Most and least futureproof specialties.

This forum made possible through the generous support of SDN members, donors, and sponsors. Thank you.
The whole basis for this thread is silly. Classifying specialties this way is pointless. Nobody can predict the future and the variables that will affect healthcare are so numerous. The only thing we can predict is that things as we know them today will change in the future. Specialties will adapt and conform to the changes. There isn't going to be any specialties that disappear or are overrun by midlevel providers, physicians will always be more desirable. In my opinion, basing a career choice on speculation isn't wise. If you truly enjoy a specialty, don't avoid it because you're uncertain of how the future will impact that specialty.
I made a similar statement and I was told by a gas doc and a surgeon 2 months ago not to make such a naive statement as a med student...

Members don't see this ad.
 
Even in the fields that are most "overrun by midlevels" like primary care and anesthesia. Don't the doctors still earn like 2.5x what a midlevel makes anyway in those fields?
 
Even in the fields that are most "overrun by midlevels" like primary care and anesthesia. Don't the doctors still earn like 2.5x what a midlevel makes anyway in those fields?
That was one thing I told the gas doc... He gave me a straight example about his compensation and a CRNA he was supervising... 40ok/year for ~55 hr/week and the CRNA makes ~ 200k/year working 40hr and has another side gig where he makes 100k working part time. Basically the CRNA makes 300k working also ~55 hrs/wk. Obviously, there is about ~100k difference in salary, but the gas doc spent 12 years in school while the CRNA spent 6.5 years...
 
  • Like
Reactions: 4 users
Members don't see this ad :)
Even in the fields that are most "overrun by midlevels" like primary care and anesthesia. Don't the doctors still earn like 2.5x what a midlevel makes anyway in those fields?

The problem is job market for people who grew up in California or Manhattan. When you are the 1 doc + 3 cnra system that's 3 attending jobs in manhattan/cali eliminated compared to all physician model.
 
  • Like
Reactions: 2 users
A conversation about CRNAs flooding the anesthesia field for physicians often doesn't mention they are saturating their own field as well. A surplus of CRNAs should more drastically lower their income relative to anesthesiologists income being lowered???

It affects both field... According to that gas doc, anesthesiologists used to write their own ticket 10+ years ago (400k/year and 10-12 wks vacation)... Not sure if I believe the vacation part of that compensation structure. He said these contracts are hard to find now.
 
I understand the fear, but this conversation always makes me laugh.

First, there's no way to predict the future. We are all speculating and for the majority of human history, our predictions have been wrong. Legislation could pass next week that may completely change our landscape...or not. There's no way to know, especially not 10-20 years out.

Second, and more importantly, there isn't a single specialty that should be put out by midlevels. The issue of income is very real. And in a "doomsday" scenario, incomes for physicians will drop a lot. But when income equalizes, MD/DO >>> NP/PA for any job. The only question that remains is did you do this for the money? And trust me, I'm not judging you if you did, but no one should be displaced by a mid level. The only thing they offer is cheap labor.
 
  • Like
Reactions: 1 user
I understand the fear, but this conversation always makes me laugh.

First, there's no way to predict the future. We are all speculating and for the majority of human history, our predictions have been wrong. Legislation could pass next week that may completely change our landscape...or not. There's no way to know, especially not 10-20 years out.

Second, and more importantly, there isn't a single specialty that should be put out by midlevels. The issue of income is very real. And in a "doomsday" scenario, incomes for physicians will drop a lot. But when income equalizes, MD/DO >>> NP/PA for any job. The only question that remains is did you do this for the money? And trust me, I'm not judging you if you did, but no one should be displaced by a mid level. The only thing they offer is cheap labor.

I agree, but the trend is not good for physicians now... One can argue that it's gravitating toward midlevel practitioners...
 
All this is happening because nursing organizations like AANA focus their resources on lobbying for their cause to protect their practice while we have our bodies, like the AAMC are too busy creating nonsense like the video interviews for EM residency to create barriers.
 
Even in the fields that are most "overrun by midlevels" like primary care and anesthesia. Don't the doctors still earn like 2.5x what a midlevel makes anyway in those fields?

We're talking about the future, not about today. Today, there are roughly 230,000 midlevels. That's a lot in absolute terms but relatively very few compared to how many are coming out the pipeline. The amount of programs out there churning them out means that over our careers that number will exceed 800,000 in the extremely unlikely scenario all growth in midlevel training spots ceases as of 2016. Realistically, it won't, and we'll hit 1m or more. Compared to the future, no field today is "overrun by midlevels" but the staggering growth in midlevel numbers ensures that in the future, every field that is susceptible to being overrun, will be. Rome didn't fall when the first 20,000 barbarians crossed the Danube, but when 200,000 crossed it did fall. Complacency is unwarranted.

On a somewhat related topic, I think I'm going to bump ortho off my "safest" list and replace it with ENT. After further thinking, ortho is notorious for utilizing PAs in both clinic and surgery. I wouldn't be surprised if there are PAs out there in high volume private practices who can (or even low-key do) do joint replacements on their own. People with more knowledge can correct me on this, but I would imagine that most ENT surgeries are solo since it's such a small anatomical area and does not require bona fide first assists. As such, the only people who receive training on ENT procedures are ENTs, since no midlevels get "incidental" training by virtue of being first assists. Also, ortho is a huge money sink for insurance and the government and is more likely to be chopped down to size compared to ENT which kind of flies under the radar, being a much smaller field.
 
Last edited:
  • Like
Reactions: 1 user
We're talking about the future, not about today. Today, there are roughly 230,000 midlevels. That's a lot in absolute terms but relatively very few compared to how many are coming out the pipeline. The amount of programs out there churning them out means that over our careers that number will exceed 800,000 in the extremely unlikely scenario all growth in midlevel training spots ceases as of 2016. Realistically, it won't, and we'll hit 1m or more. Compared to the future, no field today is "overrun by midlevels" but the staggering growth in midlevel numbers ensures that in the future, every field that is susceptible to being overrun, will be. Rome didn't fall when the first 20,000 barbarians crossed the Danube, but when 200,000 crossed it did fall. Complacency is unwarranted.

On a somewhat related topic, I think I'm going to bump ortho off my "safest" list and replace it with ENT. After further thinking, ortho is notorious for utilizing PAs in both clinic and surgery. I wouldn't be surprised if there are PAs out there in high volume private practices who can (or even low-key do) do joint replacements on their own. People with more knowledge can correct me on this, but I would imagine that most ENT surgeries are solo since it's such a small anatomical area and does not require bona fide first assists. As such, the only people who receive training on ENT procedures are ENTs, since no midlevels get "incidental" training by virtue of being first assists. Also, ortho is a huge money sink for insurance and the government and is more likely to be chopped down to size compared to ENT which kind of flies under the radar, being a much smaller field.

You think that a PA is going to be doing a total knee replacement without a physician? No shot. That is a major surgery. Minor procedures I can see PAs doing but nothing like that. I'm just a med student but that seems absolutely crazy to me. Who in their right mind would let a PA perform something like that. Maybe senile elderly patients
 
  • Like
Reactions: 3 users
You think that a PA is going to be doing a total knee replacement without a physician? No shot. That is a major surgery. Minor procedures I can see PAs doing but nothing like that. I'm just a med student but that seems absolutely crazy to me. Who in their right mind would let a PA perform something like that. Maybe senile elderly patients

It obviously wouldn't be sold as "hey, the PA is gonna do your surgery." You will be told Dr. Schmo is doing your surgery, but in reality Dr. Schmo might pop his head into the OR once in a while as his (or more likely, the hospital's) legions of PAs saw away in multiple rooms. I'm not saying it's necessarily very likely, but it's more likely in ortho than in ENT because in ortho it's very common for PAs to do legit surgery as first assists and thus acquire operating skills. The first prerequisite for being replaced is there existing somebody to replace you with, and ortho meets that prerequisite more than ENT (or plastics for that matter).
 
  • Like
Reactions: 1 users
Are you in high school? Have you ever been in an OR? Legions of PA's sawing away? That's not how joint replacements work

Yes, which is why I prefaced my hypothetical future scenario with the qualifier "not very likely."
 
We're talking about the future, not about today. Today, there are roughly 230,000 midlevels. That's a lot in absolute terms but relatively very few compared to how many are coming out the pipeline. The amount of programs out there churning them out means that over our careers that number will exceed 800,000 in the extremely unlikely scenario all growth in midlevel training spots ceases as of 2016. Realistically, it won't, and we'll hit 1m or more. Compared to the future, no field today is "overrun by midlevels" but the staggering growth in midlevel numbers ensures that in the future, every field that is susceptible to being overrun, will be. Rome didn't fall when the first 20,000 barbarians crossed the Danube, but when 200,000 crossed it did fall. Complacency is unwarranted.

On a somewhat related topic, I think I'm going to bump ortho off my "safest" list and replace it with ENT. After further thinking, ortho is notorious for utilizing PAs in both clinic and surgery. I wouldn't be surprised if there are PAs out there in high volume private practices who can (or even low-key do) do joint replacements on their own. People with more knowledge can correct me on this, but I would imagine that most ENT surgeries are solo since it's such a small anatomical area and does not require bona fide first assists. As such, the only people who receive training on ENT procedures are ENTs, since no midlevels get "incidental" training by virtue of being first assists. Also, ortho is a huge money sink for insurance and the government and is more likely to be chopped down to size compared to ENT which kind of flies under the radar, being a much smaller field.

Socialized medicine will greatly reduce ortho salaries when it arrives in the US. All you have to do is take a look at the NHS and how much they ration/limit ortho surgery. Those types of elective surgeries will be the first ones on the chopping block. Yeah some patients will be able to pay cash for surgery, but how many will that really be?
 
  • Like
Reactions: 2 users
Members don't see this ad :)
Socialized medicine will greatly reduce ortho salaries when it arrives in the US. All you have to do is take a look at the NHS and how much they ration/limit ortho surgery. Those types of elective surgeries will be the first ones on the chopping block. Yeah some patients will be able to pay cash for surgery, but how many will that really be?

If socialized medicine arrives in the USA and socializes my pay I'm going to "socialize" my med school loans and move to wherever I can make the most tax-free money. Hello Dubai.
 
  • Like
Reactions: 4 users
I'm not sure why everyone keeps saying "they would NEVER let midlevels do that" It's been happening for some time. An RN gets a one year online diploma and she has a full prescription pad, woefully unqualified to use it, but the dye has been cast already. The public isn't going to rush to the defense of doctors, they're going to take who their hospital/clinic/insurance referral gives them.
 
I'm not sure why everyone keeps saying "they would NEVER let midlevels do that" It's been happening for some time. An RN gets a one year online diploma and she has a full prescription pad, woefully unqualified to use it, but the dye has been cast already. The public isn't going to rush to the defense of doctors, they're going to take who their hospital/clinic/insurance referral gives them.
The public thinks physicians are a bunch of aloof individuals who only care about $$$ and status. They got to do something to change that image.
 
The public thinks physicians are a bunch of aloof individuals who only care about $$$ and status. They got to do something to change that image.

I have no idea to what extent that is true but I don't think it makes much of a difference one way or another. The public has even less say about the utilization of midlevels over physicians than physicians do. Nobody likes calling customer support and navigating an automated system designed solely to make you so frustrated that you hang up before you can get through to "John" the offshored gentleman with the quickiemart accent, but that's what we get. Ditto for your healthcare. In a contest between a large number of atomized individuals and a few large, powerful organizations, the large powerful organizations will get their way every single time.

And the large organizations want "John," and they want midlevels. So that's what we're all gonna get.
 
Sorry just chiming in as an actual resident on this thread, actually laughing out loud at some of this stuff.

OF COURSE there are threats. To primary care docs, there are NP's and PA's. To Anesthesiologists, there are CRNA's. To radiologists, there is the development of AI ( This is my specialty btw ) , to Path, also computer based reads.

All that taken into account, you'd have to pay me wayyyy more than an orthopod or neurosurgeon makes to work the hours they do.

Find a field that interests you ( or a few ) , and pick what you feel best fits your personality. Your local radiologist is no sooner getting replaced by a computer than your local hospitalist or pharmacist is.

That being said, there's a reason i'm going into IR and not general rads..It isn't unwise to try and pick a field that seems immune to midlevel encroachment or computer algorithm encroachment. It will likely not happen for another 20 years, but willl still be within the time frame of our careers.

My point is that nobody can predict anything. Any field can potentially be midlevel replaced...but what are we left with? An army of midlevels handling medicine and a few doctors overseeing them? That would be a nightmare. Anyone that's actually done a day of residency and worked with an NP or PA in an ER, operating room, or on the floors understands the glaring deficiencies in their training compared to us. just my .02.
 
  • Like
Reactions: 7 users
It's unfortunate that a dermatologist who supposedly had to graduate at the top of his/her class with 250+, AOA, honors, research etc... may loose out to an NP who got a degree from an online university. Sad world we live in. At least there are no midlevels doing moh's and dermpath.

Agreed, but unfortunately top students go into dermatology not because the field can only be handled by top students. If i were NP id definitely want to invade derm. Huge supply of patients, and huge earning potential
 
Sorry just chiming in as an actual resident on this thread, actually laughing out loud at some of this stuff.

OF COURSE there are threats. To primary care docs, there are NP's and PA's. To Anesthesiologists, there are CRNA's. To radiologists, there is the development of AI ( This is my specialty btw ) , to Path, also computer based reads.

All that taken into account, you'd have to pay me wayyyy more than an orthopod or neurosurgeon makes to work the hours they do.

Find a field that interests you ( or a few ) , and pick what you feel best fits your personality. Your local radiologist is no sooner getting replaced by a computer than your local hospitalist or pharmacist is.

That being said, there's a reason i'm going into IR and not general rads..It isn't unwise to try and pick a field that seems immune to midlevel encroachment or computer algorithm encroachment. It will likely not happen for another 20 years, but willl still be within the time frame of our careers.

My point is that nobody can predict anything. Any field can potentially be midlevel replaced...but what are we left with? An army of midlevels handling medicine and a few doctors overseeing them? That would be a nightmare. Anyone that's actually done a day of residency and worked with an NP or PA in an ER, operating room, or on the floors understands the glaring deficiencies in their training compared to us. just my .02.

You need to leave your dark room sometimes and go to the ORs. Surgery residents work very hard. Surgeons dont have to. If they worked your hours, they'd still be making more than you. We have lots of surgeons who work crazy hours here, because they want to, whether its b/c they love it, or wants to retire early, they are getting paid really well for their job. Many surgeons here make 7 figures. The top surgeon here makes 7M. You wont be making anywhere close to that even if you work their hours cause insurance reimburses a lot more for surgery. Thats why hospitals value surgeons so much, cause they bring in the money for the hospital, not medicine docs or radiologists.

People dont realize the difference in compensation and billing between different types of doctors. Look at an example here: After Surgery, Surprise $117,000 Medical Bill From Doctor He Didn’t Know

Anesthesiologist bill was ~4k for entire case, which is longer than the surgery since anesthesia starts before the surgery and ends after the surgery ends. Yet the two surgeons involved bills 133k and 117k. Each surgeon billed 30x than the anesthesiologist. That's just how the way our system works. The billing for the surgeon is MUCH MUCH higher than other doctors. That's why hospitals profit so much from surgery. That's why surgeons are the top dogs in the hospital, cause they bring in money. Thats why surgeons can be rude as hell to all the other docs and get away with it, cause the hospital would rather fire the other doc than the surgeon.
 
Last edited:
imgres.jpg
 
  • Like
Reactions: 1 user
Similarly as an actual resident, this thread is just laughably naive. All voices of reason have been ignored.
Physicians at any level of their career complaining about the business of medicine is truly entertaining. They may or may not figure it out but often never do
 
  • Like
Reactions: 1 users
A recent article about this topic, but the comment section has been overrun by nurses.

When Your Doc Is Not a Doc: Should Nurse Practitioners Be Autonomous?

I once went to a Family doctor. To my surprise I was seen by DNP who introduced herself as Dr X. I politely said: in the academic setting I will call you a doctor but since this is a medical office, I'll refer to you as nurse. She wasn't happy to say the least. But I just refuse to call them "doctors", at least not in a medical setting.
 
Last edited:
  • Like
Reactions: 13 users
I once went to a Family doctor. To my surprise I was seen by DNP who introduced herself as Dr X. I politely said: in the academic setting I will call you a doctor but since this is a medical office, I'll refer to you as nurse. She wasn't happy to say the least. But I just refuse to call them "doctors", at least not in a medical setting.

the cajones on you haha

not so shy after all!
 
  • Like
Reactions: 2 users
Everyone says AI will replace radiology, but does anyone have evidence of how well that is going for the programmers/developers? Will the hospital then have to take on liability of the machine (instead of the radiologist holding their own liability as I understand it)?
LOL I doubt it. Half the time the actual radiologist's read is worthless. I had a medical student ask if I look at the rads read and I was like... No.
 
LOL I doubt it. Half the time the actual radiologist's read is worthless. I had a medical student ask if I look at the rads read and I was like... No.

That's remarkably arrogant.

I always look at the image and the read.

My ability to read images is very "surgery focused" - its looking at the lesion, the surrounding blood supply, operative planning. It often misses the forest for the trees as a result.

The radiologists pick up on a lot and do a lot routinely that I don't even know how to do.

A lot of times I just go down there and talk with them too if it's ever something I'm really unclear on or if I think something different may be going on than what they read.
 
  • Like
Reactions: 14 users
You need to leave your dark room sometimes and go to the ORs. Surgery residents work very hard. Surgeons dont have to. If they worked your hours, they'd still be making more than you....

Just wondering why you think the salary surveys (mgma, medscape) often show anesthesiologists and radiologists as making more or close to the same as general surgeons when you say general surgeons bill like 30x as much per hour or whatever.. Do the general surgeons work a small fraction of the hours of gas and rads attendings? Because I haven't got that impression. Are high earners just not reporting to these surveys and if that's the case don't you think it would also be true for gas and rads? Or are you just talking about surgical sub-specialties or something?
 
It's actually going pretty well. They are feeding hundreds of thousands of images to AIs to get them to learn. Ive heard some places have even hired radiologists to help with the learning process. And I am guessing yes regarding liability. But usually when a hospital employed doctor get sued, the hospital gets sued with it anyway. not a big difference, especially with a trend towards capping damage compensations

Liability is the last issue they have to solve before AI can really start rolling

This is something you should have thought about before embarking onto this journey...

Oh come now is that where you were thinking about when you chose pre-med in college? Encroachment?

I got some issue with this sentiment. If you are in academic neurosurgery, you are in a secure turf and PA/NP can increase your earnings.

However, how do you define "simple"?

Is placing an EVD a simple procedure? I suppose you will tell me no. Is placining a central line or mediport simple procedure? You may say, sure, it's simple. Let's train PAs to do it.

Before you know it, it's a few academic physicians and an army of PAs. When you already got your job, it's not a big deal, but to declare things simple (things like consult or "basic workup"), you are handing away medicine to mid levels and decrease demand for physicians, ultimately decreasing demand for physicians.

In that world, I am sure you and me, from the ivory tower to the next, will be fine. But what about the majority of posters here who don't go to an big ivory tower? What about the vast majority of DOs? Are most of their jobs so simple that a NP can do?

Here's the deal. You can train NP and PAs to do ANY Procedure. Hell, if you argue that work up for NPH is simple, I can counter and say basic stroke endovascular work is simple too.

However, you never know whether a work up or a problem or a procedure is going to be simple, and I am sure you know that very well.

NPs and PAs, due to limitations of their training, don't know what they don't know and will not recognize when a problem is no longer "simple". That will lead to patient harm.

As a result, we simply cannot declare things as "simple" and hand them away to mid levels. This happened already, to anesthesia.

Alternatively, we can give most things to mid levels, close most med schools instead of the top 30, and train enough physicians only to staff academic centers and a few to lead private pracicss. Is that the future you would like to see?

The issue also becomes if you're a surgeon for example and mid-levels are doing all of your pre-op, post-op and non-surgical care considering you are the expert at cutting, they you really are just a brain mechanic at that point, and not a fully-rounded physician.

After 5-10 years of that I can't imagine your skills at the bedside would be particularly strong.

The problem is job market for people who grew up in California or Manhattan. When you are the 1 doc + 3 cnra system that's 3 attending jobs in manhattan/cali eliminated compared to all physician model.

Have to imagine it would be 1-2 extra docs, but the point stands.

I understand the fear, but this conversation always makes me laugh.

First, there's no way to predict the future. We are all speculating and for the majority of human history, our predictions have been wrong. Legislation could pass next week that may completely change our landscape...or not. There's no way to know, especially not 10-20 years out.

Second, and more importantly, there isn't a single specialty that should be put out by midlevels. The issue of income is very real. And in a "doomsday" scenario, incomes for physicians will drop a lot. But when income equalizes, MD/DO >>> NP/PA for any job. The only question that remains is did you do this for the money? And trust me, I'm not judging you if you did, but no one should be displaced by a mid level. The only thing they offer is cheap labor.

Yes, but in a day and age where medical school is $70,000/year for many of us, the idea of compensation starts to become very real when you are going into residency for 3-5 years, then fellowship for another couple. Coming out in your mid-30s, trying to get married, buy a house, raise a family, pay off your loans starts to become almost unfeasable depending on your specialty. And with government repayment programs always in flux, uncomfortable questions start having to be asked.
 
  • Like
Reactions: 1 users
Just wondering why you think the salary surveys (mgma, medscape) often show anesthesiologists and radiologists as making more or close to the same as general surgeons when you say general surgeons bill like 30x as much per hour or whatever.. Do the general surgeons work a small fraction of the hours of gas and rads attendings? Because I haven't got that impression. Are high earners just not reporting to these surveys and if that's the case don't you think it would also be true for gas and rads? Or are you just talking about surgical sub-specialties or something?

Not so much general surgeons but subspecialty surgeons (ENT, Urology, Neuro, ortho, optho, plastics). Gen surgeons are just chilling on the beach all day long. jk. but they do see a lot of clinic patients which eat away at their earnings in addition to lower reimbursement for their surgeries. Gen surgeons are like the primary care of surgery, like IM vs cards/GI
 
  • Like
Reactions: 1 users
Just wondering why you think the salary surveys (mgma, medscape) often show anesthesiologists and radiologists as making more or close to the same as general surgeons when you say general surgeons bill like 30x as much per hour or whatever.. Do the general surgeons work a small fraction of the hours of gas and rads attendings? Because I haven't got that impression. Are high earners just not reporting to these surveys and if that's the case don't you think it would also be true for gas and rads? Or are you just talking about surgical sub-specialties or something?

Not so much general surgeons but subspecialty surgeons (ENT, Urology, Neuro, ortho, optho, plastics). Gen surgeons are just chilling on the beach all day long. jk. but they do see a lot of clinic patients which eat away at their earnings in addition to lower reimbursement for their surgeries. Gen surgeons are like the primary care of surgery, like IM vs cards/GI

Billing is just ridiculously screwed up. And yes gen surg tends to be on the lower end of billing/compensation compared to sub specialties.

But billing just isn't accurately tied to effort/difficulty/risk. It's based on RVU's - relative value units set by a committee. They've tried revising these RVUs many times to try and help re-align incentives but it turns out its very hard to down value someone from what they were previously being paid (and no one wants to up value since there isn't exactly a ton of interest from Medicare/insurers to pay more).

As an example of some of the issues with billing:

If I had an OR day with 6 inguinal hernias, I would earn more money than I would for an OR day with one Whipple procedure. A hernia is a ~30-40 minute case in experienced hands with minimal morbidity rates and is almost exclusively an outpatient procedure. Your patients are healthy, happy, and go home. A whipple is a 5 (or more) hour procedure that is generally regarded as one of the more difficult ones we do. The patients are sick at baseline and the operation carries with it a 20+ percent major morbidity rate as well as a prolonged hospital stay and a not insignificant mortality rate (2-5%).

Which of those days sounds better to you? 6 easy procedures, go home on time at the end of the day, minimal risk, no postoperative care involved. Versus one very hard procedure with a lot of risk and a ton of postoperative care.

But the whipple's RVUs are too low to make up for all that extra work and risk.

As another example: We often do many procedures that have multiple billing codes involved. For example a ventral hernia repair - we often combine this with a procedure called a component release (incising the oblique muscle to decrease tension on the fascia repair).

Doing the actual component release portion of the case takes about an additional 20 minutes, requires minimal extra exposure or dissection beyond what you do for the hernia repair itself, and adds essentially no morbidity. Yet, the component release is worth more RVUs than the entire hernia repair! In the early days of using this technique, it was not uncommon for a plastic surgeon to scrub in to do the component release and bill for it separately, making more money for their 20 minutes of work than the primary surgeon did for the entire case!
 
  • Like
Reactions: 8 users
Billing is just ridiculously screwed up. And yes gen surg tends to be on the lower end of billing/compensation compared to sub specialties.

But billing just isn't accurately tied to effort/difficulty/risk. It's based on RVU's - relative value units set by a committee. They've tried revising these RVUs many times to try and help re-align incentives but it turns out its very hard to down value someone from what they were previously being paid (and no one wants to up value since there isn't exactly a ton of interest from Medicare/insurers to pay more).

As an example of some of the issues with billing:

If I had an OR day with 6 inguinal hernias, I would earn more money than I would for an OR day with one Whipple procedure. A hernia is a ~30-40 minute case in experienced hands with minimal morbidity rates and is almost exclusively an outpatient procedure. Your patients are healthy, happy, and go home. A whipple is a 5 (or more) hour procedure that is generally regarded as one of the more difficult ones we do. The patients are sick at baseline and the operation carries with it a 20+ percent major morbidity rate as well as a prolonged hospital stay and a not insignificant mortality rate (2-5%).

Which of those days sounds better to you? 6 easy procedures, go home on time at the end of the day, minimal risk, no postoperative care involved. Versus one very hard procedure with a lot of risk and a ton of postoperative care.

But the whipple's RVUs are too low to make up for all that extra work and risk.

As another example: We often do many procedures that have multiple billing codes involved. For example a ventral hernia repair - we often combine this with a procedure called a component release (incising the oblique muscle to decrease tension on the fascia repair).

Doing the actual component release portion of the case takes about an additional 20 minutes, requires minimal extra exposure or dissection beyond what you do for the hernia repair itself, and adds essentially no morbidity. Yet, the component release is worth more RVUs than the entire hernia repair! In the early days of using this technique, it was not uncommon for a plastic surgeon to scrub in to do the component release and bill for it separately, making more money for their 20 minutes of work than the primary surgeon did for the entire case!

Yea its messed up. Same with Anesthesia. A day in endoscopy earns more money than a 8 -12 hr panc kidney transplant. And I'm not sure how exactly RVU works, cause anesthesiology supposedly has the highest RVU out of the departments by a long shot (2015 physician compensation, work RVU by specialty), the next closest is CT surgery. Yet surgery bills way more than anesthesia, esp orthopedics. And those specialists end up making more as well. Heme onc makes more than anesthesiologists with not even 50% of the RVU.. and its not even a surgical field
 
  • Like
Reactions: 1 user
Yea its messed up. Same with Anesthesia. A day in endoscopy earns more money than a 8 -12 hr panc kidney transplant. And I'm not sure how exactly RVU works, cause anesthesiology supposedly has the highest RVU out of the departments by a long shot (2015 physician compensation, work RVU by specialty), the next closest is CT surgery. Yet surgery bills way more than anesthesia, esp orthopedics. And those specialists end up making more as well. Heme onc makes more than anesthesiologists with not even 50% of the RVU.. and its not even a surgical field

For heme/onc specifically, they profit from the margin on buying/selling chemo to patients, and I don't think that's reflected in the RVUs
 
For heme/onc specifically, they profit from the margin on buying/selling chemo to patients, and I don't think that's reflected in the RVUs
I think this is called "buy and bill" but not sure how lucrative that is for heme/onc now after all the cuts a few years ago? Also, hasn't it moved onto white bagging for a ton of the cancer drugs?
 
Anyone thinking AI will replace radiologists doesn't have a good understanding of radiology. AI will assist radiologists, not replace them. I have zero concerns about AI replacing radiologists.

I don't trust automatic EKG readers--I always over-read the auto-read as a prelim medicine intern, and about 5% of the time the automatic read was wrong either due to just being plain wrong or over-calling an artifact. And somehow we think AI will take over reading plain x-ray films, let alone CT's and MRI's.
 
  • Like
Reactions: 1 users
You need to leave your dark room sometimes and go to the ORs. Surgery residents work very hard. Surgeons dont have to. If they worked your hours, they'd still be making more than you. We have lots of surgeons who work crazy hours here, because they want to, whether its b/c they love it, or wants to retire early, they are getting paid really well for their job. Many surgeons here make 7 figures. The top surgeon here makes 7M. You wont be making anywhere close to that even if you work their hours cause insurance reimburses a lot more for surgery. Thats why hospitals value surgeons so much, cause they bring in the money for the hospital, not medicine docs or radiologists.

People dont realize the difference in compensation and billing between different types of doctors. Look at an example here: After Surgery, Surprise $117,000 Medical Bill From Doctor He Didn’t Know

Anesthesiologist bill was ~4k for entire case, which is longer than the surgery since anesthesia starts before the surgery and ends after the surgery ends. Yet the two surgeons involved bills 133k and 117k. Each surgeon billed 30x than the anesthesiologist. That's just how the way our system works. The billing for the surgeon is MUCH MUCH higher than other doctors. That's why hospitals profit so much from surgery. That's why surgeons are the top dogs in the hospital, cause they bring in money. Thats why surgeons can be rude as hell to all the other docs and get away with it, cause the hospital would rather fire the other doc than the surgeon.


Dude. what the F are you talking about? How much did you smoke before you wrote this post? you've got me laughing on the floor. You're obviously a delusional medical student ( or pre-med ? ) - Some of my best friends and family members are surgery residents and attendings. Unless you're doing neuro, or high end ortho, you're not even touching anywhere near a million bucks. NO WHERE NEAR.

Sure, there are some surgeons that make even 10 million dollars per year. There are interventional radiologists making 10 million a year doing strictly PAD and nephrology clots. They are EXTREME examples. There are also family practice guys making millions of bucks. It's not the average.

Your average general surgeon makes 300-400k. your average specialist surgeon makes 400-600 k, with some specialties a little bit higher. Your average radiologist is probably working in the near 400-450 range as partner, and interventionist is about 10-20% higher than that. Very much in the same boat for much less worked hours AT work - perhaps surgeons are actually at work for similar hours, but in my experience, their 'on call' burden from home is higher. I have nothing but respect for surgeons and do believe they earn every dime they earn, and more. It's not an easy job and requires a lot of training. You don't have to take my word for any of these income numbers - look at pretty much ANY survey. They line up with my numbers, not your exaggerated ones.

and YES - hospitals DO value surgeons because they bring in money for the surgery. You're a complete idiot if you think surgeons are billing 100k for surgeries on average. The average surgeon gets 1000 bucks for an appendectomy, if they are LUCKY. Guess what the hospital charges for just as much on a daily basis? Imaging. The hospital is pocketing the facility fees for every x ray, ct scan, mri, IR procedure, etc.

You are absolutely clueless, almost to the point that it makes me angry as to how ill informed you are.

PS - also, surgeons being rude to other docs? Are you on crack - who do you think refers patients to the surgeons for procedures? not everything is an emergency. All elective procedures get referred to the surgeons who suck up the most. you freaking idiot. Jesus you've given me a headache.
 
Last edited:
  • Like
Reactions: 2 users
LOL I doubt it. Half the time the actual radiologist's read is worthless. I had a medical student ask if I look at the rads read and I was like... No.

Wow. this forum is really full on full of idiots.
 
  • Like
Reactions: 1 user
Similarly as an actual resident, this thread is just laughably naive. All voices of reason have been ignored.


Thank you.

Money squabbles and stupid stuff aside - I just don't get where these people are coming from.

Surgeons work super freaking hard, and they are definitely the 'business bringers' of the hospital - but to think that it's easy to make anywhere near a million dollars as a surgeon is absolutely ludicrous. ( ortho, neuro excluded )

Also, to think you are reading your own radiology imaging and not paying attention to the reads - like, wtf? Our surgery residents come down pretty often ( or call ) and ask us to go over imaging with them to help guide / plan for surgical procedures constantly.

to everyone: it's a team effort. Everyone works hard. Radiologists work hard in a different way ( burning their eyes out reading 100 ct scans a day ) , than internists do ( rounding and listening to patients complain while trying to diagnose things appropriately ) than surgeons do ( toiling in the OR all day and also having to deal with clinic ) -

Please, learn to respect one another. Money is relative. You're going to do well in most fields in medicine, don't plan on getting rich or becoming a millionaire very easily in any field, you'll be disappointed.
 
  • Like
Reactions: 5 users
You need to leave your dark room sometimes and go to the ORs. Surgery residents work very hard. Surgeons dont have to. If they worked your hours, they'd still be making more than you. We have lots of surgeons who work crazy hours here, because they want to, whether its b/c they love it, or wants to retire early, they are getting paid really well for their job. Many surgeons here make 7 figures. The top surgeon here makes 7M. You wont be making anywhere close to that even if you work their hours cause insurance reimburses a lot more for surgery. Thats why hospitals value surgeons so much, cause they bring in the money for the hospital, not medicine docs or radiologists.

People dont realize the difference in compensation and billing between different types of doctors. Look at an example here: After Surgery, Surprise $117,000 Medical Bill From Doctor He Didn’t Know

Anesthesiologist bill was ~4k for entire case, which is longer than the surgery since anesthesia starts before the surgery and ends after the surgery ends. Yet the two surgeons involved bills 133k and 117k. Each surgeon billed 30x than the anesthesiologist. That's just how the way our system works. The billing for the surgeon is MUCH MUCH higher than other doctors. That's why hospitals profit so much from surgery. That's why surgeons are the top dogs in the hospital, cause they bring in money. Thats why surgeons can be rude as hell to all the other docs and get away with it, cause the hospital would rather fire the other doc than the surgeon.


Also, based on your other idiotic posts, you're obviously a medical student. I was blown away as to the idiocy of your post because I thought maybe you were an actual resident or physician.
 
  • Like
Reactions: 1 users
Anyone thinking AI will replace radiologists doesn't have a good understanding of radiology. AI will assist radiologists, not replace them. I have zero concerns about AI replacing radiologists.

I don't trust automatic EKG readers--I always over-read the auto-read as a prelim medicine intern, and about 5% of the time the automatic read was wrong either due to just being plain wrong or over-calling an artifact. And somehow we think AI will take over reading plain x-ray films, let alone CT's and MRI's.

AI assistance means more productivity per radiologist, which still harms your job market because demand will decrease. It's why CRNAs are worrying for anesthesia, even if 3-4 of them are being supervised by 1 MD
 
  • Like
Reactions: 1 user
So what specialties are futureproof again?
 
  • Like
Reactions: 3 users
AI assistance means more productivity per radiologist, which still harms your job market because demand will decrease. It's why CRNAs are worrying for anesthesia, even if 3-4 of them are being supervised by 1 MD


Agreed. This is a reasonable concern - but again, we're likely looking at about 20 years before actual implementation of any type of AI reading MRI's and CT's and actually coming up with usable reports. So yeah, maybe in that time it will reduce some jobs for radiologists...but also, a heck of a lot of other stuff can happen in 20 years.

People were saying anesthesiologists would be extinct by now. CRNA's have proliferated like crazy, but still plenty of an anesthesia shortage. Residency spots have actually been increasing to meet the need.
 
So what specialties are futureproof again?

For the next 20 years? Aside from surgical specialties ( because I don't see robots doing surgery anytime soon ) - Nothing. There are no guarantees in anything.
 
  • Like
Reactions: 1 users
PS, just wanted to add - I switched over from my current programs diagnostic radiology program into our new integrated radiology residency position this past year.

IR is growing in leaps and bounds - both in terms of interventional oncology, but also in terms of uterine artery embolizations, prostate embo's, neuro IR / stroke, etc. There is a lot more on the horizon. For those of you that like procedures, but don't necessarily want to do them ALL the time - consider integrated IR. I'll be double boarded in diagnostics and interventional when i finish, and there are lots of job opportunities. And again, unlikely that a midlevel or computer will replace you.
 
  • Like
Reactions: 4 users
AI assistance means more productivity per radiologist, which still harms your job market because demand will decrease. It's why CRNAs are worrying for anesthesia, even if 3-4 of them are being supervised by 1 MD

Not necessarily true. I expect AI to over-call, creating a lot of false positives which will have to be checked by a radiologist. This is a whole lot different than 3 CRNAs replacing an MD anesthesiologist. I anticipate that the main contribution of AI will be increasing the accuracy of radiologists.
 
  • Like
Reactions: 1 user
Dude. what the F are you talking about? How much did you smoke before you wrote this post? you've got me laughing on the floor. You're obviously a delusional medical student ( or pre-med ? ) - Some of my best friends and family members are surgery residents and attendings. Unless you're doing neuro, or high end ortho, you're not even touching anywhere near a million bucks. NO WHERE NEAR.

Sure, there are some surgeons that make even 10 million dollars per year. There are interventional radiologists making 10 million a year doing strictly PAD and nephrology clots. They are EXTREME examples. There are also family practice guys making millions of bucks. It's not the average.

Your average general surgeon makes 300-400k. your average specialist surgeon makes 400-600 k, with some specialties a little bit higher. Your average radiologist is probably working in the near 400-450 range as partner, and interventionist is about 10-20% higher than that. Very much in the same boat for much less worked hours AT work - perhaps surgeons are actually at work for similar hours, but in my experience, their 'on call' burden from home is higher. I have nothing but respect for surgeons and do believe they earn every dime they earn, and more. It's not an easy job and requires a lot of training. You don't have to take my word for any of these income numbers - look at pretty much ANY survey. They line up with my numbers, not your exaggerated ones.

and YES - hospitals DO value surgeons because they bring in money for the surgery. You're a complete idiot if you think surgeons are billing 100k for surgeries on average. The average surgeon gets 1000 bucks for an appendectomy, if they are LUCKY. Guess what the hospital charges for just as much on a daily basis? Imaging. The hospital is pocketing the facility fees for every x ray, ct scan, mri, IR procedure, etc.

You are absolutely clueless, almost to the point that it makes me angry as to how ill informed you are.

PS - also, surgeons being rude to other docs? Are you on crack - who do you think refers patients to the surgeons for procedures? not everything is an emergency. All elective procedures get referred to the surgeons who suck up the most. you freaking idiot. Jesus you've given me a headache.

Is this a joke? An average surgeon gets 1000$ for an appendectomy? Serious? Do an appendectomy and go home. You just made 1000$. The anesthesiologist gets like 50 bucks. Do you know how long it takes to do an appendectomy?

It's about volume bro. Surgeons are often their own boss. Their income depends on their patient volume. The point was surgeon's bill is far higher than others. Show me the IR doc making 10M. Show me the family med doctor making millions (unless hes running a pill mill or fraud.)

And clearly based on your posts, you are obviously a pre med wanting to go into radiology. You clearly know nothing about anything other than your few family members or what not who are general surgeons. And based on what you said, clearly you can't do math either. At 1k per appy, all you need to do is 1000 to reach 1M, and I'm guessing appy isn't the highest paying procedure either. And Gen surg is the IM of surgery.
 
Last edited:
Is this a joke? An average surgeon gets 1000$ for an appendectomy? Serious? Do an appendectomy and go home. You just made 1000$. The anesthesiologist gets like 50 bucks. Do you know how long it takes to do an appendectomy?

It's about volume bro. Surgeons are often their own boss. Their income depends on their patient volume. The point was surgeon's bill is far higher than others. Show me the IR doc making 10M. Show me the family med doctor making millions (unless hes running a pill mill or fraud.)

You're a joke. It was just my point - that at the very most for a procedure that may take the surgeon ( idk, 20 minutes ), there is still turnaround time, workup, initial consultation, and follow up required of the surgeon. Surgeon's aren't making 10k every day doing appendectomies. They are handling bowel obstructions, whipple's, whatever else. And no, anesthesia won't get 50 bucks. That's not how anesthesia billing works.

Uh, sure, - here's a link:

Medicare Unmasked: Behind the Numbers

That's medicare billing from 2014. Considering medicare makes up about 20-30% ish of most of these guys income, you do the math. The highest earning IR guys are making 3-5 million. Add in their likely insurance billing ( not public ), That's probably close to 10 mil gross,
( given overhead probably eats away some of that ).

Family practice is similar. General surgery is actually lower than IR across the board.

My point is - These guys are exceptions. There's some ophtho guy that made almost 20 mil just off medicare a few years ago and has a jet. THESE ARE EXCEPTIONS.

your AVERAGE surgeon makes the SAME as your average ANESTHESIOLOGIST and RADIOLOGIST and EM DOC. I know this butt hurts you, but it's the truth, 'bro'.
 
  • Like
Reactions: 1 users
P.S. I'm in an integrated IR residency as of this july. I don't ever anticipate to make 7 figures. Is it doable? Sure. But i'm realistic. Chances are we will all be much closer to the average than the ceiling.
 
Top