How has your perception of radiology changed?

[Taurus]

Unfortunately, as seems to be the case for every lifestyle specialty, derm has exposed itself to a great deal of risk and the most likely explanation is greed and lack of concern for future dermatologists. Because of the dearth of dermies, the simplicity of practice, and the 9-5 lifestyle, mid-level encroachment has already happened and will continue until derm faces a similar situation to ophth and gas. This threat is far more grave than, for example, teleradiology and will have a profound impact on the derm job market in the 10-20 year timeframe. Here's just one thread on this: http://forums.studentdoctor.net/showthread.php?t=719052

Also, the only good reasons to go into derm are either to practice cosmetic derm or be a mohs surgeon. The cosmetic derm job market is worse than the rads job market and even after entering it, will be fiercely competitive for the rest of your life. In the last 10 years, there have been many, many cosmetic derm and plastics practices that have went straight up bankrupt due to lower discretionary spending secondary to the economy. Since there are no real regulations on scope of practice, there are more FPs running medispas and doing Botox than dermies. Also, facial cosmetic derm is legitimately shared by plastics, ENT, ophtho, OMFS and illegitimately shared by everyone else. Once derm NPs hit the market, the consequences of artificially restricting spots will become more obvious and derm's job market will contract. Regarding mohs surgery, in addition to the massive cuts it's already experienced essentially cutting salaries in half, it's not at all glamorous or sexy and you have to deal with elderly cancer pts daily. All things considered, derm is still a good option but IMO, rads is still better and has the better long-term outlook, particularly since it's more technology-based and therefore evolves faster, creating new revenue streams and differentiable assets. All of that said, I have a lot of friends in derm and have a lot of respect for the field. But of the dermatologists I know, the only ones making radiology-level (400k) salaries are working like dogs as already mentioned.

Excellent post.

Derm is a good field because of the lifestyle and it is somewhat insulated by govt cuts. It's hard to beat no weeknight call and no weekends. The residency is also much easier than most.

However, I think that it comes down to your personality. If you are Mr. Hollywood Personality and Looks and are business savvy, derm or plastics are great choices. But if you are somewhat introverted like me and are into new technologies, I think radiology is a better fit.

With that said, radiology residency is not that bad at all, relatively speaking. I'm on a really easy rotation now and I will only work 9 hours total this week! Most weeks of the year I work 40 hours or less. Maybe during IR rotations I do 60. I wish that I didn't have to work overnight and weekends, but hey it's better than when I was taking medicine call as an intern.

I also think that lifestyle as a radiology attending depends on the type of job you want. If you want to maximize your income, then you'll be working like a dog, nights and weekends. If you want a better lifestyle, it's less income but you may be happier overall.

If you really want to do cosmetics, just remember that no field owns it. Practically any health-related provider from physician, PA, NP, dentists, pharmd, etc can and do offer it. My wife is a dentist and we know of practices that offer botox and dermal fillers. If you're business savvy, then just do cosmetics.

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[shark2000]

Unfortunately, as seems to be the case for every lifestyle specialty, derm has exposed itself to a great deal of risk and the most likely explanation is greed and lack of concern for future dermatologists. Because of the dearth of dermies, the simplicity of practice, and the 9-5 lifestyle, mid-level encroachment has already happened and will continue until derm faces a similar situation to ophth and gas. This threat is far more grave than, for example, teleradiology and will have a profound impact on the derm job market in the 10-20 year timeframe. Here's just one thread on this: http://forums.studentdoctor.net/showthread.php?t=719052

Also, the only good reasons to go into derm are either to practice cosmetic derm or be a mohs surgeon. The cosmetic derm job market is worse than the rads job market and even after entering it, will be fiercely competitive for the rest of your life. In the last 10 years, there have been many, many cosmetic derm and plastics practices that have went straight up bankrupt due to lower discretionary spending secondary to the economy. Since there are no real regulations on scope of practice, there are more FPs running medispas and doing Botox than dermies. Also, facial cosmetic derm is legitimately shared by plastics, ENT, ophtho, OMFS and illegitimately shared by everyone else. Once derm NPs hit the market, the consequences of artificially restricting spots will become more obvious and derm's job market will contract. Regarding mohs surgery, in addition to the massive cuts it's already experienced essentially cutting salaries in half, it's not at all glamorous or sexy and you have to deal with elderly cancer pts daily. All things considered, derm is still a good option but IMO, rads is still better and has the better long-term outlook, particularly since it's more technology-based and therefore evolves faster, creating new revenue streams and differentiable assets. All of that said, I have a lot of friends in derm and have a lot of respect for the field. But of the dermatologists I know, the only ones making radiology-level (400k) salaries are working like dogs as already mentioned.

Overall, agree with many good points.

Everybody and their mother is doing cosmetics. I know even IR doctors doing it. And you don't really need residency for it. It is a week course or you can learn it from someone.

Mohs Surgery is a different story. It is a good gig. It had major cuts recently, like almost everything in medicine. But honestly, for the level of income and also a procedural field, it is one of the better ones, if not the best ones. Consider that it is relatively clean field with controllable hours, minimum complications and surgery level income. I would choose it anytime over any surgical field including IR.

Dermatologists who have a sustainable practice do it by offering a package to the patient. For example they offer a combination of medical, surgical and cosmetic services to the same patient. In this way, they offer something beyond the family practitioners. For example, they offer Skin lesion bispsy, Mohs surgery, Derm ablation, Botox, Collagen and .... to the same patient. Otherwise, they can not win the game over family doctors.

To medical students: At the end of the day, patient contact sucks. And it really sucks. If you want to go that way, go to some field with least amount of contact, mostly outpatient, i.e. Derm, ophtha, .... The most successful clinicians, if they can, change the type of their practice into outpatient. For example, I know of a general surgeon, who is doing colonoscopies and minor procedures all day long in his office (gush, who wants to do that? ). Though to me it is a horrible job, but still is better than inpatient surgery (It seems that he also agreed with me so he changed his practice).

 

[speeddemon]

Overall, agree with many good points.

Everybody and their mother is doing cosmetics. I know even IR doctors doing it. And you don't really need residency for it. It is a week course or you can learn it from someone.

Mohs Surgery is a different story. It is a good gig. It had major cuts recently, like almost everything in medicine. But honestly, for the level of income and also a procedural field, it is one of the better ones, if not the best ones. Consider that it is relatively clean field with controllable hours, minimum complications and surgery level income. I would choose it anytime over any surgical field including IR.

Dermatologists who have a sustainable practice do it by offering a package to the patient. For example they offer a combination of medical, surgical and cosmetic services to the same patient. In this way, they offer something beyond the family practitioners. For example, they offer Skin lesion bispsy, Mohs surgery, Derm ablation, Botox, Collagen and .... to the same patient. Otherwise, they can not win the game over family doctors.

To medical students: At the end of the day, patient contact sucks. And it really sucks. If you want to go that way, go to some field with least amount of contact, mostly outpatient, i.e. Derm, ophtha, .... The most successful clinicians, if they can, change the type of their practice into outpatient. For example, I know of a general surgeon, who is doing colonoscopies and minor procedures all day long in his office (gush, who wants to do that? ). Though to me it is a horrible job, but still is better than inpatient surgery (It seems that he also agreed with me so he changed his practice).

shark,

Thanks for all your contributions to the radiology forum.

I have always wanted to do radiology, but the job market seems very bad from what I can see. I am going to med school in a few months, and my end goal is to get a job in a major city in either Texas or Florida. I want to work less than 70 hours a week and make 250k+ as well.

Do you think it would be better to do radiology or a surgical specialty to achieve this goal?

 

[MDPhDeac]

What is the average salary of an engineer or financial analyst? Probably 80k, but you have not screwed up your life. You had a nice life in your 20s.

What is the average salary of a family doctor? 150K, but you have f..ed up the best years of your life, studying, going to school or taking H&P in the hospital.

What is a successful financial analyst doing in NYC? He is working 70 hours a day, but he makes make in 4-5 mil range. Still he has not f.. up his 20s. Also he get to sleep at night.

Assuming you meant 70 hrs/wk here...then the getting to sleep at night still applies. As far as not f-ing up his/her 20s, that's a little far fetched. Anyone making 7 figs in finance surely f-ed up his/her 20s as he/she surely worked 100+ hrs/wk to get to that position.

A while back, I spoke to a friend in finance who currently makes 7 figs working for a hedge fund and probably working around 70-80 hrs/wk, most weeks. His road to that position was really hard. He basically sold his soul working 100+ hrs/wk to get there and continues to sell his soul on a daily basis as he risks billions in an attempt to make bank for his firm. A lot of the bets he places are the kind that can cripple the economy if they go wrong. He freely admits that people like him are what is wrong with capitalism and the reason the economy sucks right now. He was once pre-med and did some volunteering for an application he never submitted. Now he says he'd like to use some of his free time to volunteer at a homeless shelter or something to make up for the potential damage he does on a daily basis, but says he never can get up the courage to do it because he'd feel like such a hypocrite when he still went to work the next day. I asked him when he was relatively drunk about whether he was happy. His response...no.

Bottom line...money will not make you happy and even if you choose a field for a great lifestyle or great salary, work will still consume a significant portion (~70% ??) of your life. Try to make sure you're gonna love what you do (as best as anyone can), even if you think something like derm looks great from a lifestyle/financial perspective.

 

[vm26]

shark,

Thanks for all your contributions to the radiology forum.

I have always wanted to do radiology, but the job market seems very bad from what I can see. I am going to med school in a few months, and my end goal is to get a job in a major city in either Texas or Florida. I want to work less than 70 hours a week and make 250k+ as well.

Do you think it would be better to do radiology or a surgical specialty to achieve this goal?

surgical specialty, if you're very good you have much more control of your career...whether you're an awesome radiologist or a crappy one, you are both accepting medicare with it's never-ending cuts

 

[Silent Cool]

shark,

Thanks for all your contributions to the radiology forum.

I have always wanted to do radiology, but the job market seems very bad from what I can see. I am going to med school in a few months, and my end goal is to get a job in a major city in either Texas or Florida. I want to work less than 70 hours a week and make 250k+ as well.

Do you think it would be better to do radiology or a surgical specialty to achieve this goal?

You are willing to work 70 hours per week for 250K? There must be better options out there for 250K. I mean that's quite a bit of cash, but in medicine there must be something that will give you a better $/hour ratio.

 

[deleted116380]

You are willing to work 70 hours per week for 250K? There must be better options out there for 250K. I mean that's quite a bit of cash, but in medicine there must be something that will give you a better $/hour ratio.

You can be a hospitalist and make $250k/yr and work the 7 on 7 off schedule (84 hrs a week when you do work). Of course depends where you want to live...might not be able to get that in a big city. One of the PGY2 IM residents at my program got an offer like that for a place in TN iirc. With benefits and additional bonuses it was $300k/yr potential.

EM docs can make that kind of pay as well...and for "regular" hours. If you're willing to work that many hours, you can make that much in almost any specialty unless you're dead set on living in a high tax place like Chicago and want to see only Medicaid pts.

At least for the time being. Not sure what it's like 7-10yrs down the line when he/she would be done training.

 

[shark2000]

shark,

Thanks for all your contributions to the radiology forum.

I have always wanted to do radiology, but the job market seems very bad from what I can see. I am going to med school in a few months, and my end goal is to get a job in a major city in either Texas or Florida. I want to work less than 70 hours a week and make 250k+ as well.

Do you think it would be better to do radiology or a surgical specialty to achieve this goal?

Do Derm. Work 40 hours a week and make 250 K.

Do Radiology and go into VA system or academics. Work 50 hours a week and make 250K.

Do IM subspecialties like Allergy/Immunology. Work 50 hours per week and make 250K.

If with current standards, you are good with 200-250 K, there are lots of good options in medicine. Go for what you enjoy.

Some surgical subspecialties do not give you the opportunity to work 50 hours and make money, unless you go into VA system. For example, barely you can find a trauma surgery or orthopedics jobs in competitive market that you can work 50 hours. Radiology has gone also the same way. Part time job does not exist. Unless you become the BIG GUY in these fields, where you can dictate your hours and your income.

It is interesting how different fields have evolved in competitive markets. For example, Dermatology and Radiology both were considered life style fields 20 years ago. In the last 20 years, Dermatology gave priority to life style over pay. As a result, on national averages they make less than many fields, but they kept their average working hours also low. This is the exact opposite of radiology. You can argue that the nature of the fields (esp emergency versus non emergency) had a great impact on this trend. Though I agree with this argument, personally I think there is much more into it.

 

[speeddemon]

Do Derm. Work 40 hours a week and make 250 K.

Do Radiology and go into VA system or academics. Work 50 hours a week and make 250K.

Do IM subspecialties like Allergy/Immunology. Work 50 hours per week and make 250K.

If with current standards, you are good with 200-250 K, there are lots of good options in medicine. Go for what you enjoy.

Some surgical subspecialties do not give you the opportunity to work 50 hours and make money, unless you go into VA system. For example, barely you can find a trauma surgery or orthopedics jobs in competitive market that you can work 50 hours. Radiology has gone also the same way. Part time job does not exist. Unless you become the BIG GUY in these fields, where you can dictate your hours and your income.

It is interesting how different fields have evolved in competitive markets. For example, Dermatology and Radiology both were considered life style fields 20 years ago. In the last 20 years, Dermatology gave priority to life style over pay. As a result, on national averages they make less than many fields, but they kept their average working hours also low. This is the exact opposite of radiology. You can argue that the nature of the fields (esp emergency versus non emergency) had a great impact on this trend. Though I agree with this argument, personally I think there is much more into it.

Thanks man. Really appreciate all your help and general insight.

 

[jejun]

Location: NYC i see.

Not surprised.

For potential applicants, I would think long and hard before taking a residency position in new york. Ive heard horror stories about job hunts there

How much impact does your residency program have in job search? Does going to a top academic program make it significantly easier in the current market?

 

[cowme]

That all depends.

The general notion is that it would be easier coming from a top notch place, but from my anecdotal evidence, it is brutal no matter where you come from. I have met residents from Michigan and UCSF who had to do two fellowships because they couldn't find jobs. I have also met residents from no-name community land jobs in southern cal with body fellowships.

Anectodal evidence, obviously, but I think it just points to the fact that this whole process is random and determined by luck as much as anything else.

At the end of the day, just bust your butt no matter where you are. If you are a great resident, you are more likely than not to land a tolerable job.

I do think that if you train in a rough market, like new york, cali, etc, you are going to have a tougher time, regardless of your program name

 

[shark2000]

That all depends.

The general notion is that it would be easier coming from a top notch place, but from my anecdotal evidence, it is brutal no matter where you come from. I have met residents from Michigan and UCSF who had to do two fellowships because they couldn't find jobs. I have also met residents from no-name community land jobs in southern cal with body fellowships.

Anectodal evidence, obviously, but I think it just points to the fact that this whole process is random and determined by luck as much as anything else.

At the end of the day, just bust your butt no matter where you are. If you are a great resident, you are more likely than not to land a tolerable job.

I do think that if you train in a rough market, like new york, cali, etc, you are going to have a tougher time, regardless of your program name

Agree.

The rule of thumb is jobs go to the graduates of local known program first. Also groups prefer to hire someone who will stay in that area for long time. The last thing a group wants is to hire someone and do all the credential work, then after 1-2 years he leaves the place for San Francisco.

There are more jobs in midwest than coastal big cities. So, don't get surprised to see a graduate of well reputable midsize program in midwest or Texas or Michigan gets a job in these areas easier than a graduate of MGH or UCSF.

On the other hand, if you are not from a big program from SF or Boston, it is near impossible to find a job, at least a decent one, in these areas.

The conclusion is, go to the best program in the area that you want to live in the future. If you are in Texas, put UTs over MGH or UCSF (I know, it may be difficult).

These are just something you may do to increase your chance. Finding a job is very random and you just need one offer. In this market, it is really like a gamble. Most of it, is out of your control.

 

[Paddington]

Unfortunately, as seems to be the case for every lifestyle specialty, derm has exposed itself to a great deal of risk and the most likely explanation is greed and lack of concern for future dermatologists. Because of the dearth of dermies, the simplicity of practice, and the 9-5 lifestyle, mid-level encroachment has already happened and will continue until derm faces a similar situation to ophth and gas. This threat is far more grave than, for example, teleradiology and will have a profound impact on the derm job market in the 10-20 year timeframe. Here's just one thread on this: http://forums.studentdoctor.net/showthread.php?t=719052

Dermatologists do one thing and that is to tightly limit the supply of Dermatologists. Every Dermatologist in this country has a long waiting list of folks to see them. Given the tight supply, they have a lot of negotiating power for their procedure billing codes. They can easily cram in 30-40 patients a day.

But only Dermatologists can get away with that. If Pediatricians tried the same thing, there would be a lot of dead kids. In Derm, their safety valve is that other folks in the system (like Allergists, ER docs, PCP's, Plastic Surgeons, etc.) altogether can provide some of the backup emergency services. As such, there aren't people dropping dead from the 3 month waiting list to see Dermatologists. E.g. Someone has a suspicious skin lesion, the PCP refers to Derm (for medical eval.) and also to a Plastic Surgeon (for immediate excision). The Plastic Surgeon excises it. Pathology comes back positive. Maybe they see an Oncologist. By the time they get in to see the Dermatologist, the ball is already rolling.

Dermatology gave priority to life style over pay. As a result, on national averages they make less than many fields

Are you kidding? Derm. money is huge. Perhaps the average is pulled down by the fact that there's a disproportionate number of females who tend to work part time. Many if not most Derms. are also establishing satellite beauty parlor type places joined to their clinics from which they get plenty of additional income that's accounted for under a separate business, which may not show under their official "salary".

With Obamacare, I think everyone will take a "haircut". Except for Dermatology.

 

[shark2000]

Dermatologists do one thing and that is to tightly limit the supply of Dermatologists. Every Dermatologist in this country has a long waiting list of folks to see them. Given the tight supply, they have a lot of negotiating power for their procedure billing codes. They can easily cram in 30-40 patients a day.

But only Dermatologists can get away with that. If Pediatricians tried the same thing, there would be a lot of dead kids. In Derm, their safety valve is that other folks in the system (like Allergists, ER docs, PCP's, Plastic Surgeons, etc.) altogether can provide some of the backup emergency services. As such, there aren't people dropping dead from the 3 month waiting list to see Dermatologists. E.g. Someone has a suspicious skin lesion, the PCP refers to Derm (for medical eval.) and also to a Plastic Surgeon (for immediate excision). The Plastic Surgeon excises it. Pathology comes back positive. Maybe they see an Oncologist. By the time they get in to see the Dermatologist, the ball is already rolling.



Are you kidding? Derm. money is huge. Perhaps the average is pulled down by the fact that there's a disproportionate number of females who tend to work part time. Many if not most Derms. are also establishing satellite beauty parlor type places joined to their clinics from which they get plenty of additional income that's accounted for under a separate business, which may not show under their official "salary".

With Obamacare, I think everyone will take a "haircut". Except for Dermatology.

Are you getting paid for advertising Dermatology on a radiology forum or you are doing it for free?

 

[ManBroDude]

...
On the other hand, if you are an excellent med student consider other fields that have had more balanced job markets historically, better lifestyles, and interesting work. I do not think that a medical student in a 1-2 month rotation can truly appreciate how radiology will be once you start working as an attending anyways. There is a lot of risk going into this field right now given the length of training, lack of jobs, and other negative trends as discussed above.

What other fields were you thinking?

 

[NJWxMan]

I once met a very nice child psychiatrist during a third year clerkship. He had entered residency in a surgical specialty and left for child psychiatry after completing three years. I still remember the words rolling off his tongue..."Child psychiatry...best kept secret in medicine." Actually, I think he was a bit biased, because forensic psychiatry is probably the best kept secret in medicine. In any case, compared to derm, child psychiatry definitely ranks up there with lifestyle, hours, and low risk. The shortage of child psychiatrists has actually led to the majority of child psychiatrists creating cash private practices, often collecting $400 for an initial one hour evaluation and $175 for half hour follow up. The opportunities are limitless as well if you want to avoid the confines of a private practice. Honestly, I really cannot put my finger on any true setbacks to child psychiatry.

Dermatologists do one thing and that is to tightly limit the supply of Dermatologists. Every Dermatologist in this country has a long waiting list of folks to see them. Given the tight supply, they have a lot of negotiating power for their procedure billing codes. They can easily cram in 30-40 patients a day.

But only Dermatologists can get away with that. If Pediatricians tried the same thing, there would be a lot of dead kids. In Derm, their safety valve is that other folks in the system (like Allergists, ER docs, PCP's, Plastic Surgeons, etc.) altogether can provide some of the backup emergency services. As such, there aren't people dropping dead from the 3 month waiting list to see Dermatologists. E.g. Someone has a suspicious skin lesion, the PCP refers to Derm (for medical eval.) and also to a Plastic Surgeon (for immediate excision). The Plastic Surgeon excises it. Pathology comes back positive. Maybe they see an Oncologist. By the time they get in to see the Dermatologist, the ball is already rolling.



Are you kidding? Derm. money is huge. Perhaps the average is pulled down by the fact that there's a disproportionate number of females who tend to work part time. Many if not most Derms. are also establishing satellite beauty parlor type places joined to their clinics from which they get plenty of additional income that's accounted for under a separate business, which may not show under their official "salary".

With Obamacare, I think everyone will take a "haircut". Except for Dermatology.

 

[badasshairday]

Honestly, I really cannot put my finger on any true setbacks to child psychiatry.

I can. Dealing with really depressing mental illness in children. Including PTSD from sexual/verbal/physical abuse. Homicidal ideation, suicidal ideation.

 

[BS81]

I can. Dealing with really depressing mental illness in children. Including PTSD from sexual/verbal/physical abuse. Homicidal ideation, suicidal ideation.

Don't forget the parents...

 

[Dral]

You guys/gals sure do like talking about Derm over here. I wish we talked about Radiology as much over on our board...or anything other than 'what are my chances' for that matter. haha

Anyway, the stuff with the mid-levels...no one seems to worry about it. It's the same issue as the cosmetics point someone made: Dermatologists offer the whole package to patients. Mid-levels just don't know how to manage the higher acuity things (acuity is a relative term here, haha). Those people that ONLY have lower acuity things may see mid-levels. That's fine. It may affect Dermatologists a bit. It's easy to adjust practices though.

People who are willing to pay out of pocket will almost always prefer a Derm or PS. As someone else pointed out, people are willing to pay. We see medicare/medicaid patients almost exclusively and even in this economy, a decent number of them are paying out of pocket for elective procedures and laser (fewer go for botox or fillers, but still some do). It's pretty amazing to see, tbh.

And for introverted types, there is always dermpath...plus that gives one the option to split time between clinic and 'chillin' at the scope'.

However, I don't think I would ever convince someone wanting to do radiology to do derm instead. I was thinking rads for awhile, but my shadow experience turned me away. I still think it's a great field though and think that if it's what someone wants to do, they should do it.

In terms of money, I think the most recent data has rads def. above derm. For myself, I see stuff on our resident bulletin board about East Coast positions: 4 day work week, ~350k and such. I can't believe those things exist, but they are there in black and white. They've gotta be really high patient load places I guess.

 

[Taurus]

It's the same issue as the cosmetics point someone made: Dermatologists offer the whole package to patients.

Like most people who go into derm, I have no interest in medical derm. Medical derm can keep all the melanoma and psoriasis to themselves.

Let's be honest here. Most people go into derm because of the cosmetics. As I've pointed out before, no one owns cosmetics and practically anyone with a health-related license including NP/PA, dentists, podiatrists, and pharmacists can get into it. I agree that derm and plastics have an advantage over any other group wanting to do cosmetics but for the entrepreneurial-minded there's huge opportunity. Even for derm people, cosmetics is no sure thing because the barrier to starting a cosmetics practice is low and the competition from other derm and non-derm practices is intense. I think that if you have a head for business then you can be successful no matter your background.

I can see two areas in radiology that one can get into cosmetics. IR and mammo. IR can ablate varicose veins and do injections. Mammo is where the opportunity is bigger. Think about it. You have 40+ year old women who are insecure about their looks as they age and they come to you at least once a year for mammo. It's a huge opportunity to sell them add-on services such as botox and derm fillers. For example, this mammography practice:

http://unionsquareradiology.com/cosmetics/

By supplementing your practice with cosmetics and not being 100% dependent on it, these hybrid practices take on less risk and increase their income potential. It's the same way that derm practices depend on both medical derm and cosmetics.

 

[shark2000]

Cosmetic part of dermatology is done by everybody and their mother.

Medical part of it is done to some part by family doctors. But overall, it is in the realm of dermatology if it gets a little complex. The advantage of dermatology is the ability to visit a patient in 5-10 minutes. Nothing else in medicine can do that. Since dermatology board has kept its trainee numbers low, every dermatologist visits probably twice as patients as a family doctor.

Then they have skin biopsies and also Dermatopathology.

Mohs surgery is another field that they have relatively exclusive hands on it.

Options:

- If you want to have an outpatient clinic only, you can. You can be like a non procedural specialist, but with the potential to see twice patients in the same time spent in clinic and do biopsies. Think about it. No inpatient. Nothing life threatening. Relatively healthy patients. Most young and happy patients.

- If you want to do procedures, do Mohs surgery. One of the highest paid fields in medicine.

- If you hate all of these, do Dermatopathology. One of the highest paid fields in medicine.

I didn't like dermatology. I'd rather work 3 days as radiologist than one day as dermatologist. But from business stand point, it is the best gig in medicine. I choose dermatology over any other field in medicine, anytime.

 

[droliver]

I think there are some big misconceptions on the current and future profitability of cosmetic procedures as a dermatologist. The level of cosmetic procedures a dermatologist can do are easily commoditized and it's a race to the bottom from there. The internet and the whole Groupon phenomena essentially killed the profitabilty of most of these services as they can be delegated to less expensive labor and there's a very low bar to entry. For example, a 100u vial of Botox (~ 5 treatments areas worth) may have generated a net profit of $1000 in 2005, but that same amount of injections nets $450 in 2013 as the product costs have increased and the amount you can command for treatment has fallen by 1/3 in most markets. LAser hair removal #'s, formerly a pretty nice and steady revenue stream, look even worse as there is a plethora of competitors that will all do it cheaper then the next guy/girl.

If you want a somewhat protected field in derm, it's Moh's all the way, as there's really no one person who can replace the path skill part of it with the minor surgeries they do. They don't make rock star money anymore, but it's a pretty solid living. General derm OTOH is going to hit the wall soon I think as they going to be so dependent on Medicare rates. They will always be busy, but the per patient revenue is continuing to get clipped and their most frequent procedural codes for biopsies and ablation got stung. General derm is also vulnerable to NP/PA creep

 

[shark2000]

I think there are some big misconceptions on the current and future profitability of cosmetic procedures as a dermatologist. The level of cosmetic procedures a dermatologist can do are easily commoditized and it's a race to the bottom from there. The internet and the whole Groupon phenomena essentially killed the profitabilty of most of these services as they can be delegated to less expensive labor and there's a very low bar to entry. For example, a 100u vial of Botox (~ 5 treatments areas worth) may have generated a net profit of $1000 in 2005, but that same amount of injections nets $450 in 2013 as the product costs have increased and the amount you can command for treatment has fallen by 1/3 in most markets. LAser hair removal #'s, formerly a pretty nice and steady revenue stream, look even worse as there is a plethora of competitors that will all do it cheaper then the next guy/girl.

If you want a somewhat protected field in derm, it's Moh's all the way, as there's really no one person who can replace the path skill part of it with the minor surgeries they do. They don't make rock star money anymore, but it's a pretty solid living. General derm OTOH is going to hit the wall soon I think as they going to be so dependent on Medicare rates. They will always be busy, but the per patient revenue is continuing to get clipped and their most frequent procedural codes for biopsies and ablation got stung. General derm is also vulnerable to NP/PA creep

It seems that you are a plastic surgeon who has chosen the wrong field.

You are either reading radiology forum or badmouthing Derm. It is clear to me that you wanted to enter either of those.

Anyway, your statement about Derm is correct. But show me any other field which is not facing decreased reimbursements and stung procedures.

Mohs surgery is not making rock star money, but the same for any other field. At least, you re not killing yourself doing procedures at 3am.

 

[Taurus]

I think there are some big misconceptions on the current and future profitability of cosmetic procedures as a dermatologist. The level of cosmetic procedures a dermatologist can do are easily commoditized and it's a race to the bottom from there. The internet and the whole Groupon phenomena essentially killed the profitabilty of most of these services as they can be delegated to less expensive labor and there's a very low bar to entry. For example, a 100u vial of Botox (~ 5 treatments areas worth) may have generated a net profit of $1000 in 2005, but that same amount of injections nets $450 in 2013 as the product costs have increased and the amount you can command for treatment has fallen by 1/3 in most markets. LAser hair removal #'s, formerly a pretty nice and steady revenue stream, look even worse as there is a plethora of competitors that will all do it cheaper then the next guy/girl.

I agree. Standalone nonsurgical cosmetics practices are risky because the bar to entry is low and competition is stiff. That's why it makes more sense to make cosmetics as an add-on service to supplement your practice's income rather than to be solely reliant on cosmetics. Derm practices provide medical derm and cosmetics. Mammo practices can provide mammo and cosmetics for example. Dental practices clean your teeth and give you botox on the side.

If you want a somewhat protected field in derm, it's Moh's all the way, as there's really no one person who can replace the path skill part of it with the minor surgeries they do. They don't make rock star money anymore, but it's a pretty solid living. General derm OTOH is going to hit the wall soon I think as they going to be so dependent on Medicare rates. They will always be busy, but the per patient revenue is continuing to get clipped and their most frequent procedural codes for biopsies and ablation got stung. General derm is also vulnerable to NP/PA creep

I agree that every specialty has to provide something unique that no other field or midlevel can provide completely. If not and the knowledgebase/procedure can be copied, then other fields/midlevels will try to steal it for themselves. Look at primary care. There's nothing unique to it that prevents midlevels from taking it over. For derm, may be they have a stranglehold on Moh's. For radiology, I would say body and mammo. Radiology lost cardiac nucs, vascular work, etc because it was lucrative and other clinical fields controlled the patient.

 

[Dral]

You have 40+ year old women who are insecure about their looks as they age and they come to you at least once a year for mammo. It's a huge opportunity to sell them add-on services such as botox and derm fillers. For example, this mammography practice:

http://unionsquareradiology.com/cosmetics/

By supplementing your practice with cosmetics and not being 100% dependent on it, these hybrid practices take on less risk and increase their income potential. It's the same way that derm practices depend on both medical derm and cosmetics.

That's an interesting concept. TBH, that's a lot of what it's about. People show up on the doorstep of derms and PSs for cosmetics. We can also 'sell' procedures. This is why we have a bit of an advantage. But selling the procedures to patients, regardless of specialty, is how you do it.

A savvy practitioner who knows what they are doing can make a pretty successful side business out of cosmetics. It is of course always volatile. I really enjoy cosmetics, but I would never consider making it my sole practice interest.

If I had a radiologist vs a non-supervised midlevel (even one who was more derm oriented), I'd rather see the physician doing the procedures. If one isn't careful and doesn't understand proper counteractive measures, one can necrose half the patients face off if they are not careful with what they do. I just think physicians have a better handle on that sort of thing.

My intention is not to badmouth midlevels. I think they are a great asset to healthcare. There are a bunch of bright ones I'm sure. But IN GENERAL, I picture them more as 'doers' in contrast to physicians who are more of 'understanders' AND 'doers'.

 

[Taurus]

That's an interesting concept. TBH, that's a lot of what it's about. People show up on the doorstep of derms and PSs for cosmetics. We can also 'sell' procedures. This is why we have a bit of an advantage. But selling the procedures to patients, regardless of specialty, is how you do it.

That's 90% of the game. Getting the customer into the store. Once there, you can start selling them services. That's why it makes a lot of sense for fields where you have repeat customers to supplement with cosmetics. Dentistry and mammo are great examples. People come in x2 a year to get their teeth cleaned. Women come in annually to get mammos. As long as you're not pushy about it and maybe even undercut the competition on price, you should be able to convert some of your primary customers into cosmetic ones too.

 

[Paddington]

I once met a very nice child psychiatrist during a third year clerkship. He had entered residency in a surgical specialty and left for child psychiatry after completing three years. I still remember the words rolling off his tongue..."Child psychiatry...best kept secret in medicine." Actually, I think he was a bit biased, because forensic psychiatry is probably the best kept secret in medicine. In any case, compared to derm, child psychiatry definitely ranks up there with lifestyle, hours, and low risk. The shortage of child psychiatrists has actually led to the majority of child psychiatrists creating cash private practices, often collecting $400 for an initial one hour evaluation and $175 for half hour follow up. The opportunities are limitless as well if you want to avoid the confines of a private practice. Honestly, I really cannot put my finger on any true setbacks to child psychiatry.

I don't know about that. I actually did do a rotation in Child Psychiatry. The days were fairly long. The practitioners were all bitter, cynical people. The other medical student on the clerkship said he couldn't take the mental anguish from listening to these insane, sociopathic kids' stories all day. Of course it was all inpatient, I can see it being a lot easier than that on the outpatient side.

The fee schedule that you speak of is pretty much what everyone doing clinical medicine gets. More typical might be $80 for a followup, but you can do about 4 of these in an hour in most specialties. That is not a huge amount of money, once you deduct the overhead (which is significant even for a lone Psychiatrist with a small office and a receptionist).

Also, Dermatology's success is only partly due to the cosmetic aspect. Even if you took that away completely, Dermatology would still be lucrative, for the amount of work you do. As stated above, they can see patients very quickly. Physician surveys back up that often Dermatologists are seeing 30-40 patients a day. Simply put, in most other clinical specialties it is very difficult to do that kind of volume, even with extreme efficiency. The short supply of Dermatologists also ensures that every Derm has a long waiting list of people, while most other clinicians are out there hustling for patients (including doing things like inpatient or consults to build up/maintain their practice).

 

[Silent Cool]

Of those fields, I would only pick derm over radiology.

Surgery residency, especially ortho and NS, is a killer. Life as an attending surgeon is brutal as well. Furthermore, ortho and NS are definitively not immune. In addition to imaging, ortho, spine, and pain are in the crosshairs of CMS. It's only a matter of time before they get hit. Like derm, plastics is only good if you know how to successfully run your own cosmetics practice, which is a lot harder than most appreciate. If not, you'll be doing debridements and flaps for decubitus ulcers for the rest of your career.

Taurus,

Is this really true for Ortho? I thought Ortho had a lot of flexibility as an attending.

 

[Taurus]

Taurus,

Is this really true for Ortho? I thought Ortho had a lot of flexibility as an attending.

You can work as much as you want as a surgeon, as they like to say. Your salary will reflect it. Thats how they get med students to go into surgery, but 20% drop out during residency. Lifestyle of typical full-time surgeon sucks.

 

[Paddington]

I think every Orthopedic resident thinks that they will get out and have an easy 9-5 job doing elective surgeries like joint replacements. But that's the same idea everyone has. And most people picking and choosing a surgeon will choose to go to someone whose older and more established. So they have to spend years doing trauma call.

 

[qxrt]

Here's interesting data that might provide insight on what radiologists and other specialties might think of their own specialties:

Radiology seems to attract the highest percentage of people who would otherwise not want to be in medicine. If you look at the medscape physician compensation survey in 2013, radiologists are the least likely to choose medicine as a career if they had to choose again (at 33%). Derm and ortho are a close second, at 37%. And yet, if you look at the "would you choose the same specialty again" replies, there's an inverse correlation, with 51% of radiologists, 56% of orthos, and 76%(!) of derms who would choose the same specialty. On the flip side, specialties like family practice and emergency medicine have 62% and 52%, respectively, willing to stay in medicine, yet only 28% and 41% who would want to stay in the same specialty.

One possible inference is, physicians in these traditionally competitive specialties think their field is so great that they'd rather quit medicine than choose another specialty, while physicians in traditionally less competitive specialties seem to be falling prey to the "grass is greener on the other side" phenomenon of wanting to choose a different specialty.

Another possible explanation is, physicians in competitive specialties choose them because there is much about medical management that they dislike; therefore, they choose specialties that are least based on medical management and more on procedures/non-management services.

Salary is another likely factor, but given that derm is somewhere in the middle of the pack based on salary and is really mainly popular because of lifestyle, it may not be the most significant factor.

 

[PalRad]

I'm new to SDN so please excuse any naïveté in my post.

I'm a board-certified, fellowship-trained diagnostic radiologist who has been out of training for almost 20 years. Last year, I lost my contract as the result of a rural hospital bankruptcy/closure. I work occasional locums but have had no success in finding a permanent job over the past 11+ months. I have a family to support so my situation is quite serious.

I'm considering either (1) the military (have prior experience in Reserves) or (2) a non-clinical career in health insurance (ugh!). I would much prefer private practice but no jobs seem to be available for my skill-set - even with teleradiology firms. I'm already signed up on Radworking and with multiple recruiters. It's hard to believe how bad the job market has become for my specialty. Any helpful advice would be greatly appreciated.

 

[IJL]

I'm new to SDN so please excuse any naïveté in my post.

I'm a board-certified, fellowship-trained diagnostic radiologist who has been out of training for almost 20 years. Last year, I lost my contract as the result of a rural hospital bankruptcy/closure. I work occasional locums but have had no success in finding a permanent job over the past 11+ months. I have a family to support so my situation is quite serious.

I'm considering either (1) the military (have prior experience in Reserves) or (2) a non-clinical career in health insurance (ugh!). I would much prefer private practice but no jobs seem to be available for my skill-set - even with teleradiology firms. I'm already signed up on Radworking and with multiple recruiters. It's hard to believe how bad the job market has become for my specialty. Any helpful advice would be greatly appreciated.

Surely this is a troll......

 

[circulus vitios]

What is a successful financial analyst doing in NYC? He is working 70 hours a day, but he makes make in 4-5 mil range. Still he has not f.. up his 20s. Also he get to sleep at night.

This is what my cousin told me 18 years ago. He quit med school in the middle. Then he entered law school. He is now 50, almost retired. Living is his 5 mil dollar home, completely paid off. Oh, I forgot that he has a few other properties, a lot of investment, in addition to driving his Maserati and taking care of his very high maintenance wife and also paying for his two children college expenses. But, my dream is to become like the senior partner in my group who is still working at the age of 68 and is hoping to save enough money to be able to retire in 2-3 years.

What is a 'financial analyst' and where are you pulling $4-5 million a year from? That's like equity partner managing director salary at a bulge bracket bank like Goldman Sachs, and the majority of you guys don't have anywhere near the academic pedigree to even break into investment banking, let alone the tenacity and interpersonal skills to last the 10-15 years of 80+ hours a week it takes to work your way up through the ranks.

 

[colbgw02]

What is a 'financial analyst' and where are you pulling $4-5 million a year from? That's like equity partner managing director salary at a bulge bracket bank like Goldman Sachs, and the majority of you guys don't have anywhere near the academic pedigree to even break into investment banking, let alone the tenacity and interpersonal skills to last the 10-15 years of 80+ hours a week it takes to work your way up through the ranks.

Sure, but I know not to split an infinitive, so I've got that going for me.

 

[circulus vitios]

Sure, but I know not to split an infinitive, so I've got that going for me.

 

[xrevision]

What is a 'financial analyst' and where are you pulling $4-5 million a year from? That's like equity partner managing director salary at a bulge bracket bank like Goldman Sachs, and the majority of you guys don't have anywhere near the academic pedigree to even break into investment banking, let alone the tenacity and interpersonal skills to last the 10-15 years of 80+ hours a week it takes to work your way up through the ranks.

I know people who went to Columbia and Cornell who were looking to get into financing. Most had 3.8+ GPA's in various econ/math majors. At the end of undergrad only 5 or so out of 20 actually got a job in finance, with most of the others going into medicine/law after a couple years of unsuccessfully breaking into banking/finance. Med school was considered a back-up to these folks. Out of the 5 or so that ended up in finance straight out of undergrad only 2 have not been terminated, and yes they are making big bucks now (approx 5 years out of undergrad >500k working close to 100hrs/wk).

Those 2 guys also party/drink harder than anyone I know now.

 

[meister]

That sounds kinda awful to me...

 

[bronx43]

I know people who went to Columbia and Cornell who were looking to get into financing. Most had 3.8+ GPA's in various econ/math majors. At the end of undergrad only 5 or so out of 20 actually got a job in finance, with most of the others going into medicine/law after a couple years of unsuccessfully breaking into banking/finance. Med school was considered a back-up to these folks. Out of the 5 or so that ended up in finance straight out of undergrad only 2 have not been terminated, and yes they are making big bucks now (approx 5 years out of undergrad >500k working close to 100hrs/wk).

Those 2 guys also party/drink harder than anyone I know now.

This sounds about right. You can pretty much tell if a guy went to an Ivy by the way he talks about medicine and business. People in high finance had the option of doing anything, whereas the same can only be said for a very small portion of people in medicine. But, for some reason, it's usually the latter with delusions of grandeur.

For what it's worth, I would pick the medicine route any day of the week and twice on Sunday. Finance is a sh**ty life, and there are enough business opportunities in medicine if you're saavy like that.

 

[Esquire]

.

 

[circulus vitios]

ITT pre-meds, medical students, residents, fellows, and physicians face the crushing reality that they could not, in fact, make millions in business or law.

 

[vistaril]

I once met a very nice child psychiatrist during a third year clerkship. He had entered residency in a surgical specialty and left for child psychiatry after completing three years. I still remember the words rolling off his tongue..."Child psychiatry...best kept secret in medicine." Actually, I think he was a bit biased, because forensic psychiatry is probably the best kept secret in medicine. In any case, compared to derm, child psychiatry definitely ranks up there with lifestyle, hours, and low risk. The shortage of child psychiatrists has actually led to the majority of child psychiatrists creating cash private practices, often collecting $400 for an initial one hour evaluation and $175 for half hour follow up. The opportunities are limitless as well if you want to avoid the confines of a private practice. Honestly, I really cannot put my finger on any true setbacks to child psychiatry.

lmao...child psychiatry is not a secret. Every med student in the US rotated through psychiatry at some point in med school, and most of them spent at least a little time on child psych with child psychiatrists. They saw what it was, and could see that they didn't want to do it. The fact that child psychiatry has perhaps the least capable people in all of medicine(in terms of board scores, class rank, etc) probably also contributes to people wanting to do it. Child psych may be for some, but it isn't a 'secret' in any way. To be a secret people would have to not know about it and what it is.

 

[vistaril]

I don't know about that. I actually did do a rotation in Child Psychiatry. The days were fairly long. The practitioners were all bitter, cynical people. The other medical student on the clerkship said he couldn't take the mental anguish from listening to these insane, sociopathic kids' stories all day. Of course it was all inpatient, I can see it being a lot easier than that on the outpatient side.

The fee schedule that you speak of is pretty much what everyone doing clinical medicine gets. More typical might be $80 for a followup, but you can do about 4 of these in an hour in most specialties. That is not a huge amount of money, once you deduct the overhead (which is significant even for a lone Psychiatrist with a small office and a receptionist).
QUOTE]

Plus the vast majority of child psychiatrists don't get anywhere close to 400 dollars/hr cash pay(!) for evals....Im sure some day, but this isn't the norm. Or even close to it.

 

[thefritz]

Edit, didn't realize I was resurrecting an old thread in a resident's forum. Sorry.

 

[g8orlife]

You guys are depressing.

I was thinking the same thing....

And then this gif slightly cheered me up:

ITT pre-meds, medical students, residents, fellows, and physicians face the crushing reality that they could not, in fact, make millions in business or law.

 

[Dr Neurorad]

I'm an MS3 pretty much set on radiology as a career choice, but I feel that it is a very difficult field to get a good feel for how residency or practice will actually be day in and day out, even though I've shadowed plenty. How has your perception of radiology changed over the course of residency or as you've moved into fellowship or practice? Is it what you expected it to be? Any major perks or downsides you didn't foresee?

Well for starters- the job market is worse than we saw in the mid to late 80's...
Back then we world go to CME courses and meetings, just for something to do... same as today- jobs didn't exist..
I vividly remember standing in line for doughnuts and coffee at those old meetings and someone remarking that it reminded him of the "soup kitchens" of the Great Depression... we laughed, but not too hard, deep down we knew- it wasn't too far from the truth...
Yeah.... It's déjà vue all over again...
Welcome to 2013....
and it's only going to get worse...