ACGME would defund Radiology, Dermatology, Ortho residencies

[Textbookversion]

Raising the reimbursement for E&M codes (which is what was proposed) will not pull the PCP up to the level of most specialists. Lots of specialists do a lot of E&Ms too. In many cases, the specialists are not making more because they are doing procedures instead of E&Ms, they make more because they are doing procedures in addition to their E&Ms.

For example, there is probably no physician that does more E&Ms in a day than a busy dermatologist. That is just one reason why this, this simple, well-intentioned, reasonable-sounding measure is insufficient to solve the problem that it purports to.

In other words, paying primary care docs more and specialists less is not at all the same thing as "just paying more for E&M codes" (which is what the post I was responding to said). The former would be a valid solution to the stated problem if an effective way to implement it was designed. The latter is a misguided attempt at implementation.

The point is not to eliminate all disparity in pay.

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[JGimpel]

Um, we were talking about machines. But no, if you are talking about foreign nighthawks (ie international outsourcing) this too has been tried for decades with nominal success, and the independent state licensing requirements, litigation issues, need for physicians at each facility, and need for clinicians to come to the reading room and have things shown to them, make this never likely to happen wide scale.

Who does your over-reads at night and on weekends; other than the ER doc that may already be busy?

Machines still aren't good enough at incorporating the H&P and the imaging results together, so I don't think it's the time to compare the two yet. Any idea how much GE or Siemens is charging for this stuff? I doubt it would be cost effective for a while. Just my n=1.

 

[reno911]

The point is not to eliminate all disparity in pay.

Maybe it wasn't your point, but it was anonperson's. Read his post again. When he talks about derm and rads making $150K/year, that's pretty much PCP levels.

Moreover, I can tell you as far as dermatology goes, that if you just increased the reimbursement for E&M codes, you would very likely increase the disparity (in absolute terms) between a PCP and a general dermatologist. Surely that's not your point, is it?

 

[psychmdhopeful]

I know it is hard to predict, but for those of us starting medical school now, is there any indication that the ACGME is actively trying to make this "suggestion" happen now or in the near future? These comments certainly are worrisome for us future physicians.

 

[Raryn]

I know it is hard to predict, but for those of us starting medical school now, is there any indication that the ACGME is actively trying to make this "suggestion" happen now or in the near future? These comments certainly are worrisome for us future physicians.

Not only is there zero indication that this is happening other than one op-ed (though it is by a prominent individual, yes), the ACGME has no power to do something like this. Funding is something each institution handles on their own. They don't phone back to home base and ask how much $ they should distribute to which departments.

Not to mention the programs at risk could quit the ACGME and start a competing certifying org if it was tried. The neurosurgeons have threatened to do so often enough 2/2 work hours. If they stopped getting paid, they'd find a way to do it.

The ACGME only has the power it does because everyone agrees to participate. There's no legal force behind it, except that any program not accredited by it (or, for the next couple years at least, the AOA) puts out graduates that are not considered to be employable. If the majority of programs of any number of specialties all quit, the insurance companies wouldn't have much choice but to revise policies in that regard.

 

[michaelrack]

Not to mention the programs at risk could quit the ACGME and start a competing certifying org if it was tried. The neurosurgeons have threatened to do so often enough 2/2 work hours. If they stopped getting paid, they'd find a way to do it.

The ACGME only has the power it does because everyone agrees to participate. There's no legal force behind it, except that any program not accredited by it (or, for the next couple years at least, the AOA) puts out graduates that are not considered to be employable. If the majority of programs of any number of specialties all quit, the insurance companies wouldn't have much choice but to revise policies in that regard.

The problem is that all of these quasi-governmental organizations recognize each other- you have to complete an ACGME accredited residency to get boarded by one of the ABMS, and if going to school in the US you need to go to an accredited medical school (forget the name of the accrediting org) to go to an ACGME accredited residency.

For a specialty to pull out of the ACGME, most of the residency programs of that specialty would need to agree and an alternative certifying organization would have to be set up. The first graduates of the new system would face a lot of discrimination in the job market.

 

[Taurus]

Just a few years ago, bundled payments were just rumors. Nobody could believe that fee-for-service would go away. Fast forward to the present and bundled payments are the reality in the near future. I wouldn't disregard this new rumor as impossible. It very could happen.

 

[Arcan57]

Of course. Once you start down this road the necessary conclusion is to create a ranking order of fund worthy and debit worthy residencies, and fund, defund or charge people accordingly. We need more FM so they get a salary. Derm is a privilege so they get a bill. Everything in between gets positive, negative or neutral treatment. The problem is that each path is a different number of years, so there already are some built in disincentives and for something which already has a long residency and fellowship, and it really wouldn't take much to disrupt the delicate equilibrium and result in shortages, short term, until the market corrects itself by driving up salaries in those fields. So the quality/quantity of specialty care would always be in flux. But this plan isn't about worrying what will happen down the road, it's a shortsighted approach to try to push people into primary care by making other paths suck more. (and in this respect it's a bit insulting to primary care, to boot).

The main solution to too few PCPs would be to implement a system where everyone starts out as PCPs and specializes after finishing a generalist residency. A lot of doctors would choose to stay as generalists rather than go back into training. Of course the system this creates would look exactly nothing like our current system and there would be a 3 yr period where every specialty was in short supply due to disruption in the training schedules.

Also, I thought rads income went way up in 2000 because the number of imaging tests ordered went up exponentially with the popularization of CT scans.

 

[Paddington]

If I'm not mistaken, don't PCP's get a 10-15% bonus from billing the same E&M codes for office visits compared to everyone else?

There are also many generous schemes out there to help repay loans for the PCP's. These are good, civilian jobs in the metro areas. Such things are unimaginable for specialists.

My understanding is that what makes Primary Care intolerable is the call. When they go home, their patients call them constantly for all kinds of inconsequential things. And of course they get paid nothing for taking these phone calls.

 

[sazerac]

There are also many generous schemes out there to help repay loans for the PCP's. These are good, civilian jobs in the metro areas. Such things are unimaginable for specialists.

Yet it also discourages the 10-15% of medical students who carry no debt from pursuing a career in primary care. Who wants to take a position when you'll purposefully get paid less than your peers who have loans?

Paying a bonus (which could be put towards debt or anything else) would make more sense than loan repayment.

 

[topsurgeon2010]

we have idiots running institutions who are canabalizing their own field...instead of representing our field's interests they're allowing other field's interests to over-power ours..it's a shame..they have failed the future generation of trainees and doctors

most other countries offer FREE or highly subsidized medical education..in no other nation do you have to go through 4 years of pre-med ($200,000+) then do 4 years of med school ($200,000+) and then apply for ~5 years in residency/fellowship while working on a menial taxable stipend which is what it really is...all while interest is building up on those loans..and then you finally get a job getting paid $300,000 starting at age ~33 (average age of matriculants is 24/25 since many have to take a gap year due to the increasingly competitive nature, this wasn't the case 20 years ago), but then take out taxes and malpractice insurance if you're not working for an academic institution, and in reality you are not left with as much as others want to portray..what a system..the average person does not understand this so politicians and other fields (nurses) can easily portray the doctors as earning too much and how doctors should sacrifice for the sake of their patients..they've been very effective in perpetuating this stigma against doctors..

some even go as far as perpetuating that a doctor's salary is the cause of current health care issues without taking to account the hundreds of more relevant issues (defensive medicine and malpractice liability, insurance & pharmaceutical companies, government bureaucracy, etc)...but lawyers compromise the government (so malpractice liability will not be addressed) and you have insurance and pharmaceutical companies that have very powerful lobbying groups..so guess who gets shafted at the end? doctors

then you have people like the one below...read this highly irresponsible article below by one of our very own

http://www.forbes.com/sites/peterubel/2012/08/21/its-physician-pay-stupid/

our patient's interests should always come first over money but we need to fight for our current and future interests and not let non-physicians (i.e. lawyers in government) decide the fate of our field solely because we're the easiest and politically safest targets

 

[deleted87716]

If I'm not mistaken, don't PCP's get a 10-15% bonus from billing the same E&M codes for office visits compared to everyone else?

It's 10%, only for Medicare, and not necessarily indefinite (it depends on how long Congress keeps funding it after 2015).

My understanding is that what makes Primary Care intolerable is the call. When they go home, their patients call them constantly for all kinds of inconsequential things. And of course they get paid nothing for taking these phone calls.

Not necessarily. It depends on the practice. If you train your patients well, you don't get too many stupid calls. I'm in a call group with ten other people, so I'm on call (phone calls only) one weeknight once or twice a month, and one weekend (Friday-Sunday) once every couple of months. The call volume varies from zero (no-hitters during the week are common) to maybe 6-8 calls/day on a winter weekend.

You can charge for phone treatment, if you want to. If insurance doesn't cover it, you can bill the patient directly. We're not doing that right now, but it's been discussed.

 

[deleted307836]

we have idiots running institutions who are canabalizing their own field...instead of representing our field's interests they're allowing other field's interests to over-power ours..it's a shame..they have failed the future generation of trainees and doctors

most other countries offer FREE or highly subsidized medical education..in no other nation do you have to go through 4 years of pre-med ($200,000+) then do 4 years of med school ($200,000+) and then apply for ~5 years in residency/fellowship while working on a menial taxable stipend which is what it really is...all while interest is building up on those loans..and then you finally get a job getting paid $300,000 starting at age ~33 (average age of matriculants is 24/25 since many have to take a gap year due to the increasingly competitive nature, this wasn't the case 20 years ago), but then take out taxes and malpractice insurance if you're not working for an academic institution, and in reality you are not left with as much as others want to portray..what a system..the average person does not understand this so politicians and other fields (nurses) can easily portray the doctors as earning too much and how doctors should sacrifice for the sake of their patients..they've been very effective in perpetuating this stigma against doctors..

some even go as far as perpetuating that a doctor's salary is the cause of current health care issues without taking to account the hundreds of more relevant issues (defensive medicine and malpractice liability, insurance & pharmaceutical companies, government bureaucracy, etc)...but lawyers compromise the government (so malpractice liability will not be addressed) and you have insurance and pharmaceutical companies that have very powerful lobbying groups..so guess who gets shafted at the end? doctors

then you have people like the one below...read this highly irresponsible article below by one of our very own

http://www.forbes.com/sites/peterubel/2012/08/21/its-physician-pay-stupid/

our patient's interests should always come first over money but we need to fight for our current and future interests and not let non-physicians (i.e. lawyers in government) decide the fate of our field solely because we're the easiest and politically safest targets

I sympathize and agree with most of your post -- but is it really correct to say that medical education is not highly subsidized in the US? Undergraduate medical education may not be (though it is in some states at public schools), but past posters on SDN familiar with the financials of residencies have indicated that programs receive a rough average of 100k/yr/resident from Medicare. For someone completing a four year-residency, that is 400k of government funds being directed towards the training of one physician; I think that is probably the most that can be asked for at this point and maintaining GME funds is incredibly important going forward.

 

[topsurgeon2010]

I sympathize and agree with most of your post -- but is it really correct to say that medical education is not highly subsidized in the US? Undergraduate medical education may not be (though it is in some states at public schools), but past posters on SDN familiar with the financials of residencies have indicated that programs receive a rough average of 100k/yr/resident from Medicare. For someone completing a four year-residency, that is 400k of government funds being directed towards the training of one physician; I think that is probably the most that can be asked for at this point and maintaining GME funds is incredibly important going forward.

yes you're 100% correct, I was referring more to undergraduate medical education but even then graduate medical education (i.e. residency) we're still essentially free labor for the hospital so although the residency is being subsidized that monetary benefit is going more to the hospital than to the residents

And to be fair, I was also exaggerating a lot in my post to make a point since we know not everyone pays $200,000 each for pre-med and/or med due to grants, scholarships, etc., but when you compare medical schools in other nations they still tend to be MUCH cheaper than even subsidized state schools here (not talking about majority of the Caribbean schools who charge $200,000+ because those are for-profit factories designed to prey on desperate American students)

the amount of debt plus interest over longer periods of graduate training --> much more debt than other nations

also we have to consider the fact that doctors in the US work A LOT of hours (many UK doctors work 40 hours/wk) and if you look at the dollars earned per hours worked it'll provide a much more realistic story of our compensation

point is our field has failed to change this perception and many of our own continue to perpetuate this notion that doctors (most of who are at the lower end of the income spectrum) are over-paid and should take a pay cut for the sake of learning and for our patients but these doctors don't realize they're actually hurting themselves and the entire field in the process..how about we ask insurance companies, device manufacturers and pharmaceutical companies to cut their costs instead, they're making much more money than most of us will ever make

 

[Winged Scapula]

My understanding is that what makes Primary Care intolerable is the call. When they go home, their patients call them constantly for all kinds of inconsequential things. And of course they get paid nothing for taking these phone calls.

One seems to believe that specialists don't get these sorts of calls either.

Like BlueDog notes, you can train your patients when to call and for what, but believe me, PCPs do not have a lock on "calls for inconsequential things". I got one last weekend asking me when the Steri-strips were going to come off, despite the fact that she was told orally and in written instructions to leave them on until they come off. She wanted to know EXACTLY when, as if I have some Magic 8 ball. For some reason that generated a call to the doctor on call.

 

[RadOncDoc21]

One seems to believe that specialists don't get these sorts of calls either.

Like BlueDog notes, you can train your patients when to call and for what, but believe me, PCPs do not have a lock on "calls for inconsequential things". I got one last weekend asking me when the Steri-strips were going to come off, despite the fact that she was told orally and in written instructions to leave them on until they come off. She wanted to know EXACTLY when, as if I have some Magic 8 ball. For some reason that generated a call to the doctor on call.

I hope your paging operator didn't give out your pager number like they did to me one time... I had a patient page me directly at 2 am regarding her insomnia... I damn near lost it.

 

[michaelrack]

The main solution to too few PCPs would be to implement a system where everyone starts out as PCPs and specializes after finishing a generalist residency. A lot of doctors would choose to stay as generalists rather than go back into training. .

That sounds a lot like internal medicine.... the vast majority of internal medicine residents either go on to subspecialize, or they become hospitalists.

 

[Winged Scapula]

I hope your paging operator didn't give out your pager number like they did to me one time... I had a patient page me directly at 2 am regarding her insomnia... I damn near lost it.

ONCE.

I had written discharge orders which included my cell # for the nurses to reach me if they had any questions rather than going through the office. The order clearly says, "for nursing use ONLY, not to be given to patients. This is my personal cell phone number."

The patient was suitably mortified when she called, thank goodness. As was the nursing supervisor when I called to report the actions of one of her staff.

And while we're off topic, my "favorite" page as a resident was the 230 am call from a gastric by-pass patient who hadn't lost enough weight and wanted to know what I thought about having her pouch made smaller. Just wanted to talk about it randomly, no emergency, no current problems.

 

[Smurfette]

ONCE.

I had written discharge orders which included my cell # for the nurses to reach me if they had any questions rather than going through the office. The order clearly says, "for nursing use ONLY, not to be given to patients. This is my personal cell phone number."

The patient was suitably mortified when she called, thank goodness. As was the nursing supervisor when I called to report the actions of one of her staff.

And while we're off topic, my "favorite" page as a resident was the 230 am call from a gastric by-pass patient who hadn't lost enough weight and wanted to know what I thought about having her pouch made smaller. Just wanted to talk about it randomly, no emergency, no current problems.

It is amazing what some people think cannot wait until office hours.

I have actually started telling family in my post-surgery spiel "remember that pain medicine wears off, so if s/he wakes up at 2 AM in bad pain, it's probably because s/he is due for another dose". I got a few too many phone calls where they didn't think about this at all before calling....or of taking TWO vicodin/percocet instead of one because they didn't read the bottle...

My former partner once forgot to block caller ID when she called a patient from her cell phone and the patient started to text her all of her complaints, even AFTER my partner told her that it was inappropriate for her to do so. My partner even got texts from this patient when she was on vacation (and the patient knew she was out of state).

I also have called supervisers, etc. when my direct pager or personal number has been given to a patient.

 

[smq123]

My understanding is that what makes Primary Care intolerable is the call. When they go home, their patients call them constantly for all kinds of inconsequential things. And of course they get paid nothing for taking these phone calls.

The call I take now for the outpatient general medicine clinic I work for is, pretty consistently, a joke. We also get company-issued cellphones so I never have to worry about a patient calling me for issues when I'm not on call, since I don't take incoming calls on that phone. The answering service texts us otherwise.

As a resident, one of my friends got a page from the answering service. A patient had drunk-dialed the doctor's office.

 

[SouthernSurgeon]

As a resident, one of my friends got a page from the answering service. A patient had drunk-dialed the doctor's office.

I have gotten drunk-dialed by a patient while on call as well

 

[BolderNewfy]

Bottom line is that primary care, especially IM is horribly underpaid and overworked. They need to pull money from disproportionately paid specialties such as anesthesia, rads, radiation oncology, which are way overpaid. A radiologist would have zero business if I wasnt ordering xrays and CTs. It is not appropriate for a radiologist to be pulling 400K a year working bankers hours with no call, while Im pulling barely 180K with the same debt working twice as many hours. The hospital wouldnt even be there if it wasnt for Internists. Its about time....

 

[Textbookversion]

Whoa there, someone got a bone to pick. Before you immediately rush and say, specialists are overpaid, why don't we do a little a research first. Note, I am an attending rad onc with a PCP spouse, so I have my own biases. Lets look at a few things:

1) Length of training: IM is 3 years, rads/rad onc 5 years. Longer training usually means more pay. If you do IM and then specialize in cardio, GI, etc. your salary is comparable to the specialties you just bagged on.

2) Evaluation- You have IM boards as a written and that its. I take radiation physics, radiation biology, written clinical, and oral boards. Once again, more work and scrutiny, more pay usually.

3) Work hours- this is a relative thing. I know some IM attendings that are friends of mine that work as hospitalists 1 week on/1 off pulling 180 k so if they worked every week like I do there salary would be closer to 350k, not too far from from those of us in rads/rad onc make.

4) Procedures- Most IMs I know don't do a lot of procedures; procedures will always pay more and as such specialties that ential procedures will get paid more.

You sit there and bad mouth specialties like radiology because without you ordering an xray/CT they'd be out of work. Problem is without them, we'd be back a few decades in terms of diagnostic ability. I'm not a radiologist but what I have seen in oncology in the last decade is that most of the newer docs (med oncs, surg oncs rad oncs) can't survive without that imaging and the reads you despise so much. You criticize our hours; any data on our hours compared with yours or do you just like to throw things out there.

Your comments come off as jealous and bitter. Instead of slamming other specialties, why not simply advocate for yours? Otherwise, you come off as another jerk; hopefully, the next time you need a stat CT or MRI that you can't read or have a patient with cord compression progressing on steroids, you'll remember the value of other specialties.

You work 84 hours a week? Because that's how many hours those guys on their week on are working.

 

[BolderNewfy]

Whoa there, someone got a bone to pick. Before you immediately rush and say, specialists are overpaid, why don't we do a little a research first. Note, I am an attending rad onc with a PCP spouse, so I have my own biases. Lets look at a few things:

1) Length of training: IM is 3 years, rads/rad onc 5 years. Longer training usually means more pay. If you do IM and then specialize in cardio, GI, etc. your salary is comparable to the specialties you just bagged on.

2) Evaluation- You have IM boards as a written and that its. I take radiation physics, radiation biology, written clinical, and oral boards. Once again, more work and scrutiny, more pay usually.

3) Work hours- this is a relative thing. I know some IM attendings that are friends of mine that work as hospitalists 1 week on/1 off pulling 180 k so if they worked every week like I do there salary would be closer to 350k, not too far from from those of us in rads/rad onc make.

4) Procedures- Most IMs I know don't do a lot of procedures; procedures will always pay more and as such specialties that ential procedures will get paid more.

Y

1)what about Peds, Or psych? Or infectious disease, where they undergo 2-3 extra years of fellowship to take a pay CUT.

2) Im not even going to validate this with a response

3)No this is not a "relative thing". You dont work anywhere near the hours of any hospitalist, and the hours you work are infinitely more stable for well over double the salary, doing a job a tech could easily manage (I swear you should have a stamp that sais 30Gy in 10 Fractions)

4)There is no reason that procedures pay more, they just do. Thankfully that is changing..

Guess how many times Ive been really grateful that the radiation oncologist was there for me at 2am in the ED......0

Guess how many times Ive been in the ER at 2 am cleaning up after a radiation oncologists mess ie, radiation enteritis, mucositis, etc.....Too many to count...

and by the way, the radiation oncologist has NEVER been there in the ED at 2 am with THEIR patient. So until I see you in the ED with that patient with progressing neuro deficits with me, the ER doc, and the neuro surgeon, youll get the same respect every other business man parading around in a white coat gets....just leave the real medicine up to us doctors.

 

[deleted87716]

 

[Kablammo]

Sigh, another lost soul. A few thoughts for the Bold Newfy

1. All that hate is gonna burn you up.
2. It sounds like you actually don't like your job very much, and I suspect that this is the root of your disdain for other health care providers who you think have a better gig.
3. Old ideas still work- the divide and conquer strategy being used by health care admins will contribute to the end of it all.
4. The pay taken from specialists will NOT end up in your pockets. It will, however, be temporarily distributed to many mid-level providers who will be very happy to fumble through an ER workup at 2am for half of the salary that you think is inadequate.
5. Radiologists haven't worked bankers hours in 10 years. I am in the ER at 2 am, and at our institution the radiology residents work very similar hours as their IM and EM counterparts when averaged over an entire year. We are there on evenings, weekends and nights, providing 24/7 coverage just like our EM colleagues.

Good luck partner, you're gonna need it.

 

[RadOncDoc21]

Damn, why all the hatin on rad onc!? We can't treat emergently at 2am because cancer doesn't grow at night or on weekends!

 

[Neuronix]

1) Length of training: IM is 3 years, rads/rad onc 5 years. Longer training usually means more pay. If you do IM and then specialize in cardio, GI, etc. your salary is comparable to the specialties you just bagged on.

I was curious about this, so I plotted length of training vs salary based on the Medscape 2011 data:

My plot based on shortest common training pathway to become that type of specialist.

This implies weak correlation between length of training and salary.

My personal opinion is that the most competitive medical students flock towards the highest paying specialties in general. If specialties like radiation oncology had a salary cut in half, the specialty would become far less competitive. To me, that's not a big deal, because you don't need the smartest doctors in medicine in radiation oncology. All of the field's advances back in the early IMRT days were made by doctors before this specialty paid well and was competitive.

Do the top medical students from our classes need to be in dermatology? No way. It's all driven by money, lifestyle, and length of training. But conversely, pediatrics fills most of its spots every year.

The salaries recently have reimbursed best for procedures, and procedural specialties tend to take longer to train in. If reimbursement changes, the competition for longer training specialties will decrease dramatically, but they will still fill, and we'll just have the same argument in reverse. i.e. The next generation will be arguing: Well all the smart students are in family practice because it only takes 3 years and pays the best, why would anyone train in surgery??? Because surgery is awesome, duh! I knew from the moment I was born I wanted to be a surgeon!!!

Ok, back to your pissing contest.

 

[PTPoeny]

You want to have a pissing contest fine...what don't you look up the numbers from the NRMP. Who have better stats coming out of med school, IM residents or Rad Onc residents. What specialty fills spots at non-university programs with FMGs/IMGs, etc?

1) Peds is three years like IM not 5 years. I cant speak for all peds, but my colleagues in peds onc do pretty well in academics and PP. Again, psych is relative and I speak from experience, my father in law is a psychiatrist. The job market is lower than some specialties but can be quite good.

I think the Peds example was pointing out that general peds is 3 years and the subspecialties are all 5-6 but you take a pay cut in many of them despite the longer training.

http://pediatrics.aappublications.org/content/127/2/254.full

 

[Socrates25]

Peds is an outlier and should not be used to represent medicine as a whole (disclaimer I'm a pediatrician)

It is true that peds subspecialists dont get paid all that much more compared to general peds, even though they have a minimum of 3 extra years of training. Peds cards and GI make quite a bit more more, but for alot of other peds subspecialties, the pay bump is minimal, maybe 20%. In fact, I've heard of several peds heme/onc guys who make less than general peds.

However, in the adult medicine world there is CLEARLY a huge jump in salary between general IM and subspecialties, where you can easily make double or triple what a primary care doc makes.

 

[mercaptovizadeh]

The reimbursement structure of medicine is only very loosely tied to more training, more knowledge, more hours worked, more complex/difficult patients, etc. Surgical is generally paid better than medical, as well it should be, given the greater risks involved. But there's a ton of stuff that doesn't make sense, like derm/radiology/rad onc making much better money that medicine and pediatrics or even many of the subspecialists out of IM and peds (e.g. rheum, endocrine, renal, ID, etc.). I hope that if there's a restructuring in reimbursement it takes things like this into account.

 

[mercaptovizadeh]

You want to have a pissing contest fine...what don't you look up the numbers from the NRMP. Who have better stats coming out of med school, IM residents or Rad Onc residents. What specialty fills spots at non-university programs with FMGs/IMGs, etc?

2) you don't want to validate this with a response? Lets look at the facts; what percentage of IM applicants could get into rad onc? What percentage of rad onc applicants could get into IM? You talk about real doctors, calling me and my specialty out. You are part of the problem in not realizing we are all doctors in the same profession; if you wanted cushier hours and bigger salaries, you knew the numbers when you picked a specialty. Or did you not have the stats and skills to get in?

What kind of argument is this? You deserve to be paid 2-3x what an internist makes because your grades and board scores were better in medical school? How about reimbursement being tied into the nature of the training involved and the actual work done (risks, complexity, call hours, work hours, etc.)?

Rad onc sure does get the geniuses...

 

[Neuronix]

What kind of argument is this? You deserve to be paid 2-3x what an internist makes because your grades and board scores were better in medical school? How about reimbursement being tied into the nature of the training involved and the actual work done (risks, complexity, call hours, work hours, etc.)?

Rad onc sure does get the geniuses...

I take the opposite approach to this problem. I think it's ridiculous that generalists and many other specialists (rheum, ID, endocrine, peds subspecialties, etc) get paid as little as they do. Their salary should be double. Consultation and followup codes should reimburse better to reward complex medical decision making.

I guarantee you that if you start slashing reimbursement codes, everyone will suffer. Many generalist practices, especially the higher earners, are making money with procedures in various ways, whether that's scope of practice procedures, lab tests, etc... So if you start trying to take down derm procedures, all of those skin biopsies the general doc does is also going to reimburse less. So then in trying to equalize things: derm goes from $350,000 to $250,000 a year average, but FP goes from $130,000 to $100,000 average. That would be even more ridiculous.

Remember, the pressure on salaries is only down. Everyone else is lobbying to reduce our pay while medical school gets more expensive, training gets longer, and malpractice liability increases. The more we fight, the more arguments we give to politicians, midlevels, and sensationalist journalists, all of whom could easily be reading this thread.

The point is: redistribution of salaries is a fool's errand. Stop fighting amongst yourselves and argue for improvement of salaries, not reduction. No other group of medical providers or industry sector is out there arguing about how their colleagues should make less money. It will bite them in the end. Meanwhile the device manufacturing representatives make as much as physicians, and nobody is talking about it...

 

[Raryn]

However, in the adult medicine world there is CLEARLY a huge jump in salary between general IM and subspecialties, where you can easily make double or triple what a primary care doc makes.

Tell that to the Rheumatologists. Or the Infectionists. Or the Nephrologists. Or the Endocrinologists. Or the Hepatologists (at least the ones who don't also do general GI).

Just because Cards/GI/Heme-Onc/A+I make money hand over fist doesn't mean that all IM subspecialists do.

 

[smq123]

Now, when you say things like this:

That being said, I think it makes no sense to pit specailty against specialty because it seems that we are perpetually having this arguement that the primary care docs want to take from the specialists.

But then ALSO say things like this:

In my biased eyes, what i do is more complex and requires more knowledege than what a typical hospitalist or outpatient IM does.

it makes it very hard to take your Kum-Ba-Ya stuff seriously. At all.

Because, in MY biased eyes, what I (and your wife) do is just as complex, time consuming, and demanding as what you do. It requires a different type of knowledge, but it is knowledge that many rad oncs no longer have (if they ever had it at all). I mean come on....you may have managed a bunch of CHF exacerbations as an intern, but do you honestly think you still have the knowledge to manage a complicated CHF-COPD-DM-HTN patient now? My boyfriend is a rad onc, and some of the management of non-radiation stuff that his attendings tell him to do on call is just silly. It's a different type of knowledge than yours, but no more or less complex in its own way.

So you may suggest that I try to promote my specialty, but why bother when everyone responds with, "Oh, everyone knows that primary care is so much easier than radiology/rad onc/etc."

 

[RadOncDoc21]

I think the problem with our specialty is that nobody really understands what we do and trying to explain it is a problem in itself.

Like almost everybody else, nothing worse than working your tail off everyday for somebody else to say you don't do anything and don't deserve to make what you make. I agree, primary care docs should get more but that shouldn't come out of the pockets of another doctor.

The health care industry is a trillion dollar a year industry and although doctors are the leaders in the field of medicine, we have no control over the business side of things. In the end, we all should be on the same team against the storm that is coming since most people assume doctors are greedy and shouldn't make that much money. We're already getting blasted enough from outside our field already.

 

[Textbookversion]

The point was simple; those of us in rad onc could be IM or whatever else the OP considered "a real doctor" very easily but that the OP and their colleagues would find it much more difficult or impossible to pursue our specialty.

Everyone in IM is clearly just too dumb for Rad Onc there is no way they could do live up to your amazing intellect.

thumbdown

Rad onc is competitive because it pays well. If it paid terribly, you'd find plenty of those IM docs that "just can't hack it" thriving in rad onc.

The wailing and gnashing of teeth when the RVU/RUC system gets cast aside (either by the end of fee for service or otherwise) is going to be hilarious.

 

[Sheldor]

I don’t think primary care is automatically “easier” than rads/rad onc, etc; that being said, when I get told I’m not a real doctor compared to medicine, ER, FP, surgery, etc. because I’m a rad onc, I’m sure as hell going to point out that my colleagues and I could have, based on the stats, easily could have gotten into those fields while noting that the likelihood of those “real doctors” getting into rads/rad onc/derm, etc. is a lot lower.

I just wanted to add a comment regarding that the above post that says "Rad Onc isn't as complicated", and yet myself, and many others I met on the interview trail specifically chose it because we loved how extremely complex Rad Onc is, while we felt internal medicine was not intellectually stimulating enough. So unless you have rotated through it and see what actually goes on, it seems rude to pigeon hole an entire field.

Also, this doesn't mean IM isn't complicated, but residency duration is decided so that once can "master" all the complexities needed in order to practice independently, so to say that something that takes 3 years to practice independently is more complex than something that takes 5? No. Radiation Oncology just pushes buttons? No. If you want to get an idea of the true complexity of Rad Onc for your own benefit, head over to the Rad Onc subforum and read any of the recent threads on management techniques for various malignancies. Such as:

http://forums.studentdoctor.net/showthread.php?t=988302

You'll notice nearly every treatment regimen is supported with a reference to the trial that proved its efficacy. Its a field that is so complicated that everyone has to cite the trial supporting their decisions. I dont remember the last time I heard an IM doc use a trial to debate the merits of various treatment regimens.

 

[Sheldor]

Everyone in IM is clearly just too dumb for Rad Onc there is no way they could do live up to your amazing intellect.

thumbdown

Rad onc is competitive because it pays well. If it paid terribly, you'd find plenty of those IM docs that "just can't hack it" thriving in rad onc.

The wailing and gnashing of teeth when the RVU/RUC system gets cast aside (either by the end of fee for service or otherwise) is going to be hilarious.

Well, when ever I've told folks in IM that I'm going into Rad Onc, they nearly universally say, "Wow, I could never do that." So maybe at the next big IM meeting you should let everyone know so they can stop thinking that Rad Onc is extremely difficult.

 

[badasshairday]

The reimbursement structure of medicine is only very loosely tied to more training, more knowledge, more hours worked, more complex/difficult patients, etc. Surgical is generally paid better than medical, as well it should be, given the greater risks involved. But there's a ton of stuff that doesn't make sense, like derm/radiology/rad onc.

Right because everyone admitted to the hospital has some kind of imaging done and because reading studies to rule out PE, aortic dissections, and not missing a small lung nodule on a 300 slice CT that later becomes cancer (and you can't defend yourself because that one slice is on PACS forever) is not stressful. Or calling the trauma surgeons who are trying to figure out how to take care of a small liver lac that they actually should worry about the spinal cord transection and call neurosurgery STAT. Give me a break dude. Fellowship trained radiologists have a training route as long as neurosurgery and cardiology, there is a reason for that. We provide 24/7 coverage for our ED brethren, nights, weekends, holidays, at a non-stop grind while we work.

I'm actually glad that our salaries are a bit down, so all these jealous people from other specialties who are miserable in their jobs, at least feel a little relieved.

Ridiculous. Division will make us all suffer. We are all physicians.

 

[Substance]

Right because everyone admitted to the hospital has some kind of imaging done and because reading studies to rule out PE, aortic dissections, and not missing a small lung nodule on a 300 slice CT that later becomes cancer (and you can't defend yourself because that one slice is on PACS forever) is not stressful. Or calling the trauma surgeons who are trying to figure out how to take care of a small liver lac that they actually should worry about the spinal cord transection and call neurosurgery STAT. Give me a break dude. Fellowship trained radiologists have a training route as long as neurosurgery and cardiology, there is a reason for that. We provide 24/7 coverage for our ED brethren, nights, weekends, holidays, at a non-stop grind while we work.

I'm actually glad that our salaries are a bit down, so all these jealous people from other specialties who are miserable in their jobs, at least feel a little relieved.

Ridiculous. Division will make us all suffer. We are all physicians.

Dude's right.

Radiology makes "the big call" very often, and they are expected to 100% of the time. Technology has made their work more complicated, not less. If they want to work at facemelt speed and miss something big, that's the risk they take and they will pay the consequences. If they can do it well at a high speed, they deserve every penny. They, and all physicians, are being paid for their expertise, not their time.

However, I do agree with the fee schedules being quite disparate, and somewhat illogical. It's not certain what is actually valued. A ruptured appendix is fatal unless treated, a cataract is not, yet one reimburses far greater than the other...so its not life we value. What about complexity? Well its not that either since the latter is essentially an automated procedure. I get confused by the decisions of the RUC.

Personally I would love to have true free market medicine. Our incomes would go down, but there would be opportunities to make it huge.

 

[topsurgeon2010]

internists are truly some of the most knowledgeable people in medicine..I have a great deal of respect for them..no one is arguing that they shouldn't get paid more and it is unfortunate that primary care isn't as emphasized in the US as it should be..but saying that another specialty in our field should get paid less is not what we should be advocating because people in power who dont have our field's interests in mind will take advantage of that (i.e. divide & conquer) and will use that to lower all payments for which your specialty will EVENTUALLY end up suffering also..in this economic/political climate no specialty is truly going to get a pay increase what's going to happen though is that they're is going to be a pay DECREASE across the board while making us work harder..do we really think they're going to cut specialties pay just so they can give more to internists? i don't think so, that's not how capitalism works, that money is not going to come back to any of us once it's gone...hospitals are also going to start using mid-level positions and since midlevels are so united in their fight for their interests and keep getting more and more autonomy by the day (they're already fellowships for DNPs) why would a hospital pay a doctor's salary when they can pay a mid-level position, DNP's essentially want the same autonomy as an internist...and then in the eyes of the average person they're also painting us to be the bad guys (i.e. doctor's get paid too much, health care crisis due to doctor's salary, etc) and the average person is not able to accurately discern the differences in salary among specialties they think all doctors earn a lot...the issues that are truly driving up health care costs will not be addressed because cutting a doctor's salary is the politically safest & easiest target (average person will not have sympathy for us, no real lobbying presence in DC, AMA is a joke)..and that's what we should be fighting..not each other...don't let the politicians (whether Democrat or Republican) determine the fate of our field only because we're the politically safest targets..clearly there is a lot of division among physicians and they're taking advantage of that (just look at division among us in this thread, we're on the same side...)

let's just hope what happens to us isn't the same as what happened to pilots..becoming a pilot was once a HIGHLY admired career, now they're just over-worked, in debt and highly under-paid..all doctors should read the article below to see that the threat is very real and has happened to other occupations..while I don't see it becoming as bad any time soon it's still not looking good for doctors

http://www.guardian.co.uk/world/2010/jan/11/pilot-exhausting-hours-wages

 

[mercaptovizadeh]

Aside from the failure in logic that undergirds wagy's theory that rad oncs should be paid 500,000 vs. IM's 180,000 because of a 5 vs. 3 year residency and better applicant stats, there seems to be a willful disregard of the fact that I never exclusively compared IM to rad onc. I also discussed subspecialists in medicine and pediatrics who continue to make substantially lower pay than does rad onc or dematology - for no obvious reason:

Now, let me focus on adult medicine vs. pediatrics subspecialists. In most cases, peds trains for the same number of years or 1+ because their fellowships tend to be a bit longer.

The mean income out of fellowship for a pediatric endocrinology (6 yrs training) is $186,000; that of pediatric hematology/oncology (6 yrs training) is $206,000.

For comparison, for adult endocrinology (5 yrs training) and hematology/oncology (6 yrs), the mean starting pay is $212,000 and $315,000, respectively.

Can you explain to me why the internists who treat cancer and adult endocrine problems make 10s if not 100s of thousands of dollars more than the pediatrician counterparts? Do children who have cancer count less than adults? Is managing type 1 diabetes or GH deficiency or precocious/delayed puberty in a child somehow less important than doing the analogous job in adults?

I think this has illustrated well how we have bizarre discrepancies in very similar fields (i.e. from the perspective of intellectual bent, research potential, yrs training, seriousness of the conditions, etc.) just because the patient populations are different.

So now how can you possibly explain to me why rad onc makes 2-3x what the medical oncologists (adult or pediatric) make? Are you seriously going to explain to me that board scores and AOA means that you are entitled to earn twice as much as the cancer doctor who actually performs the diagnostic workup (with pathology and radiology), interfaces with the other specialists, manages the medications/chemo/BMTs, deals with the complications (infections, renal failure, etc.), and is usually the cancer doctor who spends the most time with and bears the most emotional burden of dying cancer patients?

That's why this whole reimbursement scheme is bunk from beginning to end. I have no problem with a general surgeon making more than an internist. I have a big problem with the orthopedic surgeon making more than the general surgeon, or the rad onc making a ****-ton more than the medical/pediatric oncologists.

 

[IamnotFreud]

Aside from the failure in logic that undergirds wagy's theory that rad oncs should be paid 500,000 vs. IM's 180,000 because of a 5 vs. 3 year residency and better applicant stats, there seems to be a willful disregard of the fact that I never exclusively compared IM to rad onc. I also discussed subspecialists in medicine and pediatrics who continue to make substantially lower pay than does rad onc or dematology - for no obvious reason:

Now, let me focus on adult medicine vs. pediatrics subspecialists. In most cases, peds trains for the same number of years or 1+ because their fellowships tend to be a bit longer.

The mean income out of fellowship for a pediatric endocrinology (6 yrs training) is $186,000; that of pediatric hematology/oncology (6 yrs training) is $206,000.

For comparison, for adult endocrinology (5 yrs training) and hematology/oncology (6 yrs), the mean starting pay is $212,000 and $315,000, respectively.

Can you explain to me why the internists who treat cancer and adult endocrine problems make 10s if not 100s of thousands of dollars more than the pediatrician counterparts? Do children who have cancer count less than adults? Is managing type 1 diabetes or GH deficiency or precocious/delayed puberty in a child somehow less important than doing the analogous job in adults?

I think this has illustrated well how we have bizarre discrepancies in very similar fields (i.e. from the perspective of intellectual bent, research potential, yrs training, seriousness of the conditions, etc.) just because the patient populations are different.

So now how can you possibly explain to me why rad onc makes 2-3x what the medical oncologists (adult or pediatric) make? Are you seriously going to explain to me that board scores and AOA means that you are entitled to earn twice as much as the cancer doctor who actually performs the diagnostic workup (with pathology and radiology), interfaces with the other specialists, manages the medications/chemo/BMTs, deals with the complications (infections, renal failure, etc.), and is usually the cancer doctor who spends the most time with and bears the most emotional burden of dying cancer patients?

That's why this whole reimbursement scheme is bunk from beginning to end. I have no problem with a general surgeon making more than an internist. I have a big problem with the orthopedic surgeon making more than the general surgeon, or the rad onc making a ****-ton more than the medical/pediatric oncologists.

I think you are way off in your figures. So derm makes a ton for a number of reasons, which include the fact that they see a ton of patients since some consults take minutes literally, there's not a great number of them so they have increased volume, they have procedures which rake in $$, they do cosmetics which is cold, hard cash (one of the attendings who I did my rotation with would charge 700 bucks for a fraxel for about an hour and people would pay it), and patients are willing to pay out of pocket, both for cosmetic and non cosmetic derm stuff. That's why derm makes $$$$.

Heme/oncs make a ton of cash these days, roughly 15% or so less than rad oncs but not that far off realistically.

The reason why many peds make less $$ than adult counterparts is because many kiddos are on Medicaid which reimburses very poorly, while on the other hand, the payor mix is different for adults. Also, realize that with many specialists, the buck stops with them. So while I respect internists and I think their work is important, realize that they do have a short residency, less liability than other docs, and they are rarely the ones who make the final decision - they can consult everyone about anything and the specialist makes the final decision ultimately, which carries far less liability and responsibility vs. calling the brain bleed at 2 am that the rads person needs to call.

Also realize that many internists make far more than 180's. Your figures are old. People in my intern program were getting offers of 200-250, someone even 300k for 7 on/7off. that's not too bad for working half the year, so let's be realistic. IM is one of the most versatile medical careers there is, and you can find a niche and make decent money.

You really think that people will train for 6 years to make the same? that would be nuts. I think the quotes are 75k per year of training, which is roughly accurate if you think about what specialists vs non specialists make.

Also realize that there are pay differentials in every field. For example, corporate lawyers make far more than say family lawyers, patent lawyers make more than immigration lawyers, etc. General dentists make less than cosmetic dentists or orthodontists. It would make no sense that all specialists and non-specialists made the same would it?

Ultimately as others have pointed out it makes more sense to be united in our efforts than divided. We all know what different specialties pay, so if money is important, it makes sense to go into something that pays more no?

 

[Textbookversion]

We all know what different specialties pay, so if money is important, it makes sense to go into something that pays more no?

The point is that the reason certain things pay more is fairly disconnected from the underlying economics. Pay is set by crappy central planning run by specialists that control on the AMA's RVU committee.

The reason I'd make 2-3x the salary if I decide to do a fellowship in GI vs. rheum? Arbitrary. Completely arbitrary.

And I don't see any reason to accept things staying the same, and frankly, they won't. It's always entertaining talking to my family members that have been in medicine forever. Especially the older generation who were around when certain specialties that are really competitive now were bottom barrel. We'll be having the same conversation in 25 years with the next generation I'm sure. "Back in my day dermatology was ridiculous to get into! Incredibly competitive." "You've gotta be joking!?"

Getting back to the topic at hand though I still think it is absurd to charge residents tuition.

 

[RadOncDoc21]

Aside from the failure in logic that undergirds wagy's theory that rad oncs should be paid 500,000 vs. IM's 180,000 because of a 5 vs. 3 year residency and better applicant stats, there seems to be a willful disregard of the fact that I never exclusively compared IM to rad onc. I also discussed subspecialists in medicine and pediatrics who continue to make substantially lower pay than does rad onc or dematology - for no obvious reason:

Now, let me focus on adult medicine vs. pediatrics subspecialists. In most cases, peds trains for the same number of years or 1+ because their fellowships tend to be a bit longer.

The mean income out of fellowship for a pediatric endocrinology (6 yrs training) is $186,000; that of pediatric hematology/oncology (6 yrs training) is $206,000.

For comparison, for adult endocrinology (5 yrs training) and hematology/oncology (6 yrs), the mean starting pay is $212,000 and $315,000, respectively.

Can you explain to me why the internists who treat cancer and adult endocrine problems make 10s if not 100s of thousands of dollars more than the pediatrician counterparts? Do children who have cancer count less than adults? Is managing type 1 diabetes or GH deficiency or precocious/delayed puberty in a child somehow less important than doing the analogous job in adults?

I think this has illustrated well how we have bizarre discrepancies in very similar fields (i.e. from the perspective of intellectual bent, research potential, yrs training, seriousness of the conditions, etc.) just because the patient populations are different.

So now how can you possibly explain to me why rad onc makes 2-3x what the medical oncologists (adult or pediatric) make? Are you seriously going to explain to me that board scores and AOA means that you are entitled to earn twice as much as the cancer doctor who actually performs the diagnostic workup (with pathology and radiology), interfaces with the other specialists, manages the medications/chemo/BMTs, deals with the complications (infections, renal failure, etc.), and is usually the cancer doctor who spends the most time with and bears the most emotional burden of dying cancer patients?

That's why this whole reimbursement scheme is bunk from beginning to end. I have no problem with a general surgeon making more than an internist. I have a big problem with the orthopedic surgeon making more than the general surgeon, or the rad onc making a ****-ton more than the medical/pediatric oncologists.

Where did you get these numbers from? If anything you're quoting the top 5% and the avg is around 250-350k. In either case, your arguments could just as well have come from a mid-level who feels justified to do what an internist can do because they can manage patients the same way and spend more time with the patient.

We can go back and forth on who does more and to say we're not as important as a med onc is a true slap in the face. Before you start making judgments try to at least educate yourself on our field and what we do. Radiation is dangerous and like a surgeon we can cause more harm than good if we're not careful and backed with true evidence-based literature. How much radiation biology and physics did you learn in med school? I'm not the typical person to get into debates online but I think we all need to stop tearing each other's fields apart.

 

[Noegrus]

 

[VA Hopeful Dr]

You'll notice nearly every treatment regimen is supported with a reference to the trial that proved its efficacy. Its a field that is so complicated that everyone has to cite the trial supporting their decisions. I dont remember the last time I heard an IM doc use a trial to debate the merits of various treatment regimens.

Then you weren't paying attention. I'm a FM resident and even we bring up specific trials at rounds pretty much daily.

 

[fizzle]

Can you explain to me why the internists who treat cancer and adult endocrine problems make 10s if not 100s of thousands of dollars more than the pediatrician counterparts? Do children who have cancer count less than adults? Is managing type 1 diabetes or GH deficiency or precocious/delayed puberty in a child somehow less important than doing the analogous job in adults?

I think this has illustrated well how we have bizarre discrepancies in very similar fields (i.e. from the perspective of intellectual bent, research potential, yrs training, seriousness of the conditions, etc.) just because the patient populations are different.

So now how can you possibly explain to me why rad onc makes 2-3x what the medical oncologists (adult or pediatric) make? Are you seriously going to explain to me that board scores and AOA means that you are entitled to earn twice as much as the cancer doctor who actually performs the diagnostic workup (with pathology and radiology), interfaces with the other specialists, manages the medications/chemo/BMTs, deals with the complications (infections, renal failure, etc.), and is usually the cancer doctor who spends the most time with and bears the most emotional burden of dying cancer patients?

That's why this whole reimbursement scheme is bunk from beginning to end. I have no problem with a general surgeon making more than an internist. I have a big problem with the orthopedic surgeon making more than the general surgeon, or the rad onc making a ****-ton more than the medical/pediatric oncologists.

Pay discrepancies are not so bizarre if you take into account the principles of supply and demand. Physician pay (and indeed, all pay in general) is based not so much on the actual service provided than it is on how much people are willing to pay for a service versus how many people there are to provide said service. Primary care fields produce the highest number of graduates by far, and even though demand for them is also very high, the fact that a disproportionate number of graduates want to live in an urban, popular area drives salaries way down. Contrast that with more specialty services like dermatology or ophthalmology, which produce far fewer graduates despite still having high demand. In these cases, the supply/demand ratio is much lower, allowing these specialists to command higher salaries and higher value due to limited supply.

Now, conversely, if you specialize too far, the demand part of the equation starts to go down -- a relatively low proportion of the population develops conditions that requires the expertise of someone like a pediatric oncologist or pediatric rheumatologist (as opposed to a general oncologist). In this case, even though the supply is relatively low, the demand is also relatively low. In effect, the pediatric specialists have effectively over-specialized themselves to the point where their salaries become lower despite additional training.

I know that the perspective that many people have of medicine being a calling and salary not taking a significant role in choosing a job is present, but it just isn't realistic. It's important not to drown in the ideals of medicine when faced with the realities of society. We don't live in a fantasy world where everyone gets paid what he/she "deserves"; how else can you explain the exorbitant salaries of professional athletes/entertainers/athletic directors/etc.?

tl;dr: Nothing here that a basic class in economics couldn't answer.

 

[RadOncDoc21]

lol... so true, I got sucked into it.