Future of Rads vs Ortho??

This forum made possible through the generous support of SDN members, donors, and sponsors. Thank you.

cbtk18

Full Member
15+ Year Member
Joined
Mar 23, 2006
Messages
504
Reaction score
44
I know they are both in the crosshairs of cuts to a degree but I figured I would ask the SDN opinion: which specialty is most sustainable at current levels? Which is more vulnerable to cuts? Which has more opportunity for growth?

Members don't see this ad.
 
I know they are both in the crosshairs of cuts to a degree but I figured I would ask the SDN opinion: which specialty is most sustainable at current levels? Which is more vulnerable to cuts? Which has more opportunity for growth?

I would say Rads is more vulnerable. I think procedural specialties overall are less prone to cuts. But I'm also a little biased. :)
 
Members don't see this ad :)
I know they are both in the crosshairs of cuts to a degree but I figured I would ask the SDN opinion: which specialty is most sustainable at current levels? Which is more vulnerable to cuts? Which has more opportunity for growth?

How can you talk about cuts and lack of sustainability in the same post as opportunity for growth? Unless you mean "growth" to be "advancements," in which case, I would think radiology has more potential in that respect.

In 5-10 years time, neither specialty will be what it is today, but radiology might come back down to Earth first. The main fear I would have with ortho (if I was going into ortho) is the collapse of demand from public sector patients - Medicare. And by "demand," I don't mean that patients wouldn't want it, but that there would be far stricter criteria for these types of procedures. Orthopedics is a very good size chunk of Medicare spending annually, and very few of their services are life or death in nature. When push comes to shove for American health care (or health care anywhere for that matter), nature will overrule; necessary care will always trump luxury or quality-of-life care.
 
Both specialties are going to be just fine. I think they're different enough career paths that you should focus more on which one you enjoy more since I think the gap between the specialties 'financially' won't be that significant.
 
Both specialties are going to be just fine. I think they're different enough career paths that you should focus more on which one you enjoy more since I think the gap between the specialties 'financially' won't be that significant.

By 'financially' do you mean financially? If so, I agree.
 
The two fields are very different. You should pick the one that matches your personality best.

As for radiology, I think that it has a bright future. Here are some of my thoughts.

In the near term, I see three areas of potential growth for radiology. Virtual colonoscopy is coming and I believe that it will become a popular screening method. If so, radiologists may begin doing colonoscopies since they will have a map of the colon and know exactly where to go to find that polyp. If FP, general surgeons, and GI can do them, why can't radiologists do them too since they are trained to do procedures like central lines, G-tube placements, biopsies, drains, etc? Second, cardiac CTA will explode if clinicians in the ED and floors begin to order them. You'll start seeing requests from ED docs to rule out CAD, PE, aortic dissection, pneumothorax, etc for chest pain. For a decade, cardiology tried to take cardiac CTA from radiology but they were hamstrung by the fact that they can't read non-cardiac parts. That's why cardiologists always needed a second read by a radiologists to look at the lungs. Cardiac CTA also was not that popular because cardiologists mostly ordered them. Now that everyone will order them, cardiology can no longer control the workflow and radiology greatly benefits from this since only radiologists can read the entire scan. Third, CT lung cancer screening is coming. They are still hammering out the guidelines but you can bet that because CT is the only proven life-saving screening tool for the #1 cancer in this country that it is inevitable. The last point leads me back to my previous ones. Once the guidelines for CT lung cancer screening are established, do you think that anyone but a radiologist is gonna want to touch a CT study where the lungs (most common cancer) are included (ie, cardiac CTA)? It would be a legal minefield. That's why only radiologists read mammo studies. It's the same thing with virtual colonoscopies. There is so much that goes in the abdomen that only radiologists can fully read it. The abdomen is another legal minefield.

All three areas are huge markets and will provide plenty of work for radiologists for years to come.

CT Colonography Shown to be Comparable to Standard Colonoscopy for People Ages 65 and Over

Coronary CT Angiography Safe, Time Saving, and More Effective than Traditional Care for Evaluating Patients Arriving at Emergency Department with Chest Pain

NIH-funded study shows 20 percent reduction in lung cancer mortality with low-dose CT compared to chest X-ray
 
I was simply asking if you meant something else, due to the quotation marks around "financial."

nah, just for emphasis cuz I was on my iphone and playing around with the italics feature is too cumbersome
 
I thought virtual colonoscopy was dead on arrival. Medicare decided to not reimburse for it, and my understanding is that those companies that do pay for it only reimburse about the same as an abdomen CT. Considering that VCs are a ***** to read, there's little incentive to the radiologist to spend time reading one VC when they can read 3-4 abdominal CTs over the same period. They also take up a ton of storage space on servers.
 
Officedepot,

It wouldn't be a primary screening recommended for the entire population. It'd most likely be similar to the abdominal ultrasound screening for male smokers or ex-smokers ages 65-75. They'd just set up standards for it.

I have no clue as to whether it will happen, but if it did, it wouldn't be the entire US population.
 
Members don't see this ad :)
Great points all around. It would certainly seem reasonable that minimally invasive screening would be more advantageous aand desired.

I am currently doing an RFA project on primary tumor and the outcomes are pretty shocking. (In a good way).
 
I thought virtual colonoscopy was dead on arrival. Medicare decided to not reimburse for it, and my understanding is that those companies that do pay for it only reimburse about the same as an abdomen CT. Considering that VCs are a ***** to read, there's little incentive to the radiologist to spend time reading one VC when they can read 3-4 abdominal CTs over the same period. They also take up a ton of storage space on servers.

Yes, VC can be a pain in the ass to read, but what if you tack on extra stuff? Imagine it. You have the patient in the waiting room. The patient already had a bowel prep to get the VC. You find a 1 cm polyp. Are you going to send this patient to GI so that they can fetch it -- and collect the fee? Are will you do the colonoscopy yourself and collect the fee? Doing it yourself changes the financial equation. VC may become one of the most lucrative areas in radiology.

The current model is a joint operation between radiology and GI. Radiology reads the VC and then GI does the scoping if polyp is found. But why do you need GI to do the scoping? If FP and general surgeons do scoping, it's ridiculous to me that radiology can't do them too. IR does some pretty invasive procedures like G-tube placements, PTC, neph tubes, embolizations, etc. To a lesser extent, general radiologists do invasive procedures like drains, biopsies, central lines, etc. There's no reason why radiologists can't do scoping as well, especially if they have a map of the colon from the VC. I would bet that there will be sevral radiologists who see it the same way I do and begin to learn how to scope.

The converse is, can GI learn how to do VC and take it away from radiology? I don't think so. The abdomen is very complex. So many different systems. There's the GI tract, kidneys, liver, vessels, etc. If the abdomen was so easy to read, GI or general surgery would have taken abdomen work away from radiology a long time ago like how cardiology took away cardiac nucs. Unlike MSK plain films, I have never had one instance where a non-radiologist told me that they read the abdomen CT and don't need the radiologist report.

What I have realized about radiology is that there are turf battles that it will lose simply because we don't control the patient. For example, cardiac nucs and heart stenting; peripheral vascular work and vascular surgery; neurointerventional work and neurosurgery. It's difficult to say that you're better than a subspecialist who focuses on just one system all day. For example, orthopedic surgeons and bone plain films; neurosurgeons and neuro CT's. Radiology has two refuges. The first refuge is find body areas where there is a lot of "extra" stuff like lung fields when you're just interested in the heart or the rest of the abdomen when you're just interested in the GI tract. Unfortunately for neuroradiology, there's not much "extra" stuff when you scan the brain and that's why neurology and neurosurgery are eager to go after it. The second refuge is find something so hard that it makes nonradiologists scratch their heads. I think mammo is a good example. Chest plain films are also very subtle.

Anyways, this is getting too long. I think that radiology has a bright future. You just have to know what parts of it to focus on. Don't go into a dying branch of it. You want to go a future growth area.
 
Last edited:
Somewhat tangential to the OP, did anyone see that interventional radiology has developed a procedure for degenerative disc disease? Would take a nice bite out of one of orthos' big cash cows.
 
Yes, VC can be a pain in the ass to read, but what if you tack on extra stuff? Imagine it. You have the patient in the waiting room. The patient already had a bowel prep to get the VC. You find a 1 cm polyp. Are you going to send this patient to GI so that they can fetch it -- and collect the fee? Are will you do the colonoscopy yourself and collect the fee? Doing it yourself changes the financial equation. VC may become one of the most lucrative areas in radiology.

The current model is a joint operation between radiology and GI. Radiology reads the VC and then GI does the scoping if polyp is found. But why do you need GI to do the scoping? If FP and general surgeons do scoping, it's ridiculous to me that radiology can't do them too. IR does some pretty invasive procedures like G-tube placements, PTC, neph tubes, embolizations, etc. To a lesser extent, general radiologists do invasive procedures like drains, biopsies, central lines, etc. There's no reason why radiologists can't do scoping as well, especially if they have a map of the colon from the VC. I would bet that there will be sevral radiologists who see it the same way I do and begin to learn how to scope.

The converse is, can GI learn how to do VC and take it away from radiology? I don't think so. The abdomen is very complex. So many different systems. There's the GI tract, kidneys, liver, vessels, etc. If the abdomen was so easy to read, GI or general surgery would have taken abdomen work away from radiology a long time ago like how cardiology took away cardiac nucs. Unlike MSK plain films, I have never had one instance where a non-radiologist told me that they read the abdomen CT and don't need the radiologist report.

What I have realized about radiology is that there are turf battles that it will lose simply because we don't control the patient. For example, cardiac nucs and heart stenting; peripheral vascular work and vascular surgery; neurointerventional work and neurosurgery. It's difficult to say that you're better than a subspecialist who focuses on just one system all day. For example, orthopedic surgeons and bone plain films; neurosurgeons and neuro CT's. Radiology has two refuges. The first refuge is find body areas where there is a lot of "extra" stuff like lung fields when you're just interested in the heart or the rest of the abdomen when you're just interested in the GI tract. Unfortunately for neuroradiology, there's not much "extra" stuff when you scan the brain and that's why neurology and neurosurgery are eager to go after it. The second refuge is find something so hard that it makes nonradiologists scratch their heads. I think mammo is a good example. Chest plain films are also very subtle.

Anyways, this is getting too long. I think that radiology has a bright future. You just have to know what parts of it to focus on. Don't go into a dying branch of it. You want to go a future growth area.

These are wise words!
 
Somewhat tangential to the OP, did anyone see that interventional radiology has developed a procedure for degenerative disc disease? Would take a nice bite out of one of orthos' big cash cows.

There is a staff attending at Emory who was doing all types of percutaneous msk and ortho procedures that I had never seen anywhere else while I was interviewing for fellowships. I asked him about it and it was kind of his niche and he got into it while thinking of ideas along with his ortho buddies.
 
Yes, VC can be a pain in the ass to read, but what if you tack on extra stuff? Imagine it. You have the patient in the waiting room. The patient already had a bowel prep to get the VC. You find a 1 cm polyp. Are you going to send this patient to GI so that they can fetch it -- and collect the fee? Are will you do the colonoscopy yourself and collect the fee? Doing it yourself changes the financial equation. VC may become one of the most lucrative areas in radiology.

The current model is a joint operation between radiology and GI. Radiology reads the VC and then GI does the scoping if polyp is found. But why do you need GI to do the scoping? If FP and general surgeons do scoping, it's ridiculous to me that radiology can't do them too. IR does some pretty invasive procedures like G-tube placements, PTC, neph tubes, embolizations, etc. To a lesser extent, general radiologists do invasive procedures like drains, biopsies, central lines, etc. There's no reason why radiologists can't do scoping as well, especially if they have a map of the colon from the VC. I would bet that there will be sevral radiologists who see it the same way I do and begin to learn how to scope.

The converse is, can GI learn how to do VC and take it away from radiology? I don't think so. The abdomen is very complex. So many different systems. There's the GI tract, kidneys, liver, vessels, etc. If the abdomen was so easy to read, GI or general surgery would have taken abdomen work away from radiology a long time ago like how cardiology took away cardiac nucs. Unlike MSK plain films, I have never had one instance where a non-radiologist told me that they read the abdomen CT and don't need the radiologist report.

What I have realized about radiology is that there are turf battles that it will lose simply because we don't control the patient. For example, cardiac nucs and heart stenting; peripheral vascular work and vascular surgery; neurointerventional work and neurosurgery. It's difficult to say that you're better than a subspecialist who focuses on just one system all day. For example, orthopedic surgeons and bone plain films; neurosurgeons and neuro CT's. Radiology has two refuges. The first refuge is find body areas where there is a lot of "extra" stuff like lung fields when you're just interested in the heart or the rest of the abdomen when you're just interested in the GI tract. Unfortunately for neuroradiology, there's not much "extra" stuff when you scan the brain and that's why neurology and neurosurgery are eager to go after it. The second refuge is find something so hard that it makes nonradiologists scratch their heads. I think mammo is a good example. Chest plain films are also very subtle.

Anyways, this is getting too long. I think that radiology has a bright future. You just have to know what parts of it to focus on. Don't go into a dying branch of it. You want to go a future growth area.

It's not an issue of being able to do colonoscopies (or generic procedure X); it's a matter of wanting to do colonoscopies. If a radiologist wanted run a procedural clinic, then he either would have gone into IR or not gone into radiology in the first place.

I understand the point of taking steps to prevent encroachment from other specialties, and that's in large part why SIR wants to branch off and become its own specialty. It wants to basically become minimally-invasive surgeons, complete with clinics full of IR patients, with formal imaging training. That's great, and if it's your thing then go for it. But with respect to DR, you're talking about fundamentally changing the field and the type of person that enters it. I don't see that happening.

Despite widespread opinion to the contrary, it is easy to say that a subspecialist radiologist is better at reading head CTs than the neurosurgeon or knee MRIs than the orthopod. And any surgeon who's worth his salt realizes that - as good as he might be at reading imaging studies - the relevant subspecialized radiologist is better. That says nothing of the generalists and medicine-type folks who rely almost entirely on the radiologist's read.

The trick to keeping DR relevant is to 1) provide subspecialty reads and 2) avoid commoditization. The second one is trickier, because I don't know if the money trail will allow it, but we need to find a way to make the radiologist "part of the team" again. It's hard to do that when a faceless radiologist somewhere in Australia is providing interpretations overnight. The first one is easier, and the specialty is already well down this path.

Lastly, if you've never had a general surgeon think they can read an abdominal CT better than you, just wait awhile.
 
The two fields are very different. You should pick the one that matches your personality best.

As for radiology, I think that it has a bright future. Here are some of my thoughts.

In the near term, I see three areas of potential growth for radiology. Virtual colonoscopy is coming and I believe that it will become a popular screening method. If so, radiologists may begin doing colonoscopies since they will have a map of the colon and know exactly where to go to find that polyp. If FP, general surgeons, and GI can do them, why can't radiologists do them too since they are trained to do procedures like central lines, G-tube placements, biopsies, drains, etc? Second, cardiac CTA will explode if clinicians in the ED and floors begin to order them. You'll start seeing requests from ED docs to rule out CAD, PE, aortic dissection, pneumothorax, etc for chest pain. For a decade, cardiology tried to take cardiac CTA from radiology but they were hamstrung by the fact that they can't read non-cardiac parts. That's why cardiologists always needed a second read by a radiologists to look at the lungs. Cardiac CTA also was not that popular because cardiologists mostly ordered them. Now that everyone will order them, cardiology can no longer control the workflow and radiology greatly benefits from this since only radiologists can read the entire scan. Third, CT lung cancer screening is coming. They are still hammering out the guidelines but you can bet that because CT is the only proven life-saving screening tool for the #1 cancer in this country that it is inevitable. The last point leads me back to my previous ones. Once the guidelines for CT lung cancer screening are established, do you think that anyone but a radiologist is gonna want to touch a CT study where the lungs (most common cancer) are included (ie, cardiac CTA)? It would be a legal minefield. That's why only radiologists read mammo studies. It's the same thing with virtual colonoscopies. There is so much that goes in the abdomen that only radiologists can fully read it. The abdomen is another legal minefield.

All three areas are huge markets and will provide plenty of work for radiologists for years to come.

CT Colonography Shown to be Comparable to Standard Colonoscopy for People Ages 65 and Over

Coronary CT Angiography Safe, Time Saving, and More Effective than Traditional Care for Evaluating Patients Arriving at Emergency Department with Chest Pain

NIH-funded study shows 20 percent reduction in lung cancer mortality with low-dose CT compared to chest X-ray

If you read literature of 80s and 90s on the booming technologies in the future of the radiology, you will become disappointed as none of their predictions came true. Yours is no better than them.
And in fact that is what I love about radiology. Its ever changing and unpredictable future advancements. We achieve new technologies and find them very interesting. Whether they will be used in a large scale is effected by many factors that are out of control.

IMO, MRI is the future of radiology esp with faster sequences and newer ones. I don't want to go into the details but take a look at great influence of some relatively older ones like HASTE, FLASH (or FFE or SPGR ) , FISP and .. on body MR. Or take a look at calcium MR for OA.

I totally disagree with your predictions:

1- VC: if you want to do colonoscopies, go to GI. Never ever I see a radiologist doing colonoscopy and it will not happen. VC may take some share of market if it is reimbursed by medicare. That will not happen in the foreseeable future because of bad economy. The only usage of VC for medicare is decreasing reimbursements of conventional colonoscopy. In a very few academic centers where there is less financial incentive, there is collaboration between GIs and rads and they are doing VC for free, but it is not money maker at all in the pp.
Bottom line: It will not be used in a large scale in the near future.

2- Cardiac CTA: Still not a very big money maker in pp. It is very good for low risk patients to r/o ACS. It is almost useless when there is significant coronary calcification which consist most of the patients. The other major problem with Triple rule out is the phase of contrast which should be compromised for at least one of the structures. Cardiologists are very cautious about it as it is almost the only potential major technology in their field these days.
Bottom line: Most likely it will replaced a fraction of cardiac stress tests, but will not be a big money maker. IMO, it will be taken by cardiologists, though not completely.

3- Lung cancer screening: Is currently reimbursed by medicare. Is a low dose chest CT with lower resolution. Many smokers have had chest CT in the last 3-4 years for some other indication. The reimbursement for it is very low.
Bottom line: Will not be a big money maker, but will add to some studies. The reimbursement is low.

Despite all these, the field is very dynamic and challenging. Still one of the fastest growing fields in medicine. The imaging will grow at least as fast as now in the future.

To the OP: With decreasing reimbursements the gap between all medical fields including primary care doctors will be small. DO whatever you like.
These two fields are so different that you can not say you like both of them. Both are great fields.
 
Do you really think that FM will pay simular to Ortho or rads in the future?
How is 450k/yr going to become 150k/yr? That would be quite a jump. I imagine most would take the shortest residency possible of this was the case.


To the OP: With decreasing reimbursements the gap between all medical fields including primary care doctors will be small. DO whatever you like.
These two fields are so different that you can not say you like both of them. Both are great fields.
 
There is a staff attending at Emory who was doing all types of percutaneous msk and ortho procedures that I had never seen anywhere else while I was interviewing for fellowships. I asked him about it and it was kind of his niche and he got into it while thinking of ideas along with his ortho buddies.


Ahhh ok. I was referring to this abstract at this past weeks SIR conference:

“Percutaneous Image-guided Transplantation of Human Mesenchymal Stem Cells for the Treatment of Symptomatic Degenerated Intervertebral Discs,” J.D. Prologo, department of radiology, vascular and interventional radiology; D. Hart, department of neurosurgery; Z. Love, Z. Lee, department of radiology, all University Hospitals Case Medical Center, Cleveland, Ohio; D. Corn, A. Sattar, L.W. Yuan, N. Tenley, department of biomedical engineering, Case Western Reserve University, Cleveland, Ohio.

Either way, very cool stuff!
 
Do you really think that FM will pay simular to Ortho or rads in the future?
How is 450k/yr going to become 150k/yr? That would be quite a jump. I imagine most would take the shortest residency possible of this was the case.

I said it will be small and it means smaller compared to current situation.
Currently in big cities family doctors make around 100-120K and ortho people make around 400-500K , at least in my neighborhood. So the gap is about 5 times. It will be around 2 times in the future.
That is only my guess. Probably in the future most doctors make 150-300K with PMDs in 150K range and ortho around 300K.
Also don't forget that a family doctor starts to make money about 4 years earlier. Also the pay per hour is not bad even if you compare it to ortho.
 
Do you really think that FM will pay simular to Ortho or rads in the future?
How is 450k/yr going to become 150k/yr? That would be quite a jump. I imagine most would take the shortest residency possible of this was the case.

Well, even if ortho made $200k vs FM's $150k, you would still go with $200k over the span of a 25 year career from a money standpoint. The length of residency argument is such a reach that I can't believe people take it seriously, especially if the discrepancy is anything over $30k/year. The only confounding factor is that people would prefer to make money sooner in their lives versus later, but I think this is still overblown with the way things currently are.
 
I'd probably put the range of salaries from 150-350 in the future. MedPac wants to effectively cut specialist salaries by 30% in the next 3 years. An average ortho doc making 500k would make 350k after those cuts. I think the upper limits for a doc will reach 500k in the future rather than the 700-800k you hear about.
 
I don't think the pay would change that drastically. Especially not in this economy with inflation and what not.

Honestly I'm not even sure how value is determined in health care. Why does a radiologist get paid more? It's not like they're aren't a lot of them after all. Who knows. I will also add I don't necessarily think FM or primary care should get paid more. I simply don't think a lot of what they do warrants higher pay. There's no good way to accurately measure what value they have. There is an easy way to determine the value of a surgery or procedure or ct scan report. Thus the reason why ortho and rads will always make a lot more (I'd say 4x more) than primary care docs.

Ok, I'm sorry, but this is epic fail. Essentially every statement in this post makes little to no sense.

So, you don't think pay would change that drastically. Ok, that's fine, but what's your reasoning? Based on the following statement about "this economy" and "inflation," I'm really curious. What exactly is your understanding of the current state of the economy? And how does inflation play into this understanding?

You don't know how value is determined in health care. Good, because neither do I. In fact, no one does. The entire pricing mechanism is an intrinsic property of a free market. The price of a good or service is the price of a good or service because consumers are willing to pay the given amount. Health care is as far from a free market as you can get in this country, so prices in the industry are nothing more than price-fixing aided by legislation.

Then after proclaiming that you have no idea how prices are begotten, you go on to set a price for primary care services. Then, you go on to say there's no way to measure their value. Ok, good. So, upon what principle are you drawing to say FM is worth a certain value? You "simply don't think a lot of what they do warrants higher pay." Why not? What are your parameters for determining higher pay? And why? And how can your specific parameters be used as a pricing mechanism?

There's an easy way to measure the value of a surgery or ct report? Oh really? How? So, because there's an easy way to measure the value of a surgery or CT report, ortho and radiology "deserves" more money? About 4x? Hey, while you're pulling economic principles out of your ass, can you find a way to maintain aggregate demand in the economy without monstrous government stimulus?
 
It's not an issue of being able to do colonoscopies (or generic procedure X); it's a matter of wanting to do colonoscopies. If a radiologist wanted run a procedural clinic, then he either would have gone into IR or not gone into radiology in the first place.

I understand the point of taking steps to prevent encroachment from other specialties, and that's in large part why SIR wants to branch off and become its own specialty. It wants to basically become minimally-invasive surgeons, complete with clinics full of IR patients, with formal imaging training. That's great, and if it's your thing then go for it. But with respect to DR, you're talking about fundamentally changing the field and the type of person that enters it. I don't see that happening.

Despite widespread opinion to the contrary, it is easy to say that a subspecialist radiologist is better at reading head CTs than the neurosurgeon or knee MRIs than the orthopod. And any surgeon who's worth his salt realizes that - as good as he might be at reading imaging studies - the relevant subspecialized radiologist is better. That says nothing of the generalists and medicine-type folks who rely almost entirely on the radiologist's read.

The trick to keeping DR relevant is to 1) provide subspecialty reads and 2) avoid commoditization. The second one is trickier, because I don't know if the money trail will allow it, but we need to find a way to make the radiologist "part of the team" again. It's hard to do that when a faceless radiologist somewhere in Australia is providing interpretations overnight. The first one is easier, and the specialty is already well down this path.

Lastly, if you've never had a general surgeon think they can read an abdominal CT better than you, just wait awhile.

I think radiology needs to "think outside the box" and get creative. We need to learn from our past mistakes, ie, collaborating with cardiology and vascular surgery because we are in a collegial atmosphere at academic centers only to watch them steal cardiac nucs, echoes, stenting, and PVD

How did radiology allow cardiology and vascular surgery to do it? Simple. These clinical services like cardiology, vascular surgery, nephrology, urology, neurology, neurosurgery, etc interact with and control patient flow. If a cardiologist orders a study, he demands to read those images and do those procedures or he'll take his patients to a different hospital. Damn the radiologists. The hospital bends over backwards to make them happy and screws radiology. Years ago when radiology still did cardiac nucs at my hospital, my attending told me how the CEO let it slip at a departmental meeting that the most important service in the hospital was cardiology and that they wanted to make them happy, to the appall and jeers from the radiologists in the meeting. And it wasn't long after that radiology lost cardiac nucs. Like many academic centers, radiology at my instituion has lost PVD work to vascular surgery, ob ultrasound to ob/gyn, and recently neurointerventional work to neurosurgery.

We need to follow the model from mammo. If a PCP orders a mammo, the radiologists does diagnostic screening but also the procedures like ultrasound and biopsies. Could the radiologist refer the patient to a breast surgeon to get the biopsy? Sure and some do. But why? If you get the referral, then you control patient flow and you can decide what studies and procedures to do before you refer the patient to another specialist. That's the model that the clinical services use against radiology. We need to take a page out of their playbook. If a PCP orders a VC, then you control patient flow and if it becomes accepted practice for radiology to do colonoscopies then you can decide to do the procedures and only refer them to a GI doc if you feel uncomfortable with it. If you do the colonoscopy, that patient will not even appear on GI's radar.

Screenings are one of the best ways for radiology to circumvent the specialists. The orders for mammo, VC, and lung cancer screening won't be coming from specialists like cardiology or GI for the most part. They will come from PCP's who have no interest or expertise in reading imaging studies or doing procedures. Radiology had been eroded because the specialists like cardiology and vascular surgery initially ordered studies like cardiac nucs and angios for radiology to do them but over time decided to do it themselves. VC's, for example, will never take off for radiology if GI orders them only when they have a failed colonoscopy. VC's just like cardiac CTA's, CT lung screening, etc will take off when everyone orders them.

I think that you make valid points. I've heard the same thing said by many people. But I think that the approach is too passive. Do you think that cardiology or vascular surgery could have stolen all of that work from radiology if they played by the professional rules? No. A few aggressive people wanted more and realized that they didn't need radiology and decided to do it themselves.

In order for radiology to move into the future, it will have to rock the boat like how other specialties have done. In this highly competitive and shrinking health dollars world, it's every specialty for themselves. You either fight or become irrelevant.
 
This is the best I could do quickly but here's a couple wikipedia articles on health care pricing for those interested:

http://en.wikipedia.org/wiki/Health_care_prices

http://en.wikipedia.org/wiki/Resource-Based_Relative_Value_Scale

from the second:
"Price setting
The RBRVS for each CPT code is determined using three separate factors: physician work, practice expense, and malpractice expense. The average relative weights of these are: physician work (52%), practice expense (44%), malpractice expense (4%).[2] A method to determine the physician work value was the primary contribution made by the Hsiao study. The RUC examines each new code to determine a relative value by comparing the physician work of the new code to the physician work involved in existing codes.

The practice expense, determined by the Practice Expense Review Committee, consists of the direct expenses related to supplies and non-physician labor used in providing the service, and the pro rata cost of the equipment used. In addition, there is an amount included for the indirect expenses.

In the development of the RBRVS, the physician work (including the physician's time, mental effort, technical skill, judgment, stress and an amortization of the physician's education), the practice expense and the malpractice expense are factored into the result. The calculation of the fee includes a geographic adjustment. The RBRVS does not include adjustments for outcomes, quality of service, severity, or demand."





the above is just used for medicare but as we all know medicare reimbursements essentially determine how much private insurance reimburses. I actually wrote my above post before I saw these two wikipedia articles. Interesting to see I was essentially correct in my thought process. So no "epic fail" on my part.

Jesus Christ, you missed the entire point of my argument. This is why economics should be a prereq for medical school, as I think all physicians should bear at least a fundamental understanding of how the world works economically outside and inside of medicine.

My point isn't how RVUs are calculated. I know how they are calculated, and I find it utterly baseless. My point is that there is zero market basis for this. Why should "physician work" be used? How exactly do you use this as a pricing mechanism? You can't. And why on earth would the expense of the practice be utilized for reimbursement for a given service? Only the cost of the equipment and ancillary staff should be accounted for, but no statement about the inherent service provided can be made. Do construction workers operating million dollar cranes get paid more than lead architects who use nothing but a pencil and paper? They are basically assuming random parameters in order to artificially tack on reimbursement numbers, when in reality, pricing cannot be determined outside of supply and demand economics. This is economics 101.

Therefore, your initially assessment that you don't understand why physicians are paid what they are is correct. My problem is when you completely abandoned this realization to conclude that primary care services are worth 25% of procedural services. This is not only contradictory, but incorrect.

In a bizarro world where American health care is a free market, can I see a scenario where proceduralists are paid more? I suppose I can, but it is theoretical at best, and until you actually price it in a free market, no statements about pricing can be made objectively.
 
Healthcare will never be a free market because demand is inelastic. If you tell someone they need to pay $x to stay alive, at what point do they say no? If physicians had free reign to set prices and no morals, we could be billionaires.
 
And so if payment structures generally continued to be determined the same way pay will not change a whole lot even if reimbursements are decreased. Be aware that as reimbursements are cut for rads they are not then subsequently be increased for primary care. They can only decrease pay to a point otherwise people will just quit. It takes a long time to become a radiologist or surgeon. Much longer than primary care. Why would someone go through the extra training if they could do half the training in a less mentally and technically difficult field and make the same amount of money?

What the hell are you talking about? If reimbursement rates are cut, how would that not change pay? In fact, as reimbursements decrease, overall compensation will decrease even more rapidly due to the fact that your overhead remains the same while your revenue shrinks. This is true in private practice or corporate structures.
I understand that reimbursement will not increase much for primary care. What's your point? I never said PCPs will make more - only that the gap will be drastically smaller.

LOL, people will just quit? And do what, exactly? You have zero skill outside of medicine that can be utilized to make anything near what you can in medicine.
If you mean that medical students will stop going into surgery, you're actually wrong. It's a zero sum game. Someone will have to go into every field regardless of whether they love it or not.
If you mean that undergrads will stop going to medical school, we've talked about this many times on this forum. If tuition is subsidized fully, physician compensation has a whole lot of room to go down before you see an efflux away from medicine as a profession.
 
Healthcare will never be a free market because demand is inelastic. If you tell someone they need to pay $x to stay alive, at what point do they say no? If physicians had free reign to set prices and no morals, we could be billionaires.

Well, they simply say yes until they no longer can afford it. But, of course a free market also means lower prices as the market will likely be flooded with providers.

But, this scenario is unlikely to impossible, especially in the US. That is why this current pricing system is essentially nothing more than well controlled price fixing. Any reasoning made on how these prices are begotten has little objective support. It is essentially a historical remnant from the incipient days of this mutant hybrid of capitalist/socialist system we enjoy today.
 
1- VC: if you want to do colonoscopies, go to GI. Never ever I see a radiologist doing colonoscopy and it will not happen. VC may take some share of market if it is reimbursed by medicare. That will not happen in the foreseeable future because of bad economy. The only usage of VC for medicare is decreasing reimbursements of conventional colonoscopy. In a very few academic centers where there is less financial incentive, there is collaboration between GIs and rads and they are doing VC for free, but it is not money maker at all in the pp.
Bottom line: It will not be used in a large scale in the near future.

VC is not popular right now because it's not reimbursed by Medicare and most insurance. What happens when that changes? Political pressure is building. From what I have been following, I think it's inevitable. Do you realize that Obama's first colon study as President was VC?

If VC's become popular, it will spread out of the academic centers and into the community practices where the general radiologists does everything and there won't be GI there to scope.

Who knows what the future will be, but whatever it is I am prepared to adapt to the changes. That includes doing colonoscopies. If a general radiologist can do biopsies, drains, central lines, barium enemas, etc, what's the big deal with doing colonoscopies? Not all radiologists will want to do it because not everyone likes to do procedures, but I have no problem with it. And I'll collect the fee too.
 
I don't ever foresee reimbursements going up. The only way to go is down. Radiology applicants will drop off considerably, residency slots will most likely contract, the job market will significantly improve, but you'll be working more while getting paid less.
 
Agreed about the inelastic demand. There's no real way to determine the demand for something. Some aspects of "health care" are free market such as most cosmetic plastic surgery and we all know the pay in that... what makes that worth so much money - because the doc can get people to pay it. Simply no way a primary care doc could get people to even pay his breakeven price for running his/her business while also trying to make a decent living. Health care in its current state is too expensive.
Actually, no. Even cosmetic procedures do not operate in a free market currently, as legislation makes it so supply is limited and not controlled by market forces. In an entirely free market, the supply of these providers would increase until the demand is saturated.



I think I misspoke. If pay goes down for one field I don't think that will significantly lower the differences (unless you see absolutely drastic cuts) because the other field, primary care for example, won't see an increase in reimbursements.
Yes, we are talking about drastic cuts, remember? And you were supposed to explain your basis for claiming they won't, based on your understanding of inflation and the economy? I'm still waiting.

[/quote]
The US system is flawed. I guess this topic is somewhat of a pet peeve for you. That's fine. But I'm not really sure what you think is better. A pure free market for healthcare? I don't see how that's possible frankly. The system right now would be so cost prohibitive to your average american that only the very rich could afford health care. A free market cannot work with the way insurance companies are set up to reimburse in this country. The cost of care is simply too high and cannot be support by a free market. Let's say you get rid of insurance co. and medicare/medicaid... what then? It's a free market. But it's not like the cost of running a health care practice would change that drastically. The system would implode.

An example: I've been told a single chest x-ray costs $200. That is a lot of money. In fact that's more than most people can afford and especially when you need multiple cxr and then follow up studies for incidental findings. A chest ct is about, what, $1500. How in the world could your average person afford that and especially when they end up needing a cxr, chest ct, hospital admission, etc. There's just absolutely no way. It's impossible. That's why the system is the way it is with insurance co.
I agree that a full free market would be close to impossible, partly because a transition would be havoc. However, I do think that costs can be far better contained in a completely socialized system. We have the perfect storm in this country for the health care industry, due to this mutant mix of socialism and capitalism. Incentives are completely misplaced, legislation makes healthy competition impossibly difficult, private payers are squeezed incessantly by health care corporations who jack up prices (in no country in the world is a CXR $200), and public payer is unfortunately tied to a soon-bankrupt government.
The existence of private insurers does not preclude a free market. It's government interventions which do.

I'm not defending payment structure. I agree "physician work" can seem arbitrary. But my opinion is that the work done by a family physician, while great awesome work, is simply not worth the same amount of money as that done by a cardiac surgeon. It's just like the work done by a PA isn't worth the same as that done by a MD. The work done by the manager of a local McDonalds isn't worth the same as that done by Outback Steakhouse. I don't know if you're advocating for payment equality or something but really there's no objective basis for the value of any one particular job. But generally the more training and skill one has the more money one makes. A manager makes more than the cashier. Why does the cashier get paid minimum wage? Why can't the cashier be paid $15/hour? Hell I don't know. But there's plenty of cashiers who will work for $7.50/hour so that's what they get paid. Same in healthcare really. The family doc will work for 150k/year. A full time cardiac surgeon simply will not. I mean why would he? He trained 8 years after med school. He takes on so much responsibility, liability, staff, malpractice, etc. to do his job. If he was paid the same as a family doc you honestly think he still do his job?? I just simply cannot believe you think that's the case...
Ok, my point was never go argue for equality of pay. It was to demonstrate that there's no way to objectively set price points outside of a free market. So, you think one cardiac transplant surgery is worth more than one visit to the PCP... ok, fine. In a free market, I think your assessment would be true. But, both of us can make zero objective statement on HOW MUCH of a difference exists between the two.
If pay goes down people will leave. They'll find something else. I don't know what. But it's better than staying in healthcare and losing money. It becomes cost prohibitive to stay. I think part of the problem is that old time docs are used to living a certain lifestyle with their pay. I think that's changing with new grads to a small degree but people still expect to be paid well for all the years of training, studying, late nights, lost time, sacrifice, malpractice, liability, etc etc etc.

You gotta remember something. If being a MD didn't pay well likely you wouldn't get some of the smartest young people attempting to pursue medicine. There's reasons to keep the pay just high enough. And I think your seeing this kind of thing happening now with radiology. The job market is really bad. People know now they have to work a crap ton more and they are making a lot less. So lots of people who used do rads simply don't see the 6-7years of training (with fellowship(s)) as being worth it anymore and go into different fields. If pay keeps going down for rads, applicants will plummet and thus resulting in an eventual increase in pay to increase applicants or a subsequent way to perform the functions necessary of radiology with fewer people.
Ok, this is familiar. We've talked about this at length like 1000x in these forums. Doctors who are already practicing will not leave medicine. They are not "losing money." Losing money compared to what? They have zero other skill from which they can make six figures. What? You think your general surgeon is going to go get a job on Wall Street? Or your cardiologist is going to go do corporate law?
As far as the smart, young people, it depends on how low salaries in medicine get. You can easily draw capable bodies with $150-200k and subsidized tuition. There's not many options out there to guarantee you a solid six figure salary with unparalleled job security.

And what's this thing about radiology pay going back up because people are not going into it? You DO realize that it's a zero sum game, right? Medical students and residencies are like musical chairs. You can only see people move around from field to field, but there will never be huge gaps left in any one specialty. And the very small (and disappearing) gap is always filled by FMGs, so it's not possible these days for a field to decrease influx.
 
Last edited:
I don't ever foresee reimbursements going up. The only way to go is down. Radiology applicants will drop off considerably, residency slots will most likely contract, the job market will significantly improve, but you'll be working more while getting paid less.

Residency slots would have to contract by choice for some reason other than applicant numbers, which I don't see happening. Applicants won't drop off, unless people are willing to quit medical school rather than match into radiology. It's a zero sum game.
 
The AMG:FMG/IMG ratio would decrease as more FMGs and IMGs would go into rads than AMGs. That's my prediction even if residency slots don't decrease (which they could if Medicare cuts GME funding). In any case, if the situation arises that radiologists are making 300k on average the incentive will drop off precipitously to go into radiology rather than say hospitalist medicine or EM. Fewer years with a smaller difference in pay. I think we are already approaching that scenario by the fact that there were 86 unfilled spots this year whereas IM nearly filled and EM completely filled. There is not a statement on the competitiveness of radiology vs. IM/EM, just match rates.
 
VC is not popular right now because it's not reimbursed by Medicare and most insurance. What happens when that changes? Political pressure is building. From what I have been following, I think it's inevitable. Do you realize that Obama's first colon study as President was VC?

If VC's become popular, it will spread out of the academic centers and into the community practices where the general radiologists does everything and there won't be GI there to scope.

Who knows what the future will be, but whatever it is I am prepared to adapt to the changes. That includes doing colonoscopies. If a general radiologist can do biopsies, drains, central lines, barium enemas, etc, what's the big deal with doing colonoscopies? Not all radiologists will want to do it because not everyone likes to do procedures, but I have no problem with it. And I'll collect the fee too.

I bet you are a medical student at most, because your arguments are so naive.

You may be right about VC, though I doubt it. It needs almost the same preparation as colonoscopy. It need a rectal tube and air injection into the colon. And despite all these it is not as accurate as colonoscopy for detection of small polyps.

Regarding colonoscopy, your argument is ridiculous. You talk about it like a primary school student. Think about the BS that comes to your mind before writing it on a public forum over and over again.
 
The biggest concern should not be salary, but the ability to get the job you want at all. Orthos are still in quite high demand, and can pretty much name their location and day to day setup.

The job market in rads has been dead for nearly 3 years now, and while I hope it recovers, it's becoming more and more discouraging every time I read about how hard it's becoming to even get a crap paying, non partership track job in any major market anymore.
 
I bet you are a medical student at most, because your arguments are so naive.

You may be right about VC, though I doubt it. It needs almost the same preparation as colonoscopy. It need a rectal tube and air injection into the colon. And despite all these it is not as accurate as colonoscopy for detection of small polyps.

Regarding colonoscopy, your argument is ridiculous. You talk about it like a primary school student. Think about the BS that comes to your mind before writing it on a public forum over and over again.

Yes, keep believing that I am a med student. :laugh: I ask myself if you're one or if you're from GI.

Why don't you read more carefully. I'm not arguing if VC is better than optical colonoscopy. That's an academic discussion. What I am arguing about is what happens after it's approved for Medicare reimbursement. If you follow the literature and the politics, it's very likely that VC will be approved in the next few years.

So what happens when VC is approved? If you're a radiologist, are you going to refuse to do them? Do I care if you refuse? Send me all the patients who would have gone to you my way.

Let's take it one step further. If you do the VC and see a polyp, are you going to refuse to do the colonoscopy? Send it to GI to fetch the polyp?

Last time I saw, GI makes a pretty good living. Their bread and butter are colonoscopies which they schedule in 30 minute slots at these outpatient centers like a factory. So you are refusing to do a well-paid procedure? That's real smart especially when reimbursements for everything is dropping. Am I saying that learning how to scope, getting a colonoscopy suite, or getting reimbursed for it will be a slam dunk? Of course not but once that is established it will be another revenue stream for your practice. If it becomes commonplace, then it will be incorporated into more practices and residency training. Think cardiology, vascular surgery, and neurosurgery.

You haven't given me one good reason why it's impossible for radiology to get into it. Is it like surgery where you must complete a surgery residency to be competent? Is scoping some special magical skill that only GI can do? I know FP's and surgeons who do it so it can't be that hard. If I can do central lines, biopsies, drains, etc., I can scope buddy. With VC, I can do it more safely because I have a map of the colon. There's not one good reason anyone can give me as to why I can't do colonoscopies except the "ick" factor. Do you object to doing barium enemas too? Do you think it's crazy that mammographers do the screening exams as well as stereotactic, CT, and MRI guided biopsies? Maybe you don't like doing procedures but us younger guys coming out now know that we have to be able to do them to differentiate ourselves.

Dude, I could hardly care what you think or do. You're either a naive radiologists who thinks that they should stay behind a monitor only or some GI guy terrified of the future I paint. Or some stupid med student. I'll just watch my bank account go up and up. Before, they used to say cardiology, vascular surgery, or neurosurgery can't do this or that because radiology did it. Now, it's them who's laughing at you and you're on the outside looking in.
 
Last edited:
The biggest concern should not be salary, but the ability to get the job you want at all. Orthos are still in quite high demand, and can pretty much name their location and day to day setup.

The job market in rads has been dead for nearly 3 years now, and while I hope it recovers, it's becoming more and more discouraging every time I read about how hard it's becoming to even get a crap paying, non partership track job in any major market anymore.

The job market is not as bad as you read in this forum or auntminnie. It is bad, no doubt. But still people find relatively good jobs 1-2 hours from big cities.
Ortho has a good job demand now, I agree though it is not as good as you pictured. You have to build your own practice which is very difficult in large desirable areas.
 
Yes, keep believing that I am a med student. :laugh: I ask myself if you're one or if you're from GI.

Why don't you read more carefully. I'm not arguing if VC is better than optical colonoscopy. That's an academic discussion. What I am arguing about is what happens after it's approved for Medicare reimbursement. If you follow the literature and the politics, it's very likely that VC will be approved in the next few years.

So what happens when VC is approved? If you're a radiologist, are you going to refuse to do them? Do I care if you refuse? Send me all the patients who would have gone to you my way.

Let's take it one step further. If you do the VC and see a polyp, are you going to refuse to do the colonoscopy? Send it to GI to fetch the polyp?

Last time I saw, GI makes a pretty good living. Their bread and butter are colonoscopies which they schedule in 30 minute slots at these outpatient centers like a factory. So you are refusing to do a well-paid procedure? That's real smart especially when reimbursements for everything is dropping. Am I saying that learning how to scope, getting a colonoscopy suite, or getting reimbursed for it will be a slam dunk? Of course not but once that is established it will be another revenue stream for your practice. If it becomes commonplace, then it will be incorporated into more practices and residency training. Think cardiology, vascular surgery, and neurosurgery.

You haven't given me one good reason why it's impossible for radiology to get into it. Is it like surgery where you must complete a surgery residency to be competent? Is scoping some special magical skill that only GI can do? I know FP's and surgeons who do it so it can't be that hard. If I can do central lines, biopsies, drains, etc., I can scope buddy. With VC, I can do it more safely because I have a map of the colon. There's not one good reason anyone can give me as to why I can't do colonoscopies except the "ick" factor. Do you object to doing barium enemas too? Do you think it's crazy that mammographers do the screening exams as well as stereotactic, CT, and MRI guided biopsies? Maybe you don't like doing procedures but us younger guys coming out now know that we have to be able to do them to differentiate ourselves.

Dude, I could hardly care what you think or do. You're either a naive radiologists who thinks that they should stay behind a monitor only or some GI guy terrified of the future I paint. Or some stupid med student. I'll just watch my bank account go up and up. Before, they used to say cardiology, vascular surgery, or neurosurgery can't do this or that because radiology did it. Now, it's them who's laughing at you and you're on the outside looking in.

Ooh, Gush.
Stupidity does not have limits.
 
VC doesn't need to be that expensive. It also should be very conducive to automatic detection.

It will become more prevalent, but I'd wager it won't be so much a gain for radiology as a loss for GI. Real colonoscopies will still be required, but they won't be used for screening in almost everyone over 50.
 
Top