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

[Winged Scapula]

One word: Stents

Good for palliation but not necessarily for long term treatment.

Stents have changed the field, especially for CT surgery, but there is so much that cannot be stented and still requires surgical intervention that I agree that surgeons aren't going to be replaced anytime soon.

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[hans19]

One word: Stents

Surgeons do them, too. And?

Stents don't stabilize broken bones. Stents don't fix perfed bowel.

 

[latinfridley]

Whats funny about this whole thread is that all the NP/PA advocates are basically saying that with extra training they can do what MD's can do. That seems pretty obvious. Hey, if NP's/PA's or whomever want to endure 3-7 more years of additional school and training, and have the added responsibility and liability that MD's do, i'm all for it.
Lets see how many sign up for it.

 

[latinfridley]

One word: Stents

Stents have not been convincingly shown to be superior to a number vascular surgical procedures. One example, carotid endarterectomy.

 

[Faebinder]

New article in Journal of the American College of Surgeons coming up soon talking about Evidence based medicine showing the difference between H-graft portacaval shunt and the classic TIPS. Pretty much, the stent is not all that everyone makes it out to be.

 

[NNguyenMD]

Whats funny about this whole thread is that all the NP/PA advocates are basically saying that with extra training they can do what MD's can do. That seems pretty obvious. Hey, if NP's/PA's or whomever want to endure 3-7 more years of additional school and training, and have the added responsibility and liability that MD's do, i'm all for it.
Lets see how many sign up for it.

In my view, as wonderful as they all are, PA's and NP's serve one role and one role only...SCUT

 

[PCAndrew]

NNguyenMD also can see the future for what it is. The money you'll make in medicine has been and will be conected more to business practice than to clinical skill or education. Bare in mind though, that medicine is currently exempt from the rules of Adam Smith's capatilism because of third party payers. This works to the vast advantage of the very sick and very specialized. I'm betting on a correction.

In response to Sluggo

PCAndrew: 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.

Sluggo: 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!

PCAndrew: Wow. I can't dispute that I'm an idiot. That's been proven time and again. But I'm not sure an third-hand anecdote refutes the 10 year-old trend of computerization in medicine (and a 40-year old trend in every other business, we're disgustingly behind). I think your emphasis in the word "examine" is good though. Physical examination, like procedures, will be around for a good while yet. I'm just saying that any nurse can look at a toe, see that it's not moving, it's a little red, and it hurts. Then he or she can click (not even type) those tidbits into a computer and get a differential. You can do that on Google now. With each item on the differential, you can get a work up algorithm. The big toe is a good example too, because my bet is a podiatrist will deal with it if it needs an operation or injection, not an orthopod.

 

[Winged Scapula]

In my view, as wonderful as they all are, PA's and NP's serve one role and one role only...SCUT

Pretty short sighted. A good PA or NP can enhance patient care and education and provide you with more income as they can bill for their services while you are seeing more patients. I would not consider practicing without one of them on staff.

 

[Freshnstylin]

short sighted indeed...AND don't forget, with a little more training MDs can do what DOs can do!

 

[NNguyenMD]

Pretty short sighted. A good PA or NP can enhance patient care and education and provide you with more income as they can bill for their services while you are seeing more patients. I would not consider practicing without one of them on staff.

You are correct. Regretfully, I worded my earlier remarks on NP's and PA's in very poor taste. I suppose I was trying to use sarcasm to contrast what I see as unwarranted fears people seem to have of PA's and NP's replacing physicians in the OR or office. I don't think its going to happen, but I shouldn't have reduced the importance of their work to mere "scut".

Please let me clarify what I really feel of NP's and PA's. They are a VITAL resource to any medical practice. A more accurate description of their role is that they are exceptionally reliable support to attendings and residents. Not only do they help keep careful watch over your patient care in the perioperative setting, and making sure that every nook and cranny that should be tucked in, is (not being facetious here). But even more importantly they are the reason why hundreds or residents/fellows nationwide have sufficient time to train in procedures, and log in all those hours year after year training in OR's, GI suites, Cath labs, ETC. If asked, they'll see your consults, they'll pull those drains/change those dressings, they'll make sure that you follow-up on consult recs, they'll back you up in the OR when there aren't any residents, but most importantly, when they see a problem on the floor they'll fix it, and 9/10 times you'll be glad they did.

It was wrong to mislead people in this thread into thinking that anyone can do a PA or NP's job. Its akin to working in a difficult residency, except they're doing this type of work for life so you can be excellent at yours. And it is presumptuous of me to think that as a fourth year student, I am able to truly appreciate the value of these team members; interns, residents, attendings, and fellows are in much better positions to describe how much their training and practice is dependent on the services of good PA's and NP's.

Hope that clarified things, and much love to the PA and NP peeps on this board.

 

[tristanjouvin]

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.

The 7-figure-income neurosurgeon you describe appears to be violating the Stark Law by doing what he is doing. If he refers his own patients for PET scans at a facility in which he has ownership - that is violation. Wait till a federal attorney finds out, and then let's see what happens to the 7 figure income.

ANyway, in all seriousness, your comments are accurate. Variance in income between individual doctors has a lot to do with the way the practice is run as a business. On the whole, looking at a whole specialty, incomes fluctuate, going up and down every several years, based on supply and demand issues. FOr example, demand and income of primary care doctors, will keep fluctuating up and down over time. So, my philosophy is, as long as you are not going into an extinct field, DO WHAT YOU ENJOY!!!

 

[Winged Scapula]

The 7-figure-income neurosurgeon you describe appears to be violating the Stark Law by doing what he is doing. If he refers his own patients for PET scans at a facility in which he has ownership - that is violation. Wait till a federal attorney finds out, and then let's see what happens to the 7 figure income.

If I understand it correctly, its only a violation if he doesn't disclose to his patients that he refers to the center that he has a financial interest in it and offers them other places to have the tests done. You do have to be careful but as long as you disclose, I don't believe it to be a Stark violation.

 

[schwartz818]

What seems like the most solid specialty in the next 15-30 years, salary wise (atleast 250k) and job security wise. From what ive been reading on these boards, it seems like medicine is a stupid field to go into. It seems like doctors are losing their respect, salary, and freedom in practicing.

 

[mdjobexchange]

Regarding the previous posts about the Stark Law, from my reading, the Stark Law restricts a physician from receiving additional remuneration from referring patients insured by federal programs to a health facility. An example would be a surgeon getting paid to send his Medicare patients to a specific hospital. The radiologist situation may be a violation of the anti-kickback laws which are a different cup of tea. Also keep in mind (thought I am not 100% certain of this) that you can get around some of this if you are not a medicare participating provider. In addition, Surgeons and anesthesiologists can take care of patients at a surgery center where they have a percentage ownership. I believe that there is a limit on how high of a percentage they can own. In addition, many orthopedic groups own their own MRI machine. Radiology groups own their own equipment. There are numerous different hoops a group has to jump through to keep everything legal, but it comes down to how you run your business and getting good legal advice.

Regarding the best specialties, I think surgery and its specialties will have higher incomes, as well as GI and Cardiology. Anesthesia will be fine, as patients continue to get more complex and perioperative care, such as continuous nerve blocks, become more prevalent. I think general surgery is going to see some big increases because the baby boomers are going to be rupturing diverticuli left and right as they get older and students are not going into that specialty like they used to. Demand is going to be very high for well-trained general surgeons.

 

[wanabdoc]

after reading this thread I have come to two conclusions

either

1.) I should drop out of medical school and go to PA/NP school

or

2.) All medical students/residents are depressed, self-defeating, and neurotic

 

[wanabdoc]

Whats funny about this whole thread is that all the NP/PA advocates are basically saying that with extra training they can do what MD's can do. That seems pretty obvious. Hey, if NP's/PA's or whomever want to endure 3-7 more years of additional school and training, and have the added responsibility and liability that MD's do, i'm all for it.
Lets see how many sign up for it.

Lol, this is so true.

ie, any yahoo PA/nurse/properly trained gardener can cut burrholes into someone's skull (seriously, I've seen this done in africa without anesthetic.) The MD's saving grace is that most people don't want just any yahoo drilling into their head, they want someone who is intelligent, skilled, and careful to do this.


Another note, most people who can afford to travel to India for their surgury usually choose to stay here and pay a premium at a private hospital, and those who can't afford to travel to india, well don't.

 

[jmsMD]

Call me crazy, but for all the pain of pre-med, med school, and residency, I certainly hope to make some nice $$$ one day. I think it's a good question. I want to be able to take care of my parents and live comfortably myself. Money is kinda important. I sure as hell am not doing this for the good karma I get from "helping people" anymore.

FYI, a dermatologist I know made around $2 million last year.

very unlikely that figure was made in the practice of dermatology alone.

 

[Winged Scapula]

very unlikely that figure was made in the practice of dermatology alone.

I'll bet 60% or more came from selling lotions and other skin treatments.

 

[mdjobexchange]

I agree, most of the dermatologist's money probably came from selling Obagi skin products.

A plastic surgeon I worked with in the Bay Area made over 50% of his profit off his aesthetician. She did mild chemical peels, permanent make-up, dermabrasions, skin consults, etc. People paid $120 for a 20 minute dermabrasion and then paid huge money for fancy skin creams and snake oils. He had an in-office surgery room, where he did breast augs, face lifts, etc and he basically broke even off it, mostly due to high overhead with the 2 biggest culprits being rent and staff salaries.

Did you know that Enzyte, the natural male enhancement, had over $260 million in sales in 2007? What is in it? here it is:

The Enzyte recipe contains minerals such as zinc and copper, niacin
(also known as vitamin B3) and several natural products such as horny
goat weed and ginko baloba.

Americans will pay big money for horny goat weed, but not want to spend a dime to get their aortic aneurysm fixed. Maybe a little "horny goat weed" could fix it? I might try some myself.

 

[AlternateSome1]

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...

Was it like 90% of ER visits and not really an emergency? It isn't like you got evaluated for a stroke or had a ruptured triple-A.

 

[PCAndrew]

There is one thing missing from this conversation.

Generally, the talk is spot-on. Procedures make money. Low supply of a particular skill set generates demand, which makes money. Owning the facility (and billing the RVUs associated with space) makes money.

BUT

This is all a conversation based on the current Medicare paradigm. Medicare can't figure out how to pay for outcomes. So instead it pays for procedures. It pays "Thinking Docs" for their time. It pays "Doing Docs" for their procedures. Doing Docs can always get more efficient, but Thinking Docs can't generate more time.

When United figure out how to prove that paying a geriatrician to reconcile a med-list add more quality adjusted life years to an old-guys life than the surgeon that cuts out his diverticular disease, there may be a major, major overhaul in the way things work. When Aetna starts paying Pediatricians to chase fat-kids around until they lose weight instead of paying Ophthalmologists to laser their retinas thirty years later, there may be big changes.

SO

No, this isn't a pointless discussion. It's a fascinating discussion, but I think the conversation has been held in too limited a scope so far. As for the inside-the-box thinking, Anesthesiology is paid way to much to do too little. Heme-Onc however, has great PR, new successes, and (most importantly) excellent lobbyists.

 

[mashnuts]

Specialties with cosmetic procedures are typically among the highest paid.

 

[howelljolly]

Specialties with cosmetic procedures are typically among the highest paid.

Optho, ENT, Plastics, Derm. Yeah, that sounds about right.

 

[Questions]

What do you know.............the pre-med agrees with the neurologist about what makes a great surgeon.............fascinating banter from 2 obvious experts

i just thought this was such a funny observation!

 

[Doowai]

I remember as a child wanting to be a wizard. A wizard is a powerful being. He can cast spells that produce miraculous and unworldly effects. He is the guy with the grey beard who has been through the fire of experience. Wishes that others desire, he grants.
.

I remember as a kid wanting a monkey. A spider monkey. They had one at a store called Ben Franklins five and dime. When my mom would go shopping I would go back and just watch him. He could pick up things with its feet and its tail. That would be so cool to brush your teeth with your tail. My mom would not let me have a monkey. My wife now won't let me have a monkey. Some day I am going to have a monkey dammit.

 

[Doowai]

When Aetna starts paying Pediatricians to chase fat-kids around until they lose weight

What about setting it up so fat kids could chase each other? A race around the school track, winner gets to eat the loser.

 

[bobby6]

Sure, PAs are people - usually pretty bright people - so they can be trained to do things that other people are trained to do.

My strenuous objection is that no one, including PAs, can safely perform the task of surgery WITHOUT adequate training - which is by necessity the situation they are always in. It's like someone wanting to be NASA flight director after watching Apollo 13 on video a few hundred times.

Or someone who insists on walking onto a major league baseball diamond to swing at 95 mph pitches when they've played a few games of softball at the local YMCA.

There's a solution to PAs wanting to do surgery. It's called medical school followed by surgery residency.

Funny thread. PAs doing surgery independently? Never. There is no way a hospital is going to credential a PA for independent surgical privileges. Hell, it hard enough trying to get surgical privileges these days without board certification. Most hospital credentialing committees will require you obtain board certification in your surgical specialty within a define time period from graduating a surgical residency in order to maintain privileges.

Going through the credentialing process to obtain surgical privileges is enlightening. A file is kept on each surgeon and specifies each procedure he/she is allowed/privileged to perform, otherwise, they cannot perform that procedure at that hospital.

In addition, which malpractice insurance carrier would be crazy enough to provide liability coverage for a PA doing these surgical procedures independently?

 

[Excelsius]

I agree, most of the dermatologist's money probably came from selling Obagi skin products.

A plastic surgeon I worked with in the Bay Area made over 50% of his profit off his aesthetician. She did mild chemical peels, permanent make-up, dermabrasions, skin consults, etc. People paid $120 for a 20 minute dermabrasion and then paid huge money for fancy skin creams and snake oils. He had an in-office surgery room, where he did breast augs, face lifts, etc and he basically broke even off it, mostly due to high overhead with the 2 biggest culprits being rent and staff salaries.

Did you know that Enzyte, the natural male enhancement, had over $260 million in sales in 2007? What is in it? here it is:

The Enzyte recipe contains minerals such as zinc and copper, niacin
(also known as vitamin B3) and several natural products such as horny
goat weed and ginko baloba.

Americans will pay big money for horny goat weed, but not want to spend a dime to get their aortic aneurysm fixed. Maybe a little "horny goat weed" could fix it? I might try some myself.

I don't know which is better - horny goat weed or regular weed that many people buy (can cost $500>/oz) yet can't afford health insurance. Americans' willingness to pay for anything that is marketed well enough is the reason why everyone from plumbers to doctors is trying to sell whatever is possible. Business education teaches you that it's not as important how good your product is or how good you are, but rather how well you market. This is especially true in medicine where communication skills with patients are very important, yet many doctors lack the most rudimentary skills and end up not losing patients as much, but getting sued and losing money. In contrast, you can't sue your beautician if that $200 camel-toe-testicle cream ended up irritating your lips.

This thread is around 8 years old now. Anyone knows how the field has changed since then? Any particular field that came on top? To me it seems that nothing has changed much - pretty much all specialties have increased their salaries over the years, even if some are very slow. It just doesn't seem that medicine is one of those professions with large oscillations in income. Precluding any drastic government interference, things generally remain stable. Sometimes too stable compared to inflation, but that can also be a great asset in times of great economic distress.

 

[calvinNhobbes]

For the PA/NP vs MD/DO debate,

It is all about 10,000 hours (see Outliers by Gladwell)

Anyone can be a master surgeon (or master anything) as long as you are dedicated enough to spend 10,000 hours training to do it.

FYI, most surgical residencies (ie. 5+ years of INTENSE on the job training, equivalent to 10+ years of PA/NP work) log about 5000 hours of actual hands on operating time.

Moreover, it is not just logging the hours, but you need to constantly push yourself technically.

I highly recommend the book.

 

[NRAI2001]

Procedures make money is the general rule.... FP and IM docs know this and from my observations are starting to do more in office procedures themselves. Anyone know/guess what sort of effect this may have??