optho, anaesthesia, ortho, surgery, pmr,... under attack

[godfather]

it seems like virtually every field of medicine's turf is being invaded and how severe this invasion is determines how competitive the various specialties are.

optho- facing intense pressure from optomotrists(i've heard of many optho complaining bitterly of this intrusion)

anaesthsia- CRNA's

Derm- Primary care doctors(although derm is probably always going to be a competitive field it is my understanding that most insurance companies would much rather see the gp treating skin conditions rather than a dermatologist since it's so much cheaper)

pmr- pt,ot,(and for pain management it seems like their going to be battling anaestheia)

IM,FP,ER and peds- PA's and nurse practioners, as much as i hate to admit it most of the preventative measures and chronic disease management(ie diabetes,ht,high cholestrol) which represents like 90% of what these guys do can probably be easily managed by PA's, nurse practioners.

ob- nurse practioners, Fm, other surgeons

surgeons- other surgeons(seems like their all chasing the same dime) and technology(as the trend continues towards being less and less invasive the surgeon's territory is going to dwindle even more(virtually every surgical resident i've talked to agrees with this and like 90% of them plan on pursuing specialty training because of this).

radiology- technology is the only real threat i can see to this field in the short term.(ie computers reading images, otherwise no pa is going to replace the radiologist and i guess thats part of the reason why this field is so competitive now)

orthopedic surgery- not to many forseeable threats to their turf although pt,ot can take some of thier bread i guess, especially if the trend continues toward less invasive treatments.

I guess the conclusion i've drawn is that whenever any field starts receiving competition that field's allure starts diminishing. It's no coincidence that Ent,ortho, and radiology, the 3 fields which seem to be the least threatened by outside competition are also 3 of the most competitive residencies to secure. I also remember like 5 years ago how to get into optho you needed literally a signed statement from god. Nowadays it's alot less competive as salaries have come down and the cost of procedures has plummeted. After talking to some opthamologists my gut feeling tells me things are going to get a whole lot worse before they get better. It won't suprise in the next couple of years if IMGs start cropping up in a field that was once reserved for the all americas of med school. The field that's getting it's tail kicked in right now is surgery. After talking to some program directors earlier in the year, many told me that for the first time since as long as they can remember they don't expect to fill and in all likelyhood IMG's are going to flood this field in the coming years. Furthermore we all know what sort of ride anaesthesia has taken over the last 10 Years.(thank god for me things are starting to look up). Anyways this is very scary stuff to know that after so much hardwork your livelyhood can be taken away. Believe me when i was on the wards and everytime a PA knew an answer that i didn't i felt sweat running down the back of my spine. And this is not because i'm an insecure person but because it reminded me that alot of what i'm going to be doing another person can probably do for alot cheaper. After 4 years of med school i feel that doctors(no matter what field they're in) have an unalienable right to a minimum of 200k to start for all the bull**** they've gone through in the last 7 years of their training.(ps the people i really feel are underpaid are the surgeons, ie they should make at least 300k for the rest of their careers for hell they have to go through). Anyways i never thought that i would feel nervous about job prospects as a physician when i choose medicine as a career, but if anything medicine is like any other field in the sense that their are many scavengers willing to move in on your turf. My friends,it seems like it's jungle out there and we're not as insulated from all of these predators as i once thought we were.

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[drusso]

You are absolutely right. Medicine is not a ticket to an easy lifestyle any more. Physicians have to learn to be competitive in the marketplace; to show that added training equals added value. Also, physicians have to learn to be political. PTs, OT's, PA's, NP's, OD's, DC's, and clinical psychologists advance their fields not through science and rigorous clinical outcomes studies, but through legislation.

MD's and DO's need to unite and be a strong force against allied providers. Also, US graduates and US medical schools need to make a stronger case to limit the influx of IMG's.

Are you ready?

 

[jylu]

Originally posted by drusso:
•MD's and DO's need to unite and be a strong force against allied providers. Also, US graduates and US medical schools need to make a stronger case to limit the influx of IMG's.

Are you ready?•

Enjoyed both messages. In the end, everything really does come down to money.
If that wasn't the case, we wouldn't have the recent surge in physician turf wars. For example, do you honestly believe that CRNAs want the physician supervision requirement lifted so that they can better serve rural populations? Me thinks it has something more to do with the 50% of the anesthesia fee they are forced to split with their attending anesthesiologists.

And God knows about IMGs... If you take a look at some of the IMG forums scattered across the net, it seems like half of them are loaded with docs who would do anything to get into country in order to make the money we make here versus the blue collar salaries awaiting them in their homelands. Ex: Surgeons wanting to do psych or peds because of the perceived ease of getting into those programs, et al.

Here are a few quick fixes, if the American medical community was truly serious about maintaining physician salaries and what remains of physician prestige...

1. PAs/AAs/CRNAs: Severely restrict what they can and can't do and require 1 on 1 physician supervision.

2. IMGs: Allow them to come to the US ONLY on J-1 visas and change the "return home" requirement from two years to five.

 

[jylu]

As a corollary to this, my list of the six "safest" medical specialities to enter, based on how secure their "turfs" are from NP and PAs:

1. ENT - They're busy taking turf from everyone and giving up nothing. The fact that they're moving away from "ear, nose, and throat" to "head and neck" does imply something...

2. Invasive cardiology

3 (Tied). CT surgery and vascular surgery

4. Neurosurgery

5. Ortho

6. Radiology

 

[godfather]

I would just like to point out that your #1 field, ENT isn't as safe as many people perceive. ENT's and oral surgery are consistently fighing over turf( although once out of residency i've noticed oral surgery gravitates towards the dental stuff, ie pulling wisdom teeth, but i've noticed more than once them bragging about how they can essentially do anything the ent does and as a matter of fact certain hospitals in my area will have the ents and oral surgery alternate call to handle ent problems).Furthermore there is also some overlap with plastic surgery.

 

[Mr. happy clown guy]

Godfather, how would you know how to effectively treat HTN, chol, DM, back pain, etc?? What makes you think that these tasks that aparently are beneath you, are just sooooo simple to master?? I imagine fixing your cars breaks are easy too, but do you really want the plumber to do that???

Regarding PA's and NP's in EM...actually an
ED's doc fear is from too many IM and FP docs in the ED. The move is for ONLY BC/BE doctors to be in the ED.
As far as NP's and PA's...please. To see them work is agonizingly difficult. Like watching a 10 year old wash your car, you would much rather do it yourself, or not have it done at all! PA's are assistants and somehow, greedy docs have used them as ways to make money, and now PA's have egos the size of Texas. Every NP I have worked with barely capable of tying her shoe.

As for PM&R, I can assure you that PT and OT will never be able to assume the physiatrists role. As a matter of fact, PM&R has taken business FROM FP and Orthopods and has taken a stronger role in managing rehabilitation visits. Chiropractors do alot to prevent the advancement of PT/OT.

Chiroprators are the ones to watch and their insistance that they are primary care providers. Do you realize that some Chiropractors do pelvic exams and rectal exams?????

 

[godfather]

actually i'm a pretty humble guy and there isn't much i consider beneath me. The point wasn't to demean anybody. But the facts are a lot of what we do in medicine is redudant stuff for which experience counts for more than years of studying. From what i've seen a pa with 20 years experience is definately going to know some things that only experience could teach that a newly graduated physician perhaps won't. For example lets take the example of a procedure. If some layman with no med education has gotten to do 100 central lines compared to a 3rd year resident who's only done lets say 10 who do you think's going to be better at installing central lines. From what i've seen these people in these other fields generally won't ever have the same degree of understanding of disease (this isn't to generalize, i'm sure there are some very good np, pa,...etc who may be everybit as good as some physicians) as physicians, but believe me for alot of the run of the mill stuff for which even physicians are just following a simple protocol to treat or dx i'm sure these people with considerably less training can handle. hell i'm not even that smart but i swear to god im my 3rd year by end of my 1 MONTH outpaitent medicine rotation i could've handled80 % of the problems that the physician that the i was working under dealt with because some of the things were just so damn repetitive. the point of the above post is simply to point out that as medicine being run more and by costcutting bureaocrats, it is not out of the realms of possibility that more and more of what a physician traditionally does may be siphoned off to somebody who gets the job done(perhaps not as well as physician but still gets the job done) and is willing to do it cheaper. Anyways i know all of this is affecting me and the way i'm choosing my future career.

 

[Mr. happy clown guy]

Listen up bud...the point of being a primary care doctor is to have the ability to see what the future may hold for a patient to effectively manage the case and prevent future problems. To know and understand the process of disease and the consequences of your actions. Mundane tasks of drawing blood are learned through repetition, but understanding sepsis from non sterile technique is gained through education.

Why do you think we have residency?? We LEARN in residency what can't possibly be taught in 4 years of medical school.
But perhaps that is not the case for you...you apparently know it all. I mean, you DID have a month of outpatient medicine.

In fact, lets NOT have school teachers earn masters degrees...lets have Walmart managers teach our kids...I mean, they work in the world 24 hours a day...they could PROBABLY teach enough math to get by.