How’s laryngology job market and compensation in private practice?
Laryngology
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I’m not sure, but you can come here and have 100% of my laryngology patients.
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Laryngologist here - the above comment sums it up well- most ents don’t really like Laryngology stuff. The patients can be challenging, lots of general medicine, OR cases don’t pay well, and airways can mess with the cushy ent lifestyle. I was the first Laryngologist in my area and literally all my partners and every other ent in town started sending all their Lary patients within the first week I was here.
It is a bit more nuanced though. Not many PP groups looking for a dedicated sub specialist, but if you also want to do some general practice as well then sky’s the limit. And yes, your partners will quickly and happily hand off all the lary patients to you. You end up with a practice as weighted toward Laryngology as you want it to be.
The hard sell will be equipment - Laryngology is more capital intensive than ent as a whole. You will need strobes and high quality scopes - distal chip and good rigids - to practice your craft. Your volume will be dependent on how many strobes you have. PP groups will not likely have these already so the challenge may be finding a group willing to invest enough in your equipment to make the job worthwhile. Ditto additional things like an EMG for Botox, injectables, lasers, etc.
Compensation is excellent, though depends on how you’re paid. It lends itself very well to employed positions paid by wRVU as our clinics are very procedure heavy.
The strobes are also your key to the high comp. The biggest limiting factor for general ents is that a typical flex scope 31575 can’t be billed with a nasal endoscopy 31231, bronch 31622, fees 92612/13, etc. BUT - video stroboscopy 31579 absolutely can and should be. So for a simple chronic cough referral, your strobeless general partner can only bill the laryngoscopy while you can bill the nasal endoscopy and strobe together. On an RVU basis that’s 0.95 for the laryngoscopy, or 1.88+1.31 for the strobe/nasal combo. Plus E&M. And plus a FEES or Bronch if you do those too. For me, my OR day is my loss leader and by far my lowest paid day.
So with enough equipment and a busy practice, sky’s the limit really. In an employed RVU model without a cap you can hit 7 figs pretty easily. True PP eat what you kill is probably a bit less as i think some of the actual dollar reimbursements for some payors are lower than what the RVU would suggest. Even then, high six figs should be fairly easy to hit if you know what you’re doing, and add in ancillary revenue and probably easy to hit 7 figs there too.
The catch is you’re seeing Lary patients - lots of cough, globus, dysphagia, trachs, airway, and crazy singers like me!
It is a bit more nuanced though. Not many PP groups looking for a dedicated sub specialist, but if you also want to do some general practice as well then sky’s the limit. And yes, your partners will quickly and happily hand off all the lary patients to you. You end up with a practice as weighted toward Laryngology as you want it to be.
The hard sell will be equipment - Laryngology is more capital intensive than ent as a whole. You will need strobes and high quality scopes - distal chip and good rigids - to practice your craft. Your volume will be dependent on how many strobes you have. PP groups will not likely have these already so the challenge may be finding a group willing to invest enough in your equipment to make the job worthwhile. Ditto additional things like an EMG for Botox, injectables, lasers, etc.
Compensation is excellent, though depends on how you’re paid. It lends itself very well to employed positions paid by wRVU as our clinics are very procedure heavy.
The strobes are also your key to the high comp. The biggest limiting factor for general ents is that a typical flex scope 31575 can’t be billed with a nasal endoscopy 31231, bronch 31622, fees 92612/13, etc. BUT - video stroboscopy 31579 absolutely can and should be. So for a simple chronic cough referral, your strobeless general partner can only bill the laryngoscopy while you can bill the nasal endoscopy and strobe together. On an RVU basis that’s 0.95 for the laryngoscopy, or 1.88+1.31 for the strobe/nasal combo. Plus E&M. And plus a FEES or Bronch if you do those too. For me, my OR day is my loss leader and by far my lowest paid day.
So with enough equipment and a busy practice, sky’s the limit really. In an employed RVU model without a cap you can hit 7 figs pretty easily. True PP eat what you kill is probably a bit less as i think some of the actual dollar reimbursements for some payors are lower than what the RVU would suggest. Even then, high six figs should be fairly easy to hit if you know what you’re doing, and add in ancillary revenue and probably easy to hit 7 figs there too.
The catch is you’re seeing Lary patients - lots of cough, globus, dysphagia, trachs, airway, and crazy singers like me!
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I think its funny that whenever we talk about a certain field we always say that ents don't like ____ stuff
Don't like ear stuff
Don't like laryngology stuff
Don't like h&n big whacks
What do we like? T+ A, tubes and FESS? That pretty much sums up a general ENT practice? 🤣🤣
Don't like ear stuff
Don't like laryngology stuff
Don't like h&n big whacks
What do we like? T+ A, tubes and FESS? That pretty much sums up a general ENT practice? 🤣🤣
I'm in general practice.
1. I see all sorts of ear stuff (95+% of which can be managed medically or with minor procedures), but don't do any ear surgery other than tubes or myringoplasty because I was not adequately trained to do it in residency.
2. "Real" laryngology requires a pricy stroboscopy setup. I see plenty of reflux and hoarseness and have my bag of tricks to help them, which work 90% of the time. For those who have something weird or do not respond to the usual therapy, I can send to a fellowship trained laryngologist in the metro.
3. H&N cancer is not that common outside of tertiary referral centers. It's hard as a private doc to keep your skillset sharp for big whacks, and these patients are the most likely to have after-hours complications, especially if you're doing a once a year laryngectomy or something. Without a team-based approach in a high volume center, I don't believe these patients are well-served.
Most of my OR procedures are pedi cases, septoplasties, and the like. I don't do that many FESS anymore because those patients do fantastic with in-office balloons.
The large majority of my patients never see the inside of an OR (at least with me). It's a mix of everything, with a fair amount of allergy and audio/hearing aids.
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Well you’re not far off! You can probably add some basic ear/lary/HN stuff to the general practice playlist, but the referral threshold is much lower there.
It’s been interesting watching my own evolution in what I do or don’t do. I got really good training and am in an area where there’s enough referrals that I could do basically anything I want.
I did some complex ear stuff at first and while patient outcomes were great, the cases were painful for me because none of the OR staff really knew ears or knew me and the cases wound up taking more than double the time they should have taken. So I’ve slowly started referring out more and more stuff mostly because I’m too busy with other stuff I actually like doing.
The same thing happened with my Laryngology cases but I spent months teaching people and building pans and cards so I could do them efficiently. I just haven’t wanted to expend the effort on another area of cases, and with every passing year my skills and comfort in those other areas get a little weaker. I imagine this happens to many people.
The other thing I’ve seen happen both to me and other colleagues is that we start to do the math and figure out that we can make a lot more money in clinic. Like say I wanted to do a complex chronic ear case - TM + OCR + cartilage graft. Should take 3-4hrs, but would probably take me 5-6 with all the logistical hurdles plus my being a bit rusty. RVU on that is about 22, Medicare reimbursement about $2000. Now, in clinic I can do one of my hearing loss “power hours” where I pre screen audios and clump all the “grandma just needs a hearing aid” referrals into a single hour with 5 minute slots each. Because of the data review component (PTAs, tymps, etc), those can be billed as level 4 new patient visits. So that’s 30 RVUs in one hour or $2000 Medicare reimbursement. In one hour I can make roughly the same money in my office that I can in 5-6 painful hours in the OR. Now if I put in the time/effort I could probably get those cases down to 3-4 hours, maybe a bit less, but that’s a lot of effort and time.
You can extrapolate this basic fact across the field and most people end up figuring out which cases are actually lucrative and which ones are time/money sucks. The way to make money in the OR is efficiency and volume, and it’s very hard to do that with bigger cases unless you’re in a high volume referral center. So there’s just no point for me to slog through any big case I don’t enjoy if I can refer the patient out.
And that’s before we start talking about post op complications with the bigger stuff! There’s good reason most generalists narrow their practices over time.
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You can definitely, unquestionably make more money in clinic.
That being said, if I had to spend all day, every day explaining to people why they don’t actually have a sinus infection (it’s a migraine), or how they don’t actually have any evidence of otitis media or eustachian tube dysfunction, or how not all the mucus in their throat has to as a rule come from their nose, I think it’d be happier pumping septic tanks for a living.
If I was a scheisster, I’d talk all of them in to some kind of procedure that might have some placebo effect and call it a day, but I can’t do that either.
Which leaves surgery, which is easily the most enjoyable part of the job for me. Despite the fact that I could make more money burning through patients in clinic.
I have shrunk my ear surgery, mostly because I feel like chronic ears make chronic patients. Still to tympanoplasties, ear tubes, but no cholesteatomas, mastoids. I can do a lateral graft or cartilage graft pretty quickly. Takes me forever to do a mastoid now.
I agree with Otohns on my laryngology stuff. I have two fellowship trained laryngologists within an hour in two cardinal directions and even with that I refer to them maybe 2-3 times per year. Usually unnecessary.
I do some sleep surgery, when appropriate, and I’m doing hypoglossal nerve stimulators.
I do cancer cases. I don’t do cancer cases that have high rates of complication, or that I’m not doing regularly. So, I’ll do a parotid/neck, and I can do it fairly quickly, and my rate of facial paralysis is far less than 1%, and I can’t recall the last time I had a serious MRND complication (famous last words). I’ll do a thyroid cancer with Mets. Very low rates of complication, and not that time consuming in the scheme of things. But I wouldn’t do a lary. I wouldn’t attempt anything that needs major tissue transfer or a pec. Those definitely do better at a tertiary facility. And, frankly, for extreme examples of any of those things I’ll send them away. If a case is going to take me 3x longer than my average, I’ll punt.
I undoubtedly “lose” money doing those cases because I would definitely make more doing tonsils and tubes or just staying in clinic. But my sanity begs that I don’t do only those things. Money means a lot, but it isn’t the top of my pyramid.
Maybe that’ll change. I’ve been foraging my own way for 11 years now, and I’m sure at some point I’ll tighten my belt, not not any time soon.
That being said, if I had to spend all day, every day explaining to people why they don’t actually have a sinus infection (it’s a migraine), or how they don’t actually have any evidence of otitis media or eustachian tube dysfunction, or how not all the mucus in their throat has to as a rule come from their nose, I think it’d be happier pumping septic tanks for a living.
If I was a scheisster, I’d talk all of them in to some kind of procedure that might have some placebo effect and call it a day, but I can’t do that either.
Which leaves surgery, which is easily the most enjoyable part of the job for me. Despite the fact that I could make more money burning through patients in clinic.
I have shrunk my ear surgery, mostly because I feel like chronic ears make chronic patients. Still to tympanoplasties, ear tubes, but no cholesteatomas, mastoids. I can do a lateral graft or cartilage graft pretty quickly. Takes me forever to do a mastoid now.
I agree with Otohns on my laryngology stuff. I have two fellowship trained laryngologists within an hour in two cardinal directions and even with that I refer to them maybe 2-3 times per year. Usually unnecessary.
I do some sleep surgery, when appropriate, and I’m doing hypoglossal nerve stimulators.
I do cancer cases. I don’t do cancer cases that have high rates of complication, or that I’m not doing regularly. So, I’ll do a parotid/neck, and I can do it fairly quickly, and my rate of facial paralysis is far less than 1%, and I can’t recall the last time I had a serious MRND complication (famous last words). I’ll do a thyroid cancer with Mets. Very low rates of complication, and not that time consuming in the scheme of things. But I wouldn’t do a lary. I wouldn’t attempt anything that needs major tissue transfer or a pec. Those definitely do better at a tertiary facility. And, frankly, for extreme examples of any of those things I’ll send them away. If a case is going to take me 3x longer than my average, I’ll punt.
I undoubtedly “lose” money doing those cases because I would definitely make more doing tonsils and tubes or just staying in clinic. But my sanity begs that I don’t do only those things. Money means a lot, but it isn’t the top of my pyramid.
Maybe that’ll change. I’ve been foraging my own way for 11 years now, and I’m sure at some point I’ll tighten my belt, not not any time soon.
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Yeah I too look at OR as a way to maintain my own sanity. Definitely nice getting out of the office a couple days each week! It’s also sort of a loss leader - people are sent because I can do surgery if needed even if many don’t need it.
Another reason to pare down a practice is maintaining referral streams. I don’t do thyroids at all anymore because other thyroid surgeons are one of my biggest sources of vocal fold paralysis referrals. Last thing I want to do is be seen as a competitor to any of them, and I’d rather do the laryngeal framework procedures for the paralysis than the thyroids.
Definitely agree much of Laryngology doesn’t really need a sub specialist. Usually other ENTs are sending me things like complex airways, various laryngeal dystonias, benign vocal fold lesions especially in pro voice users, refractory chronic cough, early glottic cancers, challenging dysphagia cases, zenkers, vocal fold paralysis especially if permanent and needing framework surgery, etc.
Thankfully most lary patients just need a little reassurance and some voice or swallowing therapy!
Another reason to pare down a practice is maintaining referral streams. I don’t do thyroids at all anymore because other thyroid surgeons are one of my biggest sources of vocal fold paralysis referrals. Last thing I want to do is be seen as a competitor to any of them, and I’d rather do the laryngeal framework procedures for the paralysis than the thyroids.
Definitely agree much of Laryngology doesn’t really need a sub specialist. Usually other ENTs are sending me things like complex airways, various laryngeal dystonias, benign vocal fold lesions especially in pro voice users, refractory chronic cough, early glottic cancers, challenging dysphagia cases, zenkers, vocal fold paralysis especially if permanent and needing framework surgery, etc.
Thankfully most lary patients just need a little reassurance and some voice or swallowing therapy!
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As a resident reaching the other end of the horseshoe its always interesting to hear how different specialists manage their practices
