could happen, so while ortho faces less field-specific risks, it makes me more vulnerable to generalized disasters like the onset of socialized medicine or dramatic economic instability that would fuck every field were it come to pass.

So I guess the upshot is in an ideal world, I will do EM. In reality, I will see where things stand when I'm an M4 and apply accordingly, while making myself competitive for ortho in the interim in case I need to go that route.

[Rice Brah]

(07-12-2017 06:40 AM)billyb Wrote:  

I'm a specialist at the 90% level in my specialty, pulling down high 6 figures. I work like a dog though.

If you don't mind me asking, what did it take for you to get to 90th percentile income in your field? Was it simply a matter of moving to BFE and working harder than the average doc, or did it involve something in the way of business savvy setting up ancillary services etc?

Just curious to see whether getting to 90th percentile can be just a matter of "how much pain can I endure" versus having access to business opportunities that may not be reproducible by everyone.

[billyb]

it's not really anything magic. medicine is widget making nowadays. to make more money you have to make more widgets

40% work really hard and make those widgets more hours of the day

40% be really really good at your job, you don't get to 90%le without being a true superstar. you have to be better at widget making, more efficient, more accurate, highly respected so people ask you to make widgets

20% business savvy and get paid the most you can for your widgets

(07-12-2017 09:22 PM)Rice Brah Wrote:  

(07-12-2017 06:40 AM)billyb Wrote:  

I'm a specialist at the 90% level in my specialty, pulling down high 6 figures. I work like a dog though.

If you don't mind me asking, what did it take for you to get to 90th percentile income in your field? Was it simply a matter of moving to BFE and working harder than the average doc, or did it involve something in the way of business savvy setting up ancillary services etc?

Just curious to see whether getting to 90th percentile can be just a matter of "how much pain can I endure" versus having access to business opportunities that may not be reproducible by everyone.

[billyb]

just another caveat, your motivations in medicine seem to be purely monetary, and I realize that forum posts don't necessarily give a full picture of a person's personality. but honestly you need to really examine your goals. if you want to make a ton of money in medicine, there are two ways:

1 - be an absolute hack and do as much substandard work as you can possibly do and try not to kill/hurt too many people or get sued too often or simply don't care about who you do hurt/kill. typically hide somewhere in bumblefuck USA so you don't get discovered as quickly.

2 - be really really good at your job where everyone wants to give you more work, you do it really well and develop a fantastic reputation and build a thriving medical practice.

if your motivation is just money and does not involve a true love of medicine, learning, and actually helping people, the chances of you achieving #2 are slim.

[spaceman]

ER dudes i know always seemed burned out and stressed from the crazy shit they see.
I would pick the one that you enjoy more.