Show Me the Money

March 25, 2009

What plagues me is a workload much higher than I anticipated with little economic return in comparison.

When I was a second year medicine resident I sat looking across at my chief resident while we discussed my chosen career path. He shook his head with a very, very small smile.

“You know,” he said with a hint of warning in his southern drawl, “you can make more digging ditches than being a clinical endocrinologist.”

I laughed, in my self-righteous way that only inexperienced residents can, and thought to myself how wonderful it was to be going into a field in which I was genuinely interested, to make money that would be “just fine” and that my cardiologist-to-be chief resident just didn’t get it.

Who’s laughing now? Not me, that’s for sure.

It is now nearing 10 years since that conversation and I find myself sometimes struggling in my field. Yes, because of the money. A few years ago I would have been ashamed to say it because I felt then that any doctors who complained were likely those who were simply living above their means and THAT was why they were not making enough money. For goodness sake, even the worst paid doctors still make more than much of the population, right? The latter statement I believe, the former not so much anymore. What plagues me now is a workload much higher than I anticipated with little economic return in comparison. As my former mentor and chief of an endocrine division warned me when I was looking for my first job: endocrine visits do not end at clinic, because there are labs to check, letters to write and an ongoing log of phone calls to return. You essentially double a clinic load when you account for appropriate and careful follow up, even when an excellent clinic support staff undertakes the lion’s share. We do not have many emergencies, but we have a long list of continuing care that is often not reimbursed at all.

The fate that has befallen me is the same for all “non-procedural” specialties within internal medicine. We prefer to take a positive approach and call ourselves the “thinking” specialties, not to directly offend our more procedure oriented counterparts but at least to prop ourselves up a bit. Aside from switching fields altogether (law school, anyone?), what’s a struggling endocrinologist to do?

One of the fast rising new aspects of endocrinology offices is the inclusion of thyroid ultrasound and biopsy if indicated. It makes perfect sense given the amount of thyroid disease that we see and follow long-term. In the olden days only high-powered centers like UVA had endocrinology teams with enough pull to have their ultrasound machine, whereas the standard training program had to step aside under the weight of a much-more powerful radiology department who refused to let it go. But he private practice folks started in on it. Then two years ago the Endocrine Society’s thyroid nodule management guidelines formally recommended that endocrinologists familiarize themselves with thyroid ultrasound and consider getting formal training given it was a strong addition in the care of patients with thyroid nodules. Not to mention it being easier on the patient who now can have everything done in the same office instead of traipsing off to radiology and back again.

If in an academic center (and radiology does not put up a fight), an ultrasound machine is often shared between departments, for instance between ENT and endocrinology. If you are in private practice however, the cost of a new ultrasound machine can put a big dent into an already shallow pocket. A smaller-sized good ultra sound machine can still run into the 30-50K ranges. When you get up to the larger rolling machines with built in accessories for biopsies, you are talking serious money. A recent article estimated that it would take approximately 1 year of steady clinical practice to pay off the cost of an ultrasound machine where it is primarily being used for thyroid examinations and biopsies. Not too bad really, but I am sure at times that year could seem very long indeed.

Thankfully I am based in an academic center and have colleagues who already perform ultrasound-guided thyroid biopsies. Plus we have a fantastic endocrine surgeon whom I can, and will, learn from as time goes on. I have no plans of leaving my general endocrine but adding a more-decent paying thyroid clinic day will at least help me catch up on those pesky student loans. I am not asking to be a millionaire here; I’m just hoping to do better than tread water.