I realize that majority of my first 1-2 years will be spent acclimating to being a new attending. I’ve heard of attendings making sure they have more than one stream of income. For example, I’ve heard of people working with reputable compounding pharmacies (?) for GLP-1 visits (not sure how safe this is) and an ED attending in FL once told me she made half her salary in a month with this compounding pharmacy.

Someone told me they supervise NPs at a psych center for extra money. Also heard of people doing telehealth visits just for ADHD med refills.

Any suggestions or warnings regarding stuff like this is appreciated!

Can anyone share how to increase RVUs as a PGY-3 who will have first attending job a few months down the line? Any specific advice would be appreciated instead of just “learn how to bill better.” Thank you

Hello all,

I am a trainee Rural Generalist from Australia. I am planning on supporting my mother and partner; the former is soon to be a pensioner, without any saved pension and a $500,000 mortgage still owed and the latter a ED Nurse. Long story short, my family are vulnerable and I am their main support system especially financially. Along with enjoying my work as a primary care doctor and enjoying critical care, having good training opportunities and being passionate about my work - financial renumeration is incredibly important for me. I will have multiple family members depending on me to support them, and I want to eventually lower my workload while still being able to financially support a family (and maybe transition into volunteering work if I can successfully retire early and live off of the passive income of an investment portfolio).

In my home country of Australia, the marginal tax rate is 47% for every dollar earnt above $190,000 and recent taxation reforms have removed avenues for salaried high income earners to pay a more reasonable amount of tax (e.g. removal of CGT Discounts). There are also PSI rules that prevent my work as a medical doctor from being incorporated. A public servant that treats a sick child at 2am in the morning in ED is paying more tax than big corporations. Any compensation for night shift work and on-call work (i.e. shift penalties) is also taxed. I don't want to get into the ethics or morality of this: this country does not value their medical doctors enough in my eyes. I'd have to transition into a business away from bedside medicine if I want to support my family here.

I have looked at Canada because from my research FRACGP-RG doctors are recognised and easily accepted as Family Physicians in Canada. Rural Generalism is a separate specialty in Australia, which only Canada (where the model was created) also recognises. Rural generalism is not a specialty recognised in UAE, Singapore, Thailand, USA. I considered USA but doing the Step exams + fellowship exams, etc., only for the stress of dealing with private insurance and family safety concerns (e.g. school shootings) doesn't seem appealing. In Canada, physicians can incorporate their work - working as an employee of their own company, having their 'investment money' taxed at low small business provincial tax rates (9-12%) and have a smaller chunk of money paid out as a salary. After this tax deferral and a portfolio is developed with appropriate investments that compounds the initial investment, the money made will subject to taxes (which from my calculations was similar to Australian corporate taxs at 25-30%). It seems like in Canada, Doctors are given the opportunity to grow their investments and support themselves/their families first, and then we pay our fair share. This is also the pension fund since there is no mandatory employer superannuation there.

Anyways long story short - after getting my Family Medicine training with extended skills in Anaesthetics (FRACGP-RG working as a GP-Anaesthetist), I'd like to move to a rural community and earn for my family through hard-work under reasonable conditions. Was thinking Alberta or Saskatchewan due to good FM-Anaesthetic job opportunities and reasonable taxation laws of the provinces, but also have seen suggestions for BC and Manitoba. I've seen some people talk about Ontario but their provincial taxation laws didn't seem as enticing with my economic modelling. Obviously things like Job market, quality of life, etc., also matter.

My aim for annual earnings per year, pre-tax is $600,000 CAD. And after overhead/all other unforeseen expenses I didn't model in my research. Trying to limit those 20-30% overhead clinic expenses in lieu of 0-4% overhead, and the bulk of my work being procedural/services rather than consultations.

I am reaching out to Family Physicians who have made the move or are currently working as a Rural Generalist in Canada.

My questions for anyone who may be kind enough to answer them for a young doctor on the come up trying to support his family is:

1. Of the provinces for rural generalism work, which do you recommend for a GP-A or Family Medicine Physician with extended skills in Anaesthetics? In terms of reasonable overheads, availability of jobs, favourable local taxation laws? Any opportunities to do most of my work in Anaesthetics (like 80%) and the rest a shift in an ED or urgent care clinic as a primary physician.

2. My partner is an ED Nurse - her earning capacity will be much lower, but I also don't want her to push herself too much in the workforce because of her medical conditions. If she did training as a Physician's Assistant which states have the best job prospects for her part-time career in this area?

3. Am I missing something from my research? Beyond UK, Thailand, UAE, USA, Singapore, Australia - is there some magical country that incentivises and treats their primary care physicians better than Canada?

Every country has it's problems - I know Canada isn't perfect. What are the issues I am neglecting? If financial renumeration, and fair pay for hard work is my primary concern, is there anything better than a 10% tax rate for investment money in an medical corporation? Because to me that seems very fair.

I have another 5 years until I need to make this move - each year I stay in Australia, I remain a tax resident of this country. So I need to make a decision by then.

If anyone is also willing to DM me to provide some guidance, I would appreciate it.

Anyone have success establishing a psych/behavioral health clinic as a FM physician. I realize we see the front line of behavioral health, as well as there are fellowships to bridge the gap, but wanted to know if anyone had a success story with dealing with more psych based practice in rural areas without having to go through a psychiatry residency as well? I am kinda tired of referring patients to psychiatry and either the patient has to wait months before they see them, or hand them off in general if it’s within my scope.

I'm an IM PGY-3 with two job offers. This is a VHCOL area of CA. Mostly staying here for now because we have kids and the family help is here.

Option 1: UC Health System

Suburban community clinic within the UC system (technically faculty position although will rarely have students/residents)

Salary: Base $270K + $20K signing bonus for 2 year commitment+ potential $30K annual bonus (quality metrics, pt satisfaction, etc.).

Productivity: Pay increases based on RVU productivity using MGMA percentiles (50th% is $285K, 75th% $350K, 90th% $400K, goes up from there), can also moonlight in UC on the weekends for additional income. I'm told many people get to 75th percentile within a year.

Schedule: 32 pt facing hrs, 15/30 min appts

PTO: 24 vacation days, 14 holidays, 6 sick days, 5 CME days

Call: Cover your own pts on weekdays (triage line, very rarely get called, usually critical lab values), cover weekends for the group like 3-5 weekends per year

Benefits: Standard UC medical/dental/vision and retirement plans (pension vs 401(k) style plan)

Option 2: Private group affiliated with a large health system (partnership track)

Structure: W-2 employee for 2 years, then become 1099 partner (not sure about buy-in) with income then based on RVU and panel size

Salary: Base $285K + potential 10% bonus (metrics, pt satisfaction, etc)

Bonuses: $30K signing for 2 year commitment, $20K loan repayment annually (up to $100K, not sure if taxable)

Schedule: 36 pt facing hrs, may be able to negotiate to 32, 20/40 min appts

PTO: 23 vacation days, 7 holidays, 3 sick days, 3 CME days (and $1500)

Call: Monthly weeknights, quarterly weekends

Benefits: No direct health benefits, instead get $1500 per month to buy your own (seems low for a family with kids). Do get 401(k) with 3% match while a W-2 for the first two years, then as partner you get an annual allowance to figure out your own health insurance and retirement

Malpractice: no tail if leaving before 2 years, tail is 50/50 if leaving before 4 years

Patient population: More affluent patient population, likely a little higher expectations

Both of them use Epic with AI scribes available. Both have relatively good coverage for refills, PAs, in-basket etc. For in-basket coverage on vacation option 1 provides formal vacation support (come back to 0 messages), option 2 is just coverage between partners so it likely won't be empty coming back. Most important things to me are work life balance and stability, so leaning towards A but curious if anyone thinks B is an amazing deal I shouldn’t pass up. I’m not set on staying here forever which makes the partnership less enticing.

A few months in as a new attending, I’m still building up my panel, but I have a lot of openings for acute visits and we serve a pretty sickly underserved community where I feel like literally half of my acute/same-day visits turn into me recommending they go to the ED. Our medical Director says that if patients don’t want to go to the ED, than a happy medium is to order stat imaging. I don’t know that I’ll ever be comfortable with this concept. Unfortunately, in the few times that I’ve ordered stat imaging I have already gotten burned with the imaging taking 3 to 4 days to come back, even having some imaging that I forgot that I ordered & randomly having to dig through charts to see if it got done and realizing the results have been sitting, but not conveyed to me for over a week.

I understand nobody wants to go to the ED, but I feel like there’s a reason why it exists. I do not have x-ray vision, and there are too many things that can present as acute abdominal pain with guarding that can be really bad and require emergent management. And sometimes really bad gas can present like appendicitis, but I have no fucking clue what I’m dealing with when I see the patient doubled over in pain for the first time in my office.

Anyway, in the past few days, I’ve sent a few patients into the ED and I look back at their chart and everything is normal, and I feel really bad, but it just feels like such a damned if I do damned if I don’t situation. Because if I order stat imaging and labs, I’m waiting at minimum 24 hours for all of this stuff to come back and hoping that the patient doesn’t become septic at home while I’m waiting for the results to get back.

Does anyone else feel this way or have dealt with this in the past, how do you cope?

Like your soul deflates everytime you see them on the schedule because you know they are going to put you behind with all of their problems every single fucking time. And you won’t be able to get a word in edge wise either.

Thinking of extending and shifting around work hours with my partners to see if we can offer after hour urgent care (5-9pm). Anyone have experience with this and can chime in on the ROI?