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Business-oriented person - "tough" specialties still an option?


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To begin, I am not the type of person who is in medicine for the $$$, nor do I believe in the privatization of healthcare. I believe that healthcare is a human right, and I truly love the process of interacting and talking with patients, and working with them and the whole team to solve their medical problems. I would choose a career in medicine over business any day. But, as more as a hobby, I love to dabble in investments and stocks, analyzing real estate prices and generally have a bit of an entrepreneurial spirit. I would love to continue this in the future, but I am wondering, does that mean I would have to rule out the "tougher" (surgical or IM) specialties? Do you know of any residents or attendings in these fields who also have a side business or significant investments? Do you have to sacrifice one or the other?

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Practising physicians in most fields manage to have hobbies, although if it's a time intensive hobby that will obviously be less tenable in a more time intensive specialty. There are definitely residents and attendings that have entrepreneurial projects on the go, they tend to get featured once in a while at talks at my med school, so I am pretty sure they exist lol.

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You'd be surprised how many physicians are keen in their finance, how many play meme stocks, and how many are lamenting today they didn't invest in Dogecoin when it was 1 cent each haha.

You'd be surprised how many are on FB private groups talking about mortgage, banking, investing, retirement, and what not.

We don't live in Cuba or north Korean, so if you like that stuff, make it an avocation.

A specialty can be tough during residency, but when you graduate you can slowly tailor your practice to your needs. Yeah for sure if you're a surgeon and you decide to operate less you'll have more money, but if you value more free time, or use that free time to pursue other ventures that generate more return, then why not?

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You know I think in Canada we need more physician who think about the business aspect. We have too many MD who think like politicians, administrators and bureaucrats in this country. Not enough innovators, too many rent seekers! Everyone likes free lunch, but nobody likes paying for them! Too many people thinking about how to divide the pie, not enough thinking about how to make the pie bigger!

Good thing in the last 10 years new generation of physicians can gain financial education freely on the internet, now there's so much more robust discussion between physicians. Things like compensation, billing, incorporation, HR issues, running your practice, estate planning, insurance etc are not mysteries that can only be heard sotto voce in a dark corner of the bar after work anymore haha.

 

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So coming back to your original point, the key point with your medicine career is that "busy" and "not busy" come in ebbs and flows. M1 maybe busy but M2 slow, M3 busy but M4 slow after carms. maybe R1 not busy but R2 busy etc etc.

So the key is you gotta take advantage of the times when you are not busy to do 2 things:

1) lay groundwork so when you get busy you are well prepared. For example, I tell people when they are on a chill rotation in clerkship get their legal documents and paperwork in order for CaRMS. Comes carms time then you don't have to scramble to figure out how to get a paper notarized when you're doing elective in a far away city etc.

Another example: get the royal college studying going early when you are in R2. Don't delay until you are in R5. Even if the material is too advanced, at least get your hands on some old questions so you're familiar with the format and style of questions. That way in your day to day work when you have an interesting case, your mind automatically goes "hmmmm, how could I frame this unusual case in the format of an OSCE station or written question on the royal college???" 

2) efficiently recharge. don't waste the free time on things that make your more stressful. For example you wanna sleep in but your GF/BF want you to drive 3 hours to visit them, and that's stressful. Like yeah you don't wanna disappoint other people that matter to you but you can't please everyone at once too. So sometimes you gotta cut ties with "friends" who negatively impact you. 

You gotta figure out what's really "high yield" when it comes to recharge. Like if doing Tai Chi for 5 hours a days you like fine, but there's no way in residency every day you can afford to spend 5 hours doing Tai Chi lol. Some other things may be more time efficient and high yield. Going for a 10 min run is an example, or a quick cold shower for 10 minutes.

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23 hours ago, Organic Chemistry said:

To begin, I am not the type of person who is in medicine for the $$$, nor do I believe in the privatization of healthcare. I believe that healthcare is a human right, and I truly love the process of interacting and talking with patients, and working with them and the whole team to solve their medical problems. I would choose a career in medicine over business any day. But, as more as a hobby, I love to dabble in investments and stocks, analyzing real estate prices and generally have a bit of an entrepreneurial spirit. I would love to continue this in the future, but I am wondering, does that mean I would have to rule out the "tougher" (surgical or IM) specialties? Do you know of any residents or attendings in these fields who also have a side business or significant investments? Do you have to sacrifice one or the other?

Overall the best is family medicine. You start generating real money on average about 3-5 years earlier than other specialties, which means you can start seriously investing 3-5 years earlier. You don't have to worry about relocating/applying for fellowship. FM residents mostly rent for residency instead of buying property because residency is much shorter (meaning more capital or potential leverage available for investing). Work-life balance during FM residency is better than 90% of residencies, and as an attending you have a lot more control over your schedule than hospital-based specialists (meaning more likely to be able to maintain your hobbies).

But just to go through the other specialties...

Surgery: Avoid any that are stereotypically tough, because that will go beyond eating away at your hobbies like investing. Also avoid any with known terrible job markets (because you'll be spending upwards of 8+ years making resident/fellow level pay). This leaves ENT, urology, ophthalmology, and maybe plastics.

Medical: Any of them could work except maybe some of the service-heavy IM programs. You'll have some time to invest if you do anesthesia, radiology, EM, for example. The interventional fellowships (IR, IC, etc.) tend to be tough but generally they are relatively short in length.

As an attending you'll have more control over your life so you're more able to do what you enjoy. Though by that time your priorities may change. Many end up focusing on family & a few hobbies, and learn just enough about investing for future retirement.

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Derm->Mohs Surgery

You'd work 40-45 hours a week 8:30-4 and make bank. Residency is also a really chill 8-5ish.

Would leave you with plenty of time to think about how to invest the $$$ that you'd print hand over fist.

You couldn't pay me enough to do it. Doing the exact same procedure every single day would be mind numbingly boring.

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37 minutes ago, zoxy said:

Derm->Mohs Surgery

You'd work 40-45 hours a week 8:30-4 and make bank. Residency is also a really chill 8-5ish.

Would leave you with plenty of time to think about how to invest the $$$ that you'd print hand over fist.

You couldn't pay me enough to do it. Doing the exact same procedure every single day would be mind numbingly boring.

1. Derm is the hardest speciality to match into. People want it from day 1 and don't match. And if someone is lucky enough to match derm, you better not be location restricted since getting a spot in general is very tough, and you will likely not get it where you want it. Not everyone is ok moving across the country. 

2. Derm residency is not easy. You spend a huge amount of time outside of work hours studying various amounts of info compared to other specialities. The first year is mostly IM as well. There is a steep learning curve is derm is barely touched on in medical school. Also, the Royal College derm exam is hard. 

3. If you want to do a Mohs fellowship that's an extra year on top of a 5 year residency. 6 straight years of residency/fellowship is not "really chill" but a grind. It's also FOUR years of lost income had you went into FM, worked hard, invested, etc

There are trade-offs to everything. 

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5 hours ago, offmychestplease said:

1. Derm is the hardest speciality to match into. People want it from day 1 and don't match.

2. Derm residency is not easy. You spend a huge amount of time outside of work hours studying various amounts of info compared to other specialities. The first year is mostly IM as well. Also, the Royal College derm exam is hard. 

3. If you want to do a Mohs fellowship that's an extra year on top of a 5 year residency. 6 years of residency/fellowship is "not chill" 

I didn't say that it's easy to match into. But if you match it is pretty chill. I can't think of any other specialty with the same $/hours worked ratio. I think they work less than 50 hours a week on average in Canada, data from the US had Derm at 44 hours a week. They don't have to worry about a saturated job market like surgical specialties or procedural IM sub-specialties either. There are plenty of jobs for Derm all over Canada, even in the GTA and Greater Vancouver.

Also, unlike many other competitive specialties, gunning for Derm won't particularity harm your chances of matching to IM or FM as backups. In 2020, 55 candidates ranked derm as their first choice preference. Of these 55, 28 matched to derm, 25 matched to a backup specialty, and 2 went completely unmatched. It's not like Ophtho which had 18 applicants who went completely unmatched. Also I think OP is in Quebec which has 10 Derm residency spots, compared to 16 for the rest of Canada. Two of those 16 spots have a 5 year RoS service agreement so its more like 14 for the rest of Canada.

IMO, studying at home is much better than being on call or in the hospital at 3 in the morning, which is something that many other specialists have to deal with it. Sure, it may not be as chill as FM, but it's pretty darn chill for a specialty.

As for the Derm boards, it has a 98.1 percent first time pass rate according to the Royal College. I'm not sure if the data is there that the Derm Royal College exam is much harder than the exam for other specialties. Someone might argue that the Derm first time pass rate is high because everyone studies so hard but I'd need to see more data to be convinced of this.

Whatever you'd make during those 3-4 years of doing FM and finishing earlier, would pale in regards to total earnings with Derm/Derm-Mohs. There are trade-offs to every decision but lets not pretend that the trade offs for Derm are anything like the ones you'd make choosing Ortho, GenSx, or Cardiology. If I had even a speck of interest in Derm, gunning for it would be the most rational choice taking lifestyle, income and job market into consideration. It's the only specialty where you don't have to choose between location, income, and lifestyle when practising.

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Derm is a pretty good choice for sure. Don't think I've ever seen a derm resident taking consults on call. I doubt there's more reading in derm than radiology or IM. But if you're not passionate about derm it turns med school into a grind. I would've mentioned it above but I'm sure OP would've asked about derm if it was on their mind.

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1 hour ago, offmychestplease said:

1. Derm is the hardest speciality to match into. People want it from day 1 and don't match. And if someone is lucky enough to match derm, you better not be location restricted since getting a spot in general is very tough, and you will likely not get it where you want it. Not everyone is ok moving across the country. 

2. Derm residency is not easy. You spend a huge amount of time outside of work hours studying various amounts of info compared to other specialities. The first year is mostly IM as well. There is a steep learning curve is derm is barely touched on in medical school. Also, the Royal College derm exam is hard. 

3. If you want to do a Mohs fellowship that's an extra year on top of a 5 year residency. 6 straight years of residency/fellowship is not "really chill" but a grind. It's also FOUR years of lost income had you went into FM, worked hard, invested, etc

There are trade-offs to everything. 

R1 is tough in Derm... but it is literally just a rotating year, not significant different than other fields - like FM/Psych etc.  It is not comparable to the R1 year of IM, at least not in Canada - they have significantly more on-service for IM with ++ call.  But even if we say its a wash and agree R1 is comparable.....after that its no contest:
 
Compared to most other 5 year specialties, derm is in fact very chill. I have 2 colleagues who completed derm residency, and aside from the royal college year of sucking (same as all other 5 year programs), r2-r4 is very manegable. Minimal call(if any), clinic hours 9-4/5 on most rotations etc.   As for the royal college exam itself, my 2 colleagues definitely didn't study nearly as hard as IM/Rads individuals. But that is only anecdotal.

Yes, Derm have to spend time reading outside of clinic hours to continue to build their skillset...but so do all other 5 year programs. Its not like IM and Rads for example don't have to spend extra time outside of work...except with Derm your clinical hours are significantly less than IM, and not as intense as Rads.   The main difference is with Derm, you have to ensure you are familiar with all the rare derm conditions that you likely don't see in day-to-day clinic, whereas in IM, you will probably have seen most bread-butter things in clinical practice.


 

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Agree with posters above - Derm is really golden when it comes to work-life balance and $$$ per hour.  I don't even think Derm R1 is any harder (which varies per program) than a lot of FM programs especially with obstetrics.  Agree also that their Royal College isn't a walk-over, but it's no harder than some other Royal College exams (like path or rads).  

Ophtho is generally more lucrative, but the procedures are considerably more complicated and an ophtho clinic has much higher overhead.  Except for Mohs and starting some therapeutics (e.g. biologics), FPs could in theory manage most of community derm especially - it's simply a high-volume niche specialty with a great job market/flexibility.  Sure some FPs do derm, but it's more work to get "established" and there is no equivalent certification.  

Mohs is a very small niche - very lucrative, but tight job market too.

The amount of time/space discussing derm on this forum is somewhat disproportionate to the number of spots or even the number of applicants lol.    

Just like some other competitive specialties, having access to clinical and research connections early is helpful for derm - coming from a major school with a program helps.  I think it's important to think about matching to these specialties as much as about playing the system/game, even with an uneven playing field, rather than being innately exceptionally qualified (although major research experience can helpful for some programs).  

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35 minutes ago, indefatigable said:

Mohs is a very small niche - very lucrative, but tight job market too

The amount of time/space discussing derm on this forum is somewhat disproportionate to the number of spots or even the number of applicants lol.    

 I think it's important to think about matching to these specialties as much as about playing the system/game, even with an uneven playing field, rather than being innately exceptionally qualified (although major research experience can helpful for some programs).  

This is true, it is very difficult to run a Moh's only practice, especially if you're a recent graduate. Most new Mohs surgeons start out doing quite a bit of general dermatology on the side. I think the Mohs job market in Canada is slightly better than the US one though.

As for your last point, I'm in complete agreement. Without grades or a test like the USMLEs it's impossible to gauge the qualification of applicants. Eighty percent of applicants look identical on paper anyway. That's why many Derm/Ophtho/Rads programs ask for undergrad transcripts so that they have some form of data to cull the herd. Even that is pretty useless when everyone has a 3.9+, connections trump everything else. If you want Derm, it's best to go to a school that offers a Derm residency.

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1 hour ago, zoxy said:

This is true, it is very difficult to run a Moh's only practice, especially if you're a recent graduate. Most new Mohs surgeons start out doing quite a bit of general dermatology on the side. I think the Mohs job market in Canada is slightly better than the US one though.

As for your last point, I'm in complete agreement. Without grades or a test like the USMLEs it's impossible to gauge the qualification of applicants. Eighty percent of applicants look identical on paper anyway. That's why many Derm/Ophtho/Rads programs ask for undergrad transcripts so that they have some form of data to cull the herd. Even that is pretty useless when everyone has a 3.9+.

I think that's the point - the data is used to "cull the herd" - elimination is an easier goal to accomplish.  

Although, I think having Step 2 as an "objective" target is not a terrible idea except for the pressure of very big test day (warm-up for the Royal College lol) - at least the knowledge is mostly pertinent to clinical medicine.  Step 1 was almost completely useless except to lab specialties, but still some appreciated the objectivity (debatable considering "teaching" to the test).  

I'd say in the Canadian system, matching can roughly be summarized as follows: 

+ves factors for matching:  excellent letters (esp program>school) >> excellent electives  > research or cv "buffing' opportunities > school (e.g. generally "home" school>IP>OOP,...)

-ves factors: red flags >>> less electives >>  school (e.g. OOP or less "known")

excellent letters, like electives, are a bit luck of the draw - dependent on staff to some extent, but also performance and possibly other attributes like research or cv...  

red flags would be any professionalism on MSPR>failures or repeat year> previous year graduate..

Matching to a 'competitive' program means hitting as many of the +ves as possible (in priority) and missing the -ves.  

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1 minute ago, indefatigable said:

 Step 1 was almost completely useless except to lab specialties, but still some appreciated the objectivity (debatable considering "teaching" to the test). 

This is a digression from OP's post but:

The funniest thing is that some US schools construct their entire curriculum around excelling on Step1. U-Texas-Galveston, and the University of Missouri are examples of such schools. The University of Missouri was one of the first and most extreme example to do this and has the same average Step1 score as NYU, Duke, and Cornell (higher than Columbia,UChicago and Hopkins!).

Interesting thing is that their match list, while very nice for mid-low tier US School, is not as good as you'd expect based purely off of their Step scores. I assume program directors are aware of their curriculum and adjust for it.

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5 minutes ago, zoxy said:

This is a digression from OP's post but:

The funniest thing is that some US schools construct their entire curriculum around excelling on Step1. U-Texas-Galveston, and the University of Missouri are examples of such schools. The University of Missouri was one of the first and most extreme example to do this and has the same average Step1 score as NYU, Duke, and Cornell (higher than Columbia,UChicago and Hopkins!).

Interesting thing is that their match list, while very nice for mid-low tier US School, is not as good as you'd expect based purely off of their Step scores. I assume program directors are aware of their curriculum and adjust for it.

All very interesting - agree it's a digression.. haha!

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On 4/17/2021 at 1:40 PM, zoxy said:

Derm->Mohs Surgery

You'd work 40-45 hours a week 8:30-4 and make bank. Residency is also a really chill 8-5ish.

Would leave you with plenty of time to think about how to invest the $$$ that you'd print hand over fist.

You couldn't pay me enough to do it. Doing the exact same procedure every single day would be mind numbingly boring.

I’m not a dermatologist but I would disagree that Mohs surgery is doing the same procedure day in day out. The principles are the same, but the closures can get quite complex and creative. The Mohs clinic/surgeries are actually really fun.

In terms of $$$/hours worked, this is not even a debate. The best sub speciality in all of medicine for this is Medical Retina. The way it works in most centres, they don’t take any call, work 8am-4pm monday to friday and make more than most Ophthalmologists.

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21 minutes ago, Aetherus said:

I’m not a dermatologist but I would disagree that Mohs surgery is doing the same procedure day in day out. The principles are the same, but the closures can get quite complex and creative. The Mohs clinic/surgeries are actually really fun.

In terms of $$$/hours worked, this is not even a debate. The best sub speciality in all of medicine for this is Medical Retina. The way it works in most centres, they don’t take any call, work 8am-4pm monday to friday and make between 3 and 5mill.

do you mean LASIK? I thought the few guys doing LASIK are experienced opthos and it is saturated? And is this before the 60% overhead? 

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57 minutes ago, Aetherus said:

I’m not a dermatologist but I would disagree that Mohs surgery is doing the same procedure day in day out. The principles are the same, but the closures can get quite complex and creative. The Mohs clinic/surgeries are actually really fun.

I was under the impression that most closures are done by Plastic Surgeons. This is particularity true if it's a complicated closure. I'm neither a dermatologist nor a plastics surgeon so I could be wrong.

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6 hours ago, offmychestplease said:

do you mean LASIK? I thought the few guys doing LASIK are experienced opthos and it is saturated? And is this before the 60% overhead? 

Nope. LASIK is a completely different segment of the market. Refractive surgery is all private. The biggest player in that area is LASIKMD. Pretty easy to get in with them if you want to, however I think they only pay you a fraction of the price you would make otherwise.

The overhead is a bit of a black box, but for large clinics it’s quoted as being around 60%.

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Just now, zoxy said:

I was under the impression that most closures are done by Plastic Surgeons. This is particularity true if it's a complicated closure. I'm neither a dermatologist or nor a plastics surgeon but I could be wrong.

That is partially correct. Most closures are simple and closed by the MOHS surgeon. Some closures are complicated (around the eye) and are closed by Oculoplastics. I’m sure some are also closed by plastics as well. I think it depends on the mohs surgeon’s comfort, but they can do some pretty complex closures if they are comfortable with it.

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16 minutes ago, Aetherus said:

Nope. LASIK is a completely different segment of the market. Refractive surgery is all private. The biggest player in that area is LASIKMD. Pretty easy to get in with them if you want to, however I think they only pay you a fraction of the price you would make otherwise.

i am referring to Medical Retina with intravitreal injections. The overhead is a bit of a black box, but for large clinics it’s quoted as being around 60%.

so is it 1.2- 2 million after overhead or the 3-5 million you said is already after the 60% overhead??

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31 minutes ago, Aetherus said:

Nope. LASIK is a completely different segment of the market. Refractive surgery is all private. The biggest player in that area is LASIKMD. Pretty easy to get in with them if you want to, however I think they only pay you a fraction of the price you would make otherwise.

i am referring to Medical Retina with intravitreal injections. The overhead is a bit of a black box, but for large clinics it’s quoted as being around 60%.

This is somewhat unrelated but I can't believe the eye injection gravy train is still rolling in Canada. That money could be used to perform so many more services that are rationed due to the lack of money in the system.

Ophtho used to be the best paid specialty in the US as well, but the Centre for Medicare and Medicaid Services(CMS) cut their compensation every single year the fees were negotiated. Now Ophtho is merely mid-pack for procedural specialties. Retina is still the best paid Ophtho sub but again, nowhere near what it used to be before the CMS cuts.

Goes to show how even the government based systems in the US is more agile and flexible than the plodding Canadian equivalent. I keep expecting the provincial governments to cut Ophtho fees. But every time the contracts are renegotiated there are minimal cuts or no cuts to Ophtho!

Of course, I can understand why doctors don't want to give an inch when renegotiating their contracts in Canada. There's no reason to believe that the money saved will be reinvested back into the healthcare system.  In the US, when CMS cuts from one specialty/procedure it gives back to another underpaid/valued specialty. Those dynamics are not present in Canada.

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