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I finished PA school recently and started working in emerg (as part of the psych team) and cardiology. I work and manage a bunch of R1-R5s at various stages of their residency and all of them talk about debt, the CaRMS process being flawed and the ?subpar pay post-residency. I'm having a bit of trouble understanding where they're coming from, since conversations with attendings and RNs reveal they're being paid pretty well. For example, emerg docs are the highest billing at the hospital I'm at (500k+), psychiatrists are making 360k+ with no overhead, cardiologists are making 400k+, hospital internists are making 250k+, etc. Even with the debt, wouldn't these annual salaries trump ~125k debt pretty quickly? Residents always talk about my pay being great for the time I've been spending and education (6 figures for M-F 7.5 hrs, no overnight call + benefits/pension). I understand some specialties have overhead but none of the above specialties would have significant overhead (minimal to nil). I've even read people on this forum post fam medicine salaries around 250k+ for not too extravagant hours. Even after taxes, most specialties are pulling in 180-200k+ net income. That's ~15-17k/month in net income to do whatever you want, which is awesome imo! But am i missing something about the numbers here? Paying for benefits, setting aside money for retirement shouldn't take a bulk of your take home net pay and you'd still have a substantial net home pay. 

Basically, I'm wondering if it's worth heading to med school and try to up my salary to those levels. I've rotated through 90% of the med school core rotations and taken 3 electives so I have a good grasp of how clerkship works and residency, giving me an advantage. I've written the MCAT 4 years ago and my score is competitive for my in province school. I don't even mind spending ~125k to get the MD to easily pay it off after residency. I would end up applying for family medicine only given the length of other residencies at my point in life. What would others do in my position? Thanks!

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Are you sure they werent complaining about their resident salaries? I dont think ive heard of many residents complain about the salary of an attending. Residents get paid like 60k with 5K raises every year for 10 hours a day M-F, working usually 2/4 weekends a block, and overnight call (ranging from 5-6 calls a month in house to 10-11 calls for home call) all of which are specialty and block dependent.

 

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so you want to trade your current 6 figures M-F 7.5 hrs, no overnight call + benefits/pension for family medicine...? I mean sure you could, but whyyyy would you do this to yourself. Financially speaking, it doesn't make much sense at all. If it's for other reasons, then yeah go ahead...?

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17 minutes ago, offmychestplease said:

FM docs in AB can make 500,000/year- 600,000/year working full-time walk in clinics 50h/week....there are FM grads on this forum working 50 hours a week in ON making 425,000-450,000 straight out of residency...both numbers are after overhead...there also other payment modules and options to make things more interesting too...this is after a chill 2 year residency and more than many specialists with triple the residency+fellowship training time (years of lost income too...). This does not include other reasons like job security/job market/no need for fellowship/job flexibility etc Really not going to get into details but your post shows a lot of ignorance about FM. Financially speaking as you say, FM is among the best choices in medicine.

400k-500k in FM seems to be the exception rather then the norm tho

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14 minutes ago, offmychestplease said:

FM docs in AB can make 500,000/year- 600,000/year working full-time walk in clinics 50h/week....there are FM grads on this forum working 50 hours a week in ON making 425,000-450,000 straight out of residency...both numbers are after overhead...there also other payment modules and options to make things more interesting too...this is after a chill 2 year residency and more than many specialists with triple the residency+fellowship training time (years of lost income too...). This does not include other reasons like job security/job market/no need for fellowship/job flexibility etc Really not going to get into details but your post shows a lot of ignorance about FM. Financially speaking as you say, FM is among the best choices in medicine.

Financially, for OP it would make sense even after overhead being 250k. Obviously OP needs to clarify what six figures is but I'm assuming in the low 100s, so having a ~2.5x increase in salary is financially benefitting, even after 6 years of school/residency. The barrier I would see is investing the schooling time and going through CaRMS but family medicine with no substantial geographic limitations has really good odds to match as a CMG.

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Just now, offmychestplease said:

the exception not the norm is 1 million+ after overhead (yes, there are FM docs who make that)...It is doable to make that depending on what you do and the province you are in, especially if you know how to bill/etc. FM earnings are grossly underestimated by many people on this forum.

idk about other provinces but the only Ontario FM docs who make that much either bill for their entire FHT or have a pain clinic doing nerve block injections every day...

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9 hours ago, Bueno said:

I finished PA school recently and started working in emerg (as part of the psych team) and cardiology. I work and manage a bunch of R1-R5s at various stages of their residency and all of them talk about debt, the CaRMS process being flawed and the ?subpar pay post-residency. I'm having a bit of trouble understanding where they're coming from, since conversations with attendings and RNs reveal they're being paid pretty well. For example, emerg docs are the highest billing at the hospital I'm at (500k+), psychiatrists are making 360k+ with no overhead, cardiologists are making 400k+, hospital internists are making 250k+, etc. Even with the debt, wouldn't these annual salaries trump ~125k debt pretty quickly? Residents always talk about my pay being great for the time I've been spending and education (6 figures for M-F 7.5 hrs, no overnight call + benefits/pension). I understand some specialties have overhead but none of the above specialties would have significant overhead (minimal to nil). I've even read people on this forum post fam medicine salaries around 250k+ for not too extravagant hours. Even after taxes, most specialties are pulling in 180-200k+ net income. That's ~15-17k/month in net income to do whatever you want, which is awesome imo! But am i missing something about the numbers here? Paying for benefits, setting aside money for retirement shouldn't take a bulk of your take home net pay and you'd still have a substantial net home pay. 

Basically, I'm wondering if it's worth heading to med school and try to up my salary to those levels. I've rotated through 90% of the med school core rotations and taken 3 electives so I have a good grasp of how clerkship works and residency, giving me an advantage. I've written the MCAT 4 years ago and my score is competitive for my in province school. I don't even mind spending ~125k to get the MD to easily pay it off after residency. I would end up applying for family medicine only given the length of other residencies at my point in life. What would others do in my position? Thanks!

More than half of billings disappears to overhead and taxes. Then some of the money has to be set aside from other debt acquired during residency, typically a mortgage. When you join a practice there may be some need to pay out some initial lump sum or the group may ask for some portion of your billings as a junior attending (usually in saturated academic centres). Then you'll be paying per month for things like disability, life, health insurance, and retirement.

Still, all in all FM is a good career from the financial perspective. Attending positions are generally still considered well paid.

I suspect most of them are complaining about residency and fellowship pay, where you're working for minimum wage per hour and often take on greater responsibility than a PA/NP. Clearly the value of resident/fellow labour is closer figures than the current 60k/yr, but it is kept depressed for cheap labour since their licenses to practice are held hostage. The length of training in cardiology can be quite extensive as well, generally residency is 6 years at a minimum (3 years IM, 3 years cardiology), with additional years of training if you want to do a fellowship (EP, interventional, etc.). That's quite a few years of working for close to minimum wage to build up some pent up frustration at the situation.

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@offmychestplease I’m not at all ignorant about FM. Not everyone plans to run their practice in AB, not everyone wants to do walk ins, work 50-60 hrs per week, etc. Not all FM docs are making 500K per year, there’s nothing wrong with pointing that out? OP can easily do the math themselves.

When I PERSONALLY did the math, the breakeven was far later than what I anticipated. That’s all. :blink:

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14 minutes ago, offmychestplease said:

Even if we go with the much more conservative amount of 250K/year...if someone told the average person would you do 5-6 more years of training (medical school + residency) where you get paied for 2 years of that training to double your income, gain more autonomy, have higher job flexibility/security, etc I think it would be a no-brainer. Obviously, the hardest part would be to get in first. That's why I don't see how you can't understand why someone would consider FM.

I mean that isn't much more conservative - That is right in the range of average. Doesn't mean people cannot do more of course, and there are many ways family doctors have increased it. Medicine's flexibility is one of its strengths. 

Your are right in terms of the positives! I would say to be complete you have to add the say 150K+ in costs of med school, the lost of after tax income for the 4 years and any return you would make on any money invested from that, the likely interest on the costs of med school, and whatever else you could have earned in all the extra time you are now spending studying (which for the motivated is definitely not zero). Also you double your salary but the doubled part is taxed at a much higher rate than the first half so your real increase is less than half. There is also the likely loss of a true pension which is something worth a definite real value above your base salary of no small amount. 

I am 100% not saying someone shouldn't do it - if I were to do that in fact I would have to call myself out because I basically did do that when I left my career as a software engineer to go into medicine (and you have to at least start with this math assuming you would get family medicine as you cannot assume you would get any particular field you want). I would just caution saying it is a no brainer though from pure economics. Even as staff now in a higher paying speciality it will take years to mathematically come out ahead here from what I was doing with my prior high savings rate. Still glad I did make the choice I did. 

 

Edited by rmorelan
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1 hour ago, offmychestplease said:

FM docs in AB can make 500,000/year- 600,000/year working full-time walk in clinics 50h/week....there are FM grads on this forum working 50 hours a week in ON making 425,000-450,000 straight out of residency...both numbers are after overhead...there also other payment modules like FMOs and options to make things more interesting too...this is after a chill 2 year residency and more than many specialists with triple the residency+fellowship training time (years of lost income too...). This does not include other reasons like job security/job market/no need for fellowship/job flexibility etc Really not going to get into details but your post shows a lot of ignorance about FM. Financially speaking as you say, FM is among the best choices in medicine.

They might make that with 40-50 hours a week seeing patients. That doesn't include the amount of time spent doing paperwork, reviewing labs/imaging, following up on things etc.

I'm currently on a 4wk rotation with a family doc who is very transparent about finances. He has over 2000 patients on his roster and makes the money within the range of income you stated there, but I can promise you his total involvement is 80-100hrs per week and requires him to spend his weekends to catch up on all the reports he gets sent from consultants and lab work. It's not all chilling and raking in $$. The more patients you see the more you have to follow up on.

 

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4 minutes ago, offmychestplease said:

right, thanks for your experience and input. What some people here lose sight of is what people do in other careers to advance their careers. For instance, in education there are many teachers who will spend 15K on a 1.5-2 year Master's degree just so that they can raise their income by 7K/year. That's a 10% increase in income. And the tuition for the master's is 22% of their before-tax income. This is commonly accepted and seen by everyone in the field as a smart investment. Obviously, medical school and residency is much more difficult and longer but we are talking about 2-3x your income here not increasing it by 10%. 

it is true the shear timescale of things is hard to initial grasp with things (I mean of course they are - we are talking timelines longer than how long many people on the forum have been alive ha). 

(actually having done exactly that masters degree I will say many do it part time so there is no loss of income and they are set up to do exactly that with those programs, the tuition is a tax write off which helps lowering cost for it to say 12K give or take, they can count often the time towards professional activities they have to do anyway which helps, and absolutely the return on investment is then 2-3 years (7K x marginal rate of tax on the increase in salary = ~4.5-5K again against the 12K cost give or take plus the bump also applies to their pension as well. so.....well that probably is a no brainer ha! Plus the masters often isn't terribly hard by most standards. Some do the longer masters for sure - but often that is tied into actually even getting the teaching job in the first place as well which is not easy rather than just increasing the salary. I was a high school teacher for a year - the complaints people had about the system are quite impressive :)). 

It still works out mathwise for medicine of course ha - but the return on investment is not 2-3 years (your career of course is hopefully quite long as well mind you). You have to recover 350K+ in after tax income not including practise startup costs to hit even point compared at the true value of the PA salary, pension and benefits, and the higher tax rates involved along with greater time you have to spend on the job and maintaining your skills (time you could use to earn in theory more income or heaven forbid not work ha). Point is I guess is that in case anyone is wondering - a PA is a very good job, although it is totally ok to want more (and I don't mean income really with that - but just to do more stuff in your career)

   

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Just now, cotecc said:

you guys are spending 125k to get your MD???

---Quebec resident here, I'm paying about 2k per semester

sure rub it in ha

although I will say watch what happens in Quebec if you try to increase it or otherwise take advantage of the situation. There is actually a "response". They are not afraid to get shall I say vocal about the situation.  

In the rest of Canada in comparison - it goes up and is there is well basically nothing. 

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18 hours ago, Bueno said:

I finished PA school recently and started working in emerg (as part of the psych team) and cardiology. I work and manage a bunch of R1-R5s at various stages of their residency and all of them talk about debt, the CaRMS process being flawed and the ?subpar pay post-residency. I'm having a bit of trouble understanding where they're coming from, since conversations with attendings and RNs reveal they're being paid pretty well. For example, emerg docs are the highest billing at the hospital I'm at (500k+), psychiatrists are making 360k+ with no overhead, cardiologists are making 400k+, hospital internists are making 250k+, etc. Even with the debt, wouldn't these annual salaries trump ~125k debt pretty quickly? Residents always talk about my pay being great for the time I've been spending and education (6 figures for M-F 7.5 hrs, no overnight call + benefits/pension). I understand some specialties have overhead but none of the above specialties would have significant overhead (minimal to nil). I've even read people on this forum post fam medicine salaries around 250k+ for not too extravagant hours. Even after taxes, most specialties are pulling in 180-200k+ net income. That's ~15-17k/month in net income to do whatever you want, which is awesome imo! But am i missing something about the numbers here? Paying for benefits, setting aside money for retirement shouldn't take a bulk of your take home net pay and you'd still have a substantial net home pay. 

Basically, I'm wondering if it's worth heading to med school and try to up my salary to those levels. I've rotated through 90% of the med school core rotations and taken 3 electives so I have a good grasp of how clerkship works and residency, giving me an advantage. I've written the MCAT 4 years ago and my score is competitive for my in province school. I don't even mind spending ~125k to get the MD to easily pay it off after residency. I would end up applying for family medicine only given the length of other residencies at my point in life. What would others do in my position? Thanks!

From a purely economic perspective, it depends on how old you are, how much you expect to make as a family physician, your salary as a PA, and the expected value of your PA benefits + pension. I'll make a few assumptions to show you the math, but you can change them for a more accurate outlook. This message looks long, but it's pretty straightforward, so I encourage you to read it to the end. But for a quick spoiler: Probably not worth it.

My assumptions:

Age: 25

FM Ontario average income: $250,000 post-overhead = $150,000 after income tax 

PA salary: $120,000 = 84,000 after income tax

Value of PA benefits = $2,000 per year

Value of PA pension: $84,000 x 50% x 25 years (this assumes that your pension will pay half of your post-tax salary for 25 years of retirement) = $1,050,000

 

Now let's chart your net worth's trajectory, starting with PA, where you earn $84,000/year + $2,000 in benefits/year: $86,000

Age 25: $86,000;

26: $172,000;

27: $258,000;

...You get the point, so I'll skip ahead to age 39 ($258,000 + $86,000 x 12 years):

39: $1,290,000

I stopped at 39 because it's the first year that your net worth as a FM would be greater than your net worth as a PA. But we should also look at how much it's greater: $10,000 (i.e., FM net worth = $1,300,000 at age 39). I am also assuming that you made zero investments as a PA (e.g., stocks that appreciate in value), that you have zero savings right now (that would only make your net worth as a PA look better), that there is no interest on your med school debt (which only makes your net worth as FM worse), and that you will never slow down productivity as FM (e.g., taking parental leave, working fewer hours in your late 50s and early 60s).

Even ignoring these exacerbating factors, you are essentially saying that you want to sacrifice 6 years of your life (med school and residency are not chill) so that at age 39, you can have $10,000 more as a FM vs. just staying a PA. Alternatively, you can stay a PA, which would mean enjoying the rest of your 20s, having stable hours, better wellbeing because of relatively lower stress, vacations, etc. Is that worth it to you?

But wait, there's also your pension, which is valued at $1,050,000. As FM, you'd have to save $35,000/year over a 30-year career to equal that pension value. In other words, let's subtract $35,000 from the FM post-tax salary, making it equal to $115,000. If we do that, then it would take until age 50 for your FM net worth to be higher than your PA net worth. Again, the net worth difference isn't much: $14,000. So up to you, but to me, putting up with all of med school, etc. isn't worth it to just be $14,000 ahead at age 50. 

Of course, you can make more than $250,000 pre-tax/post-overhead as FM, but after speaking to several FM physicians and shadowing them, that would be working very, very hard...for *most* physicians, that requires much more than the 37.5 hours/week you currently work. Even the $250,000 post-overhead is not easy; FM physicians are going from room-to-room, doing quick 10 to 15-minute appointments, lots of paperwork, etc. It's hard work and you really have to earn every dollar you make. There are those who do walk-ins exclusively and make crazy money, but not everyone can handle the 2-5 minute walk-in appointments, and who knows, the government may restrict walk-in practice because it is very lucrative.

So all in all, if it's just about the money, I agree that you're already in a great place and should just enjoy your life now. There is a reason that residents, even with the prospect of making multiples of your salary in a few years, are telling you that you've got a good gig. It's not always about salary in an absolute sense, but everything else that comes with it (lifestyle, how early you earn that salary, pension, benefits, stress, etc.). Also consider that many physicians will have a partner who stays home to take care of the family (i.e., no income earned from the partner). Given your hours and benefits, you can just find a partner who makes a similar salary to you and be a double-income household with a reasonable lifestyle, and then be close to earning what a FM makes.

 

For completeness, here's the math for family medicine, assuming your cost of living + tuition is 45,000 per year (25,000 tuition + 20,000 for living, rent, etc.), and then ~65,000 income as a resident, and then $250,000 pre-tax income as FM:

Age 25 (M1): $-45,000;

26 (M2): $-90,000;

27 (M3): $-135,000;

28 (M4): $-180,000;

29 (PGY1): $-115,000;

30 (PGY2): $-50,000

31 (FM): $100,000

32 (FM): $250,000

...Skip to 39 ($250,000 + $150,000 x 7):

39: $1,300,000

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Great analysis by @gogogo - it's easy to overlook all these other expenses and to focus on gross billings.  

Conservative estimates e.g. living expenses and PA pension with numerous non-economic factors  to consider e.g. quality of life (OP has no overnight call now), geographic stability, uncertainty of medical school/residency etc..

 

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15 hours ago, gogogo said:

 

From a purely economic perspective, it depends on how old you are, how much you expect to make as a family physician, your salary as a PA, and the expected value of your PA benefits + pension. I'll make a few assumptions to show you the math, but you can change them for a more accurate outlook. This message looks long, but it's pretty straightforward, so I encourage you to read it to the end. But for a quick spoiler: Probably not worth it.

My assumptions:

Age: 25

FM Ontario average income: $250,000 post-overhead = $150,000 after income tax 

PA salary: $120,000 = 84,000 after income tax

Value of PA benefits = $2,000 per year

Value of PA pension: $84,000 x 50% x 25 years (this assumes that your pension will pay half of your post-tax salary for 25 years of retirement) = $1,050,000

 

Now let's chart your net worth's trajectory, starting with PA, where you earn $84,000/year + $2,000 in benefits/year: $86,000

Age 25: $86,000;

26: $172,000;

27: $258,000;

...You get the point, so I'll skip ahead to age 39 ($258,000 + $86,000 x 12 years):

39: $1,290,000

I stopped at 39 because it's the first year that your net worth as a FM would be greater than your net worth as a PA. But we should also look at how much it's greater: $10,000 (i.e., FM net worth = $1,300,000 at age 39). I am also assuming that you made zero investments as a PA (e.g., stocks that appreciate in value), that you have zero savings right now (that would only make your net worth as a PA look better), that there is no interest on your med school debt (which only makes your net worth as FM worse), and that you will never slow down productivity as FM (e.g., taking parental leave, working fewer hours in your late 50s and early 60s).

Even ignoring these exacerbating factors, you are essentially saying that you want to sacrifice 6 years of your life (med school and residency are not chill) so that at age 39, you can have $10,000 more as a FM vs. just staying a PA. Alternatively, you can stay a PA, which would mean enjoying the rest of your 20s, having stable hours, better wellbeing because of relatively lower stress, vacations, etc. Is that worth it to you?

But wait, there's also your pension, which is valued at $1,050,000. As FM, you'd have to save $35,000/year over a 30-year career to equal that pension value. In other words, let's subtract $35,000 from the FM post-tax salary, making it equal to $115,000. If we do that, then it would take until age 50 for your FM net worth to be higher than your PA net worth. Again, the net worth difference isn't much: $14,000. So up to you, but to me, putting up with all of med school, etc. isn't worth it to just be $14,000 ahead at age 50. 

Of course, you can make more than $250,000 pre-tax/post-overhead as FM, but after speaking to several FM physicians and shadowing them, that would be working very, very hard...for *most* physicians, that requires much more than the 37.5 hours/week you currently work. Even the $250,000 post-overhead is not easy; FM physicians are going from room-to-room, doing quick 10 to 15-minute appointments, lots of paperwork, etc. It's hard work and you really have to earn every dollar you make. There are those who do walk-ins exclusively and make crazy money, but not everyone can handle the 2-5 minute walk-in appointments, and who knows, the government may restrict walk-in practice because it is very lucrative.

So all in all, if it's just about the money, I agree that you're already in a great place and should just enjoy your life now. There is a reason that residents, even with the prospect of making multiples of your salary in a few years, are telling you that you've got a good gig. It's not always about salary in an absolute sense, but everything else that comes with it (lifestyle, how early you earn that salary, pension, benefits, stress, etc.). Also consider that many physicians will have a partner who stays home to take care of the family (i.e., no income earned from the partner). Given your hours and benefits, you can just find a partner who makes a similar salary to you and be a double-income household with a reasonable lifestyle, and then be close to earning what a FM makes.

 

For completeness, here's the math for family medicine, assuming your cost of living + tuition is 45,000 per year (25,000 tuition + 20,000 for living, rent, etc.), and then ~65,000 income as a resident, and then $250,000 pre-tax income as FM:

Age 25 (M1): $-45,000;

26 (M2): $-90,000;

27 (M3): $-135,000;

28 (M4): $-180,000;

29 (PGY1): $-115,000;

30 (PGY2): $-50,000

31 (FM): $100,000

32 (FM): $250,000

...Skip to 39 ($250,000 + $150,000 x 7):

39: $1,300,000

awesome analysis ha :)

I would point one thing that makes it even worse for FM - regardless of how you evaluate the pension amount (which may be higher than 50% - often 60% occurs) whatever that amount is worth more than the doctor just saving the same amount (a pension worth say 1 million is worth more than that doctor having a pile of month at 1 million). The reason is the real world you have deal with inflation so that money is invested. Those investments for a doctor can go up or down in value - so the amount they could take each year without destroying the base amount can go up or down, but for the pension the outcome is guaranteed - and it is guaranteed for longer than 25 years - it just keeps going forever. That sort of protection is hard to come by - and in retirement investments it is very expense to buy.  As a rough rule of thumb a pension that spits out 40K a year is worth more a million dollars  (roughly 50% of the 120 pretax salary of the PA is 60K would would require a pension valued between 1.5 million and 2 million to make work). 

Although I should say similarly the doctor wouldn't be just packing away 35K a year either in a savings account - that would also be invested so the amount should grow faster than inflation, reducing the amount needed to be saved to hit the same target as the pension.

The net effects could cancel each out depending on the return rate, inflation and so on - still for many a flat out guaranteed amount with minimal work involved on your part is very valuable indeed!

The other thing is that so far we are assuming that both the PA and doctor don't actually spend anything. Which obviously isn't going to happen - but once you factor that in you see the way the doctor can pull ahead. If it costs 84,000 a year to live on the PA is saving nothing as that is their full salary after tax (but still has an amazing pension so is probably more than fine anyway - they don't have the same issues with saving - or at least saving for retirement). If the doctor can manage to live on 84,000 they will have left over savings (66K give or take in your model). If that money is then invested over time and grows the return will overwhelm the PA - but that require discipline and some training to do well.  Income is not wealth - wealth is not what you make, it is only what you save and compound interest applied to those savings is very powerful. Above is also easy to say - but there is a lot of pressure on doctors not to live radically below their means (I don't care I am doing it anyway ha) and some of this high savings rates would be uncommon. If doctors don't save then we are back right at your example - where it takes a very long time to reach a break even point. 

This stuff is complex but worth going through - (hopefully I got the points above correct!) and I have to thank you again for adding that analysis!

 

 

 

Edited by rmorelan
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10 hours ago, offmychestplease said:

Thank you for sharing your thoughts and analysis. I want to concede that you really made me look at things from a different perspective. I came into medicine without any real job prospects from my BSc like many people and so medicine was a HUGE surge...anything above a min wage job would have been a better investment/life lol which is why I so strongly recommended OP to pursue this path...but really if you are someone already making good money at a young age, and like your job it doesn't seem like the best move always..

a gracious response on the internet! A welcome sight indeed - and I think you still aren't wrong that ultimately family medicine very likely comes ahead (with more work) and the opportunity to increase the income for family medicine is potentially there which tilts the numbers. This stuff isn't easy and medicine isn't the only path of course. 

 

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