MD & DO In what specialties is the sky NOT falling?

[tradkeke]

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Hearing attendings talk, going on the sub-specialty forums here, and listening to other medical students about literally almost every specialty, everyone has a doom and gloom outlook (take a look at the recent EM forum posts).

Is there any specialty where everyone isn't dreading the future?

 

[deleted859689]

Intensivist/CCM?

 

[Chibucks15]

Everything is gonna be fine. Since I’ve been alive the world was supposed to end at least 4 times. People just like to complain

 

[PhillyMed777]

Not an easy lifestyle but surgery and surgical sub specialties in particular are doing great and will continue to do so

 

[radsisrad]

Hearing attendings talk, going on the sub-specialty forums here, and listening to other medical students about literally almost every specialty, everyone has a doom and gloom outlook (take a look at the recent EM forum posts).

Is there any specialty where everyone isn't dreading the future?

Derm

 

[Osminog]

Derm

Subject to PA and NP encroachment.

 

[Giovanotto]

Subject to PA and NP encroachment.

I'm surprised non-academic, outpatient derm is still a lucrative business. Seems like NPs would be all over that.

 

[ace_inhibitor111]

Cardiology, GI, ENT, ortho likely still safe. Even vascular and in lesser magnitude Urology is starting to hyperexpand now

 

[You shall know the Truth]

Pathology

 

[stickflip723]

Cardiology, GI, ENT, ortho likely still safe. Even vascular and in lesser magnitude Urology is starting to hyperexpand now

"Hyperexpand" meaning the demand is enormous and will continue to grow? Because that was my understanding.

 

[efle]

All the procedural/operative stuff

 

[curbsideconsult]

Plastics and trauma. Because vanity and stupidity will always be a thing.

 

[BoneWizard]

Pathology

I guess add Rad Onc in there.

 

[Dr G Oogle]

Picking specialties based on current trends that are good or bad is a fool’s errand. A few years ago rads had a terrible job market a few years ago and many good programs were not matching all their spots. RO is in similar position now but Will probably rebound. They even presented something last year at a national conference about how we are training too many urogyn/female urology even though only about 40-50 are coming out each in total for something that has 400-600K surgeries performed annually and not taking into account that there fewer and fewer generalist (urologists and obgyn) doing these surgeries. Bottom line pick something based on what you like; an overview of the field and pros and cons will vary with every single person you talk to, some will be bullish and some bearish. It depends on their own personal circumstances, you can have a sh&$&y life as an orthopod and a great one as a pathologist, it really depends on you.

 

[VA Hopeful Dr]

I'm surprised non-academic, outpatient derm is still a lucrative business. Seems like NPs would be all over that.

They are. Doesn't matter.

There are 2 derm practices in my town. One is majority mid-level the other is zero mid-level.

The former group is where I send my whiny patients with rashes. The latter group is where I send concerning lesions or legit issues like discoid lupus.

 

[radsisrad]

Subject to PA and NP encroachment.

If an MD has graduated from a derm residency and passed his/her boards and can't figure out how to hang a shingle and make a killing on the selling point of being a dermatology doctor, I can't say I have all that much sympathy. And PAs currently cannot work without MDs, as far as I know, so all it would take to mitigate that threat is a generation or two of derms who refuse to hire PAs.

 

[efle]

If an MD has graduated from a derm residency and passed his/her boards and can't figure out how to hang a shingle and make a killing on the selling point of being a dermatology doctor, I can't say I have all that much sympathy. And PAs currently cannot work without MDs, as far as I know, so all it would take to mitigate that threat is a generation or two of derms who refuse to hire PAs.

I think it varies by state, with a lot of the midwestern and southern states allowing PA and NP independent practice

 

[deleted831695]

Cardiology, GI, ENT, ortho likely still safe. Even vascular and in lesser magnitude Urology is starting to hyperexpand now

So what about specialties for us (below) average students?

 

[Dr G Oogle]

So what about specialties for us (below) average students?

Below average can match IM and do a fellowship or do GS

 

[DoctwoB]

Cardiology, GI, ENT, ortho likely still safe. Even vascular and in lesser magnitude Urology is starting to hyperexpand now

Not sure how Urology has hyperexpanded. AUA match spots have increased by about 20% over a decade, about half of which is just the absorption of former osteopathic programs. Even if it were 20% new spots, that hasn’t kept pace with the rate of increase of the senior population (i.e a large percentage of urology patients). Urology is in a great position regarding workforce/job prospects.

 

[libertyyne]

Do what you love, and be open to different geography and it will all be fine.

 

[ace_inhibitor111]

So what about specialties for us (below) average students?

Primary care (IM, FM, psych) are still decent in my opinion, but you have to at least beat out your peers in terms of affability and availability so you can develop a strong, loyal patient base. Anesthesia IMO is still decent for the time being. Hospitals would still rather have an anesthesiologist over a CRNA for the same pay, and the number of new residents hasn’t grown too much over the past decade.

Not sure how Urology has hyperexpanded. AUA match spots have increased by about 20% over a decade, about half of which is just the absorption of former osteopathic programs. Even if it were 20% new spots, that hasn’t kept pace with the rate of increase of the senior population (i.e a large percentage of urology patients). Urology is in a great position regarding workforce/job prospects.

Yeah I take that back, Uro is still looking bright but I was concerned that they are expanding more than other niche specialties like ENT. If they slowed down a bit I would be more bullish on them.

 

[Mass Effect]

Primary care (IM, FM, psych) are still decent in my opinion, but you have to at least beat out your peers in terms of affability and availability so you can develop a strong, loyal patient base. Anesthesia IMO is still decent for the time being. Hospitals would still rather have an anesthesiologist over a CRNA for the same pay, and the number of new residents hasn’t grown too much over the past decade.

When was the last time you heard PCP referred to as psych? No matter what organizations lump psych among primary care (and the reason for this is because it's in need as much as IM or FM), it actually isn't in practice unless maybe if you're practicing in a very rural area. They don't manage anything beyond mental health, though they order tests to monitor the side effects of the meds. But I have yet to see a psychiatrist start a statin in someone or take on HTN or DM, for example.

 

[NotaCop]

Primary care (IM, FM, psych) are still decent in my opinion, but you have to at least beat out your peers in terms of affability and availability so you can develop a strong, loyal patient base. Anesthesia IMO is still decent for the time being. Hospitals would still rather have an anesthesiologist over a CRNA for the same pay, and the number of new residents hasn’t grown too much over the past decade.



Yeah I take that back, Uro is still looking bright but I was concerned that they are expanding more than other niche specialties like ENT. If they slowed down a bit I would be more bullish on them.

average age of current practicing urologists per the last study I can remember on this is like mid or late 50s. Big wave of retirement is anticipated to come. If anything, growth in number of spots is simply accounting for this but most I’ve heard talk on the subject say that there will still be a shortage

 

[ace_inhibitor111]

average age of current practicing urologists per the last study I can remember on this is like mid or late 50s. Big wave of retirement is anticipated to come. If anything, growth in number of spots is simply accounting for this but most I’ve heard talk on the subject say that there will still be a shortage

Urologists have always been older on average. The percentage of urologists over 55 was 47.7% in 2007 and 50.1% in 2017. Compared to something like anesthesiology, where 33% were over age 55 in 2007 and in now 51.7% are over age 55. Or cardiology, 44.6% were over age 55 in 2007, and now 60.9% are over age 55, etc.

Point is, there won’t be some sudden big wave of retirees, urology reached a steady state years ago and many urologists work until they’re really old. Expanding residencies without data to back up demand is always a bad idea. Look at Canada, many of their urologists, orthopedists, neurosurgeons etc. are unemployed, and its not like they’re population stopped aging.

U.S. Physician Workforce Data Dashboard

The U.S. Physician Workforce Data Dashboard provides the most current data available about the physician workforce across specialties.

www.aamc.org

 

[BoneWizard]

Wait.

How is this not a massive problem for these fields? Like cardio. I can only imagine the number of Americans with heart disease going upward with an aging population and rise in obesity. If 60% of cardiologists retire in the next 10-15 years, won't there be a massive shortage unless we ramp up the amount of cardiologists starting like 10 years ago?

 

[ace_inhibitor111]

Wait.

View attachment 293789

How is this not a massive problem for these fields? Like cardio. I can only imagine the number of Americans with heart disease going upward with an aging population and rise in obesity. If 60% of cardiologists retire in the next 10-15 years, won't there be a massive shortage unless we ramp up the amount of cardiologists starting like 10 years ago?

No, because it mostly reflects the fact that young cardiologists are choosing the interventional or electrophysiology route. There might be a greater demand than other specialties but definitely not a shortage. In the last 5 years fellowship spots for cards have increased by 15%

 

[Piskaupf]

IR because they are taking over surgery. Neuro and urology because of the agin doctor population which is expected to retire soon and very high demand; EMG payments have been slashed so neuro has nowhwre to go but up.

 

[AnatomyGrey12]

Anything surgical

Cardiology, GI, ENT, ortho likely still safe. Even vascular and in lesser magnitude Urology is starting to hyperexpand now

Vascular is absolutely desperate for more surgeons, and the demand is only going up.

 

[Chrish]

Wonder why no mention of diagnostic radiology. AI fear is overblown considering not a single practicing radiologist is concerned over this. And it’s the most foolproof speciality from mid-level encroachment along with surgery..

 

[Link0358]

This question has been asked for as long as I’ve lurked on SDN since high school (~10 years) and nothing has really changed except salaries have gone up.

Every speciality is safe, and by talking to docs fresh out of residency, job offers are as good as they have ever been.

 

[Piskaupf]

Wonder why no mention of diagnostic radiology. AI fear is overblown considering not a single practicing radiologist is concerned over this. And it’s the most foolproof speciality from mid-level encroachment along with surgery..

I wouldnt trust a radiologist’s thoughts on whether AI is going to take their job. An AI expert’s opinion is much more valid. Many AI experts have said radiologists should not be trained anymore because AI is going to take their jobs

 

[slowthai]

I wouldnt trust a radiologist’s thoughts on whether AI is going to take their job. An AI expert’s opinion is much more valid. Many AI experts have said radiologists should not be trained anymore because AI is going to take their jobs

You cannot be serious about this. Even radiologists with experience in machine learning are saying that this AI paranoia is totally overblown. I reckon these people have the most credibility in these discussions as they know the practice of radiology inside and out and they also know how the advancement of AI could potentially affect the field.

 

[ace_inhibitor111]

Wonder why no mention of diagnostic radiology. AI fear is overblown considering not a single practicing radiologist is concerned over this. And it’s the most foolproof speciality from mid-level encroachment along with surgery..

Rads Professor at Stanford. Seems pretty damning...

 

[BoneWizard]

Rads Professor at Stanford. Seems pretty damning...

I'm still just a student but I feel like there were a few issues like implementation, certification and adoption that were glossed over.
Also what happens if there's a complex problem.

 

[libertyyne]

IR because they are taking over surgery. Neuro and urology because of the agin doctor population which is expected to retire soon and very high demand; EMG payments have been slashed so neuro has nowhwre to go but up.

This is false, if anything procedures developed by IR docs are taken by the primary surgery service and they just do them endovascularly. RF radio ablation, and endovascular procedures that vascular surgery does come to mind.

 

[kb1900]

This is false, if anything procedures developed by IR docs are taken by the primary surgery service and they just do them endovascularly. RF radio ablation, and endovascular procedures that vascular surgery does come to mind.

I’m there with you. Just spent a week on IR and for cases like TACE etc. we always had a liver fellow in the back observing

 

[Dantrolene FC]

I wouldnt trust a radiologist’s thoughts on whether AI is going to take their job. An AI expert’s opinion is much more valid. Many AI experts have said radiologists should not be trained anymore because AI is going to take their jobs

Weren’t machines supposed to take over anesthesia like 10-20 years ago?

I also don’t think patients would be ok with having a computer diagnose them.

 

[LatentStudying]

I'm still just a student but I feel like there were a few issues like implementation, certification and adoption that were glossed over.
Also what happens if there's a complex problem.

There are other areas in core ML that focus on that problem (handling manifold shifts, etc). A lot of work in med w/ ML is more of a 'look, med applications aren't a unique case and things work as normal on them'. You'd definitely want something like a seldonian framework over it or other type of performance bound to let the user know the model is 'out of its comfort zone'.

 

[UnoMas]

IR because they are taking over surgery. Neuro and urology because of the agin doctor population which is expected to retire soon and very high demand; EMG payments have been slashed so neuro has nowhwre to go but up.

IR is taking the scraps from surgery if anything. This is because IR is not a primary service, doesn't manage their own patients, relies on referral/consults from other services i.e. not owning the patients. This means you get the ****ty patients or things that noone else would touch or at an inconvenient hours. And like another poster above alluded to, things that IR develop if the primary services find profitable they will incorporate into their practice

That is the double-edged sword of not being a primary service.

 

[Matthew9Thirtyfive]

I think it varies by state, with a lot of the midwestern and southern states allowing PA and NP independent practice

I’m not sure that’s true about PAs. The AAPA and this document from the AMA say 47 states require supervision and 2 require collaborative agreements. New Mexico requires supervision for PAs with less than 3 years of experience and for specialty PAs.

This is from 2018, so unless a bunch of states completely changed in the last year, it’s probably still the same.

https://www.ama-assn.org/media/21466/download

 

[efle]

I’m not sure that’s true about PAs. The AAPA and this document from the AMA say 47 states require supervision and 2 require collaborative agreements. New Mexico requires supervision for PAs with less than 3 years of experience and for specialty PAs.

This is from 2018, so unless a bunch of states completely changed in the last year, it’s probably still the same.

https://www.ama-assn.org/media/21466/download

True I think it's NP that has more freedoms and the fine print about PAs is that only some patients have to be directly supervised. Otherwise they can do visits 100% themselves and only have anything discussed with the MD/DO if they think it's necessary. In that document the wording is "– In most states (47), PA scope of practice is determined with the supervising/collaborating physician at the practice site"

Which, in cases where the physician wants to run a fleet of PAs seeing half a dozen patients at a time while they chill in the back, going to be a big scope

 

[Matthew9Thirtyfive]

True I think it's NP that has more freedoms and the fine print about PAs is that only some patients have to be directly supervised. Otherwise they can do visits 100% themselves and only have anything discussed with the MD/DO if they think it's necessary. In that document the wording is "– In most states (47), PA scope of practice is determined with the supervising/collaborating physician at the practice site"

Which, in cases where the physician wants to run a fleet of PAs seeing half a dozen patients at a time while they chill in the back, going to be a big scope

Right, but the poster you quoted was saying that all it would take is widespread refusal of MDs to hire/train PAs and that would put that problem to rest. Which is true if 47 states require a supervisory model. Never going to happen though.

 

[efle]

Right, but the poster you quoted was saying that all it would take is widespread refusal of MDs to hire/train PAs and that would put that problem to rest. Which is true if 47 states require a supervisory model. Never going to happen though.

Game theory, man. If I can hire someone to see all the sniffles and coughs that I'm way overtrained for while skimming a profit off them, you're damn right I'll hire several, regardless of what it does to the market when everyone follows suit

 

[Matthew9Thirtyfive]

Game theory, man. If I can hire someone to see all the sniffles and coughs that I'm way overtrained for while skimming a profit off them, you're damn right I'll hire several, regardless of what it does to the market when everyone follows suit

Yep. That’s why I said it’ll never happen. People never go for the mutually beneficial play.

 

[deleted87051]

IR is taking the scraps from surgery if anything. This is because IR is not a primary service, doesn't manage their own patients, relies on referral/consults from other services i.e. not owning the patients. This means you get the ****ty patients or things that noone else would touch or at an inconvenient hours. And like another poster above alluded to, things that IR develop if the primary services find profitable they will incorporate into their practice

That is the double-edged sword of not being a primary service.

There are PLENTY of upsides not being a primary service too. And in my little corner of the world IR is swamped. Many end stage patients for sure though.

 

[badasshairday]

I wouldnt trust a radiologist’s thoughts on whether AI is going to take their job. An AI expert’s opinion is much more valid. Many AI experts have said radiologists should not be trained anymore because AI is going to take their jobs

LOL

 

[badasshairday]

IR is taking the scraps from surgery if anything. This is because IR is not a primary service, doesn't manage their own patients, relies on referral/consults from other services i.e. not owning the patients. This means you get the ****ty patients or things that noone else would touch or at an inconvenient hours. And like another poster above alluded to, things that IR develop if the primary services find profitable they will incorporate into their practice

That is the double-edged sword of not being a primary service.

Disagree. I do many things for and on patient that are too sick for surgery or have no surgical options. Often times we invent novel procedures even in the community. Patient with chest wall hematoma and coagulopathy and with aortic dissection. Too sick forsurgery. Endovascular, don'tand to mess with a dissection to get into intercostal arteries to embolize (which nobody does embolizations than IR anyways). Hmmm how about percutaneous thrombin injection of intercostal artery to shut down bleed. acute limb ischemia, tumor embolization, trauma and gi bleeding embolizations, TIPS portal venous interventional not done by anyone else. Etc.

 

[radsisrad]

Disagree. I do many things for and on patient that are too sick for surgery or have no surgical options. Often times we invent novel procedures even in the community. Patient with chest wall hematoma and coagulopathy and with aortic dissection. Too sick forsurgery. Endovascular, don'tand to mess with a dissection to get into intercostal arteries to embolize (which nobody does embolizations than IR anyways). Hmmm how about percutaneous thrombin injection of intercostal artery to shut down bleed. acute limb ischemia, tumor embolization, trauma and gi bleeding embolizations, TIPS portal venous interventional not done by anyone else. Etc.

IRs are also unparalleled in their abilities to inventively create usernames that can be construed in breathtaking-different ways. But I digress...

 

[Rekt]

Everything is gonna be fine. Since I’ve been alive the world was supposed to end at least 4 times. People just like to complain

Eventually someone's going to be right though.

Removing the possibility of medicare for all for the time being (which would hurt reimbursement across the board), taking a look at EM specifically things are especially grim and unlikely to recover. The past two years are the first time grads have had some difficulty with job placement, which will only get worse as these many new programs that opened recently and are still opening flood the market. We're also being directly targeted by the clowns in DC trying to cut EM reimbursement (which is going to pass this year because it's being sold as saving money for patients, but will just put more money into insurance pockets). And just today one of the largest national employers of EM docs cut salaries across the board by 4-10%, stopped paying for scribes, cut benefits, and increased the work hours needed to be considered full time. The other national employers will quickly follow suit because it's free money for them.

Saying that "everyone cries doom and gloom all the time everything will be fine" without any critical thought is how you end up in the above situation.