Future of medicine

[Dermpath]

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Anyone think that specialties like IM, Peds, FM, etc will ever rebound, or will they always be at the bottom in terms of competitiveness, lifestyle and pay?

 

[Law2Doc]

Anyone think that specialties like IM, Peds, FM, etc will ever rebound, or will they always be at the bottom in terms of competitiveness, lifestyle and pay?

The (reimbursement) money is always going to be better for procedures or studies performed, not office visits. Since these fields charge based primarily on the visit, (which is often routine rather than ailment specific) instead of what they did to the patient, they will always lag in pay. The commonality of the fields that make better money is they are usually heavy on procedures and studies. In terms of lifestyle, again the fields that manage the patient rather than a specific problem are going to be more time intensive and thus not translate to a lifestyle field. You can only see so many pediatrics patients during the day, and many will still call you later for additional questions, because you are their primary doctor. But you can earn the same amount of money doing a half dozen colonoscopies in a third of the time, and the patients won't call you later, they will bother the referring IM doc. Which translates to a better lifestyle for the GI specialist. And so on. This is a simplistic response, but you get my point. If your job is time intensive and you have the role as the point of care, you can never hope to make as much money or have the same lifestyle opportunities as the specialist/proceduralist.

 

[mlw03]

Anyone think that specialties like IM, Peds, FM, etc will ever rebound, or will they always be at the bottom in terms of competitiveness, lifestyle and pay?

I think yes, unless these specialties disappear altogether and primary healthcare begins to be entirely performed by allied health professionals such as NPs and PAs, with MDs and DOs acting solely as specialists.

 

[carml]

The nice thing about specializing right now is that it pays a lot more. But with the current trends, it's hard to see the fee-for-service model still intact years out from now.

Already in the works now/in the near future are things like per-disease (not per service) reimbursements that has to be divided up between all parties involved in the care of that PT, value-based purchasing, managed care-like reimbursements, medical home models, rise in employed physicians, legislatively supported changes in allowable scope of practice of physician extenders, inability of many single private practitioners to compete with economies of scale of large groups/hospitals, etc.

Fairly or not, I think this might translate to a more equal compensation for all practitioners.

 

[Dermpath]

The (reimbursement) money is always going to be better for procedures or studies performed, not office visits. Since these fields charge based primarily on the visit, (which is often routine rather than ailment specific) instead of what they did to the patient, they will always lag in pay. The commonality of the fields that make better money is they are usually heavy on procedures and studies. In terms of lifestyle, again the fields that manage the patient rather than a specific problem are going to be more time intensive and thus not translate to a lifestyle field. You can only see so many pediatrics patients during the day, and many will still call you later for additional questions, because you are their primary doctor. But you can earn the same amount of money doing a half dozen colonoscopies in a third of the time, and the patients won't call you later, they will bother the referring IM doc. Which translates to a better lifestyle for the GI specialist. And so on. This is a simplistic response, but you get my point. If your job is time intensive and you have the role as the point of care, you can never hope to make as much money or have the same lifestyle opportunities as the specialist/proceduralist.

I think this is probably one of the most thought out responses I have received on this forum, so for that, thank you. I am not going into any of these fields, I was just curious given that I believe they are such important fields, yet so undervalued at the same time financially speaking and such few people are going into them.

 

[mlw03]

I think this is probably one of the most thought out responses I have received on this forum, so for that, thank you. I am not going into any of these fields, I was just curious given that I believe they are such important fields, yet so undervalued at the same time financially speaking and such few people are going into them.

It's this way because US society says it is. There is no intrinsic reason it has to be this way.

 

[flipmd]

How are specialists paid in countries with socialized medicine? How does it compare to PCPs?

 

[Darkskies]

Don't most residents in IM end up pursuing a specialty? What percentage of AMG internal medicine residents later complete fellowships in Cards,GI,Heme/Onc,Infectious Diseases, etc.?

 

[Dermpath]

Don't most residents in IM end up pursuing a specialty? What percentage of AMG internal medicine residents later complete fellowships in Cards,GI,Heme/Onc,Infectious Diseases, etc.?

Depends by program, but realistically, other than cards, GI, most fellowships don't pay that much. ID is notorious for low pay, as well as endo, rheum, hospice/palliative care, etc.

Heme/onc pays better, but still you are not seeing the numbers you are seeing in things like rad onc, rads, etc.

 

[Dermpath]

I have been thinking lately about this, and can't quite come up with an answer.

So obviously certain specialties like derm, rads, rad onc, and even anesthesia are quite competitive, mostly because of pay/lifestyle or a combo of both.

But when you look at all specialties, and even IM fellowships, don't things balance out quite a bit?

Doesn't lifestyle and $ improve quite a bit?

 

[smq123]

I have been thinking lately about this, and can't quite come up with an answer.

So obviously certain specialties like derm, rads, rad onc, and even anesthesia are quite competitive, mostly because of pay/lifestyle or a combo of both.

But when you look at all specialties, and even IM fellowships, don't things balance out quite a bit?

Doesn't lifestyle and $ improve quite a bit?

Similar to another thread that you started....merging.

 

[Dermpath]

Similar to another thread that you started....merging.

Sorry about that!

 

[Darkskies]

I have been thinking lately about this, and can't quite come up with an answer.

So obviously certain specialties like derm, rads, rad onc, and even anesthesia are quite competitive, mostly because of pay/lifestyle or a combo of both.

But when you look at all specialties, and even IM fellowships, don't things balance out quite a bit?

Doesn't lifestyle and $ improve quite a bit?

I'm having a hard time understanding this post.

 

[Mattchiavelli]

I think they won't really see a jump in pay compared to specialists, but I think the workload is going to change to reflect the salary and thanks to the hospitalist revolution that's possible

 

[mlw03]

How are specialists paid in countries with socialized medicine? How does it compare to PCPs?

Depends on the specialty obviously. In my very small subspecialty, most Canadians in that area make significantly more than their American counterparts. Don't know about salaries in my field in western Europe or Australia.

 

[Osteoimperfecta]

Primary care is close to a big rebound, while specialists are about to tank. It will not be a gradual process either. Congress will effect this change pretty darn soon. All the indications are pointing in that direction. If Obama wins, it will be accelerated.

 

[Law2Doc]

Primary care is close to a big rebound, while specialists are about to tank. It will not be a gradual process either. Congress will effect this change pretty darn soon. All the indications are pointing in that direction. If Obama wins, it will be accelerated.

Actually, Obama seems to embrace the idea of NPs providing the bulk of primary care at better pricing, so I wouldn't be too sure that specialists would take the bigger hit under his plan, although I agree all of medicine will take a hit to some degree. The problem with primary care under any uniform coverage plan is that you have to serve as gatekeeper for more people, and if you are at the same time going to try and pare down, not increase healthcare costs, that means seeing a lot more people at a fraction of the price. So instead of seeing, say, 50 patients a day at $10 per patient reimbursement (numbers are made up) you now have to see 100 patients a day at $4.90 per patient. This allows healthcare costs to go down while allowing more people into the system. But it means primary care has to work harder for less. Sure that trickles upstream to the specialist who can charge less too, but the impact is going to be lower, because doubling the patients at the primary care level doesn't double the number of referrals (it's still some fraction of that), and for some things, eg colonoscopies, mammograms, more patients plugged into the system actually means more money for specialists, even if the per procedure reimbursements are lessened. I'm not sure the Romney plan is any better though -- it looks like medicine is in for a change regardless. But primary care is on the front line, and in any onslaught the front line gets hit first and hardest.

 

[surftheiop]

Just a minor comment, it seems a lot of medstudents equate money with lifestyle, but really they can be pretty different.

For example, in general peds, they might not make more money than other specialties, but in general they have a pretty good lifestyle as a 4 day work week is typical and hospitalists do most of their inpatient coverage.

 

[dragonfly99]

I'm afraid I agree more with Law2doc. The gov't wants access to care, but the people organizing the changes and/or new system are unlikely to understand the nuances of medicine. I think they'll be likely to try to force primary care docs to see more patients in less time, and probably also increase the number of NP/PA types delivering care. And people do not understand that one big reason most physicians end up trying to avoid primary care is too much paperwork, too much crap from the hospitals, health plans, and some patients (entitled, noncompliant, etc.), too much stress, and not just the lower salaries. Someone commented above that general peds has a "nice lifestyle". I agree that it's better hours than a neurosurgeon, but the pay is not very good for the actual amount of hours they do...remember you have to count the time they spend answering patient phone calls (and now emails also!) and doing paperwork and writing clinic notes on their "off" day, because most of the ones I talk to can't get all that **** done during their scheduled clinic hours.

I think in socialized medicine countries, they tend to "make"/train a lower percentage of specialists, and sometimes there is less of a pay differential between a specialist and primary care doc. I have heard Canadian docs do pretty well, though. I know in Germany their physicians were protesting a couple of years ago because they were making about $70-80k/year US, or so I seem to remember...

 

[jettavr6]

The (reimbursement) money is always going to be better for procedures or studies performed, not office visits. Since these fields charge based primarily on the visit, (which is often routine rather than ailment specific) instead of what they did to the patient, they will always lag in pay. The commonality of the fields that make better money is they are usually heavy on procedures and studies. In terms of lifestyle, again the fields that manage the patient rather than a specific problem are going to be more time intensive and thus not translate to a lifestyle field. You can only see so many pediatrics patients during the day, and many will still call you later for additional questions, because you are their primary doctor. But you can earn the same amount of money doing a half dozen colonoscopies in a third of the time, and the patients won't call you later, they will bother the referring IM doc. Which translates to a better lifestyle for the GI specialist. And so on. This is a simplistic response, but you get my point. If your job is time intensive and you have the role as the point of care, you can never hope to make as much money or have the same lifestyle opportunities as the specialist/proceduralist.

Very well thought out post. However, there will be a breaking point at which time, concessions will be made to the primary care physicians. The compensation to cardiologists, gastros, radiologists are all going down due to somewhat of an over supply. Primary care doctors tend to pick their referral sources very carefully. For example, if I were a PCP and need to refer a patient to a gastro for eval/scope, would I choose the Gastro who also took the follow up calls or the one who just did the scope and dumped it back on the primary care doctor? Same goes for cardiology and other specialities.

Things change very quickly in medicine and it is very difficult to predict.

 

[lowbudget]

It's a numbers game, right now.

There needs to be more of a primary care base, and right now there's not enough (at least not distributed appropriately to cover the country's need). Flood gate will open up in 2014 when pay-or-play mandatory coverage goes into effect and access is increased. Primary care will be asked to take care of more and more patients. To help with the influx, NP/PA's are being asked to help. It's a quick-and-dirty approach, in my opinion, because opening access only adds the patients whom there is "pent up demand"... and these patients tend to be sicker or more neglected in terms of their medical care, which NP/PA's are not qualified to handle on a primary care standpoint. But much like rural medicine, a warm body is better than nobody.

These days, it's expensive to hire an NP. Because you have to cover their salary and cover the salary of the supervising physician. So either the growth of NP will be limited because of their cost, or NP's will achieve independence to make it cheaper to hire them. There's one caveat: patients who have choice still demand physicians for their care.

Since there is great need for primary care physicians, there will be a lot more slots for primary care residencies, which makes primary care less competitive if you go by numbers. Because there needs to be more primary care physicians, and there's only so much money that can go around, that pool of money will be divided amongst a large number of physicians, which makes pay relative low.

Lifestyle will depend on mechanisms of payment balanced against the needs of the community. Physicians will continue to do inpatient/outpatient medicine as long as the additional income from doing additional work is worth the time/energy/effort that is spent from doing that additional work. The current environment does not encourage this. But every individual is different and our current generation of newly-minted physicians grew up during relative periods of prosperity. Unfortunately, the cost of that prosperity was a lack of focus on the family. As a result, the current generation of young physicians desire to double back and re-focus on their families. With more women in medicine than ever before, the profession is pushed to re-examine its work-life balance (in a good way, in my opinion).

That said, I think there's a lot of people economically suffering out there right now and a lot of high schoolers and premeds will be seeking economic stability in medicine. Overall, medical school will become more and more competitive (even as more medical schools are opened) and residencies will become more and more competitive overall, as funding for residencies stay flat.

I think this current wave of lifestyle seekers will swing the other way, when those most effected by the current economic crisis, start entering medical school & residency. I think the wave of physician employment will swing to back towards smaller private practices (in the very distant future) and large big-box medicine will break up as it becomes more and more inefficient to operate when organizations get too large.

While it may be a numbers game right now, with push towards more care, bigger organizations, and higher patient volume, at *some* point, someone will ask the question, well what about quality?