The Math Behind Going Back To Residency In Order To Earn A Higher Income

So you’ve decided that you aren’t making enough money as a family medicine doctor and are now considering going back to residency to specialize in something that’s a bit more lucrative.

I thought at first that this is a GP phenomenon, but it turns out that quite a few specialists would have chosen different specialties if they could go back. I don’t think I have sampled enough to know for sure, but it seems that most of the GP’s would choose a more lucrative specialty while most specialists would choose a more prestigious one. A high-risk obstetrician friend of mine, one of few in his State, wished he did cardiology instead for the prestige alone. I watched this same man do a crash C-section and get a fetus out from knife-to-skin to clamping-the-cord, in less than 60 seconds.

For those of you who don’t know, GP’s generally refers to someone who just finished 1 year of residency, allowing them to practice medicine in the US. However, for the purpose of this post and on par with how the term is used, GP will refer to any General Internal Medicine or Family Medicine doctor. These are in fact specialties, but since my own mother doesn’t think that Family Medicine is a specialty, I thought I’d mention it…. mother!

How Much Does Each Specialty Make?

This isn’t always easy to answer. We know that the private practice docs cook the books quite nicely, pocketing cash and reporting just enough to get a decent value in their practice and be able to get loans.

When working for large medical groups it’s common to see GP’s making $250-300k and specialists making $450-650k.

I think it’s fair to say that most GP’s who want to escape generalism, aim for Orthopedics, Radiology, Dermatology, ENT or EM. What is it that Ortho’s do that makes it the top choice among GP’s as an alternate career?! Do you guys get served caviar in the operating theater? Do you have fluffers in the call rooms?

Hey, how do you hide a $5 bill from an orthopedist? Lol.

In private practice, the numbers can vary quite a bit more. It depends on how many associates the practice has, how many years the specialists has been practicing for etc. One of our ENT attending at UCLA shared with me that he was taking home over $2 million a year. This man was brilliant, kind, hardworking and generous beyond anything I can describe. He and I shared a special moment involving an 18 gauge needle and some green pus when I walked into his office with my peritonsillar abscesss.

What’s The Reason You’d Go Back?

If you’re going back for prestige then you probably don’t care about the financial consequences, rightfully so. If Urology has always been your passion then glove up and ignore the dollars, success is much easier had when pursuing a passion than chasing Benji’s.

If you’re going back to make a higher salary then you have to certainly plan your move down to the T. Some lifestyle choices aren’t in line with being a specialist. An interventional radiologist who also wants to live out in the middle of the desert, far from a hospital, may not do too well. A high-risk obstetrician who wants to live in a mining town populated by dudes might have a tough time finding work.

Maybe you just hate what you do and would do anything but your field of Interventional Sports Pathology. I find that there is always something one can find to hate about any job. I wouldn’t want to be any of the rich or famous people who clog the entertainment channels, they each must deal with their fair share of crap.

What You May Not Know About Specialists

Forget getting into residency, let’s say that part is easy. Some of my GP colleagues tend to pompously think that they can easily do what a specialist does. Let’s break that down, maybe they are right.

A specialist most definitely spent more time in residency than a GP and their hard work in residency likely correlates much more directly with how good they are once they get out.

I can’t imagine that an ENT or Ortho residency is easier than a GP residency. Sure, it’s comparing apples to oranges but there is so much to master when it comes to a specialty. Not to mention that most specialists do fellowships in order to learn even more and possibly become more marketable. I don’t need to specialize in Pediatrics as a Family Medicine doctor – your child has a runny nose, I think he’ll be fine. Bam, fellowship completed.

I definitely think there is an art to practicing Family Medicine but I think there is a whole another level when it comes to being a great specialist. There are shit doctors just like there are shit presidents (written in 2017, ehem) but we aren’t talking about you going back to residency just to be a shitty specialist.

Specialists can often be successfully hired by large medical groups, but their pay may not always reflect their value. It’s easy for a plastic surgeon who loves reconstructive work on the face to be stuck with only breast reductions in their medical group.

Specialists take a lot of call. GP’s have more traditional office hours and don’t have to see patients in clinic AND do operations AND round on their patients in the hospital. Sure, there are other things GP’s do that specialists don’t have to do but I’m just trying to make all the relevant points.

Finally, Let’s Do The Math

Your Finances As A GP

Let’s say, you are 38 years old and have had your fill of managing URI’s and clicking on Lisinopril prescriptions. You’re ready for primetime and you got some dirt on the ortho residency coordinator at your local hospital, you proceed to blackmail them and they agree to let you into the program, despite your Step 1 score of 197.

As a Family Doctor, you’re earning about $300k a year gross, working a little more than the traditional 40 hours. You get to set aside about $50k in tax-deferred accounts and you have a partner with a few kids running around.

Your mortgage is only $3k a month and you have about $350k in student loan debt. Let’s assume your entire monthly overhead is $8,500/month. Your partner isn’t working currently but is willing to get back to work in order for you to realize your dream of doing 4 hip replacements a day, 4 days a week, every week, for the rest of your life. Love… so precious.

Income As A Repeat Resident

Your residency will give you 1 year credit, you are stuck doing 4 years and you have to do 1 year of fellowship. Your debt is mostly federal debt so you can go into and IBR plan, drastically reducing your monthly student loan payments.

Now, your monthly overhead is only $5,000/month and you’re earning around $3,400/month, net, as a resident.

As an FP, you were taking home around $15,000/month with your stethoscope safely stowed in your office drawer, typing away fiercely on the keyboard while the patient was describing the color of their poop to you, in vivid detail.

You Are Finally A Specialist

So, you forwent $9,100 of income every month for the next 60 months by deciding to join the ortho jocks. Since most of your student loan debt was unsubsidized, your loan balance went from $350,000 to $385,000 in this timespan.

Aha! But now you are out and about, sporting a few extra pounds, a receding hairline, at the impotent age of 43, ready to replace some hips! You find a medical group which is going to pay you $450,000 of gross income. Unfortunately, you have to move to another State.

If your medical group can help you set aside around $50k/year then you’re likely taking home somewhere around $300k/year.

You sell the house, make a little bit of money on it, from which you have to cover the moving expenses. Your children vow to hate you until the day you die because they loved their school and their friends in Nashville and don’t want to go to no stinking school in Wisconsin.

With your withered partner and angry children in tow, you set out for Wisconsin. You find a nice home up on pill hill, slap on some bug spray and report to work.

Let’s Service Some Debt

Your loans are ready for you to service them. You now have a loan payment of $4,100/month for the next 10 years. You have a new beautiful house with spectacular views of a swamp and a freeway, far in the distant, but not too far for you to hear and smell the diesel trucks. America! Love your natural resource addiction.

Your mortgage payments are much more in line with an orthopedic’s salary, shit, you ain’t no joke of an FP no more. So you pay your $5,000/month for your mortgage and start looking for that sports car you’ve been drooling over in the call room. Another $1,000/month for the lowered Cayenne. A couple grand for hairplugs and a little more for private school.

Your first paycheck arrives, and though you are in the hospital on call and can’t enjoy it, your partner texts you and tells you that it’s the biggest one ever! No, not the new shiny rock she just put on her finger from Tiffany’s, the paycheck, it’s huge! Your medical group just plopped down $23,000 into your account for the month. Another $4k/month goes straight into your retirement account, deducted from your gross income.

Overhead Of Being A Specialist

Your expenses are now around $15,000/month but that’s still $8,000/month of disposable income. Older and wiser, you use that money to pay down your student loans and mortgage.

You first attack the student loans, throwing all your extra income at it. You demolish that debt in a little under 3 years! Awesome, you are finally free of student loan debt.

Next, you have the mortgage to contend with. The balance is about $900k, not too bad. At age 47 you are ready to tackle this home debt. With that $4k/month freed up from paying off the student loan, you now have $12k/month to spend towards this goal. In just a little over 5 years, you also pay off that house, you king ding-a-ling, you. You are debt free and just hit your 52nd birthday.

Debt Free And Making A Killing

You are probably getting an even higher salary, now that you have been in practice as a specialist for nearly the past decade. Without any debt, you have around $12,000-14,000/month which you can save for retirement.

Not only do you have this incredible amount of money every month, you also have been saving for retirement every year for the past decade through your job’s retirement accounts, at the tune of a little over $50k every year. You are debt free and you have over $700k saved up in retirement accounts.

If you now start investing this disposable income, you could have another $1.1 million by age 60. Add the retirement account (even higher now) to this and you’re at $3.5 million, debt-free, ready to retire, working as an ortho specialist, replacing hips.

What You Would Have Earned/Saved Staying A GP

I probably lost a few of you, I know the math gets boring but we’re almost done. Next, I want to figure out if a GP would come out ahead sticking with their specialty or whether they are insanely ahead by going back to residency.

As a GP you’re making that $300k gross, taking home $180k/year and having the same $50k/year contributed towards retirement accounts.

If you continued living the GP lifestyle, paid off student loans and the mortgage on the cheaper house, then you would be completely debt-free by your 45th birthday. 

You would have $2.5 million just investing the extra $10k of disposable income starting at age 45 and ending by age 60. You would have another $2 million in your work sponsored retirement accounts. That’s a total of $4.5 million by age 60 as a GP.

So, you would be $1 million ahead remaining a GP doctor.

Considering The Reality Of The Numbers And Lifestyle

Going back to residency means another few years of incredibly hard work and sacrifice. This generally is followed by several years of splurging just to feel normal again.

Moving for a job is very expensive. Buying and selling a home adds costs to the move and furnishing a new place, as well all know, adds further costs.

Becoming debt-free is delayed by 7 years. I’m not sure what psychological value I could assign to this, but I find it to be an important factor. Becoming debt-free has been one of my more satisfying accomplishments.

Could you become a specialist and not have any lifestyle inflation? Sure, it’s possible. But if you went into it for the money then you must place some value on the purchasing power of income which I don’t think you could realistically divorce from.

Being a specialist means more expensive board exams, taking more expensive CME’s. It means having to take overnight call and rounding and likely having less free time. Maybe our specialist colleagues get more time per patient, but they have to deal with OR’s and waking up early and dealing with hospital administration.

Lost Income And Lost Time

In this scenario, the person is going back to residency purely for the income, not to fulfill a passion. I used an example of a 1-household income with 3 dependents, your partner and 2 kids.

The income lost going back to residency is a major factor. Furthermore, you already had picked up some momentum to increase your income by gaining experience as a GP. Once you enter a new specialty, the clock resets to zero and you have to start over again.

Income is lost when you have to look for a job, move and perhaps even when you apply for residencies and have to go to interviews.

Time, a much more valuable commodity, in my opinion, is lost in all the above. More importantly, you have to put in a lot more time learning a new trade, spending extra hours towards the beginning of your career, honing your comfort level. Remember the first few months of being a primary care doctor? Remember staying in the clinic a couple hours later than everyone else to finish charts? Remember the anxiety of working in your clinic and now knowing how to navigate the system? All that costs time, time which you have to reinvest all over again.

Mental and emotional stress isn’t often talked about by us prideful physicians. Fuck, I was burnt out to shit just a year ago. I was stressed when I had to see 50 patients in 8 hours during the busy cold and flu season. I can’t imagine the shit that specialists have to deal with.

It took me perhaps 3 years to be incredibly comfortable with my skills as an urgent care doctor. I had no problems managing my family medicine patients and I had no stress seeing the sickest of the sick in the urgent care.

Could I reach the same level of comfort in 3 years as an orthopedist? I have a feeling it would take longer, maybe because I’m older, maybe because I value my free time more, maybe because it’s just that much harder to master a surgical skill than clinical skill, I’m not sure.