It seems to me that one of the few surgical subspecialities that is currently escaping the rapid trend of downward reimbursements is orthopedics. Those guys who go off and do hand or spine fellowships make an insane amount of money. It's not surprising to see why ortho is so popular right now. However, I would be very surprised to see ortho evade the insurance companies for much longer; I think they're going to start seeing rapid decline in reimbursements as well.
Orthopedics is otherwise pretty damn cool. Surgeons always talk about the satisfaction of fixing something that is broken, etc. Well, what other specialty other than orthopedics has that instant satisfaction? I don't think there are others quite comparable.
Nevertheless, orthopedics in a large respect is based on trauma or pathologic fractures, and like all other specialties, I'm sure there are dry spells. I would think that a lot of the cutomers come from late night call-ins to trauma centers necessitating late night surgical repair. And for the guy who fancied ortho for its lack of clinic -- who do you think sees all the post-op patients? Orthopods have plenty of clinic. There's a lot of nonoperative management in orthopedics as well.
Picking ENT was somewhat a decision based on a combination of factors: complexity of cases, region of the body, lifestyle, pay, demand, academic and private practice opportunities, and OR and clinic lifestyle.
1) ENT cases can be pretty cut and dry or very complex. If you want to spend your career doing tubes (by the way, tubes can be very challenging folks; try putting tubes in a 2 month old with a subperiosteal abscess), tonsils, uncomplicated sinus surgery, septoplasties, laryngeal biopsies, and cancer work-ups, then you can do that and do very well. On the other hand, if you want to be the go-to-guy and do stapedectomies, endolymphatic sac shunting, facial nerve decompressions, vestibular nerve sectioning, and cochlear implantation, then you have that option as well.
2) In my opinion, there's no other place as complex as the head and neck. There are so many spaces, nerves, vessels, muscles, bony landmarks, and organs in this small region of the body. Above all, the face and neck are the most visible structures seen by the average human. There's just a lot of opportunity to be challenged here.
3) ENT lifestyle can be a breeze or a pain in the ass -- whatever floats your boat. As you can imagine, private practice with a team that effectively bargains minimal ER and call will reward you with short hours, great OR cases, and time to spend with your family (or whatever). They don't call it "Early Nights & Tennis" for nothing. On the otherhand, if you want to do a head and neck fellowship that trains you in microvascular anastomosis and do those 20 hour long cases, build up a huge patient population, perform research at an academic center, come in early for grand rounds, do resident reviews, prepare lectures, and be called multiple times per night when your own call by your residents, then you can do that as well. That lifestyle is very appealing for some who want to be constantly challenged and thrive on being the go-to-guy.
4) Pay for ENT isn't as high as it is for orthopedics -- not even close. It probably doesn't match neurosurgery either. The median east coast salary for all otolaryngologists is somewhere around $250,000. That's pretty good for anything, mind you. (Anesthesiology is around $275,000; general surgeon around $235,000.) It's a little bit higher if you're practicing out in the midwest. Most people in the east start around $125,000 to $150,000. In academics, it is, of course, much lower. But, academics has its trade-offs: you get residents to do all the ****.
5) The American Board of Otolaryngology and RRC limit the number of ENT residents very strictly. It's not like anesthesia where they just add residents according to demand. This, of course, keeps ENT doctors in demand. All ENTs are in demand, including generalists. Right now, pediatric otolaryngologists and facial plastic surgeons are in heavy demand, and even in academics, these guys make bank.
6) I've sort of already discussed private practice v. academics.
7) You can spend as much time in the OR as you want. A good doctor always tries to find a medical solution first. That's the way ENT is. If you want, you can do allergy and immunology and spend all week in clinic. Alternately, you can spend all week in the OR/minor procedure doing facial procedures. You could be a FESS factory if you wanted and had the patients. Of course, you could operate 2-3x a week and do clinic 2-3x a week. Whatever your practice affords you and whatever you want to do. It's unfortunate in ENT that many of the procedures we perform now as generalist actually cause you to lose money you would have made in clinic. If you spend the day doing 10-12 tubes and tonsils, you might have made more money in clinic seeing initials. It all depends. Of course, your reimbursements will be based on how savvy you are when it comes to billing.
I'm sure most of what I said is applicable to orthopedics, but this is just the ENT perspective.
Hope that helps.
I guess someone has to do it, though.
