I was pre-med in 2003 and started this account in 2004 before med school: why I (probably) would choose a different career if I had to do it over

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deleted804295

You mean in medical fields? I've seen what FAANG gigs look like up close (lived with one of their employees throughout COVID shutdown). I'm only an MS4 and it's already very apparent they made the better choice
Well if serving others in vulnerable states is comparable to sitting at a computer coding all day sure.

I've done both and as fun as coding is it really doesn't give meaning to life.
 
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efle

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Well if serving others in vulnerable states is comparable to sitting at a computer coding all day sure.

I've done both and as fun as coding is it really doesn't give meaning to life.
I mean I dont really find copying forward 90% autogenerated notes and waiting days to find placements to be super fulfilling either :/ I'm matching DR and will be looking at a screen all day regardless. Could have started staring at screens for money at age 22 instead of 32!
 
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TikiTorches

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It's hard to open up private practice in inflated suburbs/cities due to difficulty getting patient base, malpratice and overhead costs.

Many of these issues can be circumvented by having a PP friendly specialty ie psych or going rural.

In the past all doctors weren't concentrated heavily in one area so this is part of the problem.
Part of this thread is how corporations get patients and keep them in their system. Hard for pp to gain traction
 
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TikiTorches

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In private practice land, the midlevels set up shop and don't correct patients that they're not Physicians. They have a collaborative doc who is 90 miles away and has agreements all over the state with other midlevels. It's the wild west out here. No checks and balances
 
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I mean I dont really find copying forward 90% autogenerated notes and waiting days to find placements to be super fulfilling either :/ I'm matching DR and will be looking at a screen all day regardless. Could have started staring at screens for money at age 22 instead of 32!
Jeez man you sound miserable. What made you decide DR? Do you prefer less patient interaction? Was it your top choice?
 

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I mean I dont really find copying forward 90% autogenerated notes and waiting days to find placements to be super fulfilling either :/ I'm matching DR and will be looking at a screen all day regardless. Could have started staring at screens for money at age 22 instead of 32!

Obviously you can't reverse time and become 22 again, but will throw it out there that if you want to do stuff in tech DR opens a lot of doors for you. Most 22 year olds are honestly just de-bugging old code and running tests - I have a lot of friends who did CS and went straight to FAANG and it's not interesting or stimulating though they all agree the money is good. As a radiologist in tech you can actually run interesting projects and make an impact on the technology of the future. Don't forget that you aren't trapped on the clinical side of medicine.
 

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Obviously you can't reverse time and become 22 again, but will throw it out there that if you want to do stuff in tech DR opens a lot of doors for you. Most 22 year olds are honestly just de-bugging old code and running tests - I have a lot of friends who did CS and went straight to FAANG and it's not interesting or stimulating though they all agree the money is good. As a radiologist in tech you can actually run interesting projects and make an impact on the technology of the future. Don't forget that you aren't trapped on the clinical side of medicine.
Do you think CV will impact radiologist drastically in future?
 

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Obviously you can't reverse time and become 22 again, but will throw it out there that if you want to do stuff in tech DR opens a lot of doors for you. Most 22 year olds are honestly just de-bugging old code and running tests - I have a lot of friends who did CS and went straight to FAANG and it's not interesting or stimulating though they all agree the money is good. As a radiologist in tech you can actually run interesting projects and make an impact on the technology of the future. Don't forget that you aren't trapped on the clinical side of medicine.
Liability is also much lower for them than a physician
 

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My wife and I were married as medical students . I recently retired and my wife will within a year. My son went into medicine despite my wife's protests. The forces we physicians are up against to advocate for our patients are massive. Both the insurance industry and the government share the same goal, and that is cost. Quality is just lip service. All the huge administrative costs and paperwork come from government regulations. Insurers and health systems have to comply with the regulations and therefore must hire people to keep them in compliance. Either Corporate medicine or govt run healthcare takes us to the same place .Rationing generic quality healthcare to control cost. Advancing the privileges of mid levels will continue. Soon, that 250 k salary that everyone talks about for physicians will be the average salary for a mid level hospital administrator. My neighbor, a rather unimpressive sort, is a VP for the regional health system. Always flying on the corporate jet, newpaper reports 700k salary, has 3 homes. I guarantee he is not the intellectual peer of anyone on this network. I wouldn't do what he does for twice the money. I do admire his survival skills, as he was able to slurp his way up the cone, or corporate ladder. Wouldn't it great if we didn't need to spend so much money on govt or corporate beauracrats and actually use it to take care of people?
 
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TikiTorches

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Sorry, should have qualified that! I'm an academic attending - residents can't be supervised/trained by midlevels so I'm secure in my job as long as my residency program keeps its doors open
In Penn State several years ago they had an np training the anesthesia residents...
 
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Job security is much lower for them. Everything is a trade off.
Stop producing at a breakneck pace or question anything a nurse or admin says. Then you are labeled disruptive and job security for a doc is in jeopardy also. Physicians also defer alot of their life to finally become a physician. What's the opportunity costs for those other guys?
 
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efle

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Jeez man you sound miserable. What made you decide DR? Do you prefer less patient interaction? Was it your top choice?
Dont mean to sound miserable! I think I'll be a very happy radiologist. But I went straight from a Medicine subI with 80+ hour weeks into a relaxed Rads elective and the difference was night (or rather darkroom) and day. The stuff I wrote about in my personal statement is great in theory, but in practice/medschool I realized most of modern medicine is staring at screens and being a good cog in the machine.

Dont get me wrong not all grass is greener. I do not envy the guys doing crazy hours on wall street or starting out in law firms or consulting.

But this persons FAANG gig...I envy that a lot.
 
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HopeP

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But this persons FAANG gig...I envy that a lot.
Tell me about it, dealing with that conversation all weekend between younger pre-med rising junior and elder rising CS senior who already has full time offer for next summer at A->Z.
 
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Lion-O

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I'm curious if OP, and those with the same viewpoint, would have the same view if debt weren't as prominent of an issue. The two most prominent complaints I see about the field is immense debt leading to financial slavery and midlevel encroachment. I wonder if the debt was not an issue, would midlevel encroachment and the looming threat of pay decreases still be enough to dissuade people from entering medicine.

When I was applying to med school, I didn't even think about the loans. All I knew was that I needed to be a doctor, and I'd pay them off later. I suspect many of you have the same mindset. I went to a private school and graduated with a lot of debt at the time (~280,000). Paid it off in 2 years, which I'm glad I did. Nowadays it seems that's average/low debt compared to what med students have. Please see the link I put in my OP: there is the possibility you literally might not be able to pay off your debt depending what field you choose.

The physicians of today need to stand up for themselves and the physicians of tomorrow. Fingers crossed!!

There is an active group of doctors attempting to do this (see Physicians for Patient Protection), but the pessimist in me feels we're too powerless compared to the massive corporations that run healthcare.

Not only that, but (and I could be mistaken) academic medicine has completely buried its head in the sand. It blows my mind how little I was educated on the financial side of medicine in med school and residency. You go through the academic system, and minimally do you get any instruction on the business of healthcare. It's a shame, because the vast majority of us come out the other side and simply have to learn as we go for the first few years post residency. This leads to rampant abuse and being taken advantage of when you emerge into the real world.

No career is perfect

This I completely agree with. The world is unpredictable. For instance, I have many friends who've lost their jobs due to the pandemic, absolutely by no fault of their own. I feel lucky and grateful I haven't been terribly impacted.

Going into medicine currently isn't great... but I couldn't tell you a better alternative.

Is it safe to assume that such competition and salary stagnation will steer clear of surgical specialties? I'm sure the difficulties in establishing your own practice would remain viable

Every field now has been inundated with midlevels. Cards, GI, IR, ortho, EM, hospitalist. You name it and they have PAs/NPs doing their consults. Procedurally, doctors seem still somewhat protected, but the line gets blurrier all the time. At my hospital, PAs do all the paracenteses and thoracenteses for IR.

You sound miserable. Maybe you should open up a private practice and go rural so you don't have to deal with all the bureaucratic stuff.

Believe it or not, I'm not completely miserable. It's worse than it was, and I fear what the future will bring, but the positive aspects I listed in the original post still hold true. For now I'm happy.

I can't emphasize this enough, but when you get to my age chances are you will have a family, you will have settled down, your kids will be in school. Trust me, the idea of moving to a better area or a better job (honestly, even another country) crosses your mind. But then you realize your spouse has a job and connections, your kids have been at the same school for years, and uprooting is not a realistic choice. As a pre-med and med student, you take it as a given that you will be moving frequently, often great distances. Don't get me wrong, I was there. I never thought of future-me with a family and kids and a house and the inability to move as needed. Yet here I am.
 
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Here I am on a Sunday morning and curiosity got the best of me: I wonder if that old account I had in med school still works? Sure enough, it does, and here I am. I started reading SDN in 2003 and posted intermittently from 2004~2008. I lurk occasionally still under a different name.

But man, I've aged. Reading through my old posts I was probably like you all are now: full of energy and youth and a laser-like focus on getting into and succeeding in med school. And I did that. And then I did residency. And then I've... worked. Worked as a doctor for about 9 years now.

I'm inspired to write this because I regularly work with pre-health students, specifically scribes, who are applying to health programs often including medical school. For many, I've written letters of recommendation. Undoubtedly, pre-med students can often be the brightest, most passionate, driven people I know. I'm genuinely impressed by the amazing, well-rounded folks that medicine draws in.

Here's the thing. Medicine, real-world medicine, is not great and it's getting worse.

As much as I'm tempted to say, "just don't do it," I think that would be hyperbolic. On its surface, what I do is actually pretty good. I enjoy taking care of patients in the field I work in. I take pride in the expertise I've gained over the years, knowing that I'm making a difference in people's lives. The pay is good (some would argue great); I easily support my family, and really want for nothing.

But there's the bad, and there's a lot of it. Don't get me wrong - when I was pre-med, I didn't have the ability to look 15 years down the line. All I knew was that I needed to get into med school, future be damned. I'd let future me figure that out. Well, here is future me reflecting.

Corporations have taken over healthcare: hospital systems, staffing companies, insurance companies. This isn't meant to advocate for government healthcare; I'm just letting you know the current reality. It is unlikely you will open up your own private practice. It is very likely you will be hired by a massive, national corporation who will directly dictate how you practice medicine. They will tell you how many hours to work, how many patients to see in those hours, demand that you oversee undertrained PAs/NPs who you may not trust, and possibly overwhelm you to the point of patient harm. Your practice of medicine will not be doing what is best for the patient, but rather, what is best for your corporation's bottom line. You will constantly be bombarded (daily/weekly) with emails about meeting arbitrary metrics. These metrics frequently harm patients, but they make the company more money. You will struggle with your conscience: do I do what's right for this patient, or do I follow what the company tells me to keep my job?

Tied to the above is the mass proliferation of mid-levels, particularly nurse practitioners. I'm not telling you anything new, but I'm not sure if pre-meds really "get it." Doctors are being replaced by NPs. This isn't scare-mongering, this is what's happening. Five years ago, where I work, we'd have say 50 hours of doctors per day and 30 hours of mid-levels. Today, it's 40 hours of doctors and 40 hours of mid-levels. They are cheaper, and easily make corporations money (see above). Not to beat a dead horse, but NPs are not doctors. They cause harm, real patient harm, and it's only getting worse. I don't need to tell you this - you're applying to med school. But patients think they're doctors. And hospitals prefer them due to economics.

Continuing on this thought, part of the allure of going to med school is to be a doctor, to obtain that title. There's nothing wrong with that. There is no shame in recognizing that you excelled academically, you worked hard, you sacrificed, and you achieved what most others couldn't. Most people have an idea of what pre-meds/med students go through. I know it personally and damn if I'm not proud of each and every person who puts themselves through that journey. And not only that, after you become a doctor, you have to go through residency, an unrivaled training experience that few humans on this planet will ever endure.

Why do I bring that up? There's an active dismantling of respect and reverence toward physicians. Again, this is not exaggeration. Open any medical journal today. They don't say "doctor" or "physician." They say provider, practitioner, clinician. Medical journals, hospitals, insurance companies... you are not a physician. You are now a provider and are no different than NPs or PAs. A small example: where I work, NPs and PAs park in "physician parking." Residents (physicians) do not. This is the world you're entering and it will only get worse.

I didn't even touch on student debt, but please read this: Maximum Student Loan Debt to Salary Ratio | White Coat Investor

Predicting the future is hard, and I admit enough humility to know that I probably can't guess what medicine (or the world) will be like in 15 years. That said, medicine is currently getting worse and my salary is decreasing. I'm actively living below my means and saving money for a future in which I make half of what I do now. I don't know if alternative careers are better, but consider all your options long and hard before jumping into this one...

Maybe I'll log on in 2035 for an update. ;)

People have told me law is a dying industry. You will overwork yourself if you get into business and have no work/life balance. Engineers are underpaid. Being a PhD means competing for a limited number of professorships that are steadily declining each year, and all you do is write grants all day. And people have said the "golden age" of medicine is over.

I think any job will come with its drawbacks. Seems like almost everything sucks based on what people tell me.
 
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Nowadays every pre-med should know what medicine is really like especially when it comes to money before they commit themselves to this path. I mean who in their right mind would go through a neurosurgery or other lengthy residency for 100k-150k as we get closer and closer to socialized medicine. They will be miserable....
 
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Lion-O

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Take what I say with a grain of salt. When I was pre-med and in med school, I too had many doctors tell me not to go into it, and I too felt many of their concerns were overblown. And I still feel that way - many of the issues those older doctors had did not end up being issues for me. Maybe my issues won't be issues for you.

I think what it comes down to is: what are your expectations of being a doctor vs. what is the reality of being a doctor? My expectations were to have the ultimate say and decision-making in the patients I cared for. I did not expect to be responsible for a team of midlevels assigned to me by a giant corporation. But, if you go into medicine with the expectation that you will not have pure autonomy and that you will be more of a supervisor than a provider of direct patient care, perhaps you will not feel the same discontent I do.

...

Some years ago I took part in interviewing applicants to the med school I worked at. To this day, I am so impressed by the caliber of the people applying to med school. You guys/gals are incredible. The grades, the MCAT scores, the blood/sweat/tears, the research, the volunteering, the achievements, the diverse backgrounds; and on top of all that, the ability to converse easily and be personable. It honestly makes me proud to be part of that group, because in many ways I did not and still do not match up to what many pre-med students have done.

What is most utterly disheartening to me is that for those of you who make it through one of the most rigorous, competitive processes on Earth will enter an environment where your achievements... will not matter. Your worth will be dictated by the RVUs you generate and your patient satisfaction scores. You are provider, not a physician.

...

I don't mean to be completely negative. I've listed the parts that bother me the most. Here are some positive aspects that keep me going:
  • It is incredibly humbling and touching that humans allow you into the most vulnerable part of their lives. To entrust you to make decisions about their health and well-being. To look at you with eyes that say, "I'm scared, please help me." To make a difference in people's lives is a large part of pushes me through. If this aspect of medicine genuinely interests you as a pre-med, I will say it does pay off when you become a doctor.
  • I do feel like I'm an expert in my field. I know that I offer patients care that only a board certified physician in my field can provide.
  • Despite my general dissatisfaction with midlevel proliferation and being labeled a provider, I'm respected in my day to day job. I know the hospital staff and my peers respect me, as I respect them. For the most part, in the hospital setting (at least where I work), physicians are still leaders and there is no ambiguity between the level of training between doctors and midlevels.
  • I get paid very well, maybe 2-3x what I thought I'd be making when I got into medicine. I make 3x more than my parents ever did. I am able to live very comfortably, drive a nice car, save for kids' college, and save ~20-30% of my income for retirement. (Who knows how long this will hold up, and my outlook might be significantly different if I'd come out of school with more debt.)
 
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HopeP

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Nowadays every pre-med should know what medicine is really like especially when it comes to money before they commit themselves to this path. I mean who in their right mind would go through a neurosurgery or other lengthy residency for 100k-150k as we get closer and closer to socialized medicine. They will be miserable....
At least that will weed out the competition, who are in only for money leaves only with who cares about patient care, will force to reduce education expenses and hence better for everybody to afford and be happy.
This entire thread highlighted one thing, even being Dr it may not bring happiness in one's life.
 
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deleted804295

At least that will weed out the competition, who are in only for money leaves only with who cares about patient care, will force to reduce education expenses and hence better for everybody to afford and be happy.
This entire thread highlighted one thing, even being Dr it may not bring happiness in one's life.
Only for money??? You realize the most competitive surgical residencies are 7-9 years long. This is with accruing interest from 6 figure medical school debt.

It would be unjust to pay an individual who went through all of *that* 100k.
 
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Only for money??? You realize the most competitive surgical residencies are 7-9 years long. This is with accruing interest from 6 figure medical school debt.

It would be unjust to pay an individual who went through all of *that* 100k.
Agreed. Not to mention a 8+ year rigorous academic pathway beforehand.
 
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HopeP

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Only for money??? You realize the most competitive surgical residencies are 7-9 years long. This is with accruing interest from 6 figure medical school debt.

It would be unjust to pay an individual who went through all of *that* 100k.
I am talking in general to pursue medicine, expecting big bucks at end of residency. It is a vicious circle, starts with education cost resulted debt used to justify fat pay results in fat charges to patients who pays fat premium and cycle goes on...
 

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Take what I say with a grain of salt. When I was pre-med and in med school, I too had many doctors tell me not to go into it, and I too felt many of their concerns were overblown. And I still feel that way - many of the issues those older doctors had did not end up being issues for me. Maybe my issues won't be issues for you.

I think what it comes down to is: what are your expectations of being a doctor vs. what is the reality of being a doctor? My expectations were to have the ultimate say and decision-making in the patients I cared for. I did not expect to be responsible for a team of midlevels assigned to me by a giant corporation. But, if you go into medicine with the expectation that you will not have pure autonomy and that you will be more of a supervisor than a provider of direct patient care, perhaps you will not feel the same discontent I do.

...

Some years ago I took part in interviewing applicants to the med school I worked at. To this day, I am so impressed by the caliber of the people applying to med school. You guys/gals are incredible. The grades, the MCAT scores, the blood/sweat/tears, the research, the volunteering, the achievements, the diverse backgrounds; and on top of all that, the ability to converse easily and be personable. It honestly makes me proud to be part of that group, because in many ways I did not and still do not match up to what many pre-med students have done.

What is most utterly disheartening to me is that for those of you who make it through one of the most rigorous, competitive processes on Earth will enter an environment where your achievements... will not matter. Your worth will be dictated by the RVUs you generate and your patient satisfaction scores. You are provider, not a physician.

...

I don't mean to be completely negative. I've listed the parts that bother me the most. Here are some positive aspects that keep me going:
  • It is incredibly humbling and touching that humans allow you into the most vulnerable part of their lives. To entrust you to make decisions about their health and well-being. To look at you with eyes that say, "I'm scared, please help me." To make a difference in people's lives is a large part of pushes me through. If this aspect of medicine genuinely interests you as a pre-med, I will say it does pay off when you become a doctor.
  • I do feel like I'm an expert in my field. I know that I offer patients care that only a board certified physician in my field can provide.
  • Despite my general dissatisfaction with midlevel proliferation and being labeled a provider, I'm respected in my day to day job. I know the hospital staff and my peers respect me, as I respect them. For the most part, in the hospital setting (at least where I work), physicians are still leaders and there is no ambiguity between the level of training between doctors and midlevels.
  • I get paid very well, maybe 2-3x what I thought I'd be making when I got into medicine. I make 3x more than my parents ever did. I am able to live very comfortably, drive a nice car, save for kids' college, and save ~20-30% of my income for retirement. (Who knows how long this will hold up, and my outlook might be significantly different if I'd come out of school with more debt.)

May I ask what your specialty and approximate take-home pay (post-tax) is?
 

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Only for money??? You realize the most competitive surgical residencies are 7-9 years long. This is with accruing interest from 6 figure medical school debt.

It would be unjust to pay an individual who went through all of *that* 100k.

I appreciate where this is coming from, but it's fallacious to think that what physicians get paid is at all related to length or difficulty of training or what is fair. Currently, they are correlated, but not always. What physicians are paid is a complicated equation that depends on practice setting, payer mix, and sources of income / division of labor, not to mention insurer and CMS policy (moreso CMS cuz its a bigger player in the market)

Pediatric heme/onc docs go through 6 years of training, often with similar debt, and while their schedule might not be as physically taxing as a trauma surgeon's they do vital, important, and heavily taxing work. They are also one of the lowest compensated specialties in all of medicine, as are all pediatric specialists.

A general surgeon will *lose* income in the long run if they choose to go into pediatric surgery instead of private practice general surgery, but peds surg demands 3-5 more years of training than a straight-through gen surg path. And although pediatric surgeons still make more than most physicians in this country, even more than many surgeons in some cases, they are limited in where they can practice by the nature of the demands for their expertise (kids needing specialized surgery in areas that arent the brain or heart (which have their own peds subspecialists in CT and NSG) is much rarer than for adults and the practice settings tend to be academic).

an MD/PhD neurosurgeon will train for 11-14 years before becoming an attending, and if they choose to devote half their time to research as many academic neurosurgeons do they would make about 1/3 of what their private practice spine colleagues make all the while having longer training, more academic/scientific/administrative responsibilities, and busier schedules.

Neither in this system or in any other healthcare system are these two things -- effort/length of training and pay -- causatively linked. Also, in no other healthcare system in countries comparable to the US (where most have "socialized" medicine, although what that means differs depending on who u ask but certainly by US standards) do docs top out at 100-150k in annual income (with maybe the exception of Spain for non-surgical docs), also their debt is almost nonexistent. If you included wealth, taxes, debt, cost of living, and benefits into the calculation of what docs in other countries make vs the US I think you would find that a subset of US physicians make a lot more (subspecialists in private practice) but most docs are actually losing out in comparison.

I think it's also really important to think why APPs ("midlevels") are unique to the US healthcare system. No other healthcare system in the world has needed to train or produce APPs. Why is that? Cost cost cost. We are, sooner or later, going to have to reckon with the fact that if we don't have a way to systematically control cost in our healthcare system that as long as demand keeps increasing, which it will, cost cutting efforts will need to be made. The longer we wait, the more aggressive those efforts will need to be, and the profession will suffer as a result.
 
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I appreciate where this is coming from, but it's fallacious to think that what physicians get paid is at all related to length or difficulty of training or what is fair. Currently, they are correlated, but not always. What physicians are paid is a complicated equation that depends on practice setting, payer mix, and sources of income / division of labor, not to mention insurer and CMS policy (moreso CMS cuz its a bigger player in the market)

Pediatric heme/onc docs go through 6 years of training, often with similar debt, and while their schedule might not be as physically taxing as a trauma surgeon's they do vital, important, and heavily taxing work. They are also one of the lowest compensated specialties in all of medicine, as are all pediatric specialists.

A general surgeon will *lose* income in the long run if they choose to go into pediatric surgery instead of private practice general surgery, but peds surg demands 3-5 more years of training than a straight-through gen surg path. And although pediatric surgeons still make more than most physicians in this country, even more than many surgeons in some cases, they are limited in where they can practice by the nature of the demands for their expertise (kids needing specialized surgery in areas that arent the brain or heart (which have their own peds subspecialists in CT and NSG) is much rarer than for adults and the practice settings tend to be academic).

an MD/PhD neurosurgeon will train for 11-14 years before becoming an attending, and if they choose to devote half their time to research as many academic neurosurgeons do they would make about 1/3 of what their private practice spine colleagues make all the while having longer training, more academic/scientific/administrative responsibilities, and busier schedules.

Neither in this system or in any other healthcare system are these two things -- effort/length of training and pay -- causatively linked. Also, in no other healthcare system in countries comparable to the US (where most have "socialized" medicine, although what that means differs depending on who u ask but certainly by US standards) do docs top out at 100-150k in annual income (with maybe the exception of Spain for non-surgical docs), also their debt is almost nonexistent. If you included wealth, taxes, debt, cost of living, and benefits into the calculation of what docs in other countries make vs the US I think you would find that a subset of US physicians make a lot more (subspecialists in private practice) but most docs are actually losing out in comparison.
I'm not sure where you're disagreeing.

Are you saying physicians who have 6 figure debt and long residencies should make around $100k?
 

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I'm not sure where you're disagreeing.

Are you saying physicians who have 6 figure debt and long residencies should make around $100k?

I'm saying that what physicians get paid and how long their training is or how challenging their job is have nothing to do with one another. If the system could get away with paying NSGs 100k, it would. It doesnt for reasons that have nothing to do with length of training, but with supply and demand and policy decisions that get made in corporate board rooms and Washington D.C. it doesn’t matter what anyone thinks anyone else *should* be paid because that’s not how economics works in our society.
 
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I'm saying that what physicians get paid and how long their training is or how challenging their job is have nothing to do with one another. If the system could get away with paying NSGs 100k, it would. It doesnt for reasons that have nothing to do with length of training, but with supply and demand and policy decisions that get made in corporate board rooms and Washington D.C. it doesn’t matter what anyone thinks anyone else *should* be paid because that’s not how economics works in our society.
This^^^^. @Sunbodi -- at the end of the day you will be correct, because when the cost/benefit of incurring the debt and the opportunity cost of the training no longer makes sense, supply/demand will come into play, as the supply of willing participants decreases below the demand, and salaries respond. But cost and length of training does not dictate income anywhere -- academics, medicine, professional sports, Wall Street, Silicon Valley, etc., it is supply and demand.

Eventually cost and length of training impact supply, but incomes are not set by "hard" someone works, or by how long they train, or by how much their education costs. By your reasoning, doctors who receive full merit scholarships (or need based) should make less than those were full pay.
 
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what you all think should be the minimum salary for PCPs?
Whatever the market dictates. Price fixing never works, anywhere. If the market goes low enough, nobody will become PCPs, and the market will adjust, just like every other market, in history.
 
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EdgeTrimmer

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Whatever the market dictates. Price fixing never works, anywhere. If the market goes low enough, nobody will become PCPs, and the market will adjust, just like every other market, in history.
I never advocate for price fixing. Just asking what everyone thinks a fair salary is given length of education, cost and how other sectors are paying.
 
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Angus Avagadro

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Whatever the market dictates. Price fixing never works, anywhere. If the market goes low enough, nobody will become PCPs, and the market will adjust, just like every other market, in history.
This^^^^^^^^ You can beat your chest and rend your garments, but you are worth what the market will pay. Your services, like anything are worth what you can get for them.
 
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I never advocate for price fixing. Just asking what everyone thinks a fair salary is given length of education, cost and how other sectors are paying.
Okay .. but you didn't ask about fair salary, you asked about minimum salary, which is a form of price fixing.

Opinions on fair salary don't matter, because salaries aren't set by what employees think is fair. They are based on supply/demand, and as the paradigm shifts to having midlevels do more and more things previously done by PCPs, demand will drop, and relative salaries will drop as a result, which is the objective of the payers. Nothing to be done about it.

Those who care about money and are good enough will gravitate even more than they already do to higher paying specialties, while those who aren't motivated by money and those who are not good enough will be doomed to making less (relatively speaking) than their predecessors. Nothing fair about it, but it is what it is. The alternative is going out on your own, setting your own salary, and waiting for the big bucks (or whatever you think is "fair") to just roll in. :laugh:

Unfortunately, as has been pointed out above, length of education, cost, and how other sectors are paying is irrelevant. What's relevant is how much of the job can be outsourced to NPs and PAs, and how much it would cost to have them do it instead. If it doesn't make sense, you don't do it. If it took 12 years and cost $500,000 to train to drive a truck, that wouldn't make a truck driver worth $300,000 a year. Goods would just be shipped using a less expensive alternative, and truck drivers would have to find something else to do, which also wouldn't be fair.
 
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I am learning a lot from everyone, especially the personal stories. Found this from Medicaleocnomics.com Dec 2018:


What’s ruining medicine for physicians?
1. 44% Paperwork and administrative burdens
2. 41% Difficulty using EHRs
3. 26% Government regulations
4. 24% Prior authorizations
5. 19% Replacing primary care physicians with NPs/PAs
6. 18% No negotiating leverage with payers
7. 15% Rising practice staff and overhead costs
8. 15% Imbalance in primary care vs. specialist reimbursements
9. 12% MOC costs and requirements
 

TikiTorches

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Job security is much lower for them. Everything is a trade off.
I appreciate where this is coming from, but it's fallacious to think that what physicians get paid is at all related to length or difficulty of training or what is fair. Currently, they are correlated, but not always. What physicians are paid is a complicated equation that depends on practice setting, payer mix, and sources of income / division of labor, not to mention insurer and CMS policy (moreso CMS cuz its a bigger player in the market)

Pediatric heme/onc docs go through 6 years of training, often with similar debt, and while their schedule might not be as physically taxing as a trauma surgeon's they do vital, important, and heavily taxing work. They are also one of the lowest compensated specialties in all of medicine, as are all pediatric specialists.

A general surgeon will *lose* income in the long run if they choose to go into pediatric surgery instead of private practice general surgery, but peds surg demands 3-5 more years of training than a straight-through gen surg path. And although pediatric surgeons still make more than most physicians in this country, even more than many surgeons in some cases, they are limited in where they can practice by the nature of the demands for their expertise (kids needing specialized surgery in areas that arent the brain or heart (which have their own peds subspecialists in CT and NSG) is much rarer than for adults and the practice settings tend to be academic).

an MD/PhD neurosurgeon will train for 11-14 years before becoming an attending, and if they choose to devote half their time to research as many academic neurosurgeons do they would make about 1/3 of what their private practice spine colleagues make all the while having longer training, more academic/scientific/administrative responsibilities, and busier schedules.

Neither in this system or in any other healthcare system are these two things -- effort/length of training and pay -- causatively linked. Also, in no other healthcare system in countries comparable to the US (where most have "socialized" medicine, although what that means differs depending on who u ask but certainly by US standards) do docs top out at 100-150k in annual income (with maybe the exception of Spain for non-surgical docs), also their debt is almost nonexistent. If you included wealth, taxes, debt, cost of living, and benefits into the calculation of what docs in other countries make vs the US I think you would find that a subset of US physicians make a lot more (subspecialists in private practice) but most docs are actually losing out in comparison.

I think it's also really important to think why APPs ("midlevels") are unique to the US healthcare system. No other healthcare system in the world has needed to train or produce APPs. Why is that? Cost cost cost. We are, sooner or later, going to have to reckon with the fact that if we don't have a way to systematically control cost in our healthcare system that as long as demand keeps increasing, which it will, cost cutting efforts will need to be made. The longer we wait, the more aggressive those efforts will need to be, and the profession will suffer as a result.
Mid-levels are fighting for pay parity and have it already in Oregon. How does that save the system money?
 

cabinbuilder

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I basically agree with what the OP has said. I have an NP who I oversee in Texas and we get along very well, but she is very seasoned (worked L&D as a nurse for 25 years, worked in Neurosurgery for 14). She is 65 and knows what she doesn't know. Of course we work urgent care so the mindset is a little different than being someones sole PCP. I personally can't complain about my career path. Never really wanted to be a PCP and I see urgent care as the safety net for the community. My base schedule is 10 days a month. I can pick up shifts or do locums on my week off (this has changed since COVID but things are returning to normal). My pay has been "cut" due to COVID only because I am on base pay only right now due to no extra shifts. I personally could not imagine having a private practice - would not want the headache, don't want to be married to my practice, being on call, etc. I haven't had to be on call for 8 years now and I would never go back. Admin gets uglier by the week. I learned about admin the hard way when I first got out of residency- Went through 5 perm jobs in 5 years. That's why I ended up as locums for so long. Got sick of being burned by "the man" for stupid stuff and staff that doesn't like you who are not your employees so it's he said/she said games that nurses play. Am at the point that I don't trust anyone at work ever. My only consolation is that I'm in a building that is stand alone and I don't generally deal with admin at all unless there is a patient complaint and I get a call from the director. Otherwise I go to work, see the patients and go home.
 
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Mid-levels are fighting for pay parity and have it already in Oregon. How does that save the system money?
I've been thinking about this a little bit, and the answer is that it doesn't, but that's not the point. Oregon is not New York or San Francisco. I'll go out on a limb and assume the cost of living, and salaries, are a lot lower there than in big cities. I'll also take the liberty of assuming that there is a huge PCP shortage there, as compared to more popular locations with significantly higher salaries.

If my assumptions are correct, mid-levels demanding and receiving pay parity in Oregon has nothing to do with what large practice groups are doing to lower costs in other parts of the county. What happened in Oregon in that mid-levels are not replacing PCPs, but are relieving a shortage by performing comparable functions. Since those skills are apparently in high demand and low supply, they are correct to demand and receive pay parity.

And, to address points raised by @srk2021 and others above, this is yet another example of salaries being set by the market, not by what is "fair," or how much time, expense and effort went into training. Watch and see what happens if and when mid-levels receive pay parity in areas where there is no acute PCP shortage. In those instances, mid-levels will find themselves fighting themselves out of jobs, because, without cost savings, there is absolutely no reason to replace a physician with a mid-level.
 
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Damson

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@Lucca "Currently, they are correlated, but not always" Quick question about this initial point
What can cause the correlation to flatten or even break? If training time for a particular professional in demand will always be long and hard, won't the supply always be scarce?
 

Lucca

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@Lucca "Currently, they are correlated, but not always" Quick question about this initial point
What can cause the correlation to flatten or even break? If training time for a particular professional in demand will always be long and hard, won't the supply always be scarce?

technology can up-end things. For example, suppose that tomorrow we discovered a non-surgical therapy that could cure all brain cancers outright, even Glioblastoma. There would no longer be a need for NSGs to cut out brain tumors. Demand would decrease. NSGs are busy and rare enough that this would likely have a little effect on the gap between supply and demand...

but supply isn't static. Suppose that 10 years prior to our miracle brain cancer cure, demand for NSGs was increasing so much that NSG residencies decided to double the number of NSGs they train. Well, now in our hypothetical scenario the market for NSGs will tighten and supply is no longer "scarce". Hardly an apocalyptic scenario -- and its a world without brain cancer!! Yay!! -- but it would certainly affect the NSG market.

This isn't purely hypothetical either! Consider RadOnc. 10 years ago, RadOnc was one of the most competitive specialties, on par with derm/ortho/NSG in terms of competitiveness, especially at top programs. RadOnc residency slots rapidly expanded over the past 10 years due to the increased demand. However, at the same time, (grossly oversimplifying) a bunch of other factors in and outside of medicine started contracting the demand / per rad-onc. And policy came in as well, with CMS mandating as recently as last year that RadOncs could supervise the delivery of radiotherapy remotely, further reducing the demand for RadOncs. Job market contracted, recent grads have had a harder time finding a job, and that information has trickled down the training pipeline with this year RadOnc having a 99.9% match rate (literally only 1 person went unmatched and they applied to only the top 5 programs and got too cocky) and some programs beginning to reduce slots (in other words, responding to a perceived glut in supply).

Medicine is bizarre in that in spite of being essential to society, Medicine as a guild will always want to produce as much scarcity as possible but society needs supply to go up because healthcare is, well, essential for the functioning of society and to most thinking people something we, as a society, have a moral obligation to make accessible (this isn't just commie talk, i've been to Republican and Democratic senator's offices on Capitol Hill and they ALL want to expand healthcare access for their constituents they just disagree on who is doing the healthcare and FWIW GOP Senators seem more bullish on APPs than Dems because it's easier to find ways to increase the # of APPs in your (rural) state than MD/DOs). When you have a market that will not clear (supply must go up to meet demand, but supply is suppressed by guild behavior serving the interests of those in the guild) then something has got to give. Hence APPs. In other healthcare systems they simply trained more doctors and the distribution of doctors is more or less forced by fiat.

If we want to continue having a medical profession in this country where we command high incomes and get to practice more or less wherever we want with few caveats, we have to accept the fact that we will need to meet the demand for healthcare in other ways. If we don't want that method to be the expansion of APP practice rights, then we need to loosen our guild behavior and accept that most specialties would look more like RadOnc today than NSG in terms of their practice flexibility. If every part of this country were as desirable to live as any other, I dont think we would have much of a problem with that, but thats far from the case and its a big country. My own unsolicited opinion on this matter is make every single part of the country a desirable place to live with smart urban/rural planning and you will go farther in solving the provider distribution problem than anyone else has to date.
 
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Damson

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technology can up-end things. For example, suppose that tomorrow we discovered a non-surgical therapy that could cure all brain cancers outright, even Glioblastoma. There would no longer be a need for NSGs to cut out brain tumors. Demand would decrease. NSGs are busy and rare enough that this would likely have a little effect on the gap between supply and demand...

but supply isn't static. Suppose that 10 years prior to our miracle brain cancer cure, demand for NSGs was increasing so much that NSG residencies decided to double the number of NSGs they train. Well, now in our hypothetical scenario the market for NSGs will tighten and supply is no longer "scarce". Hardly an apocalyptic scenario -- and its a world without brain cancer!! Yay!! -- but it would certainly affect the NSG market.

This isn't purely hypothetical either! Consider RadOnc. 10 years ago, RadOnc was one of the most competitive specialties, on par with derm/ortho/NSG in terms of competitiveness, especially at top programs. RadOnc residency slots rapidly expanded over the past 10 years due to the increased demand. However, at the same time, (grossly oversimplifying) a bunch of other factors in and outside of medicine started contracting the demand / per rad-onc. And policy came in as well, with CMS mandating as recently as last year that RadOncs could supervise the delivery of radiotherapy remotely, further reducing the demand for RadOncs. Job market contracted, recent grads have had a harder time finding a job, and that information has trickled down the training pipeline with this year RadOnc having a 99.9% match rate (literally only 1 person went unmatched and they applied to only the top 5 programs and got too cocky) and some programs beginning to reduce slots (in other words, responding to a perceived glut in supply).

Medicine is bizarre in that in spite of being essential to society, Medicine as a guild will always want to produce as much scarcity as possible but society needs supply to go up because healthcare is, well, essential for the functioning of society and to most thinking people something we, as a society, have a moral obligation to make accessible (this isn't just commie talk, i've been to Republican and Democratic senator's offices on Capitol Hill and they ALL want to expand healthcare access for their constituents they just disagree on who is doing the healthcare and FWIW GOP Senators seem more bullish on APPs than Dems because it's easier to find ways to increase the # of APPs in your (rural) state than MD/DOs). When you have a market that will not clear (supply must go up to meet demand, but supply is suppressed by guild behavior serving the interests of those in the guild) then something has got to give. Hence APPs. In other healthcare systems they simply trained more doctors and the distribution of doctors is more or less forced by fiat.

If we want to continue having a medical profession in this country where we command high incomes and get to practice more or less wherever we want with few caveats, we have to accept the fact that we will need to meet the demand for healthcare in other ways. If we don't want that method to be the expansion of APP practice rights, then we need to loosen our guild behavior and accept that most specialties would look more like RadOnc today than NSG in terms of their practice flexibility. If every part of this country were as desirable to live as any other, I dont think we would have much of a problem with that, but thats far from the case and its a big country. My own unsolicited opinion on this matter is make every single part of the country a desirable place to live with smart urban/rural planning and you will go farther in solving the provider distribution problem than anyone else has to date.

I just want to say that this is really well-written and thoughtful

Whoever marries you is blessed
 
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TikiTorches

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I've been thinking about this a little bit, and the answer is that it doesn't, but that's not the point. Oregon is not New York or San Francisco. I'll go out on a limb and assume the cost of living, and salaries, are a lot lower there than in big cities. I'll also take the liberty of assuming that there is a huge PCP shortage there, as compared to more popular locations with significantly higher salaries.

If my assumptions are correct, mid-levels demanding and receiving pay parity in Oregon has nothing to do with what large practice groups are doing to lower costs in other parts of the county. What happened in Oregon in that mid-levels are not replacing PCPs, but are relieving a shortage by performing comparable functions. Since those skills are apparently in high demand and low supply, they are correct to demand and receive pay parity.

And, to address points raised by @srk2021 and others above, this is yet another example of salaries being set by the market, not by what is "fair," or how much time, expense and effort went into training. Watch and see what happens if and when mid-levels receive pay parity in areas where there is no acute PCP shortage. In those instances, mid-levels will find themselves fighting themselves out of jobs, because, without cost savings, there is absolutely no reason to replace a physician with a mid-level.
Mid-levels in corporations bill incident to physician. People still pay the same copays, and hospitals get higher pay for them than you think.

Mid-level are fighting for pay parity everywhere. Just because it's not in other states yet doesn't mean it won't get there
 
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