"Safe" medical fields - is surgery the only one?

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goodoldalky

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Let me explain.

I am in my 3rd year rotations, trying to figure out what I'm going to do. Over my experiences the past few years I have come to wonder if certain fields are even options.

Take all of primary care: How long is it before the priceless primary care fields are staffed by RN's, PA's, ABC's, whatever other degree comes out between now and then that can be completed in 24 months and reimbursed half as much? (At great "savings" to all...?) How long before an MD is some sort of vestigial creature in these fields, that would perhaps be ideal, but is now either underpaid or abused because things have gotten expensive and the field is now undervalued by reimbursement? Surely, there is a reason MDs are avoiding and leaving this field in droves. And these are GOOD doctors, with valuable degrees, and extensive training who would prefer to stay!

What about anesthesiology? I'm on my surgery rotation right now, and rarely is there actually a living, breathing, M.D. trained physician at the head of the bed. It's usually a CRNA. Or sometimes even a non-CRNA RN who does anesthesia, whatever that means. When it is an M.D., I can't tell the difference.

What about ER? Despite the emergencies, excitement, and allure of the field for many people, the ER I rotated in was populated by more non-MDs than MDs. Surely, running an ER is expensive and everything is about "value" these days. Seems to be the similar phenomenon here...

What about a specialty like Ophthalmology? A perennial ROAD specialty - hard to get into - wonderfully popular. Even here, O.D.s are nipping at the MD's heels, doing essentially similar clinical exams and even clamoring for surgical privelages. I was occasionally assigned to work with an OD instead of an MD during my rotation... and not that I know much, but the only way I found out was to look at the nametag.

How long is it before MD's in these fields and others go the way of the dinosaur? Let me say that I have liked aspects about all of these, but the last thing I want is someone to take my job just because they became qualified in a year or two, have less debt, and can afford to. Less than that, I'd hate to end up voluntarily leaving because things have changed so much and/or are no longer worth it.

I had a meeting with a mentor today who insinuated that in many ways surgery is the safest field to enter with an MD degree. For a variety of reasons, MDs are being pushed out of and/or voluntarily walking away from what were among the most desirable specialties 10 years ago. His contention was that in many ways entering a surgical field is one of the only ways to ensure that your job will not be sold to the lowest bidder and to ensure that your degree is not devalued because of the problems in the system.

Really.. I shudder at the thought.. but is he right? Or are there other "safe" fields?
 
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Oh man I just had this conversation on the phone like 10 minutes ago.

I understand this happens in MANY careers and fields, but I'd be curious to know how many of these fields have people borrowing $200K+ AFTER college for it.
 
goodoldalky said:
Let me explain.

I am in my 3rd year rotations, trying to figure out what I'm going to do. Over my experiences the past few years I have come to wonder if certain fields are even options.

Take all of primary care: How long is it before the priceless primary care fields are staffed by RN's, PA's, ABC's, whatever other degree comes out between now and then that can be completed in 24 months and reimbursed half as much? (At great "savings" to all...?) How long before an MD is some sort of vestigial creature in these fields, that would perhaps be ideal, but is now either underpaid or abused because things have gotten expensive and the field is now undervalued by reimbursement? Surely, there is a reason MDs are avoiding and leaving this field in droves. And these are GOOD doctors, with valuable degrees, and extensive training who would prefer to stay!

What about anesthesiology? I'm on my surgery rotation right now, and rarely is there actually a living, breathing, M.D. trained physician at the head of the bed. It's usually a CRNA. Or sometimes even a non-CRNA RN who does anesthesia, whatever that means. When it is an M.D., I can't tell the difference.

What about ER? Despite the emergencies, excitement, and allure of the field for many people, the ER I rotated in was populated by more non-MDs than MDs. Surely, running an ER is expensive and everything is about "value" these days. Seems to be the similar phenomenon here...

What about a specialty like Ophthalmology? A perennial ROAD specialty - hard to get into - wonderfully popular. Even here, O.D.s are nipping at the MD's heels, doing essentially similar clinical exams and even clamoring for surgical privelages. I was occasionally assigned to work with an OD instead of an MD during my rotation... and not that I know much, but the only way I found out was to look at the nametag.

How long is it before MD's in these fields and others go the way of the dinosaur? Let me say that I have liked aspects about all of these, but the last thing I want is someone to take my job just because they became qualified in a year or two, have less debt, and can afford to. Less than that, I'd hate to end up voluntarily leaving because things have changed so much and/or are no longer worth it.

I had a meeting with a mentor today who insinuated that in many ways surgery is the safest field to enter with an MD degree. For a variety of reasons, MDs are being pushed out of and/or voluntarily walking away from what were among the most desirable specialties 10 years ago. His contention was that in many ways entering a surgical field is one of the only ways to ensure that your job will not be sold to the lowest bidder and to ensure that your degree is not devalued because of the problems in the system.

Really.. I shudder at the thought.. but is he right? Or are there other "safe" fields?
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You're overly worried about nothing...If any of these other fields could do the same as doctors, then do you really think there is zero usefulness to all the education we undergo? Yes, as the patient load increases, the role of the physician in many fields shifts over to that of one who delegates and makes executive decisions. But the ability to make the big.tough, sometimes life or death decisions is what separates a physician from all these other fields....physicians are not defined by the procedures they do.
 
EMtaken over by non-doctors? Sure, maybe a rural one here, or some of the workforce there... but yeah, not really... They're PA's (and are awesome and totally needed), not P's.
 
Do you know any unemployed doctors? No? Exactly.

There are other fields infiltrating all of these disciplines because there's plenty of room for them. There aren't anywhere near enough anesthesiologists to cover everything these days. Emergency rooms have PAs and NPs because so many people come to the ER for non-emergent reasons. People are leaving primary care in droves because of the low reimbursement and putting up with lots of hassle, red tape and busy work.


However, surgery does seem like a "safe" field, because we'll never see an NP doing an appendectomy, let alone a Whipple. Nevertheless, some territory is being given up to interventional radiology - tunneled lines, Mediports, PEG tubes, draining abscesses, etc. It is one of the reasons I like surgery.
 
goodoldalky said:
My contention is that entire fields are becoming underpaid due to this phenomenon.

The question I would pose to you is:

Do you know any underpaid doctors?
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Do you know any underpaid teachers? underpaid government employees? underpaid small businesses? underpaid custodians? underpaid EMS? underpaid firefighters? underpaid cops?

I'm sure you know ppl who are overpaid in those areas, but if you asked them would they say they are overpaid? paid what they're worth? or underpaid? I have a feeling very few would say they're overpaid. The more you have, the more you feel you need. AT best, they'll say they're living comfortably by their standards.

I know very few doctors I would say are underpaid, but I bet when I'm an attending and I'm getting more than well-compensated for my work, but I have a family to take care of, a mortgage to take care of, student loans to take care of, and taxes are taking off a good $100,000 a year from my salary, I'm gonna guess I'll say I'm underpaid or at best, living comfortably.

In my field, EM, there are plenty of PA's who are working in ED's sometimes in partnership with a physician, sometimes somewhat independent of a physician, but they are not bringing our salaries down in general. If I wanted, I could easily find a job paying 200K-300K for a 40hour work week in a non-academic institution (just not in NY).

Salaries for FM are down not because of NP's or PA's taking over (and I do have issues with ones who overstep their bounds, make no doubt). They are down because the current pay structures rewards procedure-performing fields and specialties.
 
TheProwler said:
Do you know any unemployed doctors? No? Exactly.

There are other fields infiltrating all of these disciplines because there's plenty of room for them. There aren't anywhere near enough anesthesiologists to cover everything these days. Emergency rooms have PAs and NPs because so many people come to the ER for non-emergent reasons. People are leaving primary care in droves because of the low reimbursement and putting up with lots of hassle, red tape and busy work.


However, surgery does seem like a "safe" field, because we'll never see an NP doing an appendectomy, let alone a Whipple. Nevertheless, some territory is being given up to interventional radiology - tunneled lines, Mediports, PEG tubes, draining abscesses, etc. It is one of the reasons I like surgery.
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Probably safe, except when the government/Obama starts questioning the need for tonsillectomies/T&As, the lack of strong evidence based practice in surgery will be exposed and many procedures will be reduced in number based on restricting measures put forward by the government. And the sad part about that is large studies (the kind that take 20 years to perform) would actually confirm the beneficial role of these surgeries...but it will become impossible to conduct the studies prospectively because the government will start cutting down on the number of those procedures done, immediately. You mention whipple's, and plenty more of them are done these days, but there is no conclusive evidence of the benefit of whipple's in patients who are deemed radiologically to be incurable disease of the pancrease/bile duct, etc....here is some evidence that it extends survival and improves symptoms in incurable disease, but the evidence probably would not meet the government standard.
 
The only medical field I can see that would be in the crosshairs of midlevels is urgent care style medicine.

Face it: following an algorithm based on a non-emergency symptom complex is not rocket science. Any ol' bum can learn this type of pattern recognition and treat patients accordingly without any understanding of why they are doing it. Most patients will probably fare pretty well.

I also predict that family medicine will be a dead specialty within the next few decades, but not due to government interference. The trend has always favored specialization. Those within primary care will specialize in certain aspects such as geriatric chronic disease management, management of chronic HIV, management of simple orthopedic injuries, primary care dermatology, nutrition management, women's health, etc. True family medicine as we know it will cease to exist.
 
Scaredshizzles said:
Probably safe, except when the government/Obama starts questioning the need for tonsillectomies/T&As, the lack of strong evidence based practice in surgery will be exposed and many procedures will be reduced in number based on restricting measures put forward by the government. And the sad part about that is large studies (the kind that take 20 years to perform) would actually confirm the beneficial role of these surgeries...but it will become impossible to conduct the studies prospectively because the government will start cutting down on the number of those procedures done, immediately. You mention whipple's, and plenty more of them are done these days, but there is no conclusive evidence of the benefit of whipple's in patients who are deemed radiologically to be incurable disease of the pancrease/bile duct, etc....here is some evidence that it extends survival and improves symptoms in incurable disease, but the evidence probably would not meet the government standard.
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I actually feel that we do operate too much on some advanced cancer patients. Giving someone a slightly longer life but a dysfunctional body is often not worth it. I don't think patients are often fully informed about how difficult a recovery will be, so they just hear "Six more months," and say "Sure, why not?" They don't realize the pain of the surgery and the fatigue/nausea/discomfort of chemo, etc.

Anyways, as the population ages, there will be plenty of need for surgeons. The patient population is growing, and while some procedures will decrease in frequency, there will be plenty of new ones (like revascularizing all the limbs of diabetics).
 
Scaredshizzles said:
Probably safe, except when the government/Obama starts questioning the need for tonsillectomies/T&As, the lack of strong evidence based practice in surgery will be exposed and many procedures will be reduced in number based on restricting measures put forward by the government. And the sad part about that is large studies (the kind that take 20 years to perform) would actually confirm the beneficial role of these surgeries...but it will become impossible to conduct the studies prospectively because the government will start cutting down on the number of those procedures done, immediately. You mention whipple's, and plenty more of them are done these days, but there is no conclusive evidence of the benefit of whipple's in patients who are deemed radiologically to be incurable disease of the pancrease/bile duct, etc....here is some evidence that it extends survival and improves symptoms in incurable disease, but the evidence probably would not meet the government standard.
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This is Ronald Reagan speaking out against Medicare in 1961: http://www.youtube.com/watch?v=6FzNTB1qtFA

And I quote:
Ronald Reagan said:
[FONT=Georgia, Times New Roman, Times, serif]The doctor begins to lose freedom. . . . First you decide that the doctor can have so many patients...So a doctor decides he wants to practice in one town and the government has to say to him, you can't live in that town. They already have enough doctors. You have to go someplace else. And from here it's only a short step to dictating where he will go. . . . From here it's a short step to all the rest of socialism, to determining his pay. And pretty soon your son won't decide, when he's in school, where he will go or what he will do for a living. He will wait for the government to tell him where he will go to work and what he will do..
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Well, we have Medicare, it's pretty damn popular, it works OK, it's expensive but less so than private insurance, and the government still doesn't determine where you live, how you practice, where you go to school, or what job you take.

And comparative effectiveness won't result in a slippery slope to the government directing your practice. Breath deep, it'll all be OK.
 
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The country needs general surgeons more than any other specialty. Hospitals cannot function without them as they are probably the most important specialty in the hospital.
 
lol, biased much, mr. (ms.?) july-august surgery clerkship person?
 
TMP-SMX said:
The country needs general surgeons more than any other specialty. Hospitals cannot function without them as they are probably the most important specialty in the hospital.
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Surgery? Bah! I don't understand why they don't get rid of the entire residency and just add it on to another year of IM.
 
TheProwler said:
I actually feel that we do operate too much on some advanced cancer patients. Giving someone a slightly longer life but a dysfunctional body is often not worth it. I don't think patients are often fully informed about how difficult a recovery will be, so they just hear "Six more months," and say "Sure, why not?" They don't realize the pain of the surgery and the fatigue/nausea/discomfort of chemo, etc.

Anyways, as the population ages, there will be plenty of need for surgeons. The patient population is growing, and while some procedures will decrease in frequency, there will be plenty of new ones (like revascularizing all the limbs of diabetics).
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Diabetic disease is actually not often amenable to revascularization procedures because they have small vessel disease (on top of any large vessel athersclerosis they may have.) Just like CABG or angioplasty with stenting doesn't have ideal results in Diabetics, it is even more so the case in limbs....The majority of useful revascularization that goes on at least with current procedures, are those with PVD secondary to smoking...and well all know that unless they stop smoking, the benefits are short lived even with great graft patency.
 
JHopRevisit said:
This is Ronald Reagan speaking out against Medicare in 1961: http://www.youtube.com/watch?v=6FzNTB1qtFA

And I quote:


Well, we have Medicare, it's pretty damn popular, it works OK, it's expensive but less so than private insurance, and the government still doesn't determine where you live, how you practice, where you go to school, or what job you take.

And comparative effectiveness won't result in a slippery slope to the government directing your practice. Breath deep, it'll all be OK.
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I'm not one against reform because I know the current system just cannot persist....At the same time, I know how much more powerful the insurance industry and pharamaceutical industry is in terms of lobbying power than us physicians, and I know any national plan will have a very negative impact on physician salaries. If medicare monopolizes health insurance, then they will be able to lower reimbursement well below the level they currently offer...(And the government will lease out the medicare coverage to be run by private insurance companies, as they already do, especially with medicaid because they claim for profit companies run things a lot more efficiently...The only really big losers in this scenario will be physicians. And I'm honest to God not one of those people in it for the money, but I do think physicians need to stand up a lot more for themselves than they currently are doing, especially primary care physicians from certain unnamed new england organizations that are pushing hard for a public option.
 
Look, I'm not a doc or even a med student, but I've been a biz prof for a long time and observed similar concerns expressed in the tenuous nature of business. For what it's worth, the best, and IMO, only sure way to remain employable is to gain more knowledge than the next guy, to be able to do things that the others cannot. That means, by my understanding, the surgeon is going to be employable than the PCP and that the PCP is going to be more employable than the mid-level care provider, so long as s/he truly can add more value than the PA or NP. Not that the gen surgeon is "safe." He's got to worry about the new hot-shot that just finished a fellowship in advanced laparoscopy. The question you have to ask yourself is, "do I really have more to offer than the next guy?" I hope the answer is yes. If it's not and all you're doing is writing scripts for antibiotics, then it may be time to increase the tools in your toolbox.
 
Usernamed said:
Look, I'm not a doc or even a med student, but I've been a biz prof for a long time and observed similar concerns expressed in the tenuous nature of business. For what it's worth, the best, and IMO, only sure way to remain employable is to gain more knowledge than the next guy, to be able to do things that the others cannot. That means, by my understanding, the surgeon is going to be employable than the PCP and that the PCP is going to be more employable than the mid-level care provider, so long as s/he truly can add more value than the PA or NP. Not that the gen surgeon is "safe." He's got to worry about the new hot-shot that just finished a fellowship in advanced laparoscopy. The question you have to ask yourself is, "do I really have more to offer than the next guy?" I hope the answer is yes. If it's not and all you're doing is writing scripts for antibiotics, then it may be time to increase the tools in your toolbox.
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Well here is what you won't understand as a medical outsider...physicians have skills that aren't easily definable and obvious... As many have said, you can train a monkey to do a lot of what we do, because you don't need to have the background/theoretical knowledge to do it...That is true...However, every so often it is necessary, and more importantly, you need the background theoretical knowledge if you want to make progress in the future and actually improve the approach to an existent or new clinical problem...These other professions cannot even reflect upon the clinical problem the way physicians can...But the problem is, it is hard to quantify or reimburse this value that physicians have...In other businesses like technology, you have very defined groups of people who work on research and development, and you can compensate them directly...In medicine, every physician is to some extent a researcher and developer and innovator, and what exactly constitutes progress takes a very lengthy time period to define and appreciate.
 
Scaredshizzles said:
Well here is what you won't understand as a medical outsider...physicians have skills that aren't easily definable and obvious... As many have said, you can train a monkey to do a lot of what we do, because you don't need to have the background/theoretical knowledge to do it...That is true...However, every so often it is necessary, and more importantly, you need the background theoretical knowledge if you want to make progress in the future and actually improve the approach to an existent or new clinical problem...These other professions cannot even reflect upon the clinical problem the way physicians can...But the problem is, it is hard to quantify or reimburse this value that physicians have...In other businesses like technology, you have very defined groups of people who work on research and development, and you can compensate them directly...In medicine, every physician is to some extent a researcher and developer and innovator, and what exactly constitutes progress takes a very lengthy time period to define and appreciate.
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Doesn't seem so hard to quantify it to me actually, we have better education and that is quantifiable, can look at successful malpractice suits brought against, the difficulty of the patients seen, overall patient outcome, contribution to medical literature, etc.
 
Rendar5 said:
Doesn't seem so hard to quantify it to me actually, we have better education and that is quantifiable, can look at successful malpractice suits brought against, the difficulty of the patients seen, overall patient outcome, contribution to medical literature, etc.
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No you really cannot though. Contribution to medical literature is really reserved mainly for people who take on a research oriented career, it doesn't reflect your day to day problem solving skills.

Looking at overall patient outcome? That just strikes me as ridiculous, any physician who practices in a low SES area would be outrages, because they know their patients will have worst outcomes no matter how much effort they put in.
 
Scaredshizzles said:
No you really cannot though. Contribution to medical literature is really reserved mainly for people who take on a research oriented career, it doesn't reflect your day to day problem solving skills.

Looking at overall patient outcome? That just strikes me as ridiculous, any physician who practices in a low SES area would be outrages, because they know their patients will have worst outcomes no matter how much effort they put in.
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umm, you control and compare physicians in SES areas with PAs in non SES areas. And non-research physicians can still publish case reports. I'm just syaing, if you take each group as a whole (not this codtor in ICU of low SES and compare with PA in an FP practice of Harvard's campus), not on an individual basis and compare, you should be able to show that physicians provide a higher end level of care and contribute a higher level to medical understanding. It's why I'm not as concerned about a "take over" of my field. The NPs/PAs want to take care of their own patients? fine. they can be litigated too. This is perhaps the great equalizer 🙂

I"m comfortable that we provide better outcomes for medically complex patients and overall contribute more to medical understanding, I know most hospitals realize this, and will make sure to hire me and other EM physician groups and have PAs as support for us.

If you truly believe there is no easily discernible difference on outcome when this happens, then don't waste your time/money/complaints with med school, become a PA,/NP/DnP save tons of grief, and work in the field of your choice because you will eventually get paid equal to docs
because you'll be taken over.
 
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Rendar5 said:
umm, you control and compare physicians in SES areas with PAs in non SES areas. And non-research physicians can still publish case reports. I'm just syaing, if you take each group as a whole (not this codtor in ICU of low SES and compare with PA in an FP practice of Harvard's campus), not on an individual basis and compare, you should be able to show that physicians provide a higher end level of care and contribute a higher level to medical understanding. It's why I'm not as concerned about a "take over" of my field. The NPs/PAs want to take care of their own patients? fine. they can be litigated too. This is perhaps the great equalizer 🙂

I"m comfortable that we provide better outcomes for medically complex patients and overall contribute more to medical understanding, I know most hospitals realize this, and will make sure to hire me and other EM physician groups and have PAs as support for us.

If you truly believe there is no easily discernible difference on outcome when this happens, then don't waste your time/money/complaints with med school, become a PA,/NP/DnP save tons of grief, and work in the field of your choice because you will eventually get paid equal to docs
because you'll be taken over.
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No you can't even start doing that (comparing to providers in similar SES geographies), it just encourages physicians to dump their most difficult or non-compliant patients in order to "pad their stats." Medicine is just eons more complicated than any other field that you can guage performance statistics on.You can only control for it by randomly assigning patients to physicians....but if a government infrastructure ever tried to put that into play, there would be an enormous public outcry that people aren't allowed to choose.
 
Really, the most in danger is anesthesiology and family medicine. All the operations I've seen, the end of the table is mostly run by CRNAs and CRNA-trainees. The anesthesiologist shows up for 10 seconds, gives a thumbs up and leaves. Still, people have been predicting the end of anesthesiologist since the 90s, and the anesthesiologists have been laughing all the way to the bank. Same with radiology and concerns of outsourcing or computing advances in the 80s. Now everyone wants to be a radiologist.

Surgery is probably the safest, but only if you enjoy it anyway.
 
womp said:
Really, the most in danger is anesthesiology and family medicine. All the operations I've seen, the end of the table is mostly run by CRNAs and CRNA-trainees. The anesthesiologist shows up for 10 seconds, gives a thumbs up and leaves. Still, people have been predicting the end of anesthesiologist since the 90s, and the anesthesiologists have been laughing all the way to the bank. Same with radiology and concerns of outsourcing or computing advances in the 80s. Now everyone wants to be a radiologist.

Surgery is probably the safest, but only if you enjoy it anyway.
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On a related note, are anesthesiologist paid by procedure?
 
TMP-SMX said:
The country needs general surgeons more than any other specialty. Hospitals cannot function without them as they are probably the most important specialty in the hospital.
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Um, excuse me? Surgery is the most important specialty? I beg to differ. While there is certainly a great need for surgeons, that doesn't mean that those of us who chose to enter the primary care fields are doing anything less important. Can a patient's hypertension be managed by surgery? I don't think so, unless the patient has a pheochromocytoma or some adrenal cortical tumor. How many surgeons do you see arranging screening mammograms, Pap smears, or colonoscopies to catch cancer in the early stages before they become debilitating or deadly? Also, I doubt that many surgeons can manage a diabetic's blood sugars well enough to prevent them from going into DKA. Those of us who are in primary care help patients too. Just because we don't cut doesn't mean we can't cure or, at the very least, treat.
 
Top Gun said:
Um, excuse me? Surgery is the most important specialty? I beg to differ. While there is certainly a great need for surgeons, that doesn't mean that those of us who chose to enter the primary care fields are doing anything less important. Can a patient's hypertension be managed by surgery? I don't think so, unless the patient has a pheochromocytoma or some adrenal cortical tumor. How many surgeons do you see arranging screening mammograms, Pap smears, or colonoscopies to catch cancer in the early stages before they become debilitating or deadly? Also, I doubt that many surgeons can manage a diabetic's blood sugars well enough to prevent them from going into DKA. Those of us who are in primary care help patients too. Just because we don't cut doesn't mean we can't cure or, at the very least, treat.
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Ablation of the renal artery sympathetic plexus in intractable hypertension. J/k..plus IR will probably take that over..

Radiology is the most important field because they confirm most of the inpatient diagnoses, regardless of how confident one already is in the diagnosis....CHF exacerbation?? Well I guess so---the CT showed worsening perihilar infiltrates.
 
TMP-SMX said:
The country needs general surgeons more than any other specialty. Hospitals cannot function without them as they are probably the most important specialty in the hospital.
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Whats this probably business 😎

Top Gun said:
Um, excuse me? Surgery is the most important specialty? I beg to differ. While there is certainly a great need for surgeons, that doesn't mean that those of us who chose to enter the primary care fields are doing anything less important. Can a patient's hypertension be managed by surgery? I don't think so, unless the patient has a pheochromocytoma or some adrenal cortical tumor. How many surgeons do you see arranging screening mammograms, Pap smears, or colonoscopies to catch cancer in the early stages before they become debilitating or deadly? Also, I doubt that many surgeons can manage a diabetic's blood sugars well enough to prevent them from going into DKA. Those of us who are in primary care help patients too. Just because we don't cut doesn't mean we can't cure or, at the very least, treat.
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I try not to get involved in pissing matches, but damn...DKA! You don't have to read 20 endocrine journals a month to keep the blood sugar under 800.
 
Thanatos said:
Whats this probably business 😎



I try not to get involved in pissing matches, but damn...DKA! You don't have to read 20 endocrine journals a month to keep the blood sugar under 800.
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Well admittedly its not that hard to keep a patient from going into DKA. But managing chronic problems like DM tend to be more of an internist's area of expertise. Unless the diabetic decides to go for a pancreatic transplant.
 
Bah!

Surgery is not safe from midlevels, or from reimbursement cuts. What isn't taken by Interventional-Radiology/Cardiology/Pulmonology/Pain/Nephrology is being chipped away at by RNFAs, and PAs. RN-First Assistants have been around for a while, and are probably getting more privileges as RNs in general do.

Look at any journal of surgery. Half of the articles suggest that conservative non-operative management is as good as surgical management. Once the insurance companies start throwing the evidence back in the face of the surgeons, they are going to be told that they cant operate, and will not get paid.
 
Scaredshizzles said:
Ablation of the renal artery sympathetic plexus in intractable hypertension. J/k..plus IR will probably take that over..

Radiology is the most important field because they confirm most of the inpatient diagnoses, regardless of how confident one already is in the diagnosis....CHF exacerbation?? Well I guess so---the CT showed worsening perihilar infiltrates.
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A) Why on earth would you get a CT for CHF. And it's not infiltrates, it's congestion.

B) Any good surgeon, internist, emergency medicine physician, neurologist, orthopod, and any other number of fields knows how to interpret the imaging for their field. Of those, I'd say that emergency medicine probably needs the most help from the radiologists (especially given the broad spectrum of studies they order) but it's really important to be able to read your own films. It doesn't take a radiologist to diagnose a CHF exacerbation, an appy, diverticulitis, pneumonia, or a fracture in many/most cases. It's much better to view the radiologist as a consultant than as the sole master of radiologic diagnosis.

mmmcdowe said:
On a related note, are anesthesiologist paid by procedure?
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Some are, some are salaried. Practice structure varies.
 
SoCuteMD said:
A) Why on earth would you get a CT for CHF. And it's not infiltrates, it's congestion.

B) Any good surgeon, internist, emergency medicine physician, neurologist, orthopod, and any other number of fields knows how to interpret the imaging for their field. Of those, I'd say that emergency medicine probably needs the most help from the radiologists (especially given the broad spectrum of studies they order) but it's really important to be able to read your own films. It doesn't take a radiologist to diagnose a CHF exacerbation, an appy, diverticulitis, pneumonia, or a fracture in many/most cases. It's much better to view the radiologist as a consultant than as the sole master of radiologic diagnosis.
.
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Clearly you missed the sarcasm in my post.

Except on the infiltrates/congestion part....It is both in CHF exacerbations....You have pulmonary vascular congestion all the time, and you get spillover in the form of pleural effusion (or worsening effusion) and perihilar infiltrates in exacerbations.
 
So here's something that may shock you a bit --- I just finished a clerkship at a busy level 2 trauma ER. Take a WAG at who got
sent down when we needed a neurosurgery consult? Yep - PA-C
and he made the decisions (at least what I saw) about whether
to go/no-go to the OR. Pedi-surg? Yep, CPNP was down there
doing the decisions/making the call.....

I do NOT know whether they did the actual cutting, but I was kinda
surprised they were there. I've personally had some bad experiences
with NPs and, while I can develop an attitude quickly if I don't
watch it, the one's I've interacted with made me think 'Everyone
wants to be a doctor, but no one wants to go to med school'.......

Good topic and very timely.....I've got a lot of the same questions....
 
SoCuteMD said:
B) Any good surgeon, internist, emergency medicine physician, neurologist, orthopod, and any other number of fields knows how to interpret the imaging for their field. Of those, I'd say that emergency medicine probably needs the most help from the radiologists (especially given the broad spectrum of studies they order) but it's really important to be able to read your own films. It doesn't take a radiologist to diagnose a CHF exacerbation, an appy, diverticulitis, pneumonia, or a fracture in many/most cases. It's much better to view the radiologist as a consultant than as the sole master of radiologic diagnosis.
Click to expand...

Yeah, I am sure all those clinicians can interpret their imaging until they miss that lung nodule on a chest film or miss that mass in the pancreatic head on a CT they ordered for an appy and then find themselves in a court of law with an expert witness (i.e. radiologist) testifying about the 'standard of care'.
 
gluon999 said:
Yeah, I am sure all those clinicians can interpret their imaging until they miss that lung nodule on a chest film or miss that mass in the pancreatic head on a CT they ordered for an appy and then find themselves in a court of law with an expert witness (i.e. radiologist) testifying about the 'standard of care'.
Click to expand...

Really?

Are you in clinicals yet?

Clinicians interpret their own imaging all the time, and these sorts of mistakes don't happen. They act on what they see (i.e. what they ordered the imaging for in the first place). You dont need to be a radiologist to be able to see a pancreatic mass. Clinicans see enough imaging to get good at it, and especially so when they need to memorize the anatomy before they go in for a procedure. Gimmie a break.

If anything, they look at the official read later to make sure they didnt miss anything. Radiologists write useless reports nowadays "Right lung opacity suggestive of infiltrate vs. atelectasis. Pleural effusion can not be excluded. Pneumothorax can not be excluded. Recommend clinical correlation." And they dont say anything about some blatantly obvious and puzzling lesion elsewhere, nor do they mention the bullet stuck in the chest.

The clinicians have to march down to the reading room and talk to the radiologist if they want any useful information.
 
mmmcdowe said:
Journal: Troll carcass in alley this morning, banned for asking about prestige. This forum is afraid of me. I have seen its true face. The threads are extended gutters and the gutters are full of neuroticism and when the threads finally lock, all the vermin will flame. The accumulated filth of all their "MD vs DO?" and "Which school should I go to" will foam up about their waists and all the mods and admins will look up and shout 'Save us!' And I'll look down, and whisper 'Lol whut?'
Click to expand...

Sorry for the thread hijack (well not really) but that's the best sig I've ever seen.
 
howelljolly said:
Really?

Are you in clinicals yet?

Clinicians interpret their own imaging all the time, and these sorts of mistakes don't happen. They act on what they see (i.e. what they ordered the imaging for in the first place). You dont need to be a radiologist to be able to see a pancreatic mass. Clinicans see enough imaging to get good at it, and especially so when they need to memorize the anatomy before they go in for a procedure. Gimmie a break.

If anything, they look at the official read later to make sure they didnt miss anything. Radiologists write useless reports nowadays "Right lung opacity suggestive of infiltrate vs. atelectasis. Pleural effusion can not be excluded. Pneumothorax can not be excluded. Recommend clinical correlation." And they dont say anything about some blatantly obvious and puzzling lesion elsewhere, nor do they mention the bullet stuck in the chest.

The clinicians have to march down to the reading room and talk to the radiologist if they want any useful information.
Click to expand...


Am I in clinicals yet? Yes, I am 4th year. And I have seen enough attending clinicians mess up interpretations of images. Sure clinicians usually look at the images, but surgeons won't touch a patient without the radiologist's blessing. You think when a surgeon orders a CT for a r/o appy, he/she cares to look at every single other organ on the scan??? I don't think so. That is how lesions get missed and clinicians get sued. You think the ER is going to d/c a patient with headache before the radiologist gives the read on the head CT? Hell no!

And you are saying that the clinician's are better at reading images than radiologists? Then why don't they just start billing for it too? I am sure the jury would be sympathetic when the clinician misses the pre-cancerous lesion that they never bothered to look at. 🙄

The truth is, legal liability is so high that most attendings (ranging from IM to ER to surgeons, save trauma) will not make a decision about patient care until the radiologist tells them what the FINAL verdict is.
 
howelljolly said:
Bah!

Surgery is not safe from midlevels, or from reimbursement cuts. What isn't taken by Interventional-Radiology/Cardiology/Pulmonology/Pain/Nephrology is being chipped away at by RNFAs, and PAs. RN-First Assistants have been around for a while, and are probably getting more privileges as RNs in general do.
Click to expand...

Are you on drugs? RNFAs first assist. Hence the name. They're a RN with a few weeks of extra classes. Surgeons better also watch out for those scrub techs, they're probably going to start doing lap choles too!

For the most part surgeons are in a far better position for midlevel turf battles than most of the rest of medicine. But they're certainly not immune to reimbursement cuts, especially with the constant media drumbeat of "cut payment for procedures". But at least they can be reasonably sure their job will be similar in 20 years. I suspect in basic outpatient medicine the solo doc will be an anachronism replaced by one doctor overseeing several midlevels like in anesthesia.
 
gluon999 said:
Am I in clinicals yet? Yes, I am 4th year. And I have seen enough attending clinicians mess up interpretations of images. Sure clinicians usually look at the images, but surgeons won't touch a patient without the radiologist's blessing.
Click to expand...
Yes, they will. I saw it all the time on trauma surgery. The general surgeons also relied on their own interpretations of small bowel obstructions on CT. Of course you have a radiologist do a thorough read, but that doesn't mean you need them to hold your hand through every series of pictures.
 
TheProwler said:
Yes, they will. I saw it all the time on trauma surgery.
Click to expand...

Read my post above. I already mentioned it.

The general surgeons also relied on their own interpretations of small bowel obstructions on CT. Of course you have a radiologist do a thorough read, but that doesn't mean you need them to hold your hand through every series of pictures.
Click to expand...

There have been so many times when a surgeon asks for the radiologists report with the belly open and has the circulator read it for him/her. Heck, I just got off a shift where we consulted the cardiothoracic surgeon for a case and he comes down, looks at the CT scan, is not sure how to proceed with the patient and says "Lets swing by the radiology room" (the rads report wasn't back yet).
 
gluon999 said:
Is not.
Click to expand...

TheProwler said:
Is so.
Click to expand...

I think you guys need to realize that medicine is practiced differently in different institutions and by different people. Maybe the local culture in one place is that everyone waits for radiology's interpretation. That doesn't mean it's universal.

Generalizing from one or two experiences is a bad habit.
 
pseudoknot said:
I think you guys need to realize that medicine is practiced differently in different institutions and by different people. Maybe the local culture in one place is that everyone waits for radiology's interpretation. That doesn't mean it's universal.

Generalizing from one or two experiences is a bad habit.
Click to expand...


Exactly what I was going to say.

Where I am, everyone - from the surgeons, to the gastroenterologists, to the intensivists, to the oncologists, and even the ID guys - interprets their own imaging. Thats just the way it is here. Students, residents, and attendings just have the habit of looking at the images on system.

When I did CT surgery, nobody got cut unless the actual films (Imagine that!!!!) are up on the lightbox in the OR. Reading the written report to the surgeon in the OR? That would never happen here.

ICU rounds begins in the dark, with the team gathered around a PACS station. Each patients latest images gets looked at and compared to the previous day.

So, its cultural.
 
vasca said:
I kind of disagree with the second statement about lower economical groups being destinted to die. I live in a relatively poor country working in the hospital for the poor. Guess what? Those homeless people with appendicitis aren't dying like flies. The success rate for even complex appendicectomies even in older adults is very high. Some of the insanely complex surgeries have poor outcomes, but the patiet was already with several bad factors going for them and would have died even in the Mayo clinic. Our hospital has an insanely great cetoacidosis survival rate. I think I've only see one die and we get like 20-30 of em a month. Some doctors have told me that in other hospitals that actually have resources (lol) have insanely bad outcomes with cetoacidosis because the doctors creep out and put too much fluid at once. I've seen a guy with 1100 glucose talk and seemed like nothing was going on. One of my pals got a patient that won the month's record with over 1300 glucose and the patient did fine. We treat the injuries and diseases the higher up hospitals are too scared to treat and do our best. My dad once got a nasty hand injury that one of the finest private hospitals didn't want to treat. Had he gone to my place they would have fixed him in 20 minutes. I've fixed far worse injuries (gotta love Nylon 4-0) that most people would have told the patient was impossible to fix. More resources doesn't mean always better medicine. When you're exposed to the worst of the worst, you learn how to treat the worst of the worst and not be a chicken when a similar case pops up if you ever go to a high tech clinic. I'd wonder if the average Mayo Clinic doctor is familiar treating Chagas disease or hepatic abscesses. I've yet to see a Chagas because of the city I live in, but we get our hepatic abscesses every 2-3 months.
Click to expand...

Hepatic abscesses are certainly not uncommon here....A ratio shift in bacterial compared to amoebic abscesses of course, and they are managed differently, but in any case...

The outcomes difference I speak of based on SES has nothing to do with acute medical care actually, and it probably only has a little bit to do with primary care also....What you have to ask yourself is why do you see so much ketoacidosis where you are...Even if only 5% of patients are dying from it, that still adds up to be a lot of younger lives lost when you're seeing a lot more of that disease compared to higher SES places...There is a very significant gap in health outcomes between economic and racial classes in the United States, and I don't think anyone would say that it has mainly to do with the sort of medical care those people receive when they do go to a clinic or hospital...Rather it has to do with patient factors (genetic, psychosocial stressers perhaps) and also to do with access to care/when people actually decide to seek help.

I'll give you an example, and this doesn't even necessarily have to do with SES.... Aspirin cuts the risk of mortality after myocardial infarct by about 25%, and countless research dollars have been spent on finding superior antiplatelet drugs that can augment that efficacy---including one new medication (a reversible blocker of ADP activation) which beat out clopidogrel in a trial published in NEJM last week....However, there is a 50-100% increase in mortality following MI in patients who experience depression or anxiety in the following year...And yet no where near as much attention is paid to a factor like that...it isn't considered medicine.
 
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pseudoknot said:
I think you guys need to realize that medicine is practiced differently in different institutions and by different people. Maybe the local culture in one place is that everyone waits for radiology's interpretation. That doesn't mean it's universal.

Generalizing from one or two experiences is a bad habit.
Click to expand...

In my current program where I'm an EM resident, we read all our own plain films and very rarely wait for a radiology read before we act on it. Sometimes we'll request a wet read, but I'd say maybe 5% or less of the time? If the radiologist sees something that we miss on a discharge, our follow-up office takes care of it. The one time where we tend to ask for wet reads is on pediatric fractures where we suspect something more subtle. We do our own initial head CT and Chest CT reads, but we tend to wait for the radiologist read before acting on those, and same goes for the more complex ultrasounds that we send out for (as opposed to the ultrasounds we perform ourselves). Abd CT we are not as comfortable with at all, and always like at least the full wet read before we act on it. Emergency CT turnaround times are quite fast fortunately.

That's just an example of a wide variety within one department of what we read ourselves and dont' read ourselves. As pseudo said, it really depends on the culture of the place because I definitely know EDs that act similarly and differently.
 
Scaredshizzles said:
But the problem is, it is hard to quantify or reimburse this value that physicians have.
Click to expand...

I couldn't disagree more. I said a was a business professional, not clueless. Ask the guy having his heart replaced and see if he thinks his physician has a quantifiable skill set. And given the way my insurance provider arranges their reimbursement schedule, I'd say there was a pretty concrete fee set for every procedure I've ever had. The "value" of the MD is debatable, but not what's being argued - I'll admit that I've taken my kid to the doctor before just to have him reassure me that it's "just a cold" and not "leukemia." There is a peace of mind hearing it from a professional, but as long as others encroach upon this previously MD-reserved right, reimbursements are going to plummet.

Look, it seems pretty obvious that if MD's want to start/keep making a lot money in today's America, they're going to have to stop trading their time for money. Even if you are a surgeon, the minute you leave the OR, you're not making a dime.
 
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Usernamed said:
I couldn't disagree more. I said a was a business professional, not clueless. Ask the guy having his heart replaced and see if he thinks his physician has a quantifiable skill set. And given the way my insurance provider arranges their reimbursement schedule, I'd say there was a pretty concrete fee set for every procedure I've ever had. The "value" of the MD is debatable, but not what's being argued - I'll admit that I've taken my kid to the doctor before just to have him reassure me that it's "just a cold" and not "leukemia." There is a peace of mind hearing it from a professional, but as long as others encroach upon this previously MD-reserved right, reimbursements are going to plummet.

Look, it seems pretty obvious that if MD's want to start/keep making a lot money in today's America, they're going to have to stop trading their time for money. Even if you are a surgeon, the minute you leave the OR, you're not making a dime.
Click to expand...

Well yeah. You just argued against yourself.

It is not hard to quantify and reimburse a procedure. That is why your doctor has a "concrete fee set for every procedure".

What is hard to quantify and reimburse is, the value of expert advice, aka "the peace of mind [in] hearing it from a professional.

And this is precisely why cardiologists and gastroenterologists make money, and internists do not. Because Cards and GI do procedures, and internists give expert advice.
 
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Few good things can come from less intelligent/less educated people (RN's, etc.) assuming the role of a PCP. The most challenging thing in all of medicine is to be a GOOD PCP and we need the best and brightest among us to step up to that role. Downgrading the role of the PCP to essentially a triage nurse and then replacing it accordingly with a triage nurse is a big mistake. While we're at it, why not get rid of the PCP entirely and replace it with patient self-education via WebMD?
 
ropeadope1983 said:
Few good things can come from less intelligent/less educated people (RN's, etc.) assuming the role of a PCP. The most challenging thing in all of medicine is to be a GOOD PCP and we need the best and brightest among us to step up to that role. Downgrading the role of the PCP to essentially a triage nurse and then replacing it accordingly with a triage nurse is a big mistake. While we're at it, why not get rid of the PCP entirely and replace it with patient self-education via WebMD?
Click to expand...

Might drive down some expenses :laugh:
 
atkinsje said:
Might drive down some expenses :laugh:
Click to expand...


Unless of course it leads to more and more diseases creeping up and not being diagnosed/treated until patients are in a much more severe stage of disease. This would be a system failure in at least two ways (money and outcome).

The role of the PCP isn't just to send patients to specialists, it's also to do the things necessary to keep patients from needing to see a specialist.
 
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