Highest Paid Specialty, Historically, and for the future...

[chessgirl]

Orthoman,

I'm sorry to see such biases build up so early in your education.

Never let a paraprofessional make important clinical decisions for you. The burden is on your shoulders, and unless you have the utmost trust in their judgement you make the decision."

This is excellent advice, unfortunately, it should include all professionals. The mistake could have just have easily been make by another staff member, resident, intern, medical student, etc. It was a math error, not a "paraprofessional" error. You should be careful about the things that are ultimately your responsibility, but stereotyping leads to fuzzy thinking.

As to the importance of the comment, I have to disagree. Anecdotal incidents are always the opinions of the instructor, not endorsed by the university/college. That professor obviously had bad experiences with mid-level practioners and/or has his own biases about the profession that he is trying to impress upon you. (The valuable take home message from his anecdote is: do your own job thoroughly, and do it well) Since no one in that room was there to witness the event, except the instructor, or can attest to the character and workmanship of the people involved, you have to take it with a grain of salt. Make up your own mind about the variety of people that you will eventually work with. Don't let yourself be led by the nose.

As for my "future" of medicine prediction, after re-reading it, I realize that my projection is for at least 40-50+ yrs down the road. Much longer than most here are discussing.

---

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[Kimya]

Here's another perspective-far out there, but food for thought.

Medicine has traditionally been a very hierachical field. You either became a doctor right out of college or not at all. Other health care professionals would not usually have the chance to apply to medical school.

However, these days the lines are beginning to blur. If, as some of the (sounds like surgical residents) are saying, what really makes a surgeon is the residency, then what's stopping different points of entry into a similar sort of intense program? Yes, yes I know that current residencies are only available for allopathic/osteopathic MD's. If a PA has been working for several years in surgery, then why not provide a specialized training program for them to advance their knowledge instead of going back all the way from scratch for four years of medical school? This could include advanced coursework as well. It could include horrendous hours as well. What I'm saying is surgeon does not necessarlly have to equal four years of medical school plus 5 years of residency plus etc.

I agree with some of the other posters about the dedication needed to be an excellent surgeon. However, I could see in the future that the path to get there (and get the reimbursements) might change. I can't think of any other field that requires the sort of time committment that becoming a doctor does, and I think that was because doctors used to have a monopoly on practicing medicine (eg prescribing medications, etc). The whole medical school process is geared towards someone straight out of school with absolutely no work experience or training in the field. Could there be different paths to become a competent practitioner?

Flame away...

 

[Andrew_Doan]

Originally posted by Kimya
Here's another perspective-far out there, but food for thought.

Medicine has traditionally been a very hierachical field. You either became a doctor right out of college or not at all. Other health care professionals would not usually have the chance to apply to medical school.

However, these days the lines are beginning to blur. If, as some of the (sounds like surgical residents) are saying, what really makes a surgeon is the residency, then what's stopping different points of entry into a similar sort of intense program? Yes, yes I know that current residencies are only available for allopathic/osteopathic MD's. If a PA has been working for several years in surgery, then why not provide a specialized training program for them to advance their knowledge instead of going back all the way from scratch for four years of medical school? This could include advanced coursework as well. It could include horrendous hours as well. What I'm saying is surgeon does not necessarlly have to equal four years of medical school plus 5 years of residency plus etc.

I agree with some of the other posters about the dedication needed to be an excellent surgeon. However, I could see in the future that the path to get there (and get the reimbursements) might change. I can't think of any other field that requires the sort of time committment that becoming a doctor does, and I think that was because doctors used to have a monopoly on practicing medicine (eg prescribing medications, etc). The whole medical school process is geared towards someone straight out of school with absolutely no work experience or training in the field. Could there be different paths to become a competent practitioner?

Flame away...

No Flame here. I think the biggest problem is the advanced training. There's the problem of certification and setting standards for advanced training for PAs and Nurses. Currently, medical residencies are monitored by the ACGME. I am not sure if programs can increase their numbers without diluting the training of their current residents. The ACGME carefully regulates the number of residents at each institution and set guidelines that MUST BE MET. There's only a limited number of surgical cases at a hospital. If PAs are given surgical cases within a dedicated training program, then this may jeopardize the training of current surgical residents and fellows.

If PAs are to be trained through a formal graduate program, then many changes must occur and approval must be given by several strong regulating entities.

 

[AviatorDoc]

Just a thought...

The "residency" training wouldn't necessarily have to be ACGME-approved, at least initially. They could possibly develop their own separate programs. Then they could fight the medical establishment (ACGME/AOA) to show that they are equivalent, much as the DOs have done (and are still trying to do) with their residencies.

The road would be long & arduous, and probably start in very rural hospitals.

 

[droliver]

Wow! I remember when you had to go to medical school to be a doctor

 

[Andrew_Doan]

Originally posted by AviatorDoc
Just a thought...

The "residency" training wouldn't necessarily have to be ACGME-approved, at least initially. They could possibly develop their own separate programs. Then they could fight the medical establishment (ACGME/AOA) to show that they are equivalent, much as the DOs have done (and are still trying to do) with their residencies.

The road would be long & arduous, and probably start in very rural hospitals.

Good luck finding an insurance entity and the surgeons (a.k.a. MDs and DOs) to support this plan to train PAs surgically in a non-ACGME, non-AMA endorsed program.

 

[AviatorDoc]

Agreed, in this insurance mayhem in which we live, the process would be difficult, but who knows?

 

[Docgeorge]

sorry to get off topic for a sec, but I've been wondering what has stopped physicians form unionizing to preserve their art and ensure fair barganing when it comes to compensation. I mean uneducated (no I'm not implying that dock workers are stupid *****s) dock workers here on the west coast can make upwards of 70,000 why cant physicians unionize and protect their turf from encroachment?

 

[Andrew_Doan]

Originally posted by Docgeorge
sorry to get off topic for a sec, but I've been wondering what has stopped physicians form unionizing to preserve their art and ensure fair barganing when it comes to compensation. I mean uneducated (no I'm not implying that dock workers are stupid *****s) dock workers here on the west coast can make upwards of 70,000 why cant physicians unionize and protect their turf from encroachment?

I may be wrong, but physicians can't unionize because it'll be a monopoly and we'll set prices/compensation. I'm not completely sure on this.

 

[AviatorDoc]

As I understand it, in France, the physicians have actually gone on strike on at least one occasion in the past year or two. They refuse to see pts for all but life-threatening conditions. They also make rounds with their admissions, but that's it. The reason is that managed care has driven the average salary of a physician down to $70,000 /yr. (That's before taxes, insurance, staff expenses, etc.)

I'm not saying that would fly here in America. Just an interesting note.

 

[BellKicker]

Doctors go on strike here (Denmark; small country you've never heard of) all the time. We have to uphold something called a "minimal staff" while on strike.

It hasn't helped us money-wise, though. In a country where minimum wage is 13 dollars/h doctors top out at 100 - 120 K, regardless of specialty (except in a few lucrative private practices).

Later.

 

[Ligament]

Well, over 100 posts and 11,000 views and nobody has answered my questions yet. Have you even read my questions?

regards, Ligament

 

[AviatorDoc]

A guy named Iserson from UofA came to our school to give a little talk last year. He passed out a book on medical careers, but I can't find it offhand.

(Where did I put it?)

Anyway, it will give you the best idea of historically well-paid specialties. I like Dr. Iserson b/c he admits that finances do play a role in shaping a medical career. It even gives a little of the speculative data that you are searching for.

(What did I do with that thing?)

 

[qccbbq]

I though I read a book a couple of years back ("Hospital") which said that Cook Country staff docs are Unionized.

 

[ckent]

Originally posted by Ophtho_MudPhud
I may be wrong, but physicians can't unionize because it'll be a monopoly and we'll set prices/compensation. I'm not completely sure on this.

Doctors in private practice cannot unionize with each other to negotiate with insurance companies because it would violate anti-trust laws by allowing competeting companies (physicians) to "price fix". There was some interest in getting legislation to exempt physician from such laws, and some states have allowed select numbers of physicians to unionize without prosecuting them, but with all of the other things going on in the world of health care legislation, this issue has been ignored lately. Physicians who are all employees of the same hospital are allowed to unionize, but this doesn't give physicians nearly enough bargaining power to go against insurance companies, it only protects them from the hospital.

 

[ljube_02]

Originally posted by BellKicker
Doctors go on strike here (Denmark; small country you've never heard of) all the time. We have to uphold something called a "minimal staff" while on strike.

It hasn't helped us money-wise, though. In a country where minimum wage is 13 dollars/h doctors top out at 100 - 120 K, regardless of specialty (except in a few lucrative private practices).

Later.

100-120k does not seem bad if your college is free and you work 30hrs/wk?
$13/hr min wage? I wonder if cost of living is higher in demmark than usa?

 

[Tenesma]

well not only is the cost of living higher there - but the tax rate is ridiculously high... so if they are making 100-120k then their take=home pay is 50 to 60k at best...

 

[BellKicker]

Originally posted by ljube_02
100-120k does not seem bad if your college is free and you work 30hrs/wk?
$13/hr min wage? I wonder if cost of living is higher in demmark than usa?

OK now, 30 hours is a bit on the low side. 37 hours is the norm, although, one might end up working only 30 hours because night shifts count double.

Yup, taxes are real bad. 50-60K take home is about right! But (speaking like a socialist, which I'm not) it's not money that's totally lost. You get many things for free here, world class schools for free being one of them. Hey, we even have 25% sales tax on lots of things and 180% sales tax on cars! I think we have the second highest taxes in the world after Sweden (damn Swedes, have to beat us at everything).

Later.

 

[AviatorDoc]

You have to pay 3x the sticker price on a car ?!?!? Do poor people drive cars in denmark?

 

[BellKicker]

Originally posted by AviatorDoc
You have to pay 3x the sticker price on a car ?!?!? Do poor people drive cars in denmark?

Ha, lots of people don't own cars, not just poor people. I'd say that in the cities the majority don't have cars whereas out in the country most people have them. 2,8 times sticker price makes you think twice before buying

That's semi-socialism for 'ya.

 

[Sandpaper]

So the net pay in Denmark is 50% of gross. Same here in the States if you make anything in the upper ranges of income, which most doctors do. 39% for Federal Tax, 5-10% for state tax and there ya have it. But the 30 hours work week is sweet and the social welfare net is nice and broad as oppose to the workaholic conditions here in the States. Sign me up.

 

[BellKicker]

Originally posted by Sandpaper
So the net pay in Denmark is 50% of gross. Same here in the States if you make anything in the upper ranges of income, which most doctors do. 39% for Federal Tax, 5-10% for state tax and there ya have it. But the 30 hours work week is sweet and the social welfare net is nice and broad as oppose to the workaholic conditions here in the States. Sign me up.

Sandpaper, first off I'm surprised your taxes are that high. I didn't know that.

Our taxes work like this: If you make 20,000 dollars a year you probably pay 30% in taxes. If you make 100,000 you pay a little more than 50% (maybe close to 60%, I'm not sure). For every dollar after 60,000 a year you pay 68%. And don't forget the 25% sales tax.

So since most doctors make more than 60,000, they only bring home 32 cents per "extra" dollar they make. And that only buys them 24 cents worth of goods.

And if they want a 50,000 dollar car they have to pay 130,000 dollars for it, for which they would have to earn 406,000 dollars gross.

Convinced?

 

[ljube_02]

Thanks for the info, sounds interesting.

So basically Europe or Military medicine is great unless you do high paying specialties-family medicine must be nice there!

About cars, so who in Denmark gets to drive $90k mercedes??

 

[ljube_02]

By the way its amazing that you have so little corruption. here in nyc i even prefer to buy a digital camera from some "suspicious" store paying cash, so there would be no sales tax. and the seller probably files with irs that he sold the camera for $50 instead of $500. Seems like some people might make some great money selling cars secondhand and not paying taxes, in denmark.

 

[El Duderino]

About cars, so who in Denmark gets to drive $90k mercedes??

At least in Sweden, there are two surefire ways of getting there:

1. Inherit money.
2. Start your own company and by way of 'creative accounting' procure enough means to get the car your want.

"Studying hard" and "getting a real job" are not options if you want to make a bit of money, as a recent study showed that a college education in Sweden will, on average, land you a net income increase of - brace yourself - 5%.

 

[orthoguy]

Ok ok.............who the hell cares about Sweeden........money sucks there money sucks here...............WONDERFUL

 

[7ontheline]

Moving slightly backward to respond to a previous post: Actually, the docs at Cook County Hospital in Chicago are NOT unionized. They have been forbidden by the courts to form a union. The main reason, stated simplistically, is that they are considered "managers" as opposed to just employees, in large part because they are in charge of residents. This puts them in a position to supposedly have input on the direction of the hospital. Apparently, people who work in higher positions are not allowed to unionize. However, many doctors there complain that just because they head up the residents doesn't mean they get much of a say in anything else. I would tend to agree with the docs, although I'm sure I don't have all the info on either side of the case.

 

[El Duderino]

Hey ortho, a question was asked, and I answered it. What the he-double-toothpicks is your problem?

 

[Blitzkrieg]

Originally posted by futuremd45
Dunehog,

I hate responding to imbeciles but you leave me no choice:

First of all, I am not a wallstreet washout (again you fail to see my underlying message and quickly jump to insults). I was extremely successful... I chose to pursue medicine because I wanted the opportunity to help people. The reason I did not choose PA school is bc. I wanted the greater scope and responsibility of being a medical doctor.

Second of all, medicine is a business and since my background is in business, I strongly believe I can intelligently talk about the economics of medicine (something you obviously lack, probably in most arenas of your life).

Finally, I, unlike most of you, have chosen medicine irregardless of financial concerns. I plan to practice in an academic or indigent setting, thereby limiting my financial rewards greatly.

I find it very sad that many of you can not see outside of the box when it comes to the economic trends in medicine. Trends that you do not have to be a doctor to recognize. Actually, it is probably this arrogance that pervades medicine that got doctors in this situation in the first place.

By the way, dunehog please tell us your name, future area of specialty and location, so that we may avoid your close-minded and foolish banter.

Future,

economically speaking, I take a different standpoint.

Depending on the future political dynamics, we may see a greater privatisation of the health care system, leading to greater patient choice, lower patient costs, and higher doctor reimbursements.

Honestly, this quasi-socialistic system we currently have is failing, and anyone (note: democrats, and the like) who wants to move us towards a further socialistic system is obviously not well-versed in economics. Either we will change towards more privatisation, or we will fail. Honestly, we cannot and will not fail, for the sake of the country. Therefore, I believe that eventually, they will wake up, and we will send a trend towards privatisation. Whether it be via tax breaks, medical savings accounts, or elimination of insurance regulations, it will occur. Docs will enjoy higher compensation, quality of health care will go up, and everyone will be happy.

Ah, the joy of capitalism and the free market!

 

[save10]

I have one word for this whole thread: Asinine.

 

[deleted6669]

I thought some perspective from an actual pa might help here.....there are already postgraduate 1-2 year surgical residency programs for pa's at major medical ctrs(duke, cornell, yale, hopkins, etc.) but the goal is to train better 1st assistants not to take over the surgeons job.a good pa helping with preop/postop/rounds/surgical clinic can open up more time for the primary surgeon to do more surgery or ,heaven forbid, have a life.I agree with womansurg that in order to be aware of all the potential complications, etc one must do an md level surgical residency. there is no way around that.pa's in the future will probably be doing more procedures, especially outpatient procedures that do not require general anesthesia but I don't see pa's ever working solo in the or.in nonsurgical settings(primary care especially) I think pa's will take on larger responsibilities especially in hmo's and rural settings where they already work as primary providers.

 

[Sanman]

Just finished reading the thread, whew! that took a long time! Anyhow, as far as PA's/NP's go, I don't believe they are going anywhere. They will continue to be what they are, midlevel practitioners. Will they gain more rights? probably. Though they will never replace doctors if there is a need, they could fill it. Is it the best standard of care? no. However, If there ever comes a time when there aren't enough general surgeons to staff a hospital, properly trained mid-level practioners may save some lives compared to no surgeon. I do believe that they will be sole providers on areas that are without medical care. As far as what would happen if something went wrong and a doctor was not there to save the patient...he/she would die. As far as legality, the medical field can getaway with murder, literally. The fact that no one is allowed in the room and unaware of the facts allows this. Otherwise, lawyers would probably sew everytime a mistake was made by a resident of student. Example, A supervisor at my moms lab admitted to a patient's relative( a personal friend) that a micro biology technician misdianosed her child's culture and therefore the child died. The family sued the hospital, the hospital scolded the supervisor, who was shortly thereafter let go. The fact is medicine is a hush hush world and incompetence is often hidden. I personally, would not allow anybody..including doctors, that I personally know of operate on me if I had a choice. Luckily, I come from a very medical family and have that option. While doctor's are correct in assuming that pa's and np's aren't necessarily qualified to do some jobs w/out proper training, it is naive to think that the accountants fill not allow it if the math is in their favor. This is why it is very important to know who is doing what. Another example, numerous well- known surgery programs being shut down because they are not following the law. Just look at all the major New York hospitals ignoring the Bell laws and paying the fine because it is cheaper. I wouldn't want a surgucal resident on his/her 20th hour to operate on me as much as I wouldn't want a pa to. I believe that until the public wises up, nothing will be done. As far as dcw is concerned, I believe hat his thoughts have more to do with the need to restructure medical education to have more relvance to later career goals. I read that UCLA and some other schools are doing just that. The future of medicine as a whole will have its cyclical ups and downs just like any other business, but I doubt it will return to the way it was before managed care because medicine will continue to be seen as a business and physicians will need to take appropriate to ensure their financial security . However, a physician with a savy business sense and a good niche market will always do well. After all this, I'd like to point out that as far as formal education is concerned, I am completely UNqualified to speak on any of these issues, however I do take a keen interest in such a discussion as future earnings have more relevance to myself, being a college student and all.

 

[PCAndrew]

This is by far the best discussion I've read on SDN. First time I've posted in more than a year.

1st) Physicians ARE becoming outdated. We are (generally) too expensive, our job can be done 95% as well for 40% of the price. Yes, exceptional cases still require exceptional care, but they incur exceptional costs and consequentially, will happen less and less.

2nd) For whatever reason, no one has mentioned decision support and computerized medicine. One of the reasons that NP/PAs have made such inroads into domains traditionally held by physicians is they adapted better to new technologies. Here's a fact: If you are not using computer support in your patient care in 10 years, regardless of what you do, you will be providing worse care than a newly-minted NP/PA.

3rd) Physicians doing procedures have a longer future than the rest of us, but even their end is not only sure, but visible on the horizon.

4th) The reason it hasn't happened already is two fold. First: Third party payers. No one knows what care costs, so everyone wants the very best care. There is no consequence associated with getting the very best, consequentially we spend 18% of our GDP (nearly 2 TRILLION) on care. And growing. Insurers insulate patients from the realities of their own care.

Second, the AMA and other organizations have worked very, very hard to make sure the reimbursement system remains more or less unchanged. And the reason physicians have not unionized is because that is, more or less, the function of the AMA. It's a union without all the polarizing baggage of the United Workers of the World.

5th) The original question still hasn't been satisfactorily answered: what specialties will pay the best in 5-10 years? (a) I'm considering ophtho: good money, abundant procedures. I have an attending who observed "I make my career around fixing the mistakes of others, consequentially, I have never had any fear of future obsolescence." Good stuff. (b) Also considering geriatrics: everyone is getting old, the science is terrible in the field, and there's still a real need for people to use their judgment rather than a computer's diagnostic and treatment algorithm.

 

[deleted109597]

This is by far the best discussion I've read on SDN. First time I've posted in more than a year.

1st) Physicians ARE becoming outdated. We are (generally) too expensive, our job can be done 95% as well for 40% of the price. Yes, exceptional cases still require exceptional care, but they incur exceptional costs and consequentially, will happen less and less.

Yeah, and in 20 years, computers will be able to do greater than 95% of what NP/PAs can do by simply using algorithms based on signs and symptoms. People adapt, and move on.

2nd) For whatever reason, no one has mentioned decision support and computerized medicine. One of the reasons that NP/PAs have made such inroads into domains traditionally held by physicians is they adapted better to new technologies. Here's a fact: If you are not using computer support in your patient care in 10 years, regardless of what you do, you will be providing worse care than a newly-minted NP/PA.

Whatever they fed you at school you bought hook, line, and sinker. New grads of all schools are using computers. It's not like medical school abhors them or anything. Old docs, just like old PAs, just don't like them. They will be forced to adapt sooner or later anyway, because it is likely Medicare won't let you get by without it.

3rd) Physicians doing procedures have a longer future than the rest of us, but even their end is not only sure, but visible on the horizon.

To be replaced by whom?

4th) The reason it hasn't happened already is two fold. First: Third party payers. No one knows what care costs, so everyone wants the very best care. There is no consequence associated with getting the very best, consequentially we spend 18% of our GDP (nearly 2 TRILLION) on care. And growing. Insurers insulate patients from the realities of their own care.


Second, the AMA and other organizations have worked very, very hard to make sure the reimbursement system remains more or less unchanged. And the reason physicians have not unionized is because that is, more or less, the function of the AMA. It's a union without all the polarizing baggage of the United Workers of the World.

You left out the fact that there are some strong physician lobbies dedicated to preventing NP/PAs (and on another note, chiropractors and psychologists) from acting in roles they aren't trained in, not for the reimbursement system. But maybe you don't see it that way, and instead consider it "the man" keeping them down.

5th) The original question still hasn't been satisfactorily answered: what specialties will pay the best in 5-10 years? (a) I'm considering ophtho: good money, abundant procedures. I have an attending who observed "I make my career around fixing the mistakes of others, consequentially, I have never had any fear of future obsolescence." Good stuff. (b) Also considering geriatrics: everyone is getting old, the science is terrible in the field, and there's still a real need for people to use their judgment rather than a computer's diagnostic and treatment algorithm.

If we all had crystal balls, this question would make sense. But this question on this board is like asking the pre-meds what the best medical school is. You will get a myriad of opinions that only serve to qualify the decisions of the people who made them. Besides, it's not like we are stuck doing one job for the rest of our lives.

 

[Winged Scapula]

Way to resurrect a FOUR and a half year old thread!

I cannot fathom that the public will accept physician extenders doing their surgeries. As for physicians being phased out in these fields, at least in our lifetimes, I fail to see that most surgical diseases will be treated medically.

With regard to career choices, my friends who have completed geriatric fellowships would have a good laugh at that choice as one made for "high paying". Stick with Ophtho.

 

[PreMedDocMD]

Duplicate...oops.

 

[PreMedDocMD]

Way to resurrect a FOUR and a half year old thread!

I cannot fathom that the public will accept physician extenders doing their surgeries. As for physicians being phased out in these fields, at least in our lifetimes, I fail to see that most surgical diseases will be treated medically.

With regard to career choices, my friends who have completed geriatric fellowships would have a good laugh at that choice as one made for "high paying". Stick with Ophtho.

Whoa, this thread IS popular...I think you are the first one to say that in our lifetime, (lets say 50 years) surgeons won't be replaced. But, do you think surgeons (again, in the next 50 years) will still be making $200,000+ (current money, not including the increase of pay from inflation).

 

[PreMedDocMD]

Oh, I forgot to include my little story. When I went to the ER a little while ago, I didn't even talk to an EM doc once . The person that ordered the morphine was a PA, and a nurse administered it. Hmm...

 

[JR]

I'm considering ophtho: good money, abundant procedures. I have an attending who observed "I make my career around fixing the mistakes of others, consequentially, I have never had any fear of future obsolescence." Good stuff.

You'll make good money in ophtho, but don't consider it being high-paying. Back in the 80's cataract surgery used to pay $3200 per eye. Guess how much it pays now- $650! And that's not the end, there is a proposed global 5% Medicare cut in 2007 with a goal of cutting over 20% within 5 years. Highest paid ophtho sub-specialty is retina, but you generally give up your ophthalmology lifestyle (not true in all cases). Oh yeah, and there is that never ending optometry/ophthalmology issue. Lastly, refractive guys used to make bank a while ago when demand/supply ratio was really high, now things have leveled off and only a few people are able to sustain a practice doing just refractive. It's not all that bad, however, baby boomers are getting older and I think there will be plenty of cataracts to go around.

 

[me454555]

A few points people seem to be forgetting

1) People aren't like boots or ****s - if you get a bad boot or a bad shirt, you toss it out and buy a new one. No need to get custom made boots or shirts just cause you get one that doesn't fit quite right. The same can't be said about people. What happens in an NP/PA misses an MI that an ER doc woulda caught? What happens when that PA or NP clips the wrong vessel when a well trained surgereon woulda avoided it? You can't just say oops and return the procedure to be redone by someone else. I'm getting lasicks soon and I'm certainly not shopping for the lowest price. Even though they're all done by docs, I'm gonna make sure to get some recommendations b/c 1 screw up is 1 too many for me

2) Medical School - too many people are focusing on the useless crap we have to memorize during medical school. Any doc will tell you that most of what we learned in medical is now obsolete or they just don't use. A doc is really made in residency when they have to spend years focusing on one aspect of medicine. So what's the point of medical school? It's kinda like a sampling of all that's needed in medicine. Ask the average entering MS1 what they want to go into and then check on that same student when they match and you will find many different answers. Getting the necessary exposure to various fields, even if the knowledge is not used, is still an important aspect of medical training.

3) While the exact numbers may not matters, passing the steps does - Why not let PAs enter directly into residency? They haven't passed step I or II and prollly won't pass step III after. Whoever said that a high step score does not make a good doc is exactly right, it doesn't. However, a failing step score would certainly make for a bad doc. And thats the important point. The minimum level of competancy to get into residency is much more important than the maximum level achieved. If a PA/NP could pass the first 2 steps, and then gathered the necessarry clinical expericence to apply for a residency position then they should go ahead and do it. Of course that process of accumulating knowledge and getting experience is called medical so that brings us back to why we need to go through it.

4) If you want to continue to compare docs pay to pa's pay in the future, docs will always earn a higher salary for one simple reason. Why would anyone pay money for a PA if you could higher a doc for a similar price? In the scenerio that people are predicting, PAs take over a doc's job and we're out of work or making significantly less. What people fail to take into account is that PAs/NPs salary's and docs salaries are connected. If our salaries fall by 30% you can predict a similar drop in salaries for PAs. Again, no one wants this.

 

[dilated]

Why would anyone pay money for a PA if you could higher a doc for a similar price? In the scenerio that people are predicting, PAs take over a doc's job and we're out of work or making significantly less. What people fail to take into account is that PAs/NPs salary's and docs salaries are connected. If our salaries fall by 30% you can predict a similar drop in salaries for PAs. Again, no one wants this.

This is an interesting point I've never seen discussed. The high end PAs are already starting to abut the low end FP salary range. If medicare reimbursement cuts go through it's entirely possible that they'll overlap significantly. Is the result equivalent drops in PA salary or the bizarre scenario of physicians being able to earn more by taking jobs as physicians assistants?

 

[dwhatever]

(opps...just ignore this)

 

[fancypants]

In the year 3000….



Radiologists -->

Surgeons--> supercool robots

Pediatricians--> a slightly ******ed monkey with stickers and an otoscope

OBGYNs-->OBGYNs (I don’t think anybody’s dying to take over for them…it’s all yours, guys!)

Emergency med --> a machine that dispenses Dilaudid and removes FBs from rectums

Internal Medicine--> the five smartest kids at the local high school

Anesthesiologists --> CRNAs

Family Practice-->CRNAs

Pathologists-->CRNAs

Ortho-->really big CRNAs

CRNAs-->CRNAA -->CRNAAA -->CRNAAAA

Dermatologists -->Family Practice -->CRNAs--> Anesthesiologists --> PM&R-->Genetists

President of the USA-->CRNA

(I just know someone is going to take this seriously. If it makes you feel any better, I predicted that I will one day be replaced by a primate who knows how to do an ear exam.)..

 

[hans19]

I think you are the first one to say that in our lifetime, (lets say 50 years) surgeons won't be replaced.

Then let me be the second. SURGEONS WON'T BE REPLACED IN THIS LIFETIME.

-From a non-surgeon

 

[8744]

Are you crazy???

You can teach any monkey to do a surgery, just as you can teach any monkey to provide anesthesia, just as you can teach any monkey to treat diabetes... But, and here is the big BUT: it doesn't make you a doctor...

You mentioned that a PA after doing 500,1000 lap. choles could provide that service just as effectively... well no ****... anybody can do a lap chole: stick tubes in the belly, dissect gallbladder out, clip artery and duct, and voila... here is the flaw in your analysis of the problem... PAs don't have the training nor the depth of understanding. tell me what happens if the anatomy is different? tell me what happens if there is major vascular damage requiring conversion to an open case... does a PA know how to control severe hepatic bleeding, or know how to repair torn branches of the celiac? tell me, does a PA know how to manage a patient with septic cholecystitis requiring critical care in the ICU?

this is why PAs will never ever replace surgeons, why CRNAs will never replace anesthesiologists, why PAs will never replace internists, etc, why midwives will never replace OB/GYNs... in the long run the hospitals, HMOs will be unwilling to carry the burden of liability.....

just curious, do you think PAs can follow stroke protocols and replace neurologists? (since that is the field you are aspiring to?) everbody can follow cookbooks/algorithms.. that isn't why we went to medical school... advanced nurses or physician assistants will be there to provide basic care (that we have realized is safe for them to do) - and that is fine with me.

Too right, not to mention that surgeons have to know when not to operate. And deciding not to operate because the case is difficult doesn't count. They have to be as confident doing nothing as they are doing something. Of all the specialties where I would not want a midlevel, surgery has got to be number one...and I don't care how long the guy has first-assisted. He is in the role of trained monkey.

 

[hans19]

This is by far the best discussion I've read on SDN. First time I've posted in more than a year.

I have an attending who observed "I make my career around fixing the mistakes of others, consequentially, I have never had any fear of future obsolescence." Good stuff.

Revision procedures don't reimburse nearly as well as the primary procedures. If your attending isn't talking about procedures, then he's getting reimbursed even less.

Furthermore, it seems that, each person in his own specialty-centric view of the world likes to believe that their's is the most competent specialty in healthcare and are in the business of fixing others muck-ups. Seems a bit self-absorbed rather than 'good stuff'.

 

[hans19]

President of the USA-->CRNA

..

The way things are going now, might not be such a bad idea...

 

[sluggo]

This is by far the best discussion I've read on SDN. First time I've posted in more than a year.

1st) Physicians ARE becoming outdated. We are (generally) too expensive, our job can be done 95% as well for 40% of the price. Yes, exceptional cases still require exceptional care, but they incur exceptional costs and consequentially, will happen less and less.

NONSENSE: Here is a story for you: Patient goes to internist with swollen toe. x-ray shows nothing. Prescribes keflex and sends her home. No change in 1 week. Refers to ID. Bone scan shows "questionable osteo". 6 weeks IV abx. ID man insists things are getting better, but he is wrong. Toe looks the same. Patient gets fed up and goes to an old-dude rheumatologist, who probably does not own a computer. He EXAMINES the toe. Says it is "frozen" and says the abx were a waste. Pt. does fine.
Anyone who thinks clinical judgment will be replaced by computers is an idiot, and should go into computers and not medicine!

2nd) For whatever reason, no one has mentioned decision support and computerized medicine. One of the reasons that NP/PAs have made such inroads into domains traditionally held by physicians is they adapted better to new technologies. Here's a fact: If you are not using computer support in your patient care in 10 years, regardless of what you do, you will be providing worse care than a newly-minted NP/PA.

3rd) Physicians doing procedures have a longer future than the rest of us, but even their end is not only sure, but visible on the horizon.

4th) The reason it hasn't happened already is two fold. First: Third party payers. No one knows what care costs, so everyone wants the very best care. There is no consequence associated with getting the very best, consequentially we spend 18% of our GDP (nearly 2 TRILLION) on care. And growing. Insurers insulate patients from the realities of their own care.

Second, the AMA and other organizations have worked very, very hard to make sure the reimbursement system remains more or less unchanged. And the reason physicians have not unionized is because that is, more or less, the function of the AMA. It's a union without all the polarizing baggage of the United Workers of the World.

5th) The original question still hasn't been satisfactorily answered: what specialties will pay the best in 5-10 years? (a) I'm considering ophtho: good money, abundant procedures. I have an attending who observed "I make my career around fixing the mistakes of others, consequentially, I have never had any fear of future obsolescence." Good stuff. (b) Also considering geriatrics: everyone is getting old, the science is terrible in the field, and there's still a real need for people to use their judgment rather than a computer's diagnostic and treatment algorithm.

read above

 

[lowbudget]

Then let me be the second. SURGEONS WON'T BE REPLACED IN THIS LIFETIME.

-From a non-surgeon

One word: Stents

 

[NNguyenMD]

Hey all,

We all know what the highest paying specialties are now, but I am wondering what the highest paid specialties have been *historically*, over the past 20 or 30 years lets say.

Has radiology always paid so much? Has Generaly Surgery always paids so little (for the training)?

Question two: what specialties to you see making the most $$$ in the next 5 to 10 years?

I would guess rads will stay up there, but may have peaked by now. Same with anesthesia and the surgical subspecialties. I think FP and IM will see a big income boost since nobody wants to go into it now, thus creating a future "glut" I think the pay for PM&R may go up as the boomers age and subspecialties of PM&R become more prominent.

Of course I assume neurosurgery will always make the most, but those crazy bastards deserve it!

just speculations. what are your thoughts?

regards.

Regardless of whatever specialty you are in, always remember that medicine is a business, and how much you make in any field will highly depend on your business practices. In other words, the local demand for your services, what you will be able to bill for, how readily primary care providers will want to refer patients for your services. Of course there is always the option to go on salary for a hospital or a university (academics blech), in which you do make more in a procedure rich specialty, but it will almost always be less than your private practice counterparts. I like the idea of teaching residents and medstudents as the next guy, but I'm not taking a potential 50-100K paycut just so I can feel like the dude in "Stand and Deliver".

Neurosurgeon who works in the town an hour and a half south of here makes well over 7 figures, and it has less to do with how good a surgeon he is than you think (although I hear he is excellent). He amassed enough capital to purchase the only PET scanners in addition to several MRI machines in the area. Radiologists work for him, and he gets a cut of every scan he and his partners send for. He basically gets a piece of every work-up test ordered along the way of Dxing the spine and brain pathologies that run through his office, from the initial consultation visit to the pathology slide thats read intraoperatively. Just like Tony Soprano, he gets a taste of everything that goes down, and it has made him a very rich man.

Obviously, this is easier to do in a procedural subspecialty than in a non-procedural field. It is also easier to do in a relatively underserved rural community with lots of insured middle class professionals (big university is located there). However, I could imagine that even as an FP or Pediatrician, clever business practices can still make you a very wealthy physician. You just need to be able to provide a service that will make ALOT of people want to see you and your partners, and if you find yourself at the head of the pack all I can say is BUY BUY BUY. Purchasing medical equipment, office space, PA's, NP's, and young physician attendings is not all that different from the industrialist who buy factories and machines to manufacture. If you wanna be a rich doctor, then you gotta get excited about capital investments and growth. Know your community, know what it can provide to its patients and what it can't. Fill in the gaps and you'll be rich.

This is much more difficult to do in oversaturated places like NYC, LA, Chicago, DC, or Miami. You gotta go to where there's a demand, and where people are tired of driving 50 to 100 miles to see a doctor much less a specialist.

You wanna be a rich man, think less like Ben Carson, more like Jack Welch.