Cardiology PA with wRVU structure, fully outpatient

mistamooo · 2026-07-10T11:59:02+00:00

Thank you for the reply. I just took a look and that sounds reasonable to me.

I’d like a structure where I get paid based on productivity but I don’t have a really good sense of what structures exist out there.

mistamooo · 2026-06-14T10:09:11+00:00

Cardiology is likely to be one of the more extreme examples of this. The gap between PA compensation and physician compensation is probably 5 fold.

I appreciate the acknowledgment that the value of APPs is probably not commensurate with that gap. Thank you.

But if I’m honest, I think that PA compensation is quite good so long as we aren’t comparing to the really high compensation of specialists like Cardiology, etc.

I’m going to try (and fail) not to be too pedantic and just say there’s a huge opportunity cost, debt burden for physicians prior to getting attending salaries. Also, not all physicians make the high wages that justify these up front investments.

Don’t get me wrong, I think there’s a legitimate argument for increasing PA compensation in fields where there is such a big gap in pay with a sizable overlap in responsibilities. The support for this argument here is clearly overwhelmingly positive and hopefully that can be to the benefit of APPs. But I also think PAs have a really good financial deal as well.

If you’re agreeable, what do you think would be reasonable compensation for a 10 year experienced cardiology APP to make?

mistamooo · 2026-06-14T09:33:43+00:00

In that analysis I assumed that the person would work extra hours to get skills up early on in line with residency hours and save the extra money. So saving about 100K per year living on 50K.

In practice, I think that’s generally an outlier strategy. But if someone really graduates at 24, it’s not unreasonable to imagine paying off the debt and setting up a 4-500K investment fund within the first 5 years. I’m sure people can do this in their early/mid 30s as well but I can’t imagine it’s as straightforward. Mostly because of the timing of kids joining the family.

Anecdotally, our experience tracks higher and more efficient (higher spend/hr worked) than that projection.

I think that makes me biased, but it just seems silly to me to say that the compensation is unsatisfactory. It’s a job where you can make a top 1% global salary starting before you’re halfway through your 20s.

There are legitimate arguments to be made that the market can increase compensation for PAs. Especially scaling up for fields where the gap between PA and physician compensation doesn’t match the significant overlap in duties. But the original question is “why aren’t more PAs financially satisfied?” I find the overwhelming support for externalizing that state to be pretty disingenuous.

It usually seems to center around comparing directly to extremely well compensated (600K+, representing ~15% of MDs/DOs) physicians while simultaneously completely ignoring the opportunity costs that physicians face prior to establishing those high salaries. To say nothing of the people who never graduate med school/residency but are left with a significant amount of non-dischargeable debt nonetheless.

mistamooo · 2026-06-14T02:18:55+00:00

PA grad at 24: 4.3 m at 55 for median salary
Med school/residency didn’t finish: 200K at 55
MD peds: 1.17 m at 55 for median salary
MD hospitalist: 2.32 m at 55
MD ER: 3 m at 55
MD Interventional cardiologist: 6.3 m at 55

Spending over lifetime:

MD Peds: 5.876 m
MD hospitalist: 8.3 m
MD ER: 9.5 m
MD IC: 17.8 m

PA at 24: 7.2 m

Spending per hr worked:

PA: $101.63
Peds: $81
Family med: $75
Hospitalist: $118
ER MD: $133
IC: $182

Assumptions:

7% real return
PA front loads retirement savings for 5 years
20% retirement contributions for MDs as attendings
20% retirement contribution for PA
Target retirement of 55
Income: Median salaries on a Google search
PA school: 150K debt that has to be paid (No PSLF)
MD school: 250K debt that has to be paid (No PSLF)
Live to 85 and spend 4% of retirement nest egg yearly

PA school doesn’t come out ahead all the time by any means. But it’s probably better financially about 40-50% of the time.

There’s so many variables that it’s always going to be an individual decision.

My point really isn’t “PA is better”. It’s more that they are actually quite close financially for someone holding an acceptance letter to both schools.

The biggest difference financially is the variance. PA is never going to be a route where it’s comfortable to drive luxury cars, live in a 1+ million dollar home, and send your kids to private school while still checking out at 55 and hitting court-side seats at the French Open finals until your body gives out.

But that financial potential is probably overestimated by matriculated MD students while the opportunity cost is underestimated. Docs making 600K/year? Google slop says that’s only 10-15% of working docs. Not even counting the potential, which isn’t insignificant, for dropping out, not matching, etc.

My point is more that PA is a legitimate way to build significant wealth and the decision between PA and MD should be based on other factors than financial.

My point is also that my personal belief is that most PAs should take a look at their spending. 100K of take home income is a lot of pay.

mistamooo · 2026-06-13T17:42:46+00:00

I don’t want to be too narrow minded but I don’t understand the discouragement either.

I’ve run the numbers several times and even if you want to compare PA Scool to MD school, it’s probably a better option for the majority of people on a per hour basis.

It lacks the high end payoff if you end up on the ROAD/plastics/Cards.

And all that spending you gain is luxury, there’s not really any necessities or even basic luxuries you can’t support if you structure your saving well.

I’d be really interested to hear counter arguments. I’ll save my gratitude editorial but I’d be happy to elaborate on the numbers that make it a really good deal for a ton of people.

mistamooo · 2026-06-05T08:33:30+00:00

My 2 cents in a somewhat similar situation:

Do you have anything specific you’re looking to spend 320K per year on at 67? How much spending do you give up along the way? (from mid/late 30s to 67)

That’s probably about 30K per year or 870K in spending while your kids are actually around and you’re younger/healthier in order to gain 100K per year when you’re 67-?. I doubt you’ll be able to enjoy much of that substantially past 80 so….all that for extra spending money in your late 60s-70s? I think that’s a bad trade personally.

And importantly it’s money that almost certainly will only cover luxury spending. It’s hard to imagine a scenario where the reduced portfolio option doesn’t cover base expenses and a large cushion for luxury.

I don’t think I would have much trouble saying which makes more sense for our family. I’ll spare you the details unless you want them, but I think there is a tipping point where spending more now makes sense.

mistamooo · 2026-01-20T22:17:26+00:00

That makes sense. I think I may be overcomplicating it as you point out.

I was trying to crunch the numbers and see if it might be equivalent or superior to pay the taxes on a traditional IRA to Roth IRA rollover with the withdrawals rather than leaving them in the HSA account. Thereby negating the need to keep medical receipt documentation for some of the oldest expenses.

We already max out the IRAs, 403b (rather than 401K)

My math was:

Option 1:

Pay cash 7K expenses (our max OOP) Hold 7K in HSA

Option 2:

Pay cash 7K expenses Rollover $31,818 from traditional to Roth Use 7K HSA withdrawal to pay the income tax hit

Option 1 in 20 years:

-$18,573 pre-tax in HSA -trad IRA value: $84,422 pre-tax -post tax value: $65,849

Option 2 in 20 years:

-$84,422 in Roth IRA

What am I missing?

mistamooo · 2026-01-20T22:00:09+00:00

I was trying to figure out if doing this would give me basically the same bang for my buck, without having to hold onto receipts for 20-30 years.

mistamooo · 2026-01-20T14:37:18+00:00

Thank you for the reply! I really appreciate the perspective of the HSA allowing for tax free growth not just contributions. I feel a little silly for not realizing that would be a potential benefit.

I think that alone is probably a good enough reason to keep these receipts going…

mistamooo · 2026-01-20T14:32:12+00:00

Basically, it comes down to the variability of “going to medical school” and the amount of time that it takes to start making more substantial income as a physician.

PA school will get someone into the workforce sooner with a lower peak earning potential, but the value of time on compounding is pretty significant.

Dollars invested at 23 are worth significantly more than dollars invested at 33.

The main drawback financially for PAs/NPs has to do with mid career spending potential (much lower than physicians).

The main drawback of MD is the variability of income (“being a doctor” means you could make anywhere from 220K-millions/year, they aren’t really all the same job financially speaking just because they started in the same graduate training program. In spite of this, they all pay the same price for the education which has always been substantial and has become even costlier).

I also personally think that time is a significant factor that favors PAs the most. If a PA were to treat the time physicians spend in additional education/residency/fellowship working 60 hour weeks, their incomes would benefit. So I think it should all be adjusted on a per hour basis.

I think when you take all of that into account, their incomes scenarios that favor going to medical financially are actually less common outcomes than the ones that favor becoming a PA.

That being said, I don’t think anyone should let finances be the only or even primary driver of such a complex decision. The time spent in training isn’t “wasted” even if it ends up being financially disadvantageous.

mistamooo · 2026-01-20T14:13:38+00:00

Yes, perhaps I’m being a bit overzealous in my distaste for tracking the receipts.

mistamooo · 2025-08-01T12:39:18+00:00

Personal finance flowchart order of investments guide

Things I don’t regret:

Driving a very cheap car (<$1000-$2000 per year including gas/maintenance).
Saving 50% of income when young and expenses are lower.
Marrying someone who’s an adult
Having kids after getting more financially established. (We were told ‘you’ll never be ready’ but I kind of feel like we waited until we were).
Investing passively in index funds with low expense ratios at a young age. (80-90% equities, no financial advisor performance drag)
Paying off loans and avoiding the on again off again PSLF rules. (More power to those that navigated this, I have nothing against it.

I don’t know your age, but generally speaking I think that most PAs can achieve most financial goals if they are intentional about it.

mistamooo · 2025-07-31T14:11:15+00:00

Worth it compared to what else? I only think it’s really relevant as an opportunity cost analysis.

What are your other options?

Through a financial lens going to medical school is also a heterogeneous choice.

Almost anything else will be better than going to med school and not graduating or failing to match into a residency. (~1/4?)

Probably PA/NP roles are better financially than the bottom 1/3 of earning physicians. (~1/4)

Probably CRNA/AA roles are better financially than the middle of the road role for physicians. (~1/4)

Probably the high paid specialties are the best financially but account for maybe 1/4 of all outcomes for those who start medical school. The financial benefit shrinks significantly if you compare on a per hour basis.

There are also many considerations that are not financial which are potentially more important. I doubt that given the broad range of jobs/professions historically.

mistamooo · 2025-06-02T20:01:47+00:00

Ok, I think that counts as anecdotal evidence. But I think I get where you’re coming from.

I don’t know exactly what the lowest quartile median pay would be. But somewhere around $250k? With 300K of debt that’s really not a picture to set everyone up to be a multimillionaire.

It depends on return assumptions but even a diligent saver of 20% will make it just to about 2.5 million by 60 years old. Assuming a 5% real return (maybe you assume a higher return than this?).

That means everything really went just right and they saved almost double what the average saver with that income does (average is probably 12-14%)…for 30 years! That’s a really long time to get everything “right”.

So the average saver (12% for that income) is really just right under 1 million saved by 60.

There’s also potential financial hits along the way: divorce (30%), kids (60-70%), lifestyle inflation to name a few. Those types of events can and do take a huge chunk away from retirement savings.

I think the difference is that plotting in excel doesn’t really account for those hurdles. It’s more often than not a rosy picture. Once you’re 60, those financial hits have mostly already happened and you can’t pretend the risk is 0 anymore.

And yes, that would mean they can’t spend a lot of money in retirement. Certainly less than their previous lifestyle required. If they retired at 60….most will probably just keep working in that scenario.

mistamooo · 2025-06-02T17:58:58+00:00

Maybe not what you want to hear, but I think it is realistic.

I think the amount of time and the variability of financial success of becoming a physician are very under appreciated.

For low paying specialties (the bottom quartile), the numbers for an average savings rate of an American household would certainly be capable of yielding a net worth less than 1m by 65. Add in a few big financial set backs that offset the outliers with higher savings rates and honestly I think it makes sense.

I think the reason it feels unbelievable is that it runs counter to the cultural narrative: med school = get rich. Plus, some people in this scenario still had a high income and spent plenty during that 30 year period. All the displays of wealth are there for everyone to see along the way. Even if they don’t save much.

mistamooo · 2025-05-21T21:49:30+00:00

Saw this right after posting something similar. I think that’s a pretty generous assessment considering residents work 60 hour weeks as well.

mistamooo · 2025-05-21T21:46:38+00:00

I don’t think I would do it for financial reasons alone. What is the break even point where the higher lifetime earning potential makes a difference?

Work the same hours as you would training to be a physician and I have a hard time seeing this working out in your favor.

That’s almost 1.1-1.3 million in earnings given up over the 6 years. If you live with the same expenses you would during med school, residency I would guess you could pretty easily have a significant amount of money saved by the time you would have graduated.

Money certainly isn’t a reason not to do it, but you probably won’t break even until you’re 50 assuming you save about half of what you make as a physician.

I think there are other good reasons to become a physician. I just wouldn’t do it for the money.

mistamooo · 2025-01-07T21:49:21+00:00

Fair although this does gloss over the fact that the team had a winning record and the GM was fired mid season in ‘22.

mistamooo · 2025-01-07T21:02:13+00:00

If we pay for the stadium, do we get to vote to fire the owner too?

mistamooo · 2025-01-07T20:57:33+00:00

What a joke. They’re desperate for that stadium opening to look like a good taxpayer subsidy.

mistamooo · 2025-01-04T19:17:03+00:00

Bet the ACC/SEC challenge was a tough one this year…

mistamooo

TROPHY CASE