Could anyone please clarify the huge pay discrepancies within primary care?

[medpotato]

Primary care is one of my interests, but the huge variability in pay within it is confusing, and also definitely a factor in choosing FM vs IM vs ER.

 

For example, I have read on this forum that:

ER shifts can pay $3k for a 8 hr shift - $375 per hour

Hospitalist work - $160 / hour?

For clinic work, there are tonnes of postings on locums.ca that pay $900 for an 8 hour shift - $110 per hour

 

Yes, there is variability in number of patients/procedures, but for what might be considered "somewhat similar" work, a 3x pay difference is massive.

 

Could anyone please clarify?

The other confusing part is that I've heard a FM physician (without +1) could still pick up shifts in a semi-rural ER (50-100k population).

So depending on whether they work at a clinic / hospital, their pay could see a 3x difference?

[Bluberblubo]

What I've seen is that there is a larger variability in pay within specialties than between specialties. 

Those numbers may be true, but there are reasons why this is the case. 

You can do 5 days of hospitalist a week for 4 weeks with weekends off or work 14 days straight without much difficulty, but doing 20 ER shifts in a month or 14 days of ER shifts in a row is really tiring (but not impossible). You can pick up a locum and work $900 for 8 hours and not pay any overhead, which is nice (although maybe that's on the lower end of things), but it might be a really cushy job. There are many factors at play that you might not be aware of when looking at job postings. This shouldn't be a big factor in deciding what specialty to go into. As long as your specialty of choice has job opportunities in a place you want to work in then that should be good. You will make more than enough money in all of those 3 specialties. 

[stayblessed]

Two multipliers of income in medicine are quantity and time service rendered.

ER: Picking up overnight shifts or working for a high volume center will make you lots of $$$.  In ON, consult code in the ED by FP is $75. If you see 4 new patients an hour, that’s $300. Plus any overnight premiums. In a high volume center in the GTA where presentations are pretty cookie cutter due to patients coming in for concerns they should be seeing their FP about, the sky is the limit. 
 

Can you handle the hallway medicine and chaotic environment of those EDs? At 3AM? For long stretches of time?

Hospitalist: Hospitals often pay a stipend if it’s not a high volume centre in addition to what you bill for. Hours are 9-5 with minimal overhead. Anecdotally heard FPs breaking $300k and I don’t think that’s an anomaly. With minimal overhead that adjusts to closer to $400k assuming other docs are paying 30% overhead. Add call or the occasional ER/walk-in shift and that’s more $$$. 
 

Clinic: If you can get a FHO spot this can be quite lucrative without the pressure of ripping through patients in a FFS. Overhead and running an office may be a bit of a hassle but the hours of 9-5 are quite sustainable. You’ll be making 300 to 500k depending on your roster size. 
 

GIM billing codes are going to be higher so you can see less patients for the same amount of time as an FP. Having said that, GIM will keep you to only seeing adults with a classic set of presentations. If you want a broad scope of medicine, FP is the way to go. 
 

Good luck on the decision!

[medpotato]

Thanks for the answers!

@skyuppercutt I definitely agree that the intra-specialty differences are really not represented well by the average numbers available through Carms. But I do hesitate to assume that I will find a FP job more cushy than an ER job (maybe others will disagree), since somtimes waiting around / following up on long term cases could be more difficult than being constantly 'on' in a more hectic setting.

@stayblessed Could you please elaborate on the last part, about GIM having higher billing codes than FM hospitalists? My understanding is for the ER there can be different codes, but same amounts. I know its tough to generalize, but roughly how large would you say the difference is (like 30-50%)? 

This goes back partially to the main point of the question, which is that I want to choose a specialty based on interest, but I don't want to be underpaid relative to my colleagues doing a similar job, working similar hours, in the same setting (and I don't think anyone else should be either).

Honestly, I feel like if I chose FM did a lot of hospitalist work but my GIM colleagues were making significantly more than me for a very similar job, I would wish I had done the 3 extra years of residency.

[gangliocytoma]

2 hours ago, medpotato said:

 

Honestly, I feel like if I chose FM did a lot of hospitalist work but my GIM colleagues were making significantly more than me for a very similar job, I would wish I had done the 3 extra years of residency.

 

As with everything it depends on where you work. I know that my centre, the academic GIM staff make salaried ~$350k per year and for ?14 blocks of GIM which is 2 weeks each so 28 weeks of work. This 28 weeks doesn't include academic responsibilities and clinics they may run as well.

I've heard that GP hospitalists in the community can make anywhere from $10-14k per week working 1 week on 1 week off. If you take the middle number  and count 26 weeks then you get ~$312k. The GP hospitalist can run FM/walk-in clinics or pick up ED shifts in time off to supplement income as well. 

Yes I think there are differences in the $ for OHIP billing codes for a GP consult vs GIM consult, but otherwise the codes are the same and in many shops GP hospitalists and GIM do the exact same thing.

[gogogo]

On 6/26/2021 at 9:47 AM, stayblessed said:

Clinic: If you can get a FHO spot this can be quite lucrative without the pressure of ripping through patients in a FFS. Overhead and running an office may be a bit of a hassle but the hours of 9-5 are quite sustainable. You’ll be making 300 to 500k depending on your roster size. 

Thanks for the detailed info. Quick question: Is the 300-500k before or after overhead? Is the 500k FHO doctor working a lot, or is the average 50-60 hour week manageable with that level billing?

[QuestionsAbound]

On 6/24/2021 at 4:49 AM, medpotato said:

ER shifts can pay $3k for a 8 hr shift - $375 per hour

This is not accurate. Ask your staff docs about what they are paid. Most emergency departments are paid an hourly rate plus a % of shadow billings, and it certainly isn’t in the $300 range.

[QuestionsAbound]

16 hours ago, gogogo said:

Thanks for the detailed info. Quick question: Is the 300-500k before or after overhead? Is the 500k FHO doctor working a lot, or is the average 50-60 hour week manageable with that level billing?

They are working a lot.

[stayblessed]

On 6/27/2021 at 5:18 AM, medpotato said:

 

@stayblessed Could you please elaborate on the last part, about GIM having higher billing codes than FM hospitalists? My understanding is for the ER there can be different codes, but same amounts. I know its tough to generalize, but roughly how large would you say the difference is (like 30-50%)? 

 

Full disclosure that I am not a staff but in referencing OHIP's schedule of benefits, an FP doing an inpatient consult is $77.20. A GIM doc can either bill C135 (inpatient consultation) which is $157.00 or C435 (limited inpatient consultation) $105.25. I am not sure the difference between both of these billings. There are also premiums that go with admitting a patient as the MRP 30% applicable to both docs.

Stipends are provided hospitalist positions and I am not sure how those are distributed. While a tough discussion to broach, I recommend asking young staff/mentors/senior residents how their billing works (you don't have to ask them about how much they are exactly making). It's your right to know how you will be compensated for giving up the most valuable asset we have...time.

[medpotato]

On 6/28/2021 at 1:21 PM, QuestionsAbound said:

This is not accurate. Ask your staff docs about what they are paid. Most emergency departments are paid an hourly rate plus a % of shadow billings, and it certainly isn’t in the $300 range.

@QuestionsAbound Could you clarify what a reasonable range to expect total hourly (or shift) for a CCFP (without EM designation) working an emergency shift would be? Is this a different amount than people who have CCFP-EM and FRCPC?

 

What about overhead?

[JohnGrisham]

2 hours ago, medpotato said:

@QuestionsAbound Could you clarify what a reasonable range to expect total hourly (or shift) for a CCFP (without EM designation) working an emergency shift would be? Is this a different amount than people who have CCFP-EM and FRCPC?

 

What about overhead?

Province dependent. As far as i know, there is no pay difference in a hospital setting for an Emerg doc based on their designation. If you are working as an emerg doc in a specified hospital A, you are getting paid the same with FRCPC, CCFP-EM +1, Challenge CCFP or without.   

Someone can correct me if im wrong. The main difference is weather or not Hospital A would hire you to work there without designation X. I.e some places will only take FRCPC.

[QuestionsAbound]

2 hours ago, JohnGrisham said:

Province dependent. As far as i know, there is no pay difference in a hospital setting for an Emerg doc based on their designation. If you are working as an emerg doc in a specified hospital A, you are getting paid the same with FRCPC, CCFP-EM +1, Challenge CCFP or without.   

Someone can correct me if im wrong. The main difference is weather or not Hospital A would hire you to work there without designation X. I.e some places will only take FRCPC.

This is correct. The pay is the same regardless of your designation, with the exception of a consult code for the FRCPC staff. This may be province dependent.

5 hours ago, medpotato said:

@QuestionsAbound Could you clarify what a reasonable range to expect total hourly (or shift) for a CCFP (without EM designation) working an emergency shift would be? Is this a different amount than people who have CCFP-EM and FRCPC?

 

What about overhead?

There is no overhead. The hourly pay will vary depending on the hospital (volume, amount of coverage, etc.) and each hospital has its own hourly pay/billing split. 

 

 

 

 

[Bluberblubo]

On 6/27/2021 at 5:18 AM, medpotato said:

@skyuppercutt I definitely agree that the intra-specialty differences are really not represented well by the average numbers available through Carms. But I do hesitate to assume that I will find a FP job more cushy than an ER job (maybe others will disagree), since somtimes waiting around / following up on long term cases could be more difficult than being constantly 'on' in a more hectic setting.

 

Someone can correct me if I'm wrong here, but I'm not sure if your statement is totally accurate. You might think that an ER job is cushy, but apparently they have a really high rate of burnout, especially later in life. This I heard is also a CaRMS interview question that is asked as well. Some would feel that having complete control of your clinic, hours, staff + already knowing your patients well as is the case in family medicine is really cushy too. For example, if you already know a patient's conditions inside now, dealing with a new issue that comes up is fairly straightforward. 

On 6/27/2021 at 5:18 AM, medpotato said:

Honestly, I feel like if I chose FM did a lot of hospitalist work but my GIM colleagues were making significantly more than me for a very similar job, I would wish I had done the 3 extra years of residency.

If you want to do hospitalist work i.e. that's your interest, I would urge you to do IM. Many of my family med friends who have done the +1 in hospitalist and starting working as attendings find the work really stressful and feel that there are gaps in their knowledge. It's not uncommon to get some questions throughout the week from them on how to manage certain patients or conditions.  They are by no means "bad" doctors and have always been brilliant on every rotation they've been in, but the training we go through is just different (2 years in different specialties including 2-4 blocks of CTU, and mostly outpatient + 1 year hospitalist vs. 5 years of mostly inpatient stuff). Caveat being my N=3 and they are early in their training.

The summary is that this goes back to what I touched on earlier that you should decide based on your interest.

• Do you want to see everything + patient's family members and follow for a long time/developing lasting relations with them --> Family
• Do you want to see everything + shift work, but not follow people over time --> ER
• Do you want to only see specialized conditions, only see adults, and do lots of inpatient stuff --> GIM

Finally, billing codes can change at anytime, especially if the government decides to look for way to make up the lost costs from covid. So this should be the least of your focus.

[indefatigable]

4 hours ago, skyuppercutt said:

If you want to do hospitalist work i.e. that's your interest, I would urge you to do IM. Many of my family med friends who have done the +1 in hospitalist and starting working as attendings find the work really stressful and feel that there are gaps in their knowledge. It's not uncommon to get some questions throughout the week from them on how to manage certain patients or conditions.  They are by no means "bad" doctors and have always been brilliant on every rotation they've been in, but the training we go through is just different (2 years in different specialties including 2-4 blocks of CTU, and mostly outpatient + 1 year hospitalist vs. 5 years of mostly inpatient stuff). Caveat being my N=3 and they are early in their training.

Agree.  If you want to work primarily with adult inpatients, then IM is a much better choice.  Although there is some overlap, as the most acute aspects of hospitalist are like the least acute aspects of IM, FPs have less training to manage those conditions.  Plus there is considerable difference in billing which means hospitalists seem to end up taking on more patients which can add to stress/workload.

[bellejolie]

In my experience so far, family medicine hospitalist wards have less intense patients (less sick, less acute, more stable, LOI 3) than IM and fam docs are more than equipped to handle it. That being said, we have had our fair share of difficult cases and we consult the specialists to help. I'm at a big tertiary care centre in montreal and I am in awe with the ability the fam docs have to do hospitalist medicine. My knowledge has definitely improved a ton as a resident and think all new staff increase exponentially their knowledge in their first few years of practice.

In terms of the money, in montreal the CTU staff bill 4K a day and the fam med staff given their higher turnover bill less but similarly. Our FM ward you make between 15-18K a week (which amounts to 2-3K per day), plus residents do all the consults and there are overnight billings etc. It's a short stay so volume/turnover is very high and you can prob make up to 20K in the week if you're good at bed flow management. 

At the end of the day, no doctor is wanting for money, we are all very comfortable and will be fine. Focus on what you enjoy and less the money because you can make money in every specialty. Fam docs do really well and to me it's really a myth that being a fam doc is not lucrative. every academic staff I've met makes 400K after overhead so if they can make that much, you can too. 

[indefatigable]

18 hours ago, bellejolie said:

In terms of the money, in montreal the CTU staff bill 4K a day and the fam med staff given their higher turnover bill less but similarly. Our FM ward you make between 15-18K a week (which amounts to 2-3K per day), plus residents do all the consults and there are overnight billings etc. It's a short stay so volume/turnover is very high and you can prob make up to 20K in the week if you're good at bed flow management. 

At the end of the day, no doctor is wanting for money, we are all very comfortable and will be fine. Focus on what you enjoy and less the money because you can make money in every specialty. Fam docs do really well and to me it's really a myth that being a fam doc is not lucrative. every academic staff I've met makes 400K after overhead so if they can make that much, you can too. 

It sounds like academic FPs in Montreal can do really well - way, way above average for QC!  Maybe it's Montreal or having residents do a lot of billable work?  

According to this official guide from the Quebec student's association, the average internist bills ~450K/year with minimal overhead while the average FP bills ~310K/year with about ~250K after-overhead  (average 20%).  What's interesting is specialties like path/psych (along with ER) bill about as much as IM and 1.5 times FM .  

In Ontario, I think it's maybe closer in in terms of overall billings for FPs and IM, but mostly because of FHO/FHTs.  The consults fees for an internist are simply much higher - so hospitalist requires churning through way more patients to make comparable income (and being on call 24/7) and isn't usually sustainable for weeks on end (although I'm sure call is distributed in groups which makes it tolerable).

source: https://fmeq.ca/wp-content/uploads/2020/11/MemoireRemunerationMedecin.pdf (very last line is family med)

 

[bellejolie]

the problem i have with averages is it includes a lot of FM docs who work part time and therefore isn't really accurate. a lot of people go into FM to balance lifestyle so a great portion of fam med docs absolutely make less because they are working less. like i said i have not heard of anyone making under 400K (who even have their own clinics non academic - where you're actually faster and bill more) that works 5 days a week. @indefatigable

academic practices you make less normally, because you're paid salary and hourly. anyway medicine and FFS is about how much you work. FM you have a much wider range in how much people work depending on what kind of life they want. other specialties don't have that type of flexibility therefore they tend to have higher avg earnings. if a fam doc works 60 hrs a week, they will make a lot. if they work 30 they will make less. that's generally how it goes. you're just in a lot more control of those hours so you see a bigger range. 

highest earning fam doc in ontario in 2018 made 4 million dollars. highest earning ENT made 1.7 mil. it's up to you how you want to do your practice and fill it. 

[MaudeB]

3 hours ago, bellejolie said:

the problem i have with averages is it includes a lot of FM docs who work part time and therefore isn't really accurate. a lot of people go into FM to balance lifestyle so a great portion of fam med docs absolutely make less because they are working less. like i said i have not heard of anyone making under 400K (who even have their own clinics non academic - where you're actually faster and bill more) that works 5 days a week. @indefatigable

academic practices you make less normally, because you're paid salary and hourly. anyway medicine and FFS is about how much you work. FM you have a much wider range in how much people work depending on what kind of life they want. other specialties don't have that type of flexibility therefore they tend to have higher avg earnings. if a fam doc works 60 hrs a week, they will make a lot. if they work 30 they will make less. that's generally how it goes. you're just in a lot more control of those hours so you see a bigger range. 

highest earning fam doc in ontario in 2018 made 4 million dollars. highest earning ENT made 1.7 mil. it's up to you how you want to do your practice and fill it. 

@bellejolie, in your experience, can fam doc work part-time in Qc right out of residency, like 30 hours a week? I always wondered if its a possibility or you can only do this after years? Thanks!

[indefatigable]

4 hours ago, bellejolie said:

the problem i have with averages is it includes a lot of FM docs who work part time and therefore isn't really accurate. a lot of people go into FM to balance lifestyle so a great portion of fam med docs absolutely make less because they are working less. like i said i have not heard of anyone making under 400K (who even have their own clinics non academic - where you're actually faster and bill more) that works 5 days a week. @indefatigable

academic practices you make less normally, because you're paid salary and hourly. anyway medicine and FFS is about how much you work. FM you have a much wider range in how much people work depending on what kind of life they want. other specialties don't have that type of flexibility therefore they tend to have higher avg earnings. if a fam doc works 60 hrs a week, they will make a lot. if they work 30 they will make less. that's generally how it goes. you're just in a lot more control of those hours so you see a bigger range. 

highest earning fam doc in ontario in 2018 made 4 million dollars. highest earning ENT made 1.7 mil. it's up to you how you want to do your practice and fill it. 

Actually QC FPs were pretty upset several years ago since the previous Health Minister put in financial penalties for "part timers" - which meant that without meeting a quota of patients, the FPs would get a financial hit.

Averages are not perfect - they are suspectible to outliers and extreme values.  But there's little reason to think that the numbers above aren't an accurate reflection of most FP earnings - on the next page there's a breakdown of the number days worked for both FPs and specialists.  It's literally almost equal (190 vs 196 for FPs vs specialists).  

As another check, many other specialties are fairly flexible, notably derm in QC, for which neither a PREM nor PEM is needed (the quota based regional permission to practice for FPs and specialists respectively).  So derms are more or less free to work wherever and whenever they want within the public system and the numbers reflect the expected income (without any private billings) with minimal if any call obligations.  

Finally, I reposted the graphs that compare high earning FPs to specialists within QC.  There are are less than 500 FP billing over 500K in QC vs over 3000 specialists, suggesting that the averages are in fact accurate. 

Overall, I much prefer aggregate data since I find it's more accurate to an average practitioners and anecdotes can easily get blown out of proportion.  For example there was a recent story about a QC nurse who made 300K last year - but that's obviously a major outlier, and a lot to do with the pandemic (https://ici.radio-canada.ca/nouvelle/1812797/salaire-remuneration-infirmieres-pandemie-prime-covid-quebec)

And sometimes, when billings are way off (like the Ontario FP who billed 4M) there's something a little "off".  A number of the 1M+ FPs in Ontario were doing pain injections, including this practitioner.  A lot of this approach to pain has been discredited and I think reforms/changes have been made.

https://www.thestar.com/news/investigations/2020/09/28/thats-an-injection-mill-ontarios-top-billing-pain-doctors-capitalize-on-provinces-lax-rules-running-up-the-publics-tab-for-chronic-pain-management.html

 

 

 

 

 

[MDee2B]

1 hour ago, indefatigable said:

Actually QC FPs were pretty upset several years ago since the previous Health Minister put in financial penalties for "part timers" - which meant that without meeting a quota of patients, the FPs would get a financial penalty.

Averages are not perfect - they are suspectible to outliers and extreme values.  But there's little reason to think that the numbers above aren't an accurate reflection of most FP earnings - on the next page there's a breakdown of the number days worked for both FPs and specialists.  It's literally almost equal (190 vs 196 for FPs vs specialists).  

As another check, many other specialties are fairly flexible, notably derm in QC, for which neither a PREM nor PEM is needed (the quota based regional permission to practice for FPs and specialists respectively).  So derms are more or less free to work wherever and whenever they want within the public system and the numbers reflect the expected income (without any private billings) with minimal if any call obligations.  

Finally, I reposted the graphs that compare high earning FPs to specialists within QC.  There are are less than 500 FP billing over 500K in QC vs over 3000 specialists, suggesting that the averages are in fact accurate. 

Overall, I much prefer aggregate data since I find it's more accurate to an average practitioners and anecdotes can easily get blown out of proportion.  For example there was a recent story about a QC nurse who made 300K last year - but that's obviously a major outlier, and a lot to do with the pandemic (https://ici.radio-canada.ca/nouvelle/1812797/salaire-remuneration-infirmieres-pandemie-prime-covid-quebec)

And sometimes, when billings are way off (like the Ontario FP who billed 4M) there's something a little "off".  A number of the 1M+ FPs in Ontario were doing pain injections, including this practitioner.  A lot of this approach to pain has been discredited and I think reforms/changes have been made.

https://www.thestar.com/news/investigations/2020/09/28/thats-an-injection-mill-ontarios-top-billing-pain-doctors-capitalize-on-provinces-lax-rules-running-up-the-publics-tab-for-chronic-pain-management.html

 

 

 

 

 

Interesting content - thanks for sharing!

it should be noted that, for table 3, a day of work is simply defined as a day of work where at least 1 dollar was billed. This provides then no real distinction between a part time work day consisting of say 2 hours versus a 10-12+ hour full day of work.

Looking back then at table 2, although both FPs and specialists avg about the same number of work days (~190), I wonder how similar these figures really are given the very loose definition of a workday (1$ billed).

[indefatigable]

56 minutes ago, MDee2B said:

Interesting content - thanks for sharing!

it should be noted that, for table 3, a day of work is simply defined as a day of work where at least 1 dollar was billed. This provides then no real distinction between a part time work day consisting of say 2 hours versus a 10-12+ hour full day of work.

Looking back then at table 2, although both FPs and specialists avg about the same number of work days (~190), I wonder how similar these figures really are given the very loose definition of a workday (1$ billed).

I agree that "full-time equivalent" would be better, but the second tables shows the proportion of part-timers in FM using the proxy of days worked across both sexes and gives a reasonable stratification.  If FM were disproportionately affected compared to specialists (like many seem to think), then this means it would necessarily be reflected in "days worked" like in the stratification.  The same argument regarding number of hours could be used for a specialty like derm, but the derm averages is 400K plus vs 300K for FM.

 In absolute numbers, I'm sure that there are more part-time FPs, but that's also because there are simply more FPs than any other practitioner.

Finally, given the young age of matriculants in QC, that could mean starting to earn 250-300K gross at 25!  THat's a high-income for that age by anyone's measure (not to mention the much lower debt burden of QC IP graduates)  

[MasterDoc]

On 10/16/2021 at 5:35 PM, indefatigable said:

It sounds like academic FPs in Montreal can do really well - way, way above average for QC!  Maybe it's Montreal or having residents do a lot of billable work?  

According to this official guide from the Quebec student's association, the average internist bills ~450K/year with minimal overhead while the average FP bills ~310K/year with about ~250K after-overhead  (average 20%).  What's interesting is specialties like path/psych (along with ER) bill about as much as IM and 1.5 times FM .  

In Ontario, I think it's maybe closer in in terms of overall billings for FPs and IM, but mostly because of FHO/FHTs.  The consults fees for an internist are simply much higher - so hospitalist requires churning through way more patients to make comparable income (and being on call 24/7) and isn't usually sustainable for weeks on end (although I'm sure call is distributed in groups which makes it tolerable).

source: https://fmeq.ca/wp-content/uploads/2020/11/MemoireRemunerationMedecin.pdf (very last line is family med)

 

Are the overhead fees realistic in this chart? They seem deflated compared to the overhead listed on the CMA profiles.

[Snowmen]

On 10/18/2021 at 4:13 AM, MasterDoc said:

Are the overhead fees realistic in this chart? They seem deflated compared to the overhead listed on the CMA profiles.

They're only based on an arbitrary percentage of billings made in outpatient clinics. For instance, if you bill 300 000$ at the hospital and 100 000$ at a clinic and they assume 25% overhead for clinic billing, they'll assume that overhead is 25 000$. This is a rough estimate but not accurate.