ACGME would defund Radiology, Dermatology, Ortho residencies

[Textbookversion]

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.

ARE YOU COMPLETELY INCAPABLE OF READING?

My entire point is that here in the real world salaries are not set by supply and demand.

The entire thrust of my post is bemoaning the fact that rather than the salaries of physicians being set by the demand for his or her services, it is set by a committee that determines the RVU value of your work. How much do you get paid for working? Well it's mainly a product of RVUs and reimbursement per RVU.

How you can read my post and then give me a three paragraph "you should take high school econ hurr." I really cannot comprehend where you are coming from.

There is some serious dunning-kruger going on in your post because nearly everything you said is wrong, and ridiculous.

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[fizzle]

ARE YOU COMPLETELY INCAPABLE OF READING?

My entire point is that here in the real world salaries are not set by supply and demand.

The entire thrust of my post is bemoaning the fact that rather than the salaries of physicians being set by the demand for his or her services, it is set by a committee that determines the RVU value of your work. How much do you get paid for working? Well it's mainly a product of RVUs and reimbursement per RVU.

How you can read my post and then give me a three paragraph "you should take high school econ hurr." I really cannot comprehend where you are coming from.

There is some serious dunning-kruger going on in your post because nearly everything you said is wrong, and ridiculous.

There are many more factors that go into a physician's salary than RVUs set by a committee. Your post does not even attempt to prove anything and provides nothing but your assertion that a committee's determination of RVUs is the be-all, end-all of every physician's salary.

I do not understand why you are trying so hard to put me down despite your own negligible contributions to this thread on this matter. Dunning-Kruger, indeed. But I don't like arguing with you over the internet, so I'm bowing out of this thread.

 

[Neuronix]

I'm bowing out of this thread.

Thank you. I agree that your post was completely incorrect.

 

[Noegrus]

What this thread has turned into:

 

[reno911]

ARE YOU COMPLETELY INCAPABLE OF READING?

My entire point is that here in the real world salaries are not set by supply and demand.

The entire thrust of my post is bemoaning the fact that rather than the salaries of physicians being set by the demand for his or her services, it is set by a committee that determines the RVU value of your work. How much do you get paid for working? Well it's mainly a product of RVUs and reimbursement per RVU.

How you can read my post and then give me a three paragraph "you should take high school econ hurr." I really cannot comprehend where you are coming from.

There is some serious dunning-kruger going on in your post because nearly everything you said is wrong, and ridiculous.

There were problems with fizzle's post and yours, but I think fizzle's was closer to the truth. It is true that we have a very regulated medical marketplace, but that doesn't mean that supply and demand are not huge factors. They still are very important. Of course, in our market the outcomes we get with regard to physician reimbursement are not the same as what we would get in a completely free market. However that doesn't change the fact that many of the supply and demand factors that were mentioned have a huge impact.

To completely dismiss the effects of supply and demand as you do is flat out wrong. To convince yourself of this just consider the following: Let's say procedure A and procedure B both are equally complex and are reimbursed at the same high rate. Imagine that procedure A is used to treat a fairly common condition and procedure B is used to treat an uncommon one. Now let's say that Doctor A specializes in procedure A and Doctor B specializes in procedure B. Who do you think will make more money? Why? Was it because the medicare was reimbursing arbitrarily or was it because of something else?

Obviously, the above example is overly simplified, but is should be sufficient to convince you that supply and demand will always play a significant role in physician compensation.

 

[Silent Cool]

Rad Onc used to be non-competitive, filled mostly with FMGs and bottom-feeders.

Then their incomes skyrocketed and every AOA/260+ student became passionate about treating cancer with radiation.

Just sayin'.

 

[mercaptovizadeh]

Rad Onc used to be non-competitive, filled mostly with FMGs and bottom-feeders.

Then their incomes skyrocketed and every AOA/260+ student became passionate about treating cancer with radiation.

Just sayin'.

PM&R should pull the same stunt, and soon.

 

[mercaptovizadeh]

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.

That's a good joke. The salaries I see for rad onc are more like $400-600K. That's 2-3 times what the internist makes and generally 2 times what the medical subspecialist makes.

The analogy you made of midlevel:MD = internist:rad-onc indicates what a poor understanding you have of things, and how arrogant you've become.

I am educated enough to know what rad oncs do. I know a bit of physics (majored in it in college), I've worked extensively with radiation in the lab (both irradiating animals and handling radioactive substances), and my "stats" are good enough to get into rad onc. I have no interest in the specialty whatsoever. But it's not because of ignorance or inability, as you suppose. It's because I don't care to work nail salon hours with patients who are living and dying with cancer while earning 2x what the doctor who handles those patients from diagnosis to deathbed is earning. Just doesn't seem right. But then again, I guess that must highlight my midlevel mentality.

 

[Neuronix]

Rad Onc used to be non-competitive, filled mostly with FMGs and bottom-feeders.

Then their incomes skyrocketed and every AOA/260+ student became passionate about treating cancer with radiation.

Just sayin'.

That is a gross oversimplification. Advances in technology have dramatically expanded the role of radiation in curing cancer. The treatments have become much more modern with higher doses and less toxicity. Further, 3D/4D, inverse, and other routine planning techniques are just really cool for the technology minded medical school graduate. I doubt I would have considered the field 20 years ago.

Similar things can be said for radiology. Like radiology, it is hard to detangle the rise in modern imaging techniques (which treatment planning is very related to) with the rise in salary.

I always tell medical students to do what they love. I make $48,000/year as a resident, but I love what I do. I'm involved with research, patients (mostly curative), and the clinical practice is amazingly cool to me as I have a physics PhD and a computer programming background. I came to medical school to make an impact on life threatening disease through clinic and serious research, and that is what I do. Every day I read, interpret, apply, and work on new literature for patients. And I'm only PGY-2! At 31 as an MD/PhD it`s nice to be the equivalent of a consultant/fellow. But it certainly isn't for everyone.

 

[Jessipeds]

I would rather derm, rads, etc residents get paid. But I would also rather they keep open the slots as unfunded positions than eliminate the positions altogether. We need these doctors, but the 1997 budget freeze on total residency slots prevent us from increasing primary care residency slots without cutting specialty slots... Enter mid levels.

This is really really bad. Primary care really is at a crisis. Once again, our predecessors are screwing us.

If they can't fund it on the federal level, states, county, and local communities (businesses and non-profits) need to step up and pay for resident and medical education for all doctors.

It's so sad. I listen to all these doctors support cutting "entitlement" (which in federal budget terms includes defense, social security, Medicare and Medicaid)... But do they realize that if you cut Medicare/Medicaid that you cut medical education and residency training?

Agree with this. Even if derm and ortho residencies were unfunded and unpaid, they would still be wildly popular and there would still be no shortage of applicants applying. Case in point, DO derm residencies do not pay their residents anything and the competition is still off-the-charts to get into a DO derm residency. People know that they will make a great salary practicing derm so they are willing to sacrifice a paycheck for a few years for the pay-off in the end.

 

[Law2Doc]

Agree with this. Even if derm and ortho residencies were unfunded and unpaid, they would still be wildly popular and there would still be no shortage of applicants applying. Case in point, DO derm residencies do not pay their residents anything and the competition is still off-the-charts to get into a DO derm residency. People know that they will make a great salary practicing derm so they are willing to sacrifice a paycheck for a few years for the pay-off in the end.

Ortho residency us twice as many years as derm (and probably twice as many hours per year). While I can see people roughing it a year or two or maybe even three for a chance at a good salary, particularly in a field where you have time to moonlight during your training, i seriously doubt the number of people than can go twice that long without pay is significant.

 

[badasshairday]

This thread is pathetic. We are destroying ourselves with this divisiveness. I can't believe people advocating for lower salaries for some and that it would be OK if some specialties had unfunded residencies. You can advocate for your specialty without destroying another. What a childish thread. Makes me wish I never choose this self destructive profession.

 

[Law2Doc]

...You can advocate for your specialty without destroying another. What a childish thread. Makes me wish I never choose this self destructive profession.

you realize this divisiveness isn't from SDN, but from the head of the ACGME, who did in fact suggest that we should be robbing Peter to pay Paul because Peter has it too good. And I suspect a lot of folks later in their training don't see it as all that disadvantageous to them personally to knock out the bridge after they are more or less across.

 

[syoung]

I probably don't know much about this...and this is probably all very simplified

If the Health care costs of the US is 2.6 trillion (http://www.kaiseredu.org/Issue-Modules/US-Health-Care-Costs/Background-Brief.aspx) in 2010, expenditures and multiply by 20% that's spent on physician salaries... and we divide it by the number of physicians in America. (950,000) (http://www.ama-assn.org/ama/pub/abo...tatistics/total-physicians-raceethnicity.page) to get the rough rough average salary per physician. Obviously does not take into account differences in specialties etc.
2,600,000,000,000 * .2 / 950,000 = 540,000.

So while http://www.forbes.com/sites/peterubel/2012/08/21/its-physician-pay-stupid/ this guy claims so many of physicians are getting paid too much... hospital care is 31% of that 2.6 trillion cost. Interestingly enough 1% is government administration and 6% is NET health insurance cost (I shudder what the gross is).

There's also the Time article on healthcare costs in the hospital (ie hospital bills). What do you think about asking those non-profit hospitals to help the resident pay?

 

[syoung]

Who does the estimating? Or doesn't that depend on how you choose to break down what part of the cost goes towards that physician vs health care vs hospital...?

 

[Raryn]

I probably don't know much about this...and this is probably all very simplified

If the Health care costs of the US is 2.6 trillion (http://www.kaiseredu.org/Issue-Modules/US-Health-Care-Costs/Background-Brief.aspx) in 2010, expenditures and multiply by 20% that's spent on physician salaries... and we divide it by the number of physicians in America. (950,000) (http://www.ama-assn.org/ama/pub/abo...tatistics/total-physicians-raceethnicity.page) to get the rough rough average salary per physician. Obviously does not take into account differences in specialties etc.
2,600,000,000,000 * .2 / 950,000 = 540,000.

So while http://www.forbes.com/sites/peterubel/2012/08/21/its-physician-pay-stupid/ this guy claims so many of physicians are getting paid too much... hospital care is 31% of that 2.6 trillion cost. Interestingly enough 1% is government administration and 6% is NET health insurance cost (I shudder what the gross is).

There's also the Time article on healthcare costs in the hospital (ie hospital bills). What do you think about asking those non-profit hospitals to help the resident pay?

Physician fees make up 20% of the amount, but physician salary is gross fee revenue minus overhead. Overhead includes the rent for the building, the pay for any professionals you employ, your malpractice insurance, etc, and on average is approximately half of the fees.

Extend the calculation and that mean your estimate would be about $270k, which is probably close to right for an overall average for physician pay in the US. Give or take.

 

[badasshairday]

you realize this divisiveness isn't from SDN, but from the head of the ACGME, who did in fact suggest that we should be robbing Peter to pay Paul because Peter has it too good. And I suspect a lot of folks later in their training don't see it as all that disadvantageous to them personally to knock out the bridge after they are more or less across.

I do realize this. That is what makes it worse. Our own ACGME, which should (or at least I would think they should) be looking out for residents are the ones who are suggesting this.

 

[michaelrack]

If the Health care costs of the US is 2.6 trillion (http://www.kaiseredu.org/Issue-Modules/US-Health-Care-Costs/Background-Brief.aspx) in 2010, expenditures and multiply by 20% that's spent on physician salaries... and we divide it by the number of physicians in America. (950,000) (http://www.ama-assn.org/ama/pub/abo...tatistics/total-physicians-raceethnicity.page) to get the rough rough average salary per physician. Obviously does not take into account differences in specialties etc.
2,600,000,000,000 * .2 / 950,000 = 540,000.
?

My understanding is that the 20% figure is payments to docs, about 1/2 of which goes to overhead (such as paying office staff). Using the rest of your figures, that would equal an average salary of 270k

 

[Silent Cool]

That is a gross oversimplification. Advances in technology have dramatically expanded the role of radiation in curing cancer. The treatments have become much more modern with higher doses and less toxicity. Further, 3D/4D, inverse, and other routine planning techniques are just really cool for the technology minded medical school graduate. I doubt I would have considered the field 20 years ago.

Similar things can be said for radiology. Like radiology, it is hard to detangle the rise in modern imaging techniques (which treatment planning is very related to) with the rise in salary.

I always tell medical students to do what they love. I make $48,000/year as a resident, but I love what I do. I'm involved with research, patients (mostly curative), and the clinical practice is amazingly cool to me as I have a physics PhD and a computer programming background. I came to medical school to make an impact on life threatening disease through clinic and serious research, and that is what I do. Every day I read, interpret, apply, and work on new literature for patients. And I'm only PGY-2! At 31 as an MD/PhD it`s nice to be the equivalent of a consultant/fellow. But it certainly isn't for everyone.

Right, but what drove increased medical student interest fundamentally was money. Let's not kid ourselves, here.

Before the imaging boom that happened in the late 90's/early 2000's, Radiology was practically non-competitive. 100's of slots went unfilled each year. Their incomes weren't at the top of the heap. Fast-forward a few years and grads are coming out with immediate partnerships and 500K incomes from day one. The subsequent increase in, uh, "interest" is not at all surprising.

Yes, it is technology that drove demand and as technology has improved these fields have become more dynamic. But let's be honest--again--medical students tend to follow the money. I think that's pretty clear.

 

[Silent Cool]

This thread is pathetic. We are destroying ourselves with this divisiveness. I can't believe people advocating for lower salaries for some and that it would be OK if some specialties had unfunded residencies. You can advocate for your specialty without destroying another. What a childish thread. Makes me wish I never choose this self destructive profession.

Badass,

Do you really feel this way or are you just a bit ticked/stressed at the moment?

thanx

 

[Silent Cool]

That is a gross oversimplification. Advances in technology have dramatically expanded the role of radiation in curing cancer. The treatments have become much more modern with higher doses and less toxicity. Further, 3D/4D, inverse, and other routine planning techniques are just really cool for the technology minded medical school graduate. I doubt I would have considered the field 20 years ago.

Similar things can be said for radiology. Like radiology, it is hard to detangle the rise in modern imaging techniques (which treatment planning is very related to) with the rise in salary.

I always tell medical students to do what they love. I make $48,000/year as a resident, but I love what I do. I'm involved with research, patients (mostly curative), and the clinical practice is amazingly cool to me as I have a physics PhD and a computer programming background. I came to medical school to make an impact on life threatening disease through clinic and serious research, and that is what I do. Every day I read, interpret, apply, and work on new literature for patients. And I'm only PGY-2! At 31 as an MD/PhD it`s nice to be the equivalent of a consultant/fellow. But it certainly isn't for everyone.

Neuronix,

You are clearly a committed, intellectually-driven person and for that I have undying respect. I would argue, however, that many people entering these higher-paying fields are not. They are more interested in $$$. It is nice to see someone like you who is driven to advancing medicine and who clearly has the intellectual minerals to do so. My hat's off.

 

[Neuronix]

I would argue, however, that many people entering these higher-paying fields are not. They are more interested in $$$.

I agree with you. Some medical students are just looking for the best lifestyle and payout. I honestly don't blame them for that. If you go through medical school liking (or equally disliking) a number of specialties, picking based on which one has the best reimbursement and lifestyle seems reasonable to me. This is especially true when you're sitting on 200k+ worth of loans. Though the applicants who tell me "I'm trying to decide between rad onc and derm" drive me a little crazy. Really???

No, I take issue with program directors. Many are looking for the residents who will be easiest to train, most committed to their clinic (i.e. churning patients), and give them and the staff the least amount of difficulty. Those medical students truly committed to research/academics often have difficulties with having the highest step 1 score, best clinical grades, and best residency performance because they are split between clinic and lab. As a result, MD/PhDs have a negative reputation out there with programs. It can be difficult for them to get the positions at the top residency programs, many of which consider it an imposition to even match more than one research interested resident a year.

If it were up to me, I would pick the most academically oriented and most talented in research or other related disciplines (public health, etc) who aren't a total disaster clinically. Those residents who can walk into the program and start plugging data into my multivariate analyses, run a good western blot, or are involved with public policy from before. These are the people most likely to go on to have a serious academic career. Unfortunately, they often never get by the step 1 filter... Even interviews tend to be more of a screen for personality.

That said, research funding is so bad these days that most MD/PhDs are not continuing on a serious research path. That is generally what the programs will tell you. IGBO: I Got Burned Once on this awesome looking MD/PhD who went into private practice.

So in the end, as long as program directors are mostly clinical people who don't really understand or care about serious research, and need cheap labor to fill their program, specialties will be competitive based on step 1 scores and AOA. Because what do those things tell you... Step 1 equals least likely to fail boards, and AOA equals most likely to get along with everyone. Who is going to be the best physician? Eh. There's no test for that.

As long as the reimbursement is highest in certain specialties, the highest step 1s and AOAs and whatever is competitive this year will be there. The ones who don't have those scores will convince themselves they loved something else and never consider things they weren't competitive for. They'll then defend their own specialty to the death because it's easier to fall in love with a specialty than wish for something you could never have. And the cycle continues...