Future of Cardiology

[bostonguy911]

I am worried about the field of cardiology. With the recent changes to medicare payments and cardiology taking the biggest hit, am wondering if it will be 'worth it' to pursue cardiology.

3 years internal medicine, 3-4 years fellowship. 7 years after medical school is daunting, esp when you know that compensation keeps decreasing. Yes, people will always need a cardiologist and they project a shortage, however I am second guessing entering the field. Many cardiologist I spoke to are disgruntled and say the field is not what it use to be. I am fine with that, but 40% reduction in pay?!? that is absolutely ridiculous. for the amount of training they go through, makes me question if I should pursue another field.

Are these changes that took place Jan 1, 2010 going to be reversed? I know the ACC is attempting to do something, but I do not see medicare reversing their policies on payment. Any comments on the current situation/future outlook?

---

Members don't see this ad.

 

[NDESTRUKT]

The whole point of going into cardiology is because it's cool!

 

[bostonguy911]

yes it is cool! i like a lot, but I could also equally like ortho a lot.
no one wants to hear that the salary of your future career is going to be cut in half. makes you step back. money and time are a factor. the time to train and the compensation are what makes cardio competitive. every field has their cycle. i would just like some perspective on the current situation.

 

[Myostatin]

Your concerns are valid. Compensation for physicians overall continues to decrease. It may be cardiology and radiology this year, but ortho may very well be a target a few years down the road. I think supply and demand will eventually overcome medicare cuts, and there's certainly a ton of demand in cardiology, with many new technologies/treatments in the pipline that will only increase demand further.

Ortho and cards are very different fields - if you're truly interested in cardiology, its unlikely that you'd enjoy ortho and vice versa. If your primary concern is compensation (and I'm not saying its wrong to want to be fairly compensated for your efforts), in all seriousness you should consider leaving medicine as we are certainly not failry compensated for effort - but as for the recent cuts to cards, I would not let that sway your decisions too much.

 

[josephf1]

I sympathize wth you dilema. Who wants to train more to make the same as a hospitalist working half the hours with no call. You are right to concern yourself with salary and the future. No one knows for sure what will happen, but here are what could happen so be prepared if you bite off 3 years of fellowship and expect half a million a year when you are done.
CONS: CMS cuts are here to stay, the ACC wont get this repealed. OVer the next 4 years as cuts are implemented it will get steadly worse. The feds are on to fat salaries and too many unnecesary caths and nuc scans. The chiching ends here. Expect private insurers to follow suite shortly. Cardiologists will have a hard time running their own practices in noninvasive. They will likely get sucked into hospitals and other larger and larger groups and while they may work less hours, will make less. Probably I would guess $250,000ish for noninvasive, as they do at the VA. W/o VA benefits.
PROS: Big demand for cardiovascular treatment considering everyone is fat and eats crap. New technology like Perc Valv replacements may pump up earnings for invasive (and send CT surgery salaries down another 30%, remeber when they were kings?). Lots of truf wars with IR to be expected as these and peripheral stenting moves along. CT and MRI heart will probably never take off now as a big money maker.
In SUM: Only do it if you love it, if you want to hit half a mil youll need to do invasive or EP or Gastro. If you stick with noninvasive, your basically a glorified internist who in addition to giving the exact same meds as same internist, can toss on a few now much lower reiombursing types of imaging studies and stress tests. PLus I guess Gastro will be wacked shortly.
I have analyzed all this over and over again and am now looking more towards an alternative fellowship allowing me to work shift work like critical care. This way they may screw us for money but at least Ill still have half a life. Besides, I think the way things are going Ill make more than noninvasive cards in many markets with no overhead and no need to build or buy in to a practice.
ITs hard for so many arrogant egotistical overacheiver cardiology types to really get it that they are now screwed but they probably did it to themselves creatign all these guidelines to justify there endless very expensive often uncessary workups, I mean why are we cathing every 93 year old in my hospital? Whats the point? COURAGE trial anyone? These people have been brainwashed to be cards so long they cant even consider another career choice as I see this year its also still very competitive to get into cardio. It wont be in another 4-5 years.

 

[surgery2121]

I predict that in the next 20 years we will have found some medicine that cures coronary artery disease or dramatically reduces it. What will all the cardiologists do then?

 

[tachycore]

To be able to develop such a drug assumes we have enough knowledge in atherosclerosis and thrombosis to do so.

We simply don't.

I hear about different drugs in the clinical trial pipelines and about different mechanisms being explored where I work. Although some look promising, none look like they will hit prime time for the masses in 20 years.

Even then. If we discovered such a regimen (highly unlikely monotherapy will work), a cardiologist knowledgeable about it would still be needed to tailor therapy.

And it's not like cardiology is about only coronary atherosclerosis (the biology of which fascinates me to no end). Some in this post have alluded to the wiring (EP), the valves and structure (interventional, imaging), heart failure, congenital and familial disease follow-up, etc. It's a very diverse field, which continues to evolve and to advance with a lot more evidence than other fields of medicine.

We aren't going to be out of a job any time soon.

No matter how much other fields might enjoy that.

Oh, and bostonguy911. Ask yourself what the most common pathology in cards, ortho, etc. you'll see. Then, ask yourself if you can still be interested in it after managing it thousands of time. If yes, those are your possible specialty choices. If no, reconsider entering that specialty.

 

[dragonfly99]

There's no guarantee that ortho isn't going to get hit with reimbursement cuts as well.
CMS may backtrack on some of the cardiology imaging reimbursement cuts, but not all the way, so yes, I do think salaries will stagnate. However, IMHO as a cardiology trainee it was kind of weird that noninvasive cards makes twice what an internist makes...so it was bound to happen I think.

 

[surgery2121]

To be able to develop such a drug assumes we have enough knowledge in atherosclerosis and thrombosis to do so.

We simply don't.

I hear about different drugs in the clinical trial pipelines and about different mechanisms being explored where I work. Although some look promising, none look like they will hit prime time for the masses in 20 years.

Even then. If we discovered such a regimen (highly unlikely monotherapy will work), a cardiologist knowledgeable about it would still be needed to tailor therapy.

And it's not like cardiology is about only coronary atherosclerosis (the biology of which fascinates me to no end). Some in this post have alluded to the wiring (EP), the valves and structure (interventional, imaging), heart failure, congenital and familial disease follow-up, etc. It's a very diverse field, which continues to evolve and to advance with a lot more evidence than other fields of medicine.

We aren't going to be out of a job any time soon.

No matter how much other fields might enjoy that.

Oh, and bostonguy911. Ask yourself what the most common pathology in cards, ortho, etc. you'll see. Then, ask yourself if you can still be interested in it after managing it thousands of time. If yes, those are your possible specialty choices. If no, reconsider entering that specialty.

20 years isnt a long time esp. if you are a med. student. It'll take me 9 years from now just to become a cardiologist. I know cardiology isn't only about coronary atherosclerosis but who are we trying to kid, CAD in some way is probably responsible for 95% of what cardiologists do. And it is likely that in the next 20 years even if we don't find a cure we would have found a way to dramatically reduce it. Anyway I usually become overly necrotic when picking specialties. I was talking to a friend of mine about this. He said people are mortals. If cancer isn't going to kill them chances are its likely going to be the heart. Even if I do decide to become a cardiologist I would be glad if they do discover a cure for CAD even if it does put me out of a job. It would probably increae the average life expectancy by at least 5 years.

 

[halodoctor]

To be able to develop such a drug assumes we have enough knowledge in atherosclerosis and thrombosis to do so.

We simply don't.

I hear about different drugs in the clinical trial pipelines and about different mechanisms being explored where I work. Although some look promising, none look like they will hit prime time for the masses in 20 years.

Even then. If we discovered such a regimen (highly unlikely monotherapy will work), a cardiologist knowledgeable about it would still be needed to tailor therapy.

And it's not like cardiology is about only coronary atherosclerosis (the biology of which fascinates me to no end). Some in this post have alluded to the wiring (EP), the valves and structure (interventional, imaging), heart failure, congenital and familial disease follow-up, etc. It's a very diverse field, which continues to evolve and to advance with a lot more evidence than other fields of medicine.

We aren't going to be out of a job any time soon.

No matter how much other fields might enjoy that.

Oh, and bostonguy911. Ask yourself what the most common pathology in cards, ortho, etc. you'll see. Then, ask yourself if you can still be interested in it after managing it thousands of time. If yes, those are your possible specialty choices. If no, reconsider entering that specialty.

I would like to comment that this is the single MOST helpful post I have EVER read on any blog. Tachycore, thank you.

 

[tachycore]

20 years isnt a long time esp. if you are a med. student. It'll take me 9 years from now just to become a cardiologist. I know cardiology isn't only about coronary atherosclerosis but who are we trying to kid, CAD in some way is probably responsible for 95% of what cardiologists do. And it is likely that in the next 20 years even if we don't find a cure we would have found a way to dramatically reduce it. Anyway I usually become overly necrotic when picking specialties. I was talking to a friend of mine about this. He said people are mortals. If cancer isn't going to kill them chances are its likely going to be the heart. Even if I do decide to become a cardiologist I would be glad if they do discover a cure for CAD even if it does put me out of a job. It would probably increae the average life expectancy by at least 5 years.

I'd love it if we weren't needed as doctors. So long as there are diseases, though, we'll always be in demand.

Let me rephrase what I said about promising drugs. NONE of the recent experimental prevention drugs have made it past Phase III, meaning NO therapeutic efficacy on hard outcomes (MI, stroke, cardiovascular death). Not even noninferiority. By experimental, I mean truly novel mechanisms like CETP inhibitors. Not variations on the tried and true (e.g. prasugrel, etc.). And some of those, you give as secondary prevention to reduce already elevated CV risk (they never quite return to baseline risk, but get close).

How long does it take even a promising drug to hit the market from Phase 0? About a decade. And this is a heavy duty pharmaceutical company dedicated to combing millions of candidate substances. Even then, it'll take another several more years of outcomes data to convince the FDA for approval, unless it really is a wonder drug. How long does it take to do even a simple cardiovascular study with 5 years follow-up? At least a decade, since you have to accrue and follow patients for a very long time.

Why do you think one of the biggest criticisms of JUPITER and ARBITER-HALT6 involved their short follow-up (~2 years patient follow-up for each, in spite of both lasting at least 5 years). For cardiovascular studies, it usually takes an extremely long time (we're talking at least a decade) to pick up enough events to power your study. Unless you're studying an extremely high risk population, and even then, the follow-up PER PATIENT has to be long (~3-5 years).

I already said a bit too much by mentioning knowing about pipeline drugs and had to censor myself from saying more.

I wasn't simply speculating on the lack of a miracle regimen. I have to keep up with the preventive cardiology world since this is my research area. Hard to ask, but trust me when I say don't expect any magic cure-all cocktail for humans for the next 20 years.

 

[dragonfly99]

There is kind of a magic cure-all cocktail for humans - it's called Mediterranean diet + exercise and not smoking. Only problem is, most humans don't want to take this cocktail (like me, as I sit here eating my vanilla ice cream and reading this web site instead of being out jogging...LOL!).

 

[tachycore]

There is kind of a magic cure-all cocktail for humans - it's called Mediterranean diet + exercise and not smoking. Only problem is, most humans don't want to take this cocktail (like me, as I sit here eating my vanilla ice cream and reading this web site instead of being out jogging...LOL!).

True you slow the rate, lower the risk, and help prevent the disease. But you don't necessarily halt it or reverse it.

None of those have been proven to regress the disease, though.

And do you really want to sit for IV infusions of de-lipidated HDL (also not proven)?

 

[bigtymer]

How competitive is a pediatric cardiology fellowship compared to a general cardiology fellowship coming off of IM?

 

[dragonfly99]

tachycore...CAD is basically a disease of Western society. I believe there was a study recently that looked at very old Amazon Indians or some other indigenous people and they couldn't find people dying of cardiovascular disease. However, I agree that once one had CAD, it's hard to totally reverse it with diet and exercise. However, I believe the Dean Ornish diet was found to be able to cause CAD regression? However, it's unlikely that many patients will ever stick to such a draconian vegetarian diet. It's hard to get most to get off their couches an exercise...even I'm kind of lazy about that, and I'm a former college athlete. Maybe it's just human nature to be lazy and want to eat fattening food. I'm munching on a candy bar right now...

 

[tachycore]

First, until IVUS arrived on the scene, the concept of plaque regression was in doubt. It wasn't until the emergence of REVERSAL and ASTEROID (middle of the 2000's decade) that we even entertained that it was possible.

Second, Dr. Dean Ornish makes some interesting points about pursuing extremely low-fat and essentially vegan diets. However, of his 60 citations in PubMed, I cannot find a single one that convincingly supports plaque regression. I prefer to stay away from a diet as controversial as that and stick with the Mediterranean and the tried and true.

Third, those indigenous populations have other things to worry about (e.g. infectious diseases and starvation) than cardiovascular disease and cancer. Old for them tends to be over 30/40 years (should have stated what that publication's definition of old was). One Indonesian study found that some indigenous populations (the Sudanese) have higher concentrations of Lp(a), a prothrombotic version of LDL and thus higher cardiovascular risk. If these populations do survive to our middle-age, I'm sure they'll start facing more of the same problems as Western populations.

Lastly, a good epidemiologist/preventive cardiologist tries to look at overall trends in a population, and view exceptions as indications of something else entirely happening.

 

[dragonfly99]

No, the "old" indigenous people I was talking about (who were studied) were actually old. I'm not talking about the people who died at age 30 or 40. But yes, many do die of other diseases in many such societies (infectious dz, etc.). And there will definitely be a lot more people in developing people dying of coronary dz and strokes if the medical systems in those countries don't improve. For example, 1st chapter in Braunwald's cardiology (major cards textbook) discusses the emerging threat of cardiovascular dz throughout the world. One of the major points made is that in many developing countries the population is increasingly becoming urbanized and sedentary and in many cases adopting a Western diet and becoming obese (for example Nigeria has a high proportion of obese women) and thus developing increased incidence of CAD and strokes. At the same time, many of these countries are still plagued by AIDS, malaria and other infectious diseases...so it's a disaster waiting to happen.

 

[tachycore]

My original point still stands: got to define what old is. All I got was the lower limit being 30/40 years.

My last point also stands: exceptions indicate something else going on requiring investigation.

I would have fully appreciated what the authors of that study speculated to be the cause, if you could provide at least a citation.

And your overall point does not disagree with mine. I do agree CVD is a disease of westernized societies that will only increase in incidence.

 

[Hudson]

Lets all remember that EVERYONE in the Courage trial got cathed. That is why we cath these people to, to rule out anatomy that definitely warrants intervention. Additionally, How many of your patients would be compliant with the medical regimen in courage? Maybe 5% of mine would, and even then a large majrity of them cross over to PCI. If your 93 yo is highly functional, has angina, and their coronary anatomy is unknown then they need a cath (in the abscence of a contraindication to the procedure). Read that trial more closely it is not as universally applicable as most have made it out to be. If you want o strictly apply the courage trial to a pt, then had better had a LHC first!

Someone else mentioned that they can't believe that Non-invasive cardiologist make 2x what Internist do. Well I can. I am an Board certified Internist as well and Cardiology Fellow. Outside of critical care, not much of what an internist does is difficult. Most Cardiologist were/are some of the best internist that came out of their respective programs and know more Internal medicine than a lot of the internist that consult them. You then read Echo/CT/Do diagnostic LHC/read and perform stress tests/do cardioversions/manage high risk cardiac conditions through pregnancy, read cardiac MR and Cardiac CT, and decide who goes to surgery and who ges to PCI, who needs a valve replaced/repaired and when and how, etc. Internist make none of these high level decisions and most of them punt to us ( understandably since we train for 3 additional years to learn how to mae these decisions) this is why I can easily see how a non-interventional cardiologist should get reimbursed significantly more than an Internist. Few Internist solve the problems of their pts without leaning heavily on specialists to do it for them.

 

[RySerr21]

Arent cardiologists making like 300-400K? Maybe i'm being naive, but is a 'drastic' paycut really that 'drastic?" A 200K+ salary isnt enough to live comfortably?

 

[scudrunner]

Arent cardiologists making like 300-400K? Maybe i'm being naive, but is a 'drastic' paycut really that 'drastic?" A 200K+ salary isnt enough to live comfortably?

Very naive.

Enough to live on? Yes. But only if you want to spread out student loan payment over 30 years (so that 200K ends up costing you 500K), while trying to pay off a house and vehicles, pay the monthly bills, save for your kids' college, and save for retirement (which has to be pretty significant due to such a late start).

Commensurate with length of training, skill, knowledge, and value of service? Not in my opinion.

 

[PhilIvey]

Very naive.

Enough to live on? Yes. But only if you want to spread out student loan payment over 30 years (so that 200K ends up costing you 500K), while trying to pay off a house and vehicles, pay the monthly bills, save for your kids' college, and save for retirement (which has to be pretty significant due to such a late start).

Commensurate with length of training, skill, knowledge, and value of service? Not in my opinion.

I agree. Kids (myself included) forget about their future obligations like school debt, house, etc.

 

[bronx43]

Very naive.

Enough to live on? Yes. But only if you want to spread out student loan payment over 30 years (so that 200K ends up costing you 500K), while trying to pay off a house and vehicles, pay the monthly bills, save for your kids' college, and save for retirement (which has to be pretty significant due to such a late start).

Commensurate with length of training, skill, knowledge, and value of service? Not in my opinion.

You don't think you can do all that on $200k? The only way you wouldn't be able to pay back your loans in 15-20 years, buy a house, cars, and save up is if you're living above your means as far as the house, cars, and credit card spending.

Do a little accounting. You can easily do everything you said on $200k if you're being reasonable with your purchases.

 

[scudrunner]

You don't think you can do all that on $200k? The only way you wouldn't be able to pay back your loans in 15-20 years, buy a house, cars, and save up is if you're living above your means as far as the house, cars, and credit card spending.

Do a little accounting. You can easily do everything you said on $200k if you're being reasonable with your purchases.

I didn't say it couldn't be done, it's just going to cost you more in the long run as far as loans and retirement go.

The main point of my post was in the last part.

 

[NightVision]

You don't think you can do all that on $200k? The only way you wouldn't be able to pay back your loans in 15-20 years, buy a house, cars, and save up is if you're living above your means as far as the house, cars, and credit card spending.

Do a little accounting. You can easily do everything you said on $200k if you're being reasonable with your purchases.

200K/yr - taxes (federal, state, social security, medicare, 401K) = 120K or less

= 10K/month

Monthly bills
-5K mortgage
-3 cars (you, wife, kids) = 2K/month (insurance, gas, maintenance)
-food (family of 4) = at least 1K
-student loan (for 80K over 10yrs, my monthly bill was 900/mo), most people have 200K or more = 1500/month

right there you're up to 9500/month w/o cell phones, electric/water bills, life insurance, clothes, going to the movie, toys, text books, vacation, tuitions................

for someone who gave up a lot of fun in high school, college, residency, fellowship....arguably the best years of your life, and now works 6days/wk, 10hr/day, high stress, fear of litigation like no other field..........I DON'T THINK 200K/YR IS ENOUGH

 

[bronx43]

200K/yr - taxes (federal, state, social security, medicare, 401K) = 120K or less

= 10K/month

Monthly bills
-5K mortgage
-3 cars (you, wife, kids) = 2K/month (insurance, gas, maintenance)
-food (family of 4) = at least 1K
-student loan (for 80K over 10yrs, my monthly bill was 900/mo), most people have 200K or more = 1500/month

right there you're up to 9500/month w/o cell phones, electric/water bills, life insurance, clothes, going to the movie, toys, text books, vacation, tuitions................

for someone who gave up a lot of fun in high school, college, residency, fellowship....arguably the best years of your life, and now works 6days/wk, 10hr/day, high stress, fear of litigation like no other field..........I DON'T THINK 200K/YR IS ENOUGH

5k mortgage... are you serious?? I mean... do you realize what a 5k mortgage gets you? Even if you put only 10% down, 5k/month mortgage means your house is over $1million. That's not living within your means.
A more reasonable mortgage would be 1.8-2.3k, which nets you a $400-500k house, using current interest rates. I'm sorry, but if you're intent on living in a 7 figured house, you're tough outta luck.

And 2k/month for cars? You have more leeway with this one, but that number is quite high if you're financing.

I'm not sure what you're expecting. It isn't easy to make $200k with other means, and certainly not with as much stability. I've never heard of someone hitting $200k in corporate by their early 30s, and even if they do, they're incredibly smart and lucky.

Medicine is a good deal, even at $200k. It's easy to think that the grass is greener on the other side, but as someone who worked in "business," I'm telling you it's not as rosy as you think it is.

 

[bronx43]

I didn't say it couldn't be done, it's just going to cost you more in the long run as far as loans and retirement go.

The main point of my post was in the last part.

Last part? You mean about the length of training, skill, knowledge, and value of service?

Well, let's see. The first three are the same thing, and I have to say that it's irrelevant on an economic level. The only thing that matters is whether or not you would go through with it for $200k/year. And that is what the crux of this discussion is about. And value of service can only be determined through supply and demand, which is intrinsically connected to the above question.

Putting things into perspective, what do you think you can do which can net you $200k/year by the time you're in your early 30s with as much stability as medicine?

 

[scudrunner]

Last part? You mean about the length of training, skill, knowledge, and value of service?

Well, let's see. The first three are the same thing, and I have to say that it's irrelevant on an economic level. The only thing that matters is whether or not you would go through with it for $200k/year. And that is what the crux of this discussion is about. And value of service can only be determined through supply and demand, which is intrinsically connected to the above question.

Putting things into perspective, what do you think you can do which can net you $200k/year by the time you're in your early 30s with as much stability as medicine?

How is that irrelevant on an economic level? In my opinion, more training should be justify a higher income. And supply and demand are at the heart of the issue, which supports my position. Don't get me wrong, I think 200K a LOT of money. My argument is based on the relative income of cardiology compared to primary care/hospitalist. I guess if you disagree with this, we'll have to agree to disagree.

Also, there is a huge difference between a net income of 200K and a gross income of 200K. I was thinking in terms of gross income when the 200K figure was thrown out there (are those not the figures most surveys use?), in which case you would only bring home about 130K after taxes. With 200K net, your actual gross income is a little over 300, which is a more appropriate wage for cardiology, and thus making our disagreement a moot point.

 

[scudrunner]

5k mortgage... are you serious?? I mean... do you realize what a 5k mortgage gets you? Even if you put only 10% down, 5k/month mortgage means your house is over $1million. That's not living within your means.
A more reasonable mortgage would be 1.8-2.3k, which nets you a $400-500k house, using current interest rates. I'm sorry, but if you're intent on living in a 7 figured house, you're tough outta luck.

And 2k/month for cars? You have more leeway with this one, but that number is quite high if you're financing.

I'm not sure what you're expecting. It isn't easy to make $200k with other means, and certainly not with as much stability. I've never heard of someone hitting $200k in corporate by their early 30s, and even if they do, they're incredibly smart and lucky.

Medicine is a good deal, even at $200k. It's easy to think that the grass is greener on the other side, but as someone who worked in "business," I'm telling you it's not as rosy as you think it is.

A 5K mortgage (ie principal/interest/tax/insurance in one monthly payment) is about what it takes to buy a 600-700K house. That is not overly extravagant when you are talking about an urban or suburban setting.

 

[bronx43]

How is that irrelevant on an economic level? In my opinion, more training should be justify a higher income. And supply and demand are at the heart of the issue, which supports my position. Don't get me wrong, I think 200K a LOT of money. My argument is based on the relative income of cardiology compared to primary care/hospitalist. I guess if you disagree with this, we'll have to agree to disagree.

Also, there is a huge difference between a net income of 200K and a gross income of 200K. I was thinking in terms of gross income when the 200K figure was thrown out there (are those not the figures most surveys use?), in which case you would only bring home about 130K after taxes. With 200K net, your actual gross income is a little over 300, which is a more appropriate wage for cardiology, and thus making our disagreement a moot point.

Nothing SHOULD justify a higher income other than the supply of a certain service or good. If enough IM docs are willing to do a cardiology fellowship for $200k, then that becomes the market value for a cardiologist. More training, in itself, doesn't entitle anyone to anything.
I'm not saying cardiologists should make $200k. I think that type of compensation would cause decreased supply of future cardios. I think a proper compensation should be around $250k, compared to $170k for primary care.

There is no way a $600k house should cost 5k/month in a 30 year mortgage, insurance, and property taxes. Do your math again.

 

[scudrunner]

Nothing SHOULD justify a higher income other than the supply of a certain service or good. If enough IM docs are willing to do a cardiology fellowship for $200k, then that becomes the market value for a cardiologist. More training, in itself, doesn't entitle anyone to anything.
I'm not saying cardiologists should make $200k. I think that type of compensation would cause decreased supply of future cardios. I think a proper compensation should be around $250k, compared to $170k for primary care.

There is no way a $600k house should cost 5k/month in a 30 year mortgage, insurance, and property taxes. Do your math again.

LOL, you haven't done the math. Here is a link to a mortgage calculator http://www.mortgagecalculatorplus.com/[FONT=Verdana, Geneva, Arial, sans-serif].. 700K house, loan for 600K, 30 yrs, 6.5% interest rate, 1.5% property tax, 0.5% PMI = $4,667 per month and that is NOT including insurance. BTW, taking 30 yrs to pay off a mortgage is foolish so that payment should be increased substantially.

So... what makes you think the "proper compensation" should be $250K for cardiologists?

 

[bronx43]

LOL, you haven't done the math. Here is a link to a mortgage calculator http://www.mortgagecalculatorplus.com/[FONT=Verdana, Geneva, Arial, sans-serif].. 700K house, loan for 600K, 30 yrs, 6.5% interest rate, 1.5% property tax, 0.5% PMI = $4,667 per month and that is NOT including insurance. BTW, taking 30 yrs to pay off a mortgage is foolish so that payment should be increased substantially.

So... what makes you think the "proper compensation" should be $250K for cardiologists?

First off, $700k house on $200k salary is not living within your means. The farthest you should stretch your salary is 3x for a home. To be financially responsible, you shouldn't do more than 2.5x. And 6.5% interest rate is only if you have terrible credit. My brother just refinanced his $500k house at 3.75% interest rate.
He's paying a bit under $2.5k/month for his mortgage.
My buddy, who just bought a house, got 4.5% with mediocre credit.

But, if you have terrible credit AND have only 10% down payment (both of which are the result of terrible financial planning), then purchasing the limit of your salary is asinine. The bottom line is that you can live in a damn nice home without decapitating yourself financially.

Either way, back to the compensation. The reason why cardiologists will and should be compensated $250k is that there will still be a steady stream of IM physicians willing to go into it at that salary. This is, of course, assuming that there will be cuts in compensation across the board. In fact, that's not as much an assumption as a reality at the moment.

Therefore, if there is a steady supply of cardiologists at $250k, then that's that's their market value. On the other end of the spectrum is primary care. They're underpaid, and the direct result is a shortage of PCPs. The recent 10% increase in Medicare reimbursement rates is a reflection of this.
If you go to Best Buy to buy a TV, you will want to pay the lowest price possible for the TV. Pay too much and you're wasting money. Pay too little, and the company won't produce the TV. Therefore, the market value of the product is the least amount you would pay, and still receive said product.

If your next argument is that people will stop going into medicine, altogether, then answer the question I posed before. What are you going to do to make $250k by your early 30s with as much stability as in medicine?

 

[tibor75]

You don't think you can do all that on $200k? The only way you wouldn't be able to pay back your loans in 15-20 years, buy a house, cars, and save up is if you're living above your means as far as the house, cars, and credit card spending.

Do a little accounting. You can easily do everything you said on $200k if you're being reasonable with your purchases.

You are right...it's funny to hear the whining from clueless people on here about "woe is me! How will I ever survive on 200K!!!"

Please. If that was the case, nobody would go into academics.

The fact is there is such a thing as monthy payments. And such a thing as 529 plans.

How do people survive on 100K salaries? Gee, they save money and don't live beyond their means.

But such things are out of the realm of knowledge of greedy cardiologists.

 

[scudrunner]

First off, $700k house on $200k salary is not living within your means. The farthest you should stretch your salary is 3x for a home. To be financially responsible, you shouldn't do more than 2.5x. And 6.5% interest rate is only if you have terrible credit. My brother just refinanced his $500k house at 3.75% interest rate.
He's paying a bit under $2.5k/month for his mortgage.
My buddy, who just bought a house, got 4.5% with mediocre credit.

But, if you have terrible credit AND have only 10% down payment (both of which are the result of terrible financial planning), then purchasing the limit of your salary is asinine. The bottom line is that you can live in a damn nice home without decapitating yourself financially.

Either way, back to the compensation. The reason why cardiologists will and should be compensated $250k is that there will still be a steady stream of IM physicians willing to go into it at that salary. This is, of course, assuming that there will be cuts in compensation across the board. In fact, that's not as much an assumption as a reality at the moment.

Therefore, if there is a steady supply of cardiologists at $250k, then that's that's their market value. On the other end of the spectrum is primary care. They're underpaid, and the direct result is a shortage of PCPs. The recent 10% increase in Medicare reimbursement rates is a reflection of this.
If you go to Best Buy to buy a TV, you will want to pay the lowest price possible for the TV. Pay too much and you're wasting money. Pay too little, and the company won't produce the TV. Therefore, the market value of the product is the least amount you would pay, and still receive said product.

If your next argument is that people will stop going into medicine, altogether, then answer the question I posed before. What are you going to do to make $250k by your early 30s with as much stability as in medicine?

OK, I was refuting the fact that you claimed that my math was off, which it wasn't. A 700K house will cost 5K/mo or close to it, even if you get a better interest rate. The fact that you say that it is living beyond ones means is only relevant IF you are only bringing home 130K (grossing 200K). And don't get me wrong again, I'm not advocating that one should buy as much house as possible. This issue is digressing so I'm done with the house issue.

Following up to one of your other assertions, why do think that we would have a shortage of cardiologists at 200K but not at 250K? Is this just speculation? I suspect it is since there really is no evidence to support it. Sure there are academics who do it for that amount, but they carry only a small fraction of the cardiology work load, and actually want to be in academia/research, not private practice. So, since their motives are different, you need another incentive (in private practice) for spending an extra 3-4 years in training, otherwise you'll end up with a huge shortage.

I think that we can universally agree that 200K is a darn nice income and plenty to live on. Going back to what I said originally, in my OPINION cardiologists DESERVE a better compensation for their extra training.

Also, as stated in another thread, many of us will be in our late thirties (38-39), not early thirties, by the time we finish up.

Are you planning on going into cardiology? Seems strange that you'd be advocating a pay cut for yourself.

 

[bronx43]

OK, I was refuting the fact that you claimed that my math was off, which it wasn't. A 700K house will cost 5K/mo or close to it, even if you get a better interest rate. The fact that you say that it is living beyond ones means it only relevant IF you are only bringing home 130K (grossing 200K). And don't get me wrong again, I'm not advocating one to buy as much house as possible. This issue is digressing so I'm done with the house issue.

Following up to one of your other assertions, why do think that we would have a shortage of cardiologists at 200K but not at 250K? Is this just speculation? I suspect it is since there really is no evidence to support it. Sure there are academics who do it for that amount, but they carry only a small fraction of the cardiology work load, and actually want to be in academia/research, not private practice. So, since their motives are different, you need another incentive (in private practice) for spending an extra 3-4 years in training, otherwise you'll end up with a huge shortage.

I think that we can universally agree that 200K is a darn nice income and plenty to live on. Going back to what I said originally, in my OPINION cardiologists DESERVE a better compensation for their extra training.

Also, as it has been stated earlier in the thread, many of us will be in our late thirties (38-39), not early thirties, by the time we finish up.

Are you planning on going into cardiology? Seems strange that you'd be advocating a pay cut for yourself.

Yeah, it's basically speculation. But, I think with the way things are going, it's the way it'll be. There have been cuts across the board for specialists in the past couple of years, and there's no reason to believe there won't be more coming.
The problem with medicine is that as long as physicians are getting paid in the upper middle class range, there won't ever be a shortage of medical school applicants. As much as doctors threaten to stop working if pay keeps dropping, it's an empty threat at best. The data all show an increased workload in the face of decreased reimbursement. The reason is that doctors aren't just going to give up their income. They still have mortgages, car payments, retiring savings, and a family to support. And since doctors can't go on strike, they have no other choice but to work more. However, there will be a threshold where they simply can't put any more hours in, and that's when you'll see a real drop in compensation.

I'm currently looking over my options and trying to decide what field I want to go into. I'm doing it, however, with the mindset that current reimbursement rates aren't going to stay stagnant, due to economic pressures. I never said cardiologists shouldn't make a certain amount, because the discussion of "should" can never be anything more than idle musings. I'm just telling it like I see it from an objective perspective. My viewpoint was simply that due to simple economics and the special circumstance that physicians are in, it's inevitable that incomes are going to drop. Whether me, you, or anyone in cardiology likes it or not is entirely irrelevant.
But, my interest in cardiology goes beyond the pay. I'm considering it regardless of $200k or $300k.

 

[josephf1]

you guys are really lowballing a high payhing field. Shees, VA cardiologists can make 250 and interventional there 350.
Keep in mind the overall cuts to cards with CMS is predicted to be about 11%. Thats prior to new technologies coming down the pike. ANd cards guys are smarts, how long do you think before CT/MRI becomes a Ia guidline recommendation for chest pain rule outs.
The cardsiologists I knwo that are partners in NONINVASIVE make 600-800K so a 11% cut will put them no where near 200. I think you are all way off.
Shees, hospitalist jobs are starting well over 200 now, just check my inbox.
Also, just do some math. Lets say yo see 30 pts a day each with a $50 co pay.
Thats $1500 CASH before the insurance company pays you whatever crap they pay, lets say another $100-200 per pt depending on what you do (ECG, NST, ECHO), thats another 5000-10000 a day. Multipley that by 4 days a weel, maybe 20K and thats 80K per month and almost a millions a year. After taxes, insurance, etc, that should come to at least 300K or you got way to many office chicks. And that doesnt include procedures. And rounding. And preop evals. And TEEs. And nuchs. And Cardioversions...

 

[scudrunner]

you guys are really lowballing a high payhing field. Shees, VA cardiologists can make 250 and interventional there 350.
Keep in mind the overall cuts to cards with CMS is predicted to be about 11%. Thats prior to new technologies coming down the pike. ANd cards guys are smarts, how long do you think before CT/MRI becomes a Ia guidline recommendation for chest pain rule outs.
The cardsiologists I knwo that are partners in NONINVASIVE make 600-800K so a 11% cut will put them no where near 200. I think you are all way off.
Shees, hospitalist jobs are starting well over 200 now, just check my inbox.
Also, just do some math. Lets say yo see 30 pts a day each with a $50 co pay.
Thats $1500 CASH before the insurance company pays you whatever crap they pay, lets say another $100-200 per pt depending on what you do (ECG, NST, ECHO), thats another 5000-10000 a day. Multipley that by 4 days a weel, maybe 20K and thats 80K per month and almost a millions a year. After taxes, insurance, etc, that should come to at least 300K or you got way to many office chicks. And that doesnt include procedures. And rounding. And preop evals. And TEEs. And nuchs. And Cardioversions...

Are cardiologists able to read their own CT/MRIs (and thus bill for it)? Or does it have read by a radiologist?

 

[punjabiMD]

Are cardiologists able to read their own CT/MRIs (and thus bill for it)? Or does it have read by a radiologist?

http://www.acc.org/advocacy/pdfs/rc_imagingacccttrainingchart.pdf

couldn't find a link for cardiac MRI, but I assume it is similar. Level III for both, I believe, means that you can run your own CV imaging center. Level II, I believe qualifies you to read and bill.

CT and MRI are different beasts, however. CV MRI, while offering some ground-breaking insight into structural disease, is very technically advanced and labor-intensive work. Still exciting stuff, though, and I see MRI becoming a major player, even becoming almost as routine as echo.

 

[RySerr21]

you can also expect income from your spouse, to help pay for all of these financial burdens.

 

[caspian]

I'm sure the future cardio "doctors" fresh from their DNP residencies will be more than thrilled to handle some of those bread and butter CAD cases making 95% of your case load.
I bet they would also do it for 200K. Hell, 150K.

From http://health.usf.edu/nocms/nursing/AdmissionsPrograms/dnp_concentrations.html

The USF College of Nursing has established selected, broad, supervised residency concentrations designed to meet each resident’s individualized professional and clinical practice goals. Each clinical residency concentration is a variable credit tract with a minimum requirement of 500 clinical hours beyond the Master’s level clinical hours. The Dermatology and Cardiovascular residency concentrations require a minimum of 1000 hours beyond the Master’s level clinical hours. Residency concentrations are broadly defined by the following clinical specialties:

Dermatology*
Cardiovascular
Family Practice
Occupational Health *
Internal Medicine
Endocrinology
Neurology/Pain Management
Psychiatry
Pediatrics
Neonatology
Emergency Medicine
Acute Care

* Additional criteria may be required for admission

 

[scudrunner]

http://www.acc.org/advocacy/pdfs/rc_imagingacccttrainingchart.pdf

couldn't find a link for cardiac MRI, but I assume it is similar. Level III for both, I believe, means that you can run your own CV imaging center. Level II, I believe qualifies you to read and bill.

CT and MRI are different beasts, however. CV MRI, while offering some ground-breaking insight into structural disease, is very technically advanced and labor-intensive work. Still exciting stuff, though, and I see MRI becoming a major player, even becoming almost as routine as echo.

How do you complete these different levels of training? Does the ACC offer classes?

 

[dragonfly99]

It's done during cardiology fellowship. Level 1 is very basic, minimal training that all cardiology fellowships are required to offer. Level 2 is the training level you need to "do" anything (Level 2 echo means you are qualified to read an echo, Level 2 cath means you can do a diagnostic cath, level 2 TEE means you can do/perform a transesophageal echo). Level 3 means you can supervise/run things (Level 3 nuclear can supervise your own nuclear lab, level 3 echo you can be the echo lab supervisor, etc.). Realistically it is hard to get Level 3 in anything without doing an extra fellowship year (at least at my program). Or, if you want to be level 3 in something like echo, you have to give up all your cath months during 3rd year or something. In other words, you can be Level 2 in several things and then go into private practice, or you can be Level 1 in stuff and Level 3 in one thing and then go into academics.

For many of these areas you aren't allowed to be certified after you have finished fellowship (i.e. if you don't get past Level 2 in echo or cath during fellowship, you can't just take some class and get certified later). For nuclear and CT I think you can still go for extra training/classes to get certified postfellowship, but the powers that be are thinking of doing away with this.

 

[scudrunner]

It's done during cardiology fellowship. Level 1 is very basic, minimal training that all cardiology fellowships are required to offer. Level 2 is the training level you need to "do" anything (Level 2 echo means you are qualified to read an echo, Level 2 cath means you can do a diagnostic cath, level 2 TEE means you can do/perform a transesophageal echo). Level 3 means you can supervise/run things (Level 3 nuclear can supervise your own nuclear lab, level 3 echo you can be the echo lab supervisor, etc.). Realistically it is hard to get Level 3 in anything without doing an extra fellowship year (at least at my program). Or, if you want to be level 3 in something like echo, you have to give up all your cath months during 3rd year or something. In other words, you can be Level 2 in several things and then go into private practice, or you can be Level 1 in stuff and Level 3 in one thing and then go into academics.

For many of these areas you aren't allowed to be certified after you have finished fellowship (i.e. if you don't get past Level 2 in echo or cath during fellowship, you can't just take some class and get certified later). For nuclear and CT I think you can still go for extra training/classes to get certified postfellowship, but the powers that be are thinking of doing away with this.

Good to know, thanks for the info.

 

[sevo85288]

you guys are really lowballing a high payhing field. Shees, VA cardiologists can make 250 and interventional there 350.
Keep in mind the overall cuts to cards with CMS is predicted to be about 11%. Thats prior to new technologies coming down the pike. ANd cards guys are smarts, how long do you think before CT/MRI becomes a Ia guidline recommendation for chest pain rule outs.
The cardsiologists I knwo that are partners in NONINVASIVE make 600-800K so a 11% cut will put them no where near 200. I think you are all way off.
Shees, hospitalist jobs are starting well over 200 now, just check my inbox.
Also, just do some math. Lets say yo see 30 pts a day each with a $50 co pay.
Thats $1500 CASH before the insurance company pays you whatever crap they pay, lets say another $100-200 per pt depending on what you do (ECG, NST, ECHO), thats another 5000-10000 a day. Multipley that by 4 days a weel, maybe 20K and thats 80K per month and almost a millions a year. After taxes, insurance, etc, that should come to at least 300K or you got way to many office chicks. And that doesnt include procedures. And rounding. And preop evals. And TEEs. And nuchs. And Cardioversions...

you are joking right? MGMA median for Cardiology Invasive is 350-450 depending on geography and years out of training. $600-800K is what they bill and the account receivable. Cards has a 45% overhead. So 300-400K is the income before taxes but after overhead.

 

[Ashrouf]

I'm sure the future cardio "doctors" fresh from their DNP residencies will be more than thrilled to handle some of those bread and butter CAD cases making 95% of your case load.
I bet they would also do it for 200K. Hell, 150K.

From http://health.usf.edu/nocms/nursing/AdmissionsPrograms/dnp_concentrations.html

The USF College of Nursing has established selected, broad, supervised residency concentrations designed to meet each resident’s individualized professional and clinical practice goals. Each clinical residency concentration is a variable credit tract with a minimum requirement of 500 clinical hours beyond the Master’s level clinical hours. The Dermatology and Cardiovascular residency concentrations require a minimum of 1000 hours beyond the Master’s level clinical hours. Residency concentrations are broadly defined by the following clinical specialties:

Dermatology*
Cardiovascular
Family Practice
Occupational Health *
Internal Medicine
Endocrinology
Neurology/Pain Management
Psychiatry
Pediatrics
Neonatology
Emergency Medicine
Acute Care

* Additional criteria may be required for admission

This is a sad sad day for the field of medicine that corner cutting can take place in plain sight. Since when a nursing degree can replace an MD/DO. I am beyond bothered to see the state of medicine. DNP's and NP's can just replace physicians. Economics run medicine, and a hospital would love to hire an NP/DNP instead of an MD/DO any time of the day.

 

[Ash MD]

You're missing the central issue: "Who can I sue and how much can I get?"

You cannot sue an NP or PA=you'll get peanuts.

Physicians are the hangmen=you'll get a truckload of peanuts.

Physicians and their duties will never go away-we're currently the only peeps you can squeeze money out of.

Period.

 

[GoLytely]

This is a sad sad day for the field of medicine that corner cutting can take place in plain sight. Since when a nursing degree can replace an MD/DO. I am beyond bothered to see the state of medicine. DNP's and NP's can just replace physicians. Economics run medicine, and a hospital would love to hire an NP/DNP instead of an MD/DO any time of the day.

I disagree that they can simply replace us. I'd predict that their efforts will do nothing but create two sharply-defined tiers of quality in medicine. Most patients will end up seeing the midlevel, and, so long as some degree of private practice is still legally allowed, those who can afford to do so will see the MD or DO. This could even potentially isolate us from the government's mess and turn it on the NPs.

These nurses are being very careless here, failing to see that their position is already a good one. All that's left for them if they push onward is to find themselves stuck with more of our problems, sans respect and sans high income.

 

[sevo85288]

You're missing the central issue: "Who can I sue and how much can I get?"

You cannot sue an NP or PA=you'll get peanuts.

Physicians are the hangmen=you'll get a truckload of peanuts.

Physicians and their duties will never go away-we're currently the only peeps you can squeeze money out of.

Period.

Not true. The NPs and PAs have even bigger pockets b/c they are direct agents of hospitals or clinics; they also have a "supervising" doc who will get sued.

 

[radiodoc99]

Cath lab in 2012 will look amazing with new technology:
http://www.theheart.org/documents/sitestructure/en/content/programs/1046995/1046995.html

Also with heart failure fellowships growing, there is ample opportunity for research. Cardiology is going to be one of the greatest fields with new research in genomics and new devices.

 

[punjabiMD]

How do you complete these different levels of training? Does the ACC offer classes?

sorry, I just saw this. I believe level II certification is based on numbers. So it's best to train at an institution that has a heavy load of cardiac CT/CMR and faculty (radiology, cardiology, or both) whom are willing to supervise your training. I believe level III is also based on numbers and some additional training:

http://www.scct.org/credentialing/scct_verification_program_info_and_app_level3.pdf

can't find a link for CMR. However, it seems the best route for CMR (and probably cardiac CT), to be level 3 is to do a 1-year CV imaging fellowship.