Every internal medicine resident has to decide in the middle of their residency whether to go into primary care or become a specialist. This is a very important decision. Practicing medicine as a primary care physician is very different than doing so as a specialist.
There are financial implications to this decision as well. A primary care physician can immediately make an attending salary following residency and begin paying down student loans and saving for college, retirement, and other goals. The specialist will typically spend another three years in fellowship, making a resident’s salary. The financial reward of this fellowship is a significantly higher attending salary. According to Doximity via The Atlantic, the average internal medicine attending makes $223,000 a year, while the average specialist (cardiology, gastroenterology, hematology/oncology, pulmonary/critical care) makes approximately $360,000 a year. It would seem that from a financial perspective, being a specialist is definitely worth the upfront investment.
The “Financial Fellowship”
But what if you really want to be a primary care physician? Maybe you love the deep patient-physician relationships you form over decades with patients. Perhaps you couldn’t wait any longer to make an attending salary. Maybe you made a list of all the possible specialties, crossed each of them off for one reason or another, and decided against fellowship. Is there a way to make up the difference in salaries?
If you choose to become a primary care physician instead of a specialist, consider the “financial fellowship”. This involves living like a fellow, on a fellow’s budget, while making a primary care physician attending salary. You would live exactly like your former co-residents who chose to do cardiology or hematology/oncology fellowship, but without the crazy hours and call.
Like your co-residents, you would do this “financial fellowship” for only three years. Once you’re done, you would increase your standard of living to that of a typical attending, saving 20% of gross income.
In this scenario, how would you fare financially compared to your specialist friends?
“Financial Fellowship” vs. Real Fellowship
For our example, we make the following assumptions:
- Assume that you graduate internal medicine residency at age 30, and either begin working as a primary care physician or as a fellow (3-year fellowship).
- The primary care physician would live on a fellow’s budget of $4,000 per month. At $223,000 a year of gross income, you would have net income of approximately $168,000. This would mean you save $120,000 a year during your three-year “financial fellowship”. For the remainder of your career, you would save 20% of your gross income, or $45,000 annually.
- The specialist would not be able to save any money during fellowship. However, following fellowship, they would make approximately $360,000 a year. From this salary, they would save 20% of gross income, or $72,000.
- Both physicians earn investment returns of 7%.
- Both physicians choose to retire at age 65.
How do their retirement nest eggs compare? The primary care physician ends up with $9.6 million, while the specialist ends up with $9.2 million. By performing a “financial fellowship”, the primary care physician is able to end up with the same retirement nest egg as the significantly higher-paid specialist.
How does this compare to if the primary care physician chose not do a “financial fellowship”? What if he chose to save 20% of his gross income throughout his entire career? In this scenario, he would end up with $7.2 million at age 65, compared to $9.2 million for the specialist.
There are some caveats with this analysis:
- For simplicity, I did not include student loans. Given the final numbers, student loans would not likely have a material impact on the results of this hypothetical scenario.
- Specialists enjoy a better lifestyle during their working years. The specialist would have an annual budget of $180,000, compared to a budget of $123,000 for the primary care physician. Using Physician On Fire’s 4 Physicians example, The primary care physician would live like Dr. Benson, while the specialist would live more like Dr. Carlson.
- 7% is a pretty aggressive investment return, but is actually lower than historical market returns. If the market only returned 3% during their careers, the specialist would end up with a larger retirement nest egg. However, if the market does better than expected (for example, 11%), the differential between the PCP and specialist widens further.
- Do what you love, not what would be better for you financially. I certainly do not advise internal medicine residents to decide whether or not to do a specialty based on this analysis. It is just a thought experiment for primary care physicians who feel concerned that they will be making less than their specialist friends during their careers. The “financial fellowship” eliminates many of the advantages of a higher specialist salary.
- There is nothing stopping the fellowship-trained specialist from also doing a “financial fellowship” for a few years following training. This would put the specialist in a great position financially to work fewer hours or retire early in the future.
This example highlights the importance of saving early in your career. While this specific example was geared towards internal medicine residents, I encourage all medical students and residents to consider a “financial fellowship” following residency.
What do you think? How much did you increase your lifestyle when you were a young attending? Did you do a “financial fellowship” after residency?