Does Ortho face any threats aside from reimbursement cuts?

[Lord Humongus]

As a soon to be med-student of above average neuroticism I've been doing research on the various specialties I could see myself pursuing 4 years down the road. The results so far have not been pretty. It seems that just about every field out there is somewhere between dead (path), dying (anesthesia), on the precipice (rads), or with dark clouds gathering on the horizon (derm, EM, everything else)

Path- can't find a job, won't be paid much if you do, stuffed to the brim with FMGs.

Anesthesia: Not only are they being replaced with nurses, but residency slots are expanding and whatever contracts are out there are being taken over from PP groups by big corporate entities. Best-case end result: become liability sponge for nurses so that the managerial class can make a fortune off of your back. Worst case: unemployment.

Rads: doesn't face a problem from external threats like midlevels, so decided that if you want a job done well you better do it yourself and are endlessly expanding residencies and flooding the market. Now the standard path is no longer 5 years but 5 years + 1 or 2 fellowships or you can't find any job anywhere. After 6 or 7 years post-med school you may be able to find a job in some crappy location that pays like crap compared to just a few years ago with no fellowships. Only getting worse from there as residencies still expanding and there will always be an endless supply of FMGs more than happy to fill them no matter how bad the market gets.

Primary care: on the bright side, it's not as big a target for cuts as some of the more competitive specialties since it's always been paid like crap. On the flip side, the midlevel threat is nasty in this field. There is talk that primary care could be completely abandoned at some point to NPs and PAs. Yikes.

EM: this field is in golden age right now, with plentiful jobs, full time consisting of 12-15 shifts a month for a 400k+ salary in some places, and locums supplementary income available at $300/hr. But right now != 7 years from now when I would be an attending. In the meantime, we have the spread of corporate management groups just like in anesthesia and the growing utilization of midlevels for "fast track" in the ER, all the while residency spots are exploding by something like 100 spots every year and most attendings being young and far from retirement. You Ortho bros are smart enough so that I don't have to spell out where this is heading...

Derm: certainly the gold standard in the minds of a lot of people. They've smartly kept a lid on supply and cannot be throttled by insurance because many of their procedures are high volume but manageably priced for self-pay, and patients are young and upscale. Perfect outpatient specialty for private practice and under no threat of hospital/corporate employment encroachment. You can make major bank in this field by working hard or make very good bank by working easy. However, what the best of the best in medicine can do a nurse can do, too. Nurse practitioners are salivating and chomping at the bit, and nurse dermatology "residencies" are beginning to pop up. This will not be fast but from a med student perspective, a lot can happen in 20 years..

So those are the non-surg specialties I've considered in passing. Not really interested in the IM subspecialties at all or general IM (again with the midlevels). Obviously this is a broad and eclectic mix but it's just for research purposes since I'm not even an M1 yet.

So what about Ortho? Do you guys see any storm clouds gathering on your horizon? Seems like the Ortho olfathers have been good about keeping the number of residency slots relatively stable, and there are a lot of Orthos approaching retirement. Obviously by the time midlevels start encroaching on the surgical fields all is basically lost in medicine, if it happens.

What about private practice vs employment? I've heard rumblings that hospitals are now going after surgeons, too, but I'm not sure whether this is only ENTs/general surgeons or Orthos as well. I suppose being forced out of private practice by some combination of health system monopoly power/ and legislation vis a vis ASC ownership and distribution of bundled payments would be just about the only thing Ortho is susceptible to aside from declining reimbursements.

I'm really interested in hearing your thoughts!

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[massmocha]

It sounds like you should go into health care administration, not clinical practice. I would pick a field based on your interest in the work, not encroachment from mid-level providers and reimbursements.

 

[Lord Humongus]

I'm about to invest a minimum of 7 years of my life and well over 300k into this endeavor. In other words, if things go south, I will be in a hole too deep to dig myself out of before I turn old and die. Since this is my only life, that would kind of suck. I will not choose my direction purely based off of risk management, but I also don't think jumping in with your yes wide open is anything to feel guilty over.

 

[pd1112]

Sounds like you only care about lifestyle and money.

 

[QualityProcess]

Lord, you're not allowed to be concerned about these things until residency. THEN you can come to the physician forum and join everyone in complaining.

 

[Lord Humongus]

Sounds like you only care about lifestyle and money.

If I ask you what 2+2 is, does this mean my entire life revolves around the answer to 2+2? No, it just means I happened to ask a question about what 2+2 is. Spare me the moral grandstanding.

Lord, you're not allowed to be concerned about these things until residency. THEN you can come to the physician forum and join everyone in complaining.

I've seen this attitude a lot on here. I don't know whether it's because a lot of people on SDN come from filthy rich families and the only thing they've ever had a shortage of was moral superiority, but it's like for these people you better not look out for yourself or you're somehow defective. God forbid you see a pothole on the road ahead and swerve to avoid it. Doing such a basic human action means you are not a holier than thou goodperson and should be ashamed of yourself. To which my response is inevitably "cool story bro, now tell it again."

 

[TUGM]

Pass Step 1 first bro, then come back and ask us again.

 

[Leo Aquarius]

You're trying to figure out what everyone else is trying to figure out... where specialties will be in 10 to 20 years. Nobody knows.

So start med school and you'll be surprised at how much everything will figure itself out there. Bro, I was hell-bent on brain surgery. Ended up in Psychiatry. Never saw it coming until end of 3rd year. Trust me.

 

[tymont12]

If I ask you what 2+2 is, does this mean my entire life revolves around the answer to 2+2? No, it just means I happened to ask a question about what 2+2 is. Spare me the moral grandstanding.

I've seen this attitude a lot on here. I don't know whether it's because a lot of people on SDN come from filthy rich families and the only thing they've ever had a shortage of was moral superiority, but it's like for these people you better not look out for yourself or you're somehow defective. God forbid you see a pothole on the road ahead and swerve to avoid it. Doing such a basic human action means you are not a holier than thou goodperson and should be ashamed of yourself. To which my response is inevitably "cool story bro, now tell it again."

No matter what specialty you go into (lest it be medical genetics on an Indian reservation) you WILL make enough money to afford your loans. If you crunch the numbers, it works for any specialty over ~180K which is pretty much all of them now. I'm in a similar boat and will have over 300k in loans to pay back as well. Save me the 'this is my only life/my loans' crap. If that's what you think, then don't go to med school. You NEED to want this to make it happen.

What people are commenting on is that your 'analysis' in your first post is purely fixated on the potential job market/income/job security. They are important factors once further along in your training, but nobody has a crystal ball as to what may happen in the next 10 years, or that you will have board scores good enough to even consider ortho or derm.

 

[Slack3r]

Derm: certainly the gold standard in the minds of a lot of people. They've smartly kept a lid on supply and cannot be throttled by insurance because many of their procedures are high volume but manageably priced for self-pay, and patients are young and upscale. Perfect outpatient specialty for private practice and under no threat of hospital/corporate employment encroachment. You can make major bank in this field by working hard or make very good bank by working easy. However, what the best of the best in medicine can do a nurse can do, too. Nurse practitioners are salivating and chomping at the bit, and nurse dermatology "residencies" are beginning to pop up. This will not be fast but from a med student perspective, a lot can happen in 20 years..

Almost nothing in this post is accurate.

 

[pd1112]

If I ask you what 2+2 is, does this mean my entire life revolves around the answer to 2+2? No, it just means I happened to ask a question about what 2+2 is. Spare me the moral grandstanding.

I wasn't commenting on your morality; I couldn't care less bruh. I was referring to the way you asked your questions. When you preface them by making (mostly wrong) generalizations about the future financial & socioeconomic aspects of 8 other fields, you're not just asking what "2+2 is" anymore. I'm sure you aren't dumb/naïve enough to think that only physicians in select fields can pay off loans, but that's what it seems like when you make whiny comments about "7 year investment" and "hole too deep to dig myself out" before you've even signed a promissory.

 

[Sam212]

I'm about to invest a minimum of 7 years of my life and well over 300k into this endeavor. In other words, if things go south, I will be in a hole too deep to dig myself out of before I turn old and die. Since this is my only life, that would kind of suck. I will not choose my direction purely based off of risk management, but I also don't think jumping in with your yes wide open is anything to feel guilty over.

May I recommend leaving medicine altogether and giving your spot to someone who's truly enthusiastic about medicine?

 

[Lord Humongus]

I pity the fool who asks you guys directions. Instead of getting a simple "turn right then go straight" you'll probably launch into a diatribe questioning his motivation for wanting to go there in the first place. Peace.

 

[tymont12]

I pity the fool who asks you guys directions. Instead of getting a simple "turn right then go straight" you'll probably launch into a diatribe questioning his motivation for wanting to go there in the first place. Peace.

You asked for an opinion and people gave it to you. Just because you didn't hear what you wanted does not mean everyone else is inherently wrong or being a d**k.

Your 'analysis' sounds like every dude I've met who said they want to do spine and I know all they did was look at the average compensation and have no context for the field at all.

 

[Lord Humongus]

^^Brah, read the title of this thread again. Does it have anything to do with me, personally? Did I ask for an opinion of what is the best path for me to take? No, it's asking about what challenges, if any, face the field of Orthopedic surgery. If I were to be struck by a bolt of antimatter and transformed into pure energy, the answer to the question I posed would not change in the slightest. But all the "answers" in this thread revolve around yours truly and not the field of Orthopedics, hence the comment right above yours.

 

[tymont12]

^^Brah, read the title of this thread again. Does it have anything to do with me, personally? Did I ask for an opinion of what is the best path for me to take? No, it's asking about what challenges, if any, face the field of Orthopedic surgery. If I were to be struck by a bolt of antimatter and transformed into pure energy, the answer to the question I posed would not change in the slightest. But all the "answers" in this thread revolve around yours truly and not the field of Orthopedics, hence the comment right above yours.

Dude, your initial 'question' revolved around yours truly and your assessment of every field (most of which are wrong). You came in asking a loaded question with which you seem to already have an opinion/answer to. People aren't responding because they don't want to entertain your train of thought.

You can't figure this sort of thing out by asking people on SDN...you need to see these fields and experience them in med school. No specialty is going to go the way of the Dodo like you heavily imply in your first few sentences so go experience them and pick what you can really see yourself doing.

 

[blaqmamba]

This thread is hilarious and amusing - I hope it continues. But I just wanted to point out that every medical field will have some sort of 'challenge' given how much doctors get paid and how little insurance companies want to pay. Medicine is not the best field to enter if you are doing it for money, so be sure you want to do medicine for the other reasons before you go down this path. Specific to ortho - I don't know how much encroachment takes place by podiatrists (I'm not an orthopod), but I do remember one podiatrist telling me how much he wishes he'd been trained to do knee arthroplasty. Doubt it'll ever get that far.

 

[RejectedMD]

First off, congrats on getting into medical school! Welcome to medicine . As a current M1 who will graduate with a similar debt burden , I understand your concerns about how much money you will make.

However, I think what most of the people posting are trying to emphasize is that we can't predict the future and not even the people determining the CMS physician fee schedule can answer your question. The fact is nearly all specialties will take a hit so instead of worrying about that, I really think you should just embrace the process of choosing a medical specialty based on other factors. This is literally what going to medical school and doing rotations is for.

In the end, I'm not saying you're a bad person for being concerned about money. I'm just saying your concern about money/jobs and trying to predict what specialty will be "hot" when you're out of residency is futile. If you truly want to avoid dealing with reimbursement rates, then its simple: go into plastics or derm and set up a cosmetic/cash-only practice. Once again, nothing wrong with that. Good luck with medical school!

 

[massmocha]

Anyway, that was fun.

That thing about podiatry is scary and true. In our hospital any patient that comes in by ambulance comes to us, any foot stuff that walks in the door it is up to the ED to call us or podiatry.

Obviously there is overlap in hand with plastics and spine with neurosurgery.

As far as "mid-level" encroachment, I don't believe this is really a thing. We have NPs and PAs that handle the tedious tasks in the hospital and clinic and serve as assistants in the operating room, but they aren't taking jobs away from us. I don't know much about issues in rural America or places with doctor desserts, but I don't think advanced practitioners are allowed to operate independently anywhere. Maybe I'm wrong.

All the other threats are administrative and apply to medicine in general: bundled payments, shrinking reimbursements, patient satisfaction-related incentives

 

[MedAppRx]

1) Pay in any specialty is dependent as much on your business acumen as it is your clinical skills. Over the past 30 years you needed to have just clinical acumen. Now you need both, and I don't mean MBA. The payment migration injects pragmatism into medicine. The enemy of pragmatism is altruism, which is commonly misinterpreted and adhered to at an almost unreasonable level in medicine. A doctor who is both pragmatic and compassionate (not mutually exclusive) will continue to prosper. This combination in ortho means deferring a good deal of your clinic to a PA (except preops and complicated post-ops, essentially), establishing stringent criteria for your elective surgeries (so no total knees on 400 pd people with rheumatoid arthritis), and picking an affiliate hospital with a rapid turnover time to maximize volume. Smarter doctors will group with multiple other docs from the same fellowship groups to maximize the incentive for insurance companies to work out competitive reimbursement rates with them. Finally, keen marketing will drive patient interest up, making both hospitals and insurance plans have to negotiate with your production and your reputation. It sounds simple, but it's remarkably random and complex.

2) While I'm won't condone your very dark view of several specialties (since not even the disaster that is the current NHS in the UK has figured out how to eliminate any of them yet), as an orthopod I am keenly aware that a mid-level will never replace what I do. Podiatry is anatomy-dependent based on state regs. In New York and PA they can go to the ankle. In NJ, they can go up to (but not including) the knee. Thankfully, most podiatrists I know at my program have no interest in going any farther proximal than what PA offers them. I don't see neurosurg or plastics as a major threat to practice volumes.

3) The healthcare environment is changing. That it will be totally different in 10 years when it matters to you is VERY true. I don't share an intensely dark view of it. If anything, I see an opportunity for doctors to take real control over their careers. To do it will require a previously unpromoted level of business acumen, collective bargaining, and patient vetting. If we're capable of "getting" how basic practice marketing and management, even in the hospital setting, can be optimized, we'll be fine. Hell, we'll be fine regardless, just paid less.

If you want money, you can get rich in any field. Yes, some are easier than others, but it's possible anywhere. Ortho puts you in a GREAT position to be comfortable and make a real change for your patients while they're young enough to really feel it. To me, that makes the challenges of residency meaningless in the grand scheme.

 

[LurkerLurker]

Whew this got intense fast, lol.

I can see where the OP made it sound like he's just figuring out how to get paid, but I don't think he's asking any questions that aren't worth asking.

Just an outside perspective- I was also just accepted to medical school. I'm unbelievably honored and humbled that I'm actually going to get to study medicine and be a doctor. I'm a small business owner currently. I have friends doing exactly what I do that have figured out how to make more than most surgeons and I think I'd have a shot at it too if I stuck it out. I clicked before I knew I wanted to study medicine that it's a lousy way to make money. Sure the post residency pay checks are fat, but in a 10 year earning period there's A LOT better ways to make money. I actually realized that I wanted to do medicine when I was volunteering with a homeless health clinic and it hit me that medicine is the only place I'm going to be both intellectually stimulated in a way I want to be, and get to care for people in a way that no other profession allows.

So all that being said, I'm sort of going into medicine because I can't imagine anything else despite the money, not because of it.

And yet I'm still curious about all the things the OP is asking. Maybe once you're actually in this world it doesn't look this way, but if I just browse SDN there is sort of this pervasive attitude that we are all going to be on street corners with "will diagnose for food" signs by the time I finish residency, lol. I don't think wanting to hear what people think the problems facing their specialties are means that you are in this for all the wrong reasons...

 

[Avicenna]

Sounds like you only care about lifestyle and money.

are you not allowed to be, after devoting 11 yrs of your life to something? med school isn't a monastery, its a business

 

[pd1112]

are you not allowed to be, after devoting 11 yrs of your life to something? med school isn't a monastery, its a business

Not allowed to be what?

 

[Avicenna]

Not allowed to be what?

care about lifestyle and money

 

[Lord Humongus]

1) Pay in any specialty is dependent as much on your business acumen as it is your clinical skills. Over the past 30 years you needed to have just clinical acumen. Now you need both, and I don't mean MBA. The payment migration injects pragmatism into medicine. The enemy of pragmatism is altruism, which is commonly misinterpreted and adhered to at an almost unreasonable level in medicine. A doctor who is both pragmatic and compassionate (not mutually exclusive) will continue to prosper. This combination in ortho means deferring a good deal of your clinic to a PA (except preops and complicated post-ops, essentially), establishing stringent criteria for your elective surgeries (so no total knees on 400 pd people with rheumatoid arthritis), and picking an affiliate hospital with a rapid turnover time to maximize volume. Smarter doctors will group with multiple other docs from the same fellowship groups to maximize the incentive for insurance companies to work out competitive reimbursement rates with them. Finally, keen marketing will drive patient interest up, making both hospitals and insurance plans have to negotiate with your production and your reputation. It sounds simple, but it's remarkably random and complex.

2) While I'm won't condone your very dark view of several specialties (since not even the disaster that is the current NHS in the UK has figured out how to eliminate any of them yet), as an orthopod I am keenly aware that a mid-level will never replace what I do. Podiatry is anatomy-dependent based on state regs. In New York and PA they can go to the ankle. In NJ, they can go up to (but not including) the knee. Thankfully, most podiatrists I know at my program have no interest in going any farther proximal than what PA offers them. I don't see neurosurg or plastics as a major threat to practice volumes.

3) The healthcare environment is changing. That it will be totally different in 10 years when it matters to you is VERY true. I don't share an intensely dark view of it. If anything, I see an opportunity for doctors to take real control over their careers. To do it will require a previously unpromoted level of business acumen, collective bargaining, and patient vetting. If we're capable of "getting" how basic practice marketing and management, even in the hospital setting, can be optimized, we'll be fine. Hell, we'll be fine regardless, just paid less.

If you want money, you can get rich in any field. Yes, some are easier than others, but it's possible anywhere. Ortho puts you in a GREAT position to be comfortable and make a real change for your patients while they're young enough to really feel it. To me, that makes the challenges of residency meaningless in the grand scheme.

Thanks for the detailed reply, this is exactly the type of response I was hoping for when I created this thread.

 

[pd1112]

care about lifestyle and money

I never said that. You can care about whatever you want man; it makes no difference to me.

 

[readdoc]

You bring up valid points about how medical careers will change in coming years. People other than trained physicians will be doing the work of doctors in coming years because it's cheaper and insurance wants to pay less. That said, there will always be a need for doctors. But a doctor should always understand that much of medicine is teamwork. As a doc you'll be working with people at all levels from scrub techs to advanced nurses and PAs. Right now so much of a doctor's time is spent on paperwork, that it's tough to do actual medicine. The best way to apply your interest in medicine will be to proceed through medical school and find out what really excites you. I did and I'm glad every day that I have ortho. It's not a crime to try to plan your life as best you can, but there will be changes in life you won't see coming. My advice -- work your ass off in medical school. Get outstanding board scores. Do rotations and take them seriously. If you do everything in your power to do really well -- great grades, great boards, great recs, etc., then you can have choices. You get to choose where you want to be. Work hard.

 

[ButterfingerBBs]

i think OP's general sentiment is common and well-intentioned among many pre-meds. financial prospects and job security are part of the discussion when you are weighing any potential career.

OP expressed concern about mid-level encroachment, increasing government regulation, and decreasing pay. however, if you look around, every profession has its share of problems in today's market. it's up to you to figure out what tradeoffs you are willing to make.

i won't go into my reasons for why or why not orthopaedics, but you can read though a number of sdn and orthogate threads on this topic.

OP mentioned "reimbursement cuts" in the title, which I felt like I could add a little bit to for him/her

total joint replacements have adopted a bundled payment structure in hopes of increasing cost efficiency and encouraging provider collaboration (surgeon, anesthesia, rehab, etc). there is a belief that if this cuts costs, most orthopaedic surgeries will move to bundled payments. however, this may disproportionally affect smaller hospitals and private practice orthopods, who have less bargaining power with input costs like hardware/impants, rehab centers, and the like.

the bundled payment for total joints covers any surgery-related complications within 90-days postoperatively, and there is an abundance of data showing that orthopaedic complication rates are lower at high volume hospitals and with high volume surgeons. this is speculation of my end, but i think that over the next few years, orthopods will consolidate into large group practices run out of high-volume hospitals/surgery centers to minimize input costs, decrease complication rates, improve patient outcomes, and maximize profits.

in the long run, due to the high demand for orthopaedic services, I don't really think that the "reimbursement cuts" that OP referenced will be that significant. since most orthopaedic procedures are elective, if the costs of surgery become too high, then orthopods will charge a significant cash co-payment and/or select for patients with the insurance plans that adequately cover the costs of surgery. i know of some private hospitals and orthopods that are already starting to do this.

i think the takeaway point is that whatever field you choose, you will be able to find a way to make it worth your while. money shouldn't be the reason you go into medicine, but at the same time, you shouldn't be worrying you will default on your loans. due to the enormous barriers to entry into the market as a physician (caps on medical school and residency spots, duration of training), and the growing demand for medical care, your services will always be in demand (aka it's basically a recession-proof job) and you will make a good living (because physician demand is higher than physician supply)