The specialty that makes doctors rich and happy

A long time ago, I was very close to becoming a cardiologist.  Really.

Even though my fascination with ID and microbiology started in medical school — and believe me, not much fascinated me in medical school — the fact that all the top residents in my program were going into cardiology made me feel that somehow I should be doing this too.  Plus, the guy who was Chief of Medicine was very influential.

When I came to my senses, and realized that I wanted to go into ID, there was a small problem — I had already matched in a cardiology program. Hence, I faced the tricky task of telling the program director, “Thank you very much for your kind offer, but I’ve decided I want to be an infectious diseases specialist.”

I remember his look of annoyance (understandable).  It was soon replaced by one of disbelief.  And then came a line I will never forget:

At least your motivation isn’t financial — ID doctors get paid s–t.

All of this came back to me when I read this fascinating survey over on Medscape on what we doctors get paid.

Some of the interesting results:

  • Yes, ID specialists (median of $174,750/year) are at the lower end of the specialist scale.  Other bottom feeders?  Pediatrics, rheumatology, endocrinology, primary care …
  • And the program director at my cardiology-fellowship-that-never-happened was right:  Cardiologists are the third-highest-paid physicians (after orthopedic surgeons and radiologists), with a median income of $325,000.  20% of Cardiologists report making more than $500,000, while almost this many ID/HIV docs get < 100,000.
  • However, despite this disparity, a higher proportion of ID docs (55%) than cardiologists (45%) report they were fairly compensated. Is that because ID is the most fascinating field in medicine?  And that an endocarditis case is surely more interesting than the simple plumbing they generally care for?  (That was a joke.  Some of my best friends are cardiologists.)
  • Weird disconnect between geographic cost of living and salaries, with the lowest pay coming in the most expensive places to live.  This is of course the complete opposite of salaries in business, banking, and law.  So if you want your doctor’s pay to go further, don’t live in California or Washington/NYC/Boston!

Of course, as we tell our kids, when choosing a career, it’s not about being rich — it’s about being happy.

But if you want to be both rich and happy, the specialty-of-choice is clearly dermatology — median annual income is nearly $300,000, and a whopping 93% said they’d choose the same specialty again, the highest of all the fields surveyed.

Acne treatment never looked so good.

Paul Sax is the Clinical Director of Infectious Diseases at Brigham and Women’s Hospital. His blog HIV and ID Observations, is part of Journal Watch, where he is Editor of Journal Watch AIDS Clinical Care.

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  • Terence Ivfmd Lee

    My workload is great, but happy and fulfilling. One of the many reasons is this. Most physicians convert a sad, ill, suffering patient and return them back to their previous neutral state. That’s great, but fertility specialists convert neutral-state patients into new parents, thereby making their lives supposedly happier. At least that’s what they say, as long as you are not asking them during a 3AM diaper change.

  • Edward Pullen

    The smartest docs and hardest working docs I’ve known at every step of my career were ID specialists.  Looking at gram stains at midnight is hard work.  My wife still thinks Dr. McEniry,  the ID guy in town is brilliant after diagnosing my son’s strep lymphadenitis after everyone else thought he had a throwing injury from baseball.  He is brilliant, though by the time he saw my son it was not so tough. 

  • Anonymous

    ID is way cool, the coolest specialty in medicine by far.  Anthrax, Dengue, plague?!?  Now that is something to sink your teeth into.  I saw a case of malaria last year, the first case in this area in a decade, and I was so excited my head was spinning.  Acne?  Not so exciting.

  • Kevin

    You’re the best Paul! When I went to Marshall and said “Could you write me a letter to do GI? I think I might want to do GI” he grilled me for 1 hr and then at the end said “I’m not going to write you a letter, you probably want to do this this and this.”. And here I am – a general internist! Hah!

  • Kevin

    You’re the best Paul! When I went to Marshall and said “Could you write
    me a letter to do GI? I think I might want to do GI” he grilled me for 1
    hr and then at the end said “I’m not going to write you a letter, you
    probably want to do this this and this.”. And here I am – a general
    internist! Hah!

  • Anonymous

    My favorite ID doc labeled my COPD patient a “facultative anaerobe.” Made me laugh. He’s the same one that wrote “No vitals between 2200 and 0600.” Nurses NEVER like patients to get comfortable in the hospital, so when we grilled him, he said, “Patients are going to get better in spite of us or despite us. We might as well let them sleep because it’s the best drug we have.” Go, ID!

  • Robert Bowman

    Good points on doing what stimulates you! This is the best choice for career decisions.

    Leach did a national study and the most satisfied were pediatricians. Perhaps those knowing what they wanted to do long before graduation knew a good thing and kept at it. Geriatrics was another top career in satisfaction, even with relatively low pay and complex patients – but generally the practice sites bail out geriatrics with support teams and elderly are pretty fascinating. Family medicine was mixed and in the middle in satisfaction. My question here is which of about 5 types of family medicine varying in location, patient population, duties, etc.

    Those most subspecialized were among the least satisfied despite highest pay. They also tend to have the top standardized test scores and graduate from the most prestigious schools. The same reward system may not apply and perhaps parent and other influences moved them this direction.

    It is a guarantee that few physicians understood what they were getting into for any career, since there is so little time to assess careers – as studies are demonstrating.

    Among the problems for subspecialists: relatively few places to work as it takes substantial numbers to support each one. About 1000 zip codes claim 55 – 60% of this workforce and these are the highest cost of living locations and have the highest costs of running a practice. Subspecialists may not have the choice to stay “home” as various movements are required to train and to find a practice. They may also require multiple sites to deliver the care. Also there is the danger of separation from interacting with patients which may drive the choice of a subspecialty or this may be a consequence of so many assistants between subspecialist and patient. 

    New to consider for about 10 years from now – more and more NP and PA in areas such as cardiology. About 7% of NP direct care clinician workforce is found in cardiology already (% in cardiology doubling every 6 – 10 years) and NP has increased to 8000 NP annual grads a year. The Lewin Group had lower paid NP and PA contributing $300,000 in annual revenue compared to $700,000 for a physician cardiologist that had much higher salary and benefits. More NP and PA are hired as they also do not tend to compete with existing cardiologists in revenue, unlike hiring a physician cardiologist where the revenue to each cardiologist declines. Current grads will not face the heat, but in the near future the cost
    cutting plus the NP and PA competition plus the expansions in MD, DO,
    NP, and PA plus 75% of primary care (from 6 sources) found in
    non-primary care careers will have consequences. Dermatologists have also been hiring more NP and PA, a great choice to funnel in the higher paid billing codes and increase market share.

    The doubling of NP and PA annual grads each 6 – 12 years with declines from 50% to 25% in primary care mean ever more non-primary care workforce – subspecialty, hospital, and academic. Tens of thousands moved from primary care to teaching hospitals to fill the gap left by resident work hours restrictions. Others moved to become hospitalists or hospital or subspecialty workforce. Primary care has remained stagnant for decades and will remain so. Non-primary care doubles each 15 years when considering MD, DO, NP, and PA.

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