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Highest Paid Specialty, Historically, and for the future...

Discussion in 'General Residency Issues' started by Ligament, Sep 7, 2002.

  1. Ligament

    Ligament Interventional Pain Management
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    Hey all,

    We all know what the highest paying specialties are now, but I am wondering what the highest paid specialties have been *historically*, over the past 20 or 30 years lets say.

    Has radiology always paid so much? Has Generaly Surgery always paids so little (for the training)?

    Question two: what specialties to you see making the most $$$ in the next 5 to 10 years?

    I would guess rads will stay up there, but may have peaked by now. Same with anesthesia and the surgical subspecialties. I think FP and IM will see a big income boost since nobody wants to go into it now, thus creating a future "glut" I think the pay for PM&R may go up as the boomers age and subspecialties of PM&R become more prominent.

    Of course I assume neurosurgery will always make the most, but those crazy bastards deserve it!

    just speculations. what are your thoughts?

    regards.
     
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  3. neutropeniaboy

    neutropeniaboy Blasted ENT Attending
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    I think discussions like this are pointless.
     
  4. Ligament

    Ligament Interventional Pain Management
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    neutropenia,

    then why add to the thread? Ignore it if you dont like it. I think its a mostly pointless thread too but felt like some idle gossip, I do not post many B.S. threads on SDN.

    regards.
     
  5. Fanconi

    Fanconi Senior Member
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    Call me crazy, but for all the pain of pre-med, med school, and residency, I certainly hope to make some nice $$$ one day. I think it's a good question. I want to be able to take care of my parents and live comfortably myself. Money is kinda important. I sure as hell am not doing this for the good karma I get from "helping people" anymore. :p

    FYI, a dermatologist I know made around $2 million last year.
     
  6. yaoming

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    neutropenia, i think your reply is more pointless than anything else in this world.
     
  7. Sandpaper

    Sandpaper Member
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    No, neutropenia is right. This sort of thread is pointless because anyone and his grandma can make idle predictions and unintelligible speculations about future earnings and they would be right. Besides, the original poster does not know his ass from his head judging from the way he stirs his magic potion of guesses together. IM and FP will see income boost just because there's a need to be filled? PM&R will make more because people are aging? Jeesus. Buddy, lemme simplify it for you: the paying specialties are those that are procedure driven, not those where the docs have to see 50 patients a day for med refill just to cover overhead and put food on the table. I could go on, but I'm now a hypocrite for contributing to this madness.
     
  8. Ligament

    Ligament Interventional Pain Management
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  9. neutropeniaboy

    neutropeniaboy Blasted ENT Attending
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    Glad to be a superlative for a change.

    Seriously, why continue to discuss this subject? How in the world can you predict what a field will be like 5-10 years from now? If you want to do that sort of prediction, be a consultant. If you want to treat people and dive into medicine because it's intellectually challenging and offers an excellent career, then pick your poison.

    While income is what makes this world go around, whether you're a family practice doc or an orthopedic spine surgeon, your banking buck at 2-3 times what the average working stiff does.

    So, who cares? I think picking a specialty based on its income is indicative of a distinct lack of vision.
     
  10. yaoming

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    neutro, i think it's just for curiosity sakes. no one is goin to pick a specialty based solely or highly just on income. but sometimes ppl are curious as to how much a family, surgeon, nurse, medical lawyer, HMO executive, ambulance drivers make. doesnt mean anyone is gonna switch into any of these fields, but it's interesting to know (and perhaps discuss).
     
  11. Ligament

    Ligament Interventional Pain Management
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    people, chill out. I have already matched in my specialty, so I am not posting to choose a career based on income.

    Also, people seem to have ignored my first (and most important to me) question:

    "We all know what the highest paying specialties are now, but I am wondering what the highest paid specialties have been *historically*, over the past 20 or 30 years lets say. "

    There is no conjecturing to answer the above question, nor is it a waste of time. The history must be recorded somewhere. I simply cannot find data to answer the above question and was hoping some of you could.

    thanks.
     
  12. ckent

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    I actually found this question to be interesting too because specialty incomes do change dramatically due to outside and political forces. An example of this would be how cardiothoracic surgeons and general surgeons used to rake in millions before medicare fees and HMOs slashed their reimbursement fees by half or more. Say what you will about pursuing specialties for intellectual interests, but I say that med students do follow the money (even though they might be reluctant to admit it). Take a look at the most competetive specialties with the most applicants per spots (ortho, derm, ENT, radiology), I don't think that it's a coincidence that those are the highest paying specialties as well while the least competetive specialties (peds, psych, FP) are generally the lowest paying specialties. I agree that it's impossible to predict where specialty incomes are heading, but it is fun to speculate. Just a couple of years ago, with managed care, everyone believed that there was a glut of specialists and they were talking about reimbursing primary care providers more to bring them up to par with those doing procedures. Just ~5-10 yrs ago, it was said that you couldn't pay people enough to go into GI because everyone thought that there was a glut of GI docs. And now GI is one of the highest paid (and high pay translates into most competetive again) specialty out there. So, I agree that it's not wise to pick your specialty based on where people say that the specialty is headed. But there's nothing wrong with speculation.
     
  13. droliver

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    cuts,

    its Bariatric Surgery & what you talking about is gastric bypass surgery where you divide the stomach proximally & reconstruct it with a roux-en-y gastro-jejunostomy. You get weight loss from early satiety as the small stomach distends as well as from a malabsorption that varies with the length of the roux limb.

    Bariatrics is prob. the only growth industry (no pun intended) in general surgery right now because the reimbursement for it is pretty high & a # of surgeons have practices where they are busy enough that they can demand fee for service for the procedure. Let me tell you though....... liability issues are going to kill this cottage industry. The complication rate for fat people from anything is high & you multiply that several times for complex surgeries like this. Getting malpractice coverage to perform it is getting very diffucult & is specifically excluded by a # of carriers.

    They scare you to death when you have to take care of them post-operatively because every time they blink, you get worry that they're leaking @ their G-J anastamosis. Failure to recognize this early is frequently fatal.
     
  14. Fanconi

    Fanconi Senior Member
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    I think bovie smoke smells like corn chips.

    Anyway, if I didn't loathe general surgery (and most general surgeons) so much, I'd do plastics in a heartbeat. Wonderful field.
     
  15. droliver

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    If you don't think you'd like general surgery, you likely would not like plastic surgery either. This is hard to appreciate as a student or layperson I think. There is so much overlap b/w the specialties as Plastics has essentially evolved from gen. surgery with contributions and techniques incorporated from other disciplines. I think this is one of the reasons they have had trouble screening people for the integrated plastic surgery programs as people will apply to them that say "Oh,I'd do plastics, but I could never do general surgery" & they end up discovering that the training of the two are more similar in many ways than different.
     
  16. Fanconi

    Fanconi Senior Member
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    Naw, you're totally right. What it comes down to is that I really like skin surgery. I could spend all day cutting skin cancers off of people and making little flaps to cover the defect. Unfortunately (or fortunately), that fun stuff is generally left to the plastic surgeons. I sorta think dermatologists ought to be trained to do more of that kind of stuff.

    Sorry about the threadjacking, Ligament. I'll start my own thread on surgery in dermatology later. :laugh:
     
  17. droliver

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    Dermatology just doesn't have enough background in surgical techniques to do the more complicated reconstructive surgeries
     
  18. avandelay

    avandelay New Member

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    That's an unfair characterization. It really depends on the program where you train. Dermatology residents (you read that right, residents, not Mohs fellows) at Texas Tech, Iowa, Florida, and Miami, for example, will have performed more flaps and grafts to repair skin cancer excisions than you will have done by the end of your plastics training. On what evidence do you base your opinion above? I guess the same facts as Dr. Thomas Russell of the ACS, who looked like a boob for insinuating dermatologists don't have the requisite training to perform many of the procedures that they themselves pioneered. For pete's sake, the first textbook of cutaneous surgery was even written by a dermatologist! I don't advocate that dermatologists should be doing breast augmentation or cleft palate repair, but do you really think the latest research and technique refinement in skin cancer excision and repair are coming from the field of plastic surgery? Please.
     
  19. ckent

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    Anyways, I was re-reading what I wrote and I realized that I forgot to make predictions. Med students should read these predictions carefully and base their careers on what I write here:

    1. There will be less of a demand for all primary docs in the future (family med, peds, meds, ob/gyn) in the future; most will be replaced by cheaper NPs and PAs. The role of the primary doc will be to supervise 3-4 NPs or PAs, hence there is going to be a major glut of primary docs in the future. If you look at what the average person sees the primary doc for, I think that ~90% of all office visits to primary docs can be handled by NPs and PAs. People might complain about seeing NPs or PAs at first, but given the choice between a 20 dollar co-pay to see a doc or a 0 dollar co-pay to see an NP or PA (this is what I predict insurance cos will eventually do to phase in NPs and PAs), people will almost always opt to see the NP or PA. Once they get enough NPs and PAs to take over, income for primary docs will bottom out as there will be too many competing for too few spots. This will cause an overflow of physicians into other fields, decreasing salaries in all fields.

    2. Out-patient office visits in almost all specialties will be taken over by NPs and PAs with the specialists in a supervising role again. This is already happening in a lot of specialties with NPs seeing all the irritable bowel syndrome cases for GI docs and PAs adjusting statins and checking up on post-surgical patients. This will also cause a decrease in demand for all physicians, causing all salaries of those who do not do procedures to go down.

    3. Medicare will keep decreasing reimbursements to physicians, especially with a new prescription drug plan (the money has to come from somewhere). Eventually, medicare will run out of money and will take it out of health care providers reimbursements before they take back their new prescription drug plan.

    4. As indicated by the previous 3 predictions, docs of the future will mostly only be doing procedures for their livings. They won't get paid as much doing procedures due to the fact that there will be so many patients on medicare that every physician must accept medicare patients regardless of how much they are reimbursed. And since social security and medicare will be going bankrupt, the government will just keep on cutting.

    5. Anesthesiology will be taken over by the nurse anesthetists. Sure, it didn't happen right away, but it was only a matter of time.

    6. Radiology is a bit more difficult to predict since I know less about it. With the internet and tele-medicine catching on, one might think that competetion to read films could come from other parts of the country, but then there is the whole issue of malpractice insurance and license to practice medicine in different states. Sure, laws might be amended to allow this, but I think that kind of a change takes time. The biggest drop in their income will probably come from the government, ie medicare, decreasing their fees and insurance companies following suit.

    7. The only wealthy people in medicine will be the laser eye docs (once they perfect their tech, everyone will be getting it done), the well-screen full body CT scanner (or other similar future technology) docs, and the plastic surgeons who operate on Hollywood stars.

    All of this and more in the year 2000....(Conan O'Brien joke );)
     
  20. ckent

    ckent Membership Revoked
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    Here is a nytimes article about the future of medical reimbursements:

    http://www.nytimes.com/2002/09/22/politics/22DRUG.html

    Government Proposing Cuts in Many Medicare Payments
    By ROBERT PEAR


    ASHINGTON, Sept. 21 ? The Bush administration is proposing deep reductions in Medicare payments for a wide range of drugs and medical devices used to treat people who are elderly or disabled.

    The proposed cuts are part of a new system of paying hospitals for outpatient services. With advances in medical technology, hospitals report explosive growth in the number and kinds of procedures that can be performed in outpatient clinics, without the need for an overnight stay. Outpatient care accounts for nearly half the revenue at some hospitals.

    The cuts would affect many drugs, devices and high-technology procedures, including cancer drugs and cardiac defibrillators like the one implanted in the chest of Vice President Dick Cheney to prevent an irregular heartbeat.

    Medicare would also pay less for blood products given to people who receive transfusions but do not need overnight hospitalization. The Medicare payment for a unit of red blood cells ? about a pint ? would be cut 39 percent, to $83 next year, from $137 this year.

    Federal health officials said Medicare had been overcharged for many outpatient services. But patients have joined health care providers in protesting the proposed cuts, saying that at the new prices hospitals will be unable to provide treatment to patients who need it.

    "We were shocked when we saw the payment rates," said Christopher T. Mancill, director of reimbursement policy at the American Red Cross.

    The payment for inserting a battery-operated pacemaker and defibrillator would be cut 59 percent, to $12,102, from $29,360.

    Doctors and patients' advocates expressed concern that hospitals would stop providing services on which they consistently lose money. This could make it more difficult for Medicare patients to obtain life-saving drugs, devices and treatments.

    The government itself, in a preamble to the proposed rules, acknowledges that many of the proposed payments are "far lower" than the 2002 amounts, and it says these cuts are "of concern to us because of the potential impact on access to care." But it contends that the new rates accurately reflect hospital costs.

    The Medicare payment for a breast biopsy would be cut 27.5 percent, to $290 from $400. For injection of cisplatin, a commonly used cancer drug, the payment would be reduced 43 percent, to $24 from $42.

    For Remicade, a drug given intravenously to people with rheumatoid arthritis, the payment would be cut 39 percent, to $38.50 from $63. For Avonex, an injectable, genetically engineered drug used by people with multiple sclerosis, the payment would be reduced 36 percent, to $144 from $225.

    Hospitals would get 67 percent less for implanting an infusion pump, used to deliver medication for severe intractable pain. The payment would be cut to $1,346 from $4,079.

    Dr. Edward L. Braud of Springfield, Ill., president of the Association of Community Cancer Centers, whose members treat more than half the nation's cancer patients, said: "Hospitals will not be able to continue providing chemotherapy at the proposed rates. Patients will have less access to care."

    The new rates illustrate the problems the government has in setting payments for an industry in which goods and services are continually changing because of new technology.

    Thomas A. Ault, an expert on Medicare who worked at the Department of Health and Human Services from 1984 to 1997, said: "The new outpatient rates are pretty messed up. The relationship between what Medicare pays and what a service will cost varies erratically."

    After considering public comments on the proposal, the government will issue final rules setting payment rates, effective Jan. 1.

    Medicare received more than 110 million claims last year for hospital outpatient services, including chest X-rays, breast cancer surgery and emergency room visits for heart attacks and broken bones.

    Under Medicare, a hospital normally receives a fixed amount of money, set in advance, for each outpatient service. Similar services are grouped together in more than 500 categories. The government sets a standard payment for each category and pays the same amount for each service in that group.

    Teaching hospitals, which pioneer the use of new technology, said the proposed cuts would hit them particularly hard. "Our biggest concern is the underpayment for new technology, especially cancer therapy drugs," said William D. Petasnick, president of Froedtert Hospital, affiliated with the Medical College of Wisconsin in Milwaukee.

    Mark W. Skinner, a former president of the National Hemophilia Foundation, said hospitals could not afford to provide proper care at the new rates.

    For the blood-clotting factor most widely used by people with hemophilia, the payment would be cut 54 percent, to 52 cents a unit from $1.12. This would reduce to $1,300, from $2,800, the payment for a typical infusion provided to a hemophiliac in a hospital outpatient department.

    The formulas used by Medicare to pay doctors, hospitals and other health care providers are set by statute and regulations and are notoriously complex. The Bush administration said the new system of paying for hospital outpatient services was "arguably the most complex and difficult in the history of the Medicare program."

    Federal officials said the outpatient rates for 2003 were the first ones based on actual data from claims submitted by hospitals under the new payment system. In the past, the government often relied on data supplied by drug and device manufacturers. The government said the new numbers were more accurate, but health care lobbyists disagreed.

    Stephen J. Ubl, executive vice president of the Advanced Medical Technology Association, which represents more than 1,000 companies, said: "Hospitals tend to underreport the costs of high-tech items, and the government compounds the problem by reducing charges for all items by a standard percentage. Hospitals mark up aspirin and bandages more than a $20,000 defibrillator, so when you apply a uniform reduction, it's biased against high-tech, high-cost items."
     
  21. Bikini Princess

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    I think it's interesting how fields compete for the growth areas.

    For example, radiologists are competing with radiation oncologists for interventional procedures.

    Also, surgical specialists may be afraid of general surgeons moving in on their most expensive operations.

    Plastic surgeons are being hedged in by dermatologists for minor skin procedures.

    Orthopods might be afraid of pm&r's taking over operative consults.

    Pharmacists are wary of family practice physicians who are setting up small pharmacies within their own practice.

    In a way, all the residency fields are in a wrestling match for the most lucrative procedures, it's hard to say which ones will come out on top..


    In the future, I think the procedures which require minimal skills go to the lowest bidders, whereas the fields which keep inventing new procedures will continue to make money.

    This is because medicare/hmos usually pay more for new procedures, whereas payments for existing procedures gradually get whiddled away at.
     
  22. jargon124

    jargon124 Senior Member
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    Rads competing with Rad Onc for procedures? I've never heard of that - can someone comment on whether it's really true or not? Thanks...
     
  23. Whisker Barrel Cortex

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    Radiologists and rad oncs don't have a whole lot of competition for interventional procedures. However, radiologists have a lot of comptetion for procedures from clinical specialties. Vascular surgeons doing angios and peripheral stenting pioneered by rads. Cardiologists doing peripheral arterial stenting, nuclear cardiac imaging, cardiac CT, and in the future cardiac MRI. Neurosurgeons doing vertebroplasties and neurointerventional procedures. So, there are a lot of turf battles out there. However, since most of medicine is going the way of these elegent, minimally invasive procedures, I don't think there will be a problem with finding enough work to do.
     
  24. Andrew_Doan

    Andrew_Doan Doc, Author, Entrepreneur
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    US Physician Salaries - Salary Survey
    http://www.allied-physicians.com/salary_surveys/physician-salaries.htm


    *Survey includes base salaries, net income or hospital guarantees minus expenses

    October, 2000 - Present




    SPECIALTY Min Median Max
    Allergy/ Immunology $158,000 $255,000 $302,000
    Ambulatory $ 80,000 $115,000 $152,000
    Anesthesiology: General $172,000 $228,000 $412,000
    Anesthesiology: Pain Management $181,000 $225,000 $450,000
    Cardiology: Invasive $220,000 $292,000 $489,000
    Cardiology: Interventional $215,000 $225,000 $410,000
    Cardiology: Non-invasive $198,000 $220,000 $390,000
    Critical Care $109,000 $124,000 $160,000
    Dermatology $ 165,000 $203,000 $215,000
    Emergency Medicine $162,000 $197,000 $229,000
    Endocrinology $125,000 $157,000 $185,000
    FP (with OB) $122,000 $144,000 $175,000
    FP (w/o OB) $122,000 $135,000 $180,000
    Gastroenterology $195,000 $255,000 $325,000
    Homology/Oncology $201,348 $255,000 $275,000
    Oncology $175,000 $227,000 $270,000
    Infectious Disease $144,000 $155,000 $175,000
    Internal Medicine $132,000 $143,000 $188,000
    IM (Hospitalist) $135,000 $160,000 $190,000
    Neonatal Medicine $128,000 $179,000 $226,000
    Nephrology $170,000 $226,000 $304,000
    Neurology $142,000 $168,000 $225,000
    Obstetrics/Gynecology $150,000 $220,000 $435,000
    Gynecology $143,096 $185,000 $321,000
    Maternal/Fetal Medicine $190,000 $246,000 $272,000
    Occupational Medicine $122,000 $147,000 $154,000
    Ophthalmology $131,000 $211,000 $251,000
    Ophthalmology Retina $219,000 $360,000 $386,000
    Orthopedic Surgery $256,000 $289,000 $450,000
    Foot & Ankle $220,000 $282,000 $411,000
    Hand & Upper Extremities $258,000 $325,000 $370,000
    Hip & Joint Replacement $330,000 $391,000 $475,000
    Spine Surgery $327,000 $400,000 $785,000
    Sports Medicine $321,000 $322,000 $511,000
    Otolaryngology $174,000 $230,000 $346,000
    Pathology $149,000 $211,000 $280,000
    Pediatrics $122,000 $138,000 $154,000
    Pediatrics - Cardiology $145,000 $182,000 $227,000
    Pediatrics - Hematology/Oncology $132,000 $170,000 $231,000
    Pediatrics - Neurology $136,000 $189,000 $252,000
    Physiatry $160,000 $164,000 $233,000
    Podiatry $121,000 $128,000 $192,000
    Psychiatry $128,000 $138,000 $228,000
    Psychiatry Child $133,000 $145,000 $265,000
    Pulmonary Medicine $177,000 $198,000 $379,000
    Critical Care $120,000 $172,000 $225,000
    Radiation Oncology $221,000 $275,000 $357,000
    Radiology $220,000 $415,000 $810,000
    Rheumatology $114,000 $140,000 $189,000
    Surgery - General $211,000 $220,000 $320,000
    Surgery - Cardiovascular $446,396 $475,000 $511,326
    Surgery - Neurological $285,000 $371,000 $460,000
    Surgery - Plastic $237,811 $412,000 $820,000
    Surgery - Vascular $210,000 $315,000 $375,000
    Urology $161,000 $260,000 $318,000

    SOURCE: Allied Physicians, Inc., Los Angeles Times and Rand McNally
    *Updated October 02, 2002
     
  25. dcw135

    dcw135 Member
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    I very much agree with much of what's been already written here. When you look at the trends, as reimbursements from seeing patients goes down (despite inflation), the costs of doing business - from paying nurses, receptionists to malpractice - have been increasing. The only thing that's prevented the two lines from crossing is the fact that doctors today see more patients per unit of time than they did 10 and 20 years ago. And this is true from general primary care through sub specialized surgical procedures.

    Did you guys know that 20 years ago people could charge 2100 dollars for a 20 minute cataract procedure and collect nearly all of it? Now that money is down to 400 - 600 and ophtho has one of the highest dissatisfaction rates of any specialty (along with ortho and probably for the same reasons).

    And speaking of surgery, I don't think PAs and RNPs either should or will stay with medical fields. Already many venous cutdowns for CABGs are done by PAs. Same with neurosurgery - PAs are placing burrholes and ventriculostomies. This will only increase in the future simply because IT DOES NOT TAKE AN MD/DO OR THE YEARS OF SUFFERING TO DO MOST OF MEDICINE.

    There is no longer something sacred in "doctor" that prevents someone else from doing your job. We MDs aren't entitled to automatically receive a lifetime pass free from competition anymore, as was the case 20 years ago. PAs and RNPs can do pretty much the same job and cheaper and they're happier to do it. I'm afraid all the people who just want to be a normal pediatrician and look into ears all the time and PCPs who just want to do pap smears will have to actually compete. And this makes getting a medical degree into a RISK by virtue of assuming debt burden. The PAs have 2 years post-college and NO RESIDENCY. They are young and debt free - this thought should make anyone but the most stupid, foolhardy, or saint-like (a classic triad in pre-resident students) cringe.

    I think history is on my side as well. After the industrial revolution, artisan classes were destroyed as things were made cheaply in factories. Those artisan classes fought hard to keep their income. Just like the AMA tried to keep PAs from prescribing meds - even things like amox. As medicine becomes more and more standardized, the same things which happened to the artisans will occur to us.

    In my opinion, with my crystal ball, doctors are going to need to tap into drug money to stay afloat. That means basically running trials out of your office if you're a PCP (who are probably in the best position to do this sort of thing along with medical specialties). You diagnose Mrs. Smith with Alzheimer?s disease (something you would neither have the time nor the motivation to pick up in your 5 minute visit otherwise) and if she fits into the clinical picture well enough, you recruit her into a trial. That way you can pick up the 3 dollars of profit after taxes, rent, insurance, receptionist, etc; plus the 800 dollar bonus for placing her on the experimental drug; plus more money for follow up. Same with HTN, DM, leprosy, whatever.

    Academics depend on research money. Clinical academics will probably have to start doing things like this as well to make departments fiscally sound.

    In the short term surgery seems safe, but watch out - I predict there will be half to year long post-PA/RNP training programs to teach fairly easy procedures like lap choles and appys. Next cataracts, lasers. Then who knows, CABG? Spine?

    And really, who knows? In my med school, I'd say most of the surgical residents were terrible technicians compared with the residents at a private hospital. Yes, small number biased, but out of 5 years, 2 spent doing research and one internship (where attendings would - not joking - yell at interns for going to the OR) how many cases do the residents actually do, not just watch or help? COuld that be crammed into a year or two? Could you take a PA and make a great surgeon? Certainly. Will she charge less? Certainly.

    Let me end this monster with this: financially doctors have gotten ----ed in the past compared to other professions requiring as much training - just look at MBAs - and this is a trend sure to continue.

    Dave
     
  26. womansurg

    womansurg it's a hard life...
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    One of the main reasons I chose a community program for my training: I wanted to graduate as an excellent, competent, well rounded surgeon. A generalization, absolutely, but do look carefully at your operative experience when selecting a training program. As I've posted on other sites, the prestigious, fellowship trained grads we've seen coming through our institution more often than not were embarrassingly technically inadequate.

    As to PAs doing surgery, I could easily teach a 10 year old to do a lap appy, but that's not the point. What will he do when he puts the trocar into an unsuspected abdominal aortic aneurysm, and the patient is exsanguinating on the table? When he finds a perforated cecal carcinoma or cecal volvulus? And how accurately is that PA making the correct preoperative diagnosis in the first place?

    We have a saying in general surgery:
    it takes 10 years to learn how to do surgery,
    another 10 years to learn WHEN to do surgery,
    and another 10 years to learn when NOT to do surgery.

    The art of surgery extends far beyond the scope of the operating theater. Five years of specific surgical training, on top of your four years of medical school, will produce a very green surgeon, with tremendous deficits in knowledge and experience. For this reason, the vast majority of new grads take positions with senior partners - and their education is ongoing for years to come. There is simply no substitution for years of dedicated, focused learning and, most important, cumulative experience.

    -ws
     
  27. droliver

    Moderator Emeritus 10+ Year Member

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    I agree 100% with womansurg...... surgical procedures are easy until they aren't. At that point in time you really need the fund of knowledge you acquire with your decade's worth of education & training rather then technical skills alone to take care of people. Routine appendectomies, tracheostomies,carotid endartectomy, hernias, & gallbladders can be deceptively easy to outside observers, the first time you see a catastrophic event during one you have a new respect how suddenly you can get into trouble.
     
  28. Celiac Plexus

    Celiac Plexus Senior Member
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    "In the short term surgery seems safe, but watch out - I predict there will be half to year long post-PA/RNP training programs to teach fairly easy procedures like lap choles and appys. Next cataracts, lasers. Then who knows, CABG? Spine?"

    Recently I listened to a story about a sailor on a submarine during WWII who got appendicitis at XX thousands of feet below sea level. The 20 year-old medic on board performed an appy and the sailor survived.

    Somehow, I'd rather have a trained surgeon take my appy out. What happens if something goes wrong? What happens if that PA clips a mesenteric artery? What happens if he/she perfs the bowel? I don't think that surgeons will ever be replaced by PAs. The only people who can replace surgeons are other surgeons.
     
  29. dcw135

    dcw135 Member
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    WS:

    My point about surg residents comming out of academic programs was that some of them are probably in much the same situation as a PA who spent a year or a half year doing gall bladders. Except of course minus the fatigue and frustration and debt of that PA. So you have green residents comming out of residency and green PAs for a few years.

    I agree with everything you said, DRO Liver, including possible catastrophic events. But I still think my prediction stands. How many PAs do you think could work for/with one surgeon to backup for these events?

    Similar arguments were made against nurse anesthetics as well as industrialized goods from artisan classes. You can't make these gloves in a factory as well as some old guy can make in his shop. But people will buy the industrial gloves.

    Lay people don't really even know the difference between PAs and RNPs and MDs and DOs anyway. I have very often heard some of the VA guys tell me they were reffered in from Dr. ____, RNP.

    So quality may suffer, I'll certainly give you that. But the underlying process is inevitable. Its a wonder the entire medical priesthood has lasted this long without competition.

    And CP: who would you choose, a PA with 10 years exp or a resident comming out of a toxic program where he never got to operate?

    Also, about knowing when to operate and not - that may have been true prior to CT. Again, all of medicine is getting standardized - that's why anyone can do it - just follow the flow sheet. In a way, our efforts to make everything standardized, like every heart patient has an ASA, B-blocker, ACE, statin, has made our field doable by anyone with half a brain - including doctors.

    Pharm companies are a good option if you have money to invest it. Medical equipment also: there are some companies that will have huge market shares in markets not yet thought up. But if I had a million dollars, in addition to buying your love, I would NEVER invest it in the career of a doctor: surgical or otherwise.

    You know that I don't mean to offend. And I really admire the defense of your craft. I just think there's no hope for a financial miracle to pull doctors out of this trend. As I mentioned last time, seeing more patients and doing more procedures per day can only hold back the flow so long. Already, hospitals LOOSE money on most medicaid patients. But because bringing in some money is better than bringing in no money (and the lights are on anyway, and the nurses are on anyway), they still accept medicaid people. How long do you think that will last?
     
  30. womansurg

    womansurg it's a hard life...
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    No, no, no. The degree of your unfamiliarity with the practice of surgery is so great, it makes it hard to counter with you. Like trying to talk world politics with a fifth grader.

    Surgery residents, even those who don't get much hands on experience in the OR, have had intensive, subject specific, ongoing training with very high minimal standards of acheivement to meet for at least 5 years.

    The decision tree that goes into when to operate and what procedure to perform is often simple on paper, incredibly intangible and elusive in practice. Even your rudimentary example of a lap appy - the diagnosis of appencitis is entirely clinical. There is no lab test, no imaging test (including CT), that can approach the accuracy of diagnosis of an experienced clinician.

    Even the difference in outcomes between good, dedicated, but inexperienced surgeons and good, dedicated but experienced surgeons is profound.

    So a PA would be exchanging 2 to 4 years of PA school for 4 years of medical school. Granted - that would have marginal (but probably real) effect on outcomes if it were the only difference. It would be like comparing people who started out in public vs private kindergarten. The big difference is the experience that follows; five years of 100+ hours a week of high caliber, high speed, focused training in a subject can't be replaced by a few condensed exposures. Now you are comparing the effectiveness of a lawyer who graduated from Harvard Law with one who took a few night classes at the local community college.

    I suppose if you show me a PA who can pass USMLE parts 1, 2 and 3, can show passing Absite scores for 5 consecutive years, can pass both the oral and written components of board certification examinations, and can document activity as primary surgeon on a minimum of 900 cases, with adequate diversity and complexity of caseload - well, let the sonovabitch operate, by god.
    There simply is not a short cut here: it doesn't exist.
     
  31. droliver

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    100% in agreement. There is so much to surgery besides being able to sew,cut, & tie. I think you could for sure get someone who is not a surgeon up to speed technically for almost any procedure thru repetition (they've done this in both the third world & in orthopedic residencies :) , but you would be in trouble when things (as they quite often do) are not as simple as they appear. That's where the background you develop from your education & training come in & you can't just abbreviate it & expect the same result. It's why some integrated plastic surgery programs have failed, & its why many people don't think it (abbreviating the training) will work for cardiothoracic or vascular surgery.
     
  32. dcw135

    dcw135 Member
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    Listen to yourself WS,

    The degree of your unfamiliarity with the practice of surgery is so great, it makes it hard to counter with you. Like trying to talk world politics with a fifth grader.

    I'll mostly ignore and mention in passing that you're arguing from authority here, which is really no argument at all. But there is something here that's of use: the underlying belief needed to say it. You've suffered. That suffering has to mean something. It gives you the right to be an authority, and of course it does. But its not going to let you say that PAs can't do surgery - the market will determine that. Furthermore, what I'm predicting (and really the only thing that can falsify something like that is time) is that the suffering does not entail you to a competition free environment.

    And:
    Now you are comparing the effectiveness of a lawyer who graduated from Harvard Law with one who took a few night classes at the local community college.

    Quality may suffer as we've talked about before, as it may very have when the cotton gin replaced labor, or when shoes were made by machines and no longer tailored by hand. But the bottom line is that these changes will occur because of market forces - the market needs cheap surgeries just as much as they need cheap pap smears and cheap 10 minute visits to tell someone they're dying. And someone is there to provide provide. Does it require a Harvard law degree to defend every case? No, and the market knows it, so there exists a place for the night school lawyer. Just as I'm saying there will exist a place for a PA who wants to do choles. Perhaps not to seperate oddly conjoined twins. There's no qualitative difference between the opposite ends of many spectrums.

    In CABGs, PAs ALREADY are opening, harvesting veins, sometimes even doing some of the graft work, and closing with NO direct supervision.

    So there's no lab test, nothing else to go by but gut instinct (but is this right now and more importantly, will it be right in the future?) - that's also no argument why the PA can't do the same thing. Just teach it. If clinical experience is needed, just get it. What may happen is that med schools and residencies may actually need to start competing with PA training as well - and shorten training. Already, 80 hour work weeks must kill case volumn if post call you have to go home.

    And...
    I suppose if you show me a PA who can pass USMLE parts 1, 2 and 3... and can document activity as primary surgeon on a minimum of 900 cases, with adequate diversity and complexity of caseload - well, let the sonovabitch operate, by god.

    So should I pick a surgeon who rocked on COMPUTER TESTS over one who didn't? Is there any correlation between those silly Steps and how good at surgery a surgeon becomes? I shudder to think of my hands being better than some of the guys in school. Or on oral tests? Or on doing post-op checks? Or on keeping on top of the VS? Or on 95% of the daily resident torture?

    So when is a sugeon - MD or PA - ready to operate? At gall bladder 100? 200? 500? 1000? 1500? 2000?

    Perhaps the point is that it really isn't up to MDs- although you can be sure that like all guilds, the surgery guild will try to protect their competition free environment - its up to the market. And the market will settle for what works for less. And how about doing derm procedures? Plastics? Amputations? Ortho? Ophtho? And this is where the money is, for now, anyway. How about lines?

    As I mentioned, I actually agree with most of what you've said except your conclusions. Quality may suffer and to quote Liver, "you can't just abbreviate it [training] & expect the same result." Sure, but quality on a case by case basis is not what we're talking about. We're talking about what will happen in the future.

    Did you know that 50 years ago only doctors were allowed to take blood pressures? That procedure was thought too complex and too, sorry, vital, to trust anyone else with it. In my internship I took maybe 3-5 BPs total and put in many times that amount of a-lines - which goes to show that things in 20 years will not be as they are today.

    And given the fact that 20 years ago NO PAs cut. And given the fact that in many cases today PAs are ALREADY opening, cutting, and all the rest. And given the fact that PAs can offer NEARLY the same amount of end points as MDs. And given the fact that all of clinical medicine is becomming more and more standardized so that anyone can do it with good imaging. I'm simply going to stand by my prediction that PAs and RNPs are going to offer more competition to our entirely archaic guild by doing the same things cheaper. And this will drive profits into wishful thinking unless doctors can become more creative and streamlined - not a historic strong suit.
     
  33. orthoguy

    orthoguy Assman
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    LOL LOL LOL........................Ok here is the deal.............DCW you are talking about PA's who will always be PA's..........no matter how large you knowledge of market capitalism/how many five dollar words you can weave into a paragraph/and how extensive you knowledge of the renissance they will still be known as physician ASSISTANTS..................either you are a PA in desperate need of justifying your existance or you are an MD with no true grasp of what makes a surgeon a surgeon and a talented clinician just that............PA's and RNP's do have a place........they can work as PCP's in small rural areas and larger urban areas in need of PCP's...............routine gyn exams.............physicals etc....................so quit making brazen predictions based upon small concessions (Once doctors thoughts bp's were a sacred trust and that changed........now PA"s will be doing neuro surgery b/c of advanced imaging and a lack of need for science or any true clinical training.........LOL)........quit elevating the "profession" of those who go to the equivalent of med school lite with their 2 years of post graduate tarining to the level of surgeon.........let them do their scut/their IV's and show just how far their correspondance degree can take them
     
  34. orthoguy

    orthoguy Assman
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    ...........
     
  35. dcw135

    dcw135 Member
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    I'd jus tlike to point out to those considering a career in medicine - not only will the pay stink, but for collegues, you WILL have to deal with people like Orthoboy here. They are proud of their stupidity. And suspicious of things that are new and different. Rather like the ape in the opening of 2001.

    You say:
    no matter how large you knowledge of market capitalism/how many five dollar words you can weave into a paragraph/and how extensive you knowledge of the renissance they will still be known as physician ASSISTANTS.

    Yeah, you are a real model for something no-one else could even dream of doing. What you do is special and your obvious intellegence and wit makes the point pretty well - don't you think?

    And you go on:
    either you are a PA in desperate need of justifying your existance or you are an MD with no true grasp of what makes a surgeon a surgeon and a talented clinician just that

    Here is a 5 dollar word for you: ad hominum. It doesn't matter what I am, PA or MD or neither. Try taking the argument against the argument, not the man.

    You say:
    quit elevating the "profession" of those who go to the equivalent of med school lite with their 2 years of post graduate tarining to the level of surgeon

    Putting bones back together again really requires everything you learned over 4 long years of med school, right? You need to know the kreb cycle and what Alport syndrome is on a daily basis. Don't you see that those 4 years are nothing but nonsense?

    Also, I'm sure you've encountered nothing but wonderfully knowledable and competant MDs in your ER. Isn't it obvious that MDs can be just as bad?

    You say:
    let them do their scut/their IV's and show just how far their correspondance degree can take them

    They will. That's the point. And the answer might be down your neck.

    :love:
     
  36. DuneHog

    DuneHog Senior Member
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    DCW -

    You make some interesting predictions, although I have to wonder whether your goal in posting here is simply to be inflammatory.

    I agree with you that PAs and NPs are and will continue to play an important role in all health care fields, surgery included. However I have to disagree with your comparison of non-physician health care providers to textile mills and the industrial revolution. There is really nothing revolutionary about PAs and NPs. Sure, they undergo less training and as such may ask for less compensation for their services, but a NP or PA cannot perform a procedure faster or better than a physician. And the reduced fees by NPs and PAs really isn't all that revolutionary either when taken in the context of the overall cost of healthcare. Particularly for surgical services, the surgeons fee is often a relatively small part of the overall cost of care. Things like OR time, hospital stays, medications, implants and equipment cost much more than the surgeon's professional fee. Especially when it comes to surgery, the cost savings of replacing a physician with a NP or PA would not be worth the trade off. Not only would patient outcomes likely suffer, the additional cost of complications would outweigh the cost saving for complex procedures. Also, if PAs or NPs are functioning as the primary surgeon, they would also likely perform the pre-operative evaluation. And because PA and NPs lack of the broad clinical knowledge and training required to effectively determine whether a patient needs an operation, they would order additional expensive diagnostic tests and perform unnecessary procedures, again negating the cost benefit.

    I don't think that the public would want non-physicians acting as the primary surgeon for major operations either. There are certainly some folks out there (like many VA patients) that don't know or really seem to care that there is a difference between the training that MDs vs PAs have. However, I think these people are in the minority. Most people (particularly those with good-paying private insurance) are well aware of the difference between MDs and PAs. Now they may not mind if a PA does there pap smear, checks on them post operatively, or assists a surgeon by harvesting vein grafts for a CABG, but the majority of the public is a long way from letting a PA act as the primary surgeon for any operation.

    Even if a NP or PA does manage to convince some poor rural medicaid patient to let them do their operation, they still have to get operating privelages at a hospital. I would find it hard to believe that any hospital board would ever give a NP or PA operating privilages as a primary surgeon for political reasons alone. And politics aside, NPs and PAs certainly would be denied primary operating privilages because of legal liability, partly because there are foolhardy non-physician practitioners out there (like yourself?) who think that they can perform procedures that they don't have the training to do.
     
  37. dcw135

    dcw135 Member
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    Dunehog,

    Liked your reasonable reply. Agree, we will see what happens. As to what I am: I suppose it is relevant to mention that I'm a PGY3 in neurology. And despite how difficult many people find neuro, if med students are any indication, I still feel PAs are going to take over most clinical aspects of our patient care - especially among the poor.

    My comparison to historical guilds was to predict the behavior of the AMA and I think the analogy would stand if pushed a bit further - to a mild decrease in quality, more efficiency, and decreased cost when doctors begin to have to compete (that's the qualitative difference and deserves the name revolution, don't you think?). Standardizing clinical pathways will eventually happen for everything from elder failure to thrive to SAH (already very much occuring for things like SAH) - and that will set fertile ground for PAs and others.

    But, again, we'll see. Either way, doom and gloom for doctors, yada yada yada.
     
  38. futuremd45

    futuremd45 Junior Member
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    DCW135,

    I sadly agree with you about the future of medicine. First of all, I am starting med school next fall. However, I am an oldpremed, and I have been working on Wallstreet for many years and very familiar with economic history. In addition, I come from three generations of doctors.

    I have realized in studying industries, all succumb to market forces and eventually are driven by the maxim: "the highest quality at the cheapest price." Usually, the cheapest price wins. I agree that there is no mystical significance to a medical degree and in the end doctors are like any other service provider. If more doctors realized this they would ease many of there financial, legal and professional burdens they face. Most of the doctors I have met, and I dont mean fresh out of residencies, are so foreign to the business world that they make easy targets for bureacrats, lawyers and unscrupulous patients.

    I find it very sad that many doctors still feel that they have a higher significance than any other professional. No matter how much the other posters argue with you: you have history and current happenings on your side. Almost all the senior doctors I have spoken to are so dissatisfied by the fact that they have to deal with the hassles of malpractice, claims filing, etc (things everyone else has to face everyday) that they question their choice of field. However, I think doctors today need to accept the fact that medicine is like every other business: you will get sued if you perform a poor service (and sometimes even if you dont), you will face competition from people you believe are not as competent as you (analogous to Microsoft vs. Apple) and you will not be treated specially.

    So why you ask would I choose medicine after all this, especially since I was making much more money than most doctors will ever make and with less headache? Well, no matter how much medicine faces up to economic realities of the world, I believe the simple interaction between a doctor and patient is worth more than all the crap associated with it (I may be wrong). I think in the end you should choose a field not based on money (I have already made this mistake) and rather by the satisfaction it gives you.

    And though most of the people arguing with you have a extremely biased perspective and a false hope that things will not change, they are just fooling themselves and will most likely be disappointed. Hopefully, they did not choose this field for all the wrong reasons.

    ;)
     
  39. futuremd45

    futuremd45 Junior Member
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    oh one more thought:

    Even if PAs,RNs,etc take over many aspects of medicine, I am sure MDs will still be extremely busy treating patients. Therefore, the only thing that changes with PAs,RNs,etc encroaching into MD territory will be that MD salaries will go down. MD patient time will not go down and MD caregiving will not go down.

    So, I thought doctors were not supposed to care about money???
     
  40. orthoguy

    orthoguy Assman
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    What do you know.............the pre-med agrees with the neurologist about what makes a great surgeon.............fascinating banter from 2 obvious experts
     
  41. Yasergale

    Yasergale Junior Member
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    DCW

    You are correct about many things such as the dissatisfaction of the specialists and the "financially f_cked" issue.

    But I just can't discount the fact that you are viewing this from your medical arena and from the opinions of the physicians you work with. This is the wrong way to approach this. The US medical environment is different from coast to coast. For example, the mid-southwest gen surg guys still enjoy high reimbursements and procedures normally done by other specialties. As for the east coast, the reimbursements are not so high nor is the job satisfaction for an average gen surg in Mass.

    Although physicians have gotten reimbursement cuts post the 1997 Balance Budget acts, things are adjusting.........for the better, you just have to be patient because change is slow in the medical environment (despite the fact that the last decade of changes has been considered to be extremely rapid). I will use Boston, MA as an example since this is the environment I "grew up" in. Also Boston is a perfect "testing ground" because there are three major academic centers here: Harvard, Tufts, and Boston University. Each have there own hospitals. Now turf war is huge. There is lots of competition, just to fulfil their income and academic needs of teaching their medical students. This is perfect for the HMOs....large number of hospitals and limited patients. The environment CANNOT get any worse for the Board of Trustees in each of these hospitals. It is basically heaven for the HMOs. Now the HMOs are Lifespan, Harvard Pilgrim (I still can't stop laughing at these guys), Tufts (now merged with Lifespan, unsuccessfully, LOL), Blue Cross Blue Shields and probably couple other small timers. Obviously the bargaining power of the HMOs are larger than the hospitals. Each hospital would be forced to take lower reinbursements because if they don't, the HMO would take their patient population to another hospital. This has been the trend for the last couple years. It has shut down a couple hospitals here in our area. Like you said DCW, Doctors are not businessmen, that's why it took them so long to come up with simple idea of merging, which is easier said then done. Why? Imagine trying to merge two surgical departments together. Different culture. Different techniques. And since there are now two surgical chiefs, one has got to go. ANd you know how we all like to flock together. So if one chief goes, he takes at least a good chunk of the other attendings too. THis is not only true for surgery but it is also true for neurology, medicine, etc. Cmon, these docs worked hard for their positions and to have some idiot with no MD come in and tell him what to do? Unthinkable. THis is a failed merger (go check up on the Beth Israel and Deaconess hospital merger). Unfortunately alot of hospital mergers are like this, across the country. But there is one merger I am particularly fond of: Partners. Their merger undisputedly succeded. Partners started with Mass General and Brigham and Womens Hospital. Eventually added others. One of the main reasons for their success was all they merged was the Board of Trustees and all their administrative works (account payable dept, publicists, marketing, etc). This alone cut costs by 33%. THis is because duplicate administrative tasks were eliminated. THey did not immediately merge their departments. They actually waited until one of the chiefs retired and then they slowly managed the integration. To this day, some dept are separated and some integrated.

    My point with all this is that these administrators and physicians have been through it all. The administrators have been pushed to the brink. They have considered everything you have talked about. Using PAs, RNs, and midwives. When I looked at the potential cost benefits (done by both Partners top administrators and me) of using non MDs, it was not at all going to help the hospitals pull into the black (break even). In addition to that, they are not as cheap as you think they are. Do you really think that a PA or RN will do the job of an intern or long hours of surgery for the pay they get? In addition to that there's a shortage. The only people I can think of more distraut than the MDs are the RNs and PAs. They're not getting paid enough for what they do. I'm not even going to go into the political and social aspects. Lets just say that, its not gonna help the PAs or RNs any. (I'm not trying to put down PAs or RNs. In fact I love them, they let me have OR time while they do my dictations, discharges, notes, admits, and all sorts of other crap. THey are a gift from god to the intern). In any training program, I believe that they will place the training of the resident before any PA or RN student. So if the PA student ever gets surgical training, it will not be nearly as good as an MD. WHich brings me to another question.....why would you need a PA if you can let the resident do it....hell the resident is cheaper!

    There's a happy ending to the Boston Battleground. Partners is now huge. THey not only have several hospitals but also several practices outside the Boston area feeding in patients to their services. Now the HMOs are literally losing out. Partners has huge bargaining power. Partners can turn down an HMO offer. Because of this the HMOs patient pop will not have much of a hospital choice since Partners is so huge (they will be forced to non Partners hospitals). The patients or businesses they work for can easily switch plans that have contracts with Partners. They basically forced the HMOs take what ever reimbursement rates that Partners set. So the HMOs began to merge.....but unsuccessfully. Right now the future looks bright for physicians. Yes, the arena has changed compared to the way it was 20 years ago. The "artisans" would be proud of us.

    One more thing, about the nurse anesthetists. From what I understand, the reason they haven't gone as far as they "should have" is because of too many preventable patient deaths. There was actually a period of time when they had more power, but this changed because of their performance. This reversed the trend of using nurse anesthetists and the law determining what they can do.

    As for the physician dissatisfaction issue, I can't argue much about that. But can you really tell me that an MBA is any happier than me in this ECONOMY! A job is hard to find these days. Sure, there are "friends" or "relatives" banking it. Or are they? Just like in any field, the best and the strongest survive and they stick out. Many are actually going back to school, despite me discouraging them to. Their reason is that they need to develop their own "niche," sort of like you and I, neurology and surgery respectively.
     
  42. DuneHog

    DuneHog Senior Member
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    It always annoys me when some wall-street wash-out comes in thinking that because they know a little about the stock market they are suddenly an expert in medical economics. I think that your sweeping generalizations about the financial sense of most physicians today are simply wrong. Sure, there are some older physicians who practiced in the bygone era before managed care and had a difficult time adjusting. However, the finances of the medicine are pretty important to most practicing physicians today.


    Just curious, if you so wholeheartedly agree that MDs are no different from PAs and RNs, except that they are willing to work for less, WHY DIDN'T YOU GO TO PA SCHOOL??? PAs interact with patients the same way that MDs do! And if they are more competative economically, as you say, it would seem to be a more logical choice, particularly for a middle aged person going back to school. Please get off your high-horse. You are lying if you say that money didn't play a role in your choice to go to medical school. And if you truly don't think that there isn't anything special about being an MD, don't go to all the trouble to become one. It is a long road.

    One more piece of advice. Once you get into medical school, no one likes to here your personal statement anymore.
     
  43. yaoming

    yaoming Membership Revoked
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    just wanted to pitch in a comment. if i had a problem, i'd rather see a doctor than a nurse/PA anyday, even if i had to pay more. i had an infection (simple) once and i saw a nurse practitioner. she gave me some crap and after a few days, nothing happened. so i ended up callin my doctor, who knew of the problem right away and suggested a stronger dose of medication. it's true the NP made the correct diagnosis and treatment, but i still didnt fully trust her. so would i pay a little more just to ensure a health professional with longer medical training would help me, such that the problem will be fixed more likely and i wont have to worry about it again than see a NP for cheaper price and live with doubts? i would pay more.

    would it matter to me even more if i had chronic issues or more complicated health problems? yes, i would def choose a doctor and pay more than an NP. for a shot/vaccine or physical exam, i might not care and go with nurse, but a lot of people would rather see a doctor when it comes to anything a little bit more complicated.

    just imagine if you had diabetes. who would you see? i'd see the doctor, for a higher price, than a nurse/PA. that's my honest opinion.

    and i think u'd go ahead and pay for health insurance with a doctor just incase a really complicated health issue popped up out of thin air. if u didnt pay your dues of health insurance with doctor, and u get a complicated health problem that your nurse cant solve, u're screwed. so in the end, people will still pay their health insurance for doctors, and doctors still will be paid bank.
     
  44. futuremd45

    futuremd45 Junior Member
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    Dunehog,

    I hate responding to imbeciles but you leave me no choice:

    First of all, I am not a wallstreet washout (again you fail to see my underlying message and quickly jump to insults). I was extremely successful... I chose to pursue medicine because I wanted the opportunity to help people. The reason I did not choose PA school is bc. I wanted the greater scope and responsibility of being a medical doctor.

    Second of all, medicine is a business and since my background is in business, I strongly believe I can intelligently talk about the economics of medicine (something you obviously lack, probably in most arenas of your life).

    Finally, I, unlike most of you, have chosen medicine irregardless of financial concerns. I plan to practice in an academic or indigent setting, thereby limiting my financial rewards greatly.

    I find it very sad that many of you can not see outside of the box when it comes to the economic trends in medicine. Trends that you do not have to be a doctor to recognize. Actually, it is probably this arrogance that pervades medicine that got doctors in this situation in the first place.

    By the way, dunehog please tell us your name, future area of specialty and location, so that we may avoid your close-minded and foolish banter.
     
  45. mlafur

    mlafur Junior Member
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    well, that is it, i quit, screw eras, cancel my interviews, or maybe i will go ahead and graduate and then go back to school to get my PA degree since it seems to be better than MD.
    No, really, alot of the rich doctors i know are rich because they took the money they made and invested it in other places. For example, opening an open air MRI, opening outpatient surgery facilities, etc.
     
  46. Tenesma

    Tenesma Senior Member
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    Are you crazy???

    You can teach any monkey to do a surgery, just as you can teach any monkey to provide anesthesia, just as you can teach any monkey to treat diabetes... But, and here is the big BUT: it doesn't make you a doctor...

    You mentioned that a PA after doing 500,1000 lap. choles could provide that service just as effectively... well no ****... anybody can do a lap chole: stick tubes in the belly, dissect gallbladder out, clip artery and duct, and voila... here is the flaw in your analysis of the problem... PAs don't have the training nor the depth of understanding. tell me what happens if the anatomy is different? tell me what happens if there is major vascular damage requiring conversion to an open case... does a PA know how to control severe hepatic bleeding, or know how to repair torn branches of the celiac? tell me, does a PA know how to manage a patient with septic cholecystitis requiring critical care in the ICU?

    this is why PAs will never ever replace surgeons, why CRNAs will never replace anesthesiologists, why PAs will never replace internists, etc, why midwives will never replace OB/GYNs... in the long run the hospitals, HMOs will be unwilling to carry the burden of liability.....

    just curious, do you think PAs can follow stroke protocols and replace neurologists? (since that is the field you are aspiring to?) everbody can follow cookbooks/algorithms.. that isn't why we went to medical school... advanced nurses or physician assistants will be there to provide basic care (that we have realized is safe for them to do) - and that is fine with me.
     
  47. MrGreed

    MrGreed Member
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    Experienced PA or NP: "so you're the new chief resident...will you be needing anything from us?"

    New Intern: "no, I'm fine."

    Experienced PA or NP: "would you be some help and go do the pre-op for the lap chole in 5W and the consult in 3S."

    New Intern: "you must be mistaken, that is YOUR job...I also like my coffee black and fresh donuts in the morning...please have all consults dictated for me when I get in tomorrow morning..."

    Experienced PA or NP: "who do you think you are? I've been at this hospital for over 15 years...I'm old enough to be your father."

    New Intern: "I may be a young doctor...but I am THE DOCTOR."
     
  48. LoneSEAL

    LoneSEAL Senior Member
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    I remember as a child wanting to be a wizard. A wizard is a powerful being. He can cast spells that produce miraculous and unworldly effects. He is the guy with the grey beard who has been through the fire of experience. Wishes that others desire, he grants.


    Many aspire to be the omnipotent wizard, to wield the powerful wand of magic and fulfillment. These seekers recite spells, spells that they have stolen and copied from the ultimate wizard masters. These neophytes never learn how to create their own spells -- instead, they "recite" spells that they did not create.


    But these will never enter the promised land, for they are"doing" something that is foreign to them, something that does not come out of them, something that is rigid and unwieldy. Meanwhile, the true wizard laugh at these quacks -- the true masters cast spells not through memorization but through omniscence. They can create spells that are tailored for the situation -- they know the variables that need to be modified, the consequences that can result, and ultimately the grey that exists between the black and white.


    For they don't "do" magic, they "are"... magic.
     
  49. womansurg

    womansurg it's a hard life...
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    That's exactly right, Tenesma.

    I'm rotating at the local charity hospital right now. Because of the patient population here, most of the gallbladder presentations are complicated and advanced, due to neglect. Unlike at the private hospital, where the housewife presents after a single episode of biliary colic, you stick in your scope and peel a robin's egg blue gallbag off the liver.....here, of the 14 lap choles I've done in the past six weeks, 9 have had to go to common bile duct exploration with stone retrieval. One had to go to open approach for an impacted CBD stone in a friable, near gangrenous duct which couldn't be extracted. One had a phlegmon at the infundibulum which required me to dissect all the way back the cystic duct/CBD juncture in order to find tissue viable enough to hold an endoloop (too short to place clips...) Another had atypical anatomy with the gallbladder blood supply emerging directly off of the large hepatic artery...which had to dissected off of the gallbladder in the first place to even realize that this was the anatomy. I had to then transect the arterial radicals right on the gallbladder wall - with room only for my proximal clip and no room for a distal clip.

    Hepatobiliary surgeons will tell you that complications from 'simple lap choles' are far more frequent than people appreciate, and are devastating injuries.

    In the high volume surgical training atmosphere from which I come (we often do as many as 5 lap choles per day), there has never, not one time, been a CBD injury. I had done over 60 lap choles by the end of my second year in training - and that number is much higher now, of course. The volume and the surgical expertise of my trainers has allowed me to deal with these complicated presentations, in a way that more limited exposure never could.

    I would never get into an airplane with a pilot who's training was an abbreviated version that allowed him/her to only handle bright visability, clear skies and good weather. I sure would never get on an OR table with an operator who had inadequate training to cope with any number of complications WHICH WILL HAPPEN. It's only a matter of time.
     
  50. dcw135

    dcw135 Member
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    You can teach any monkey to do a surgery

    You said it, I didn't. If there are anatomical variations or complications, just HOW exactly is a PA worse off than a recent graduate of an academic surgical residency where she did more Whipples than lap choles? What would the PA do - well, if well trained he would do EXACTLY what an MD would do. You haven't shown me that what surgeons do is, as Loneseal's odd and probably false analogy states, magic. What would the PA do with bleeding - make it stop. Why go on - for every reaction in medicine there will be an equal and opposite algorhythmic reaction.

    The new surgeon has back up and the new PA would have backup. After awhile, with exp., neither needs backup anymore.

    WS says:
    The volume and the surgical expertise of my trainers has allowed me to deal with these complicated presentations, in a way that more limited exposure never could.

    Well, I'm happy for you. Do you think the krebs cycle helped you? So PAs are not capable of getting the same exp?

    Tens says:
    this is why PAs will never ever replace surgeons

    Other than this sentence, never say never.

    goes on:
    just curious, do you think PAs can follow stroke protocols and replace neurologists?

    I think a monkey could follow stroke protocols. My answer is a definite yes, and was stated in my last post. In that I mentioned that all of clinical medicine including neuro could be taken over by non-MDs.

    Also, PAs could probably do neurology much BETTER than some medicine, ER, and surg MDs I've encountered. Nothing beats an urgent 4AM tPA call for a wrist drop after a surgery. I just realized I could fill books along these lines.

    Perhaps one of the underlying thoughts to those who say that every chole must be done by a PA is that somehow these people have inferior minds and 2 years of training isn't enough. We are discussing, essentially 2 years that we get and PAs don't. But as we can see from orthoape's postings, MDs do not have a lock on all that is intelligent. Not only could any monkey do surgery and neuro, but that same monkey could get through med school. Do you think we are somehow special because at one point we knew the names of all the muscles in the body? Or because we memorized pharm trivia?

    Doctors are not special. We are not magical creatures. In some cases we're even worse. Check out coumadin clinics if you doubt that.

    But until we're forced to compete, we can be happy and neglectful. Telling ourselves those sweet nothings: we are special. We are good. We are not replacible.
     
  51. Tenesma

    Tenesma Senior Member
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    dcw... you are right: the Krebs cycle provides little help from day to day.... other than that you are clearly confused...

    I would say 80 to 90% of the care that we as doctors provide on a daily basis is very straightforward - and with limited education PAs/NPs can provide that exact same care... I would even argue that those PAs/NPs could provide that same care even more succesfully than some MDs, mainly due to the fact that the scope of practice of the PAs/NPs is very narrow and with a lot of repetition they can become quite astute... for example, at my old hospital there was a wonderful nurse who managed the diabetic medications for the endocrine service (she wasn't even an NP or a PA): she had been doing it for 20 years and had learned a lot, and was well trusted - and she probably outperformed all the residents, all the internists... But she still needed to call her endocrine supervisors for tougher cases.

    My arguments are focusing on the 10 to 20% of the care provided... Medical school isn't just about memorizing muscles, it is about deductive reasoning, differential diagnosis and a very broad base of medical understanding that allows with appropriate post-graduate training to manage almost all the problems in a certain field... the only way PAs and NPs can strive to replace us, is if they obtain the same extent of training as well as get that well-rounded medical school education... and if they did, they would be MDs and your original point would be self-defeating.

    you have obviously very straightforward patients, because in my experience i had PAs/NPs come crying to me for help for quite a few patients - when i did medicine, and now i have CRNAs asking for help in the management of their more complex patients.

    if MDs were shifted out of clinical medicine, who would those people turn to? Could you see those siamese kids being separated by a team of NPs, PAs, CRNAs and then being managed in the PICU by more NPs... you make me laugh so hard my cheeks are hurting...
     

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