Most and least futureproof specialties.

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They could easily argue the same when a physician harms a patient and that is far more common given how much more frequent physicians are in the direct and leading care of patients

I think the important aspect is the ratio of mistakes per provider, not the raw number across all providers. I would imagine an NP vs an MD would have somewhere between a 10 to 1 or 50 to 1 ratio of misdiagnoses/mistakes. My numbers are pure conjecture, but the point remains that an NP/PA will mess up far more frequently than a competent physician, on average.

I will admit, and it's sad to say, that the top 5% of midlevels are probably equal to or better than the bottom 5% of physicians. Again I'm making up random numbers, but a few amazing midlevels are likely better than the worst of physicians.

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The only field that is untouchable is Emergency Medicine because if a computer AI had to deal with the meth heads and drunkards that I deal with on a daily basis it would format its own damn hard drive.
 
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If our salaries go way down or our jobs are given to NPs and PAs..how do we pay back out student loans?

I am an incoming MS1 and am pretty concerned..


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No one is saying they're not an integral part of the healthcare system, but that's a completely different argument than they should be leaders of it or saying they're even qualified to do certain things without supervision. They do have full practice rights in some places, but that doesn't mean they're qualified to have those jobs or that they're going to produce the same quality of outcomes as physicians. Run a few studies showing that outcomes from mid-levels are inferior to physicians and it'll slow encroachment down, or even reverse it if the studies are harsh enough. Also, they would be idiots to ask for the same compensation, as cheaper labor is the only advantage of going with a mid-level over a physician. It would completely defeat the purpose of anyone hiring an NP or PA over a physician.

It is, but unfortunately it seems as though we've already crossed that bridge considering the practice rights situation. I really don't understand how the AMA and other physician-advocacy bodies let this happen considering the group is largely stocked full of primary care doctors in the leadership.

I agree, but until studies are publicized regarding outcomes *cough* AMA WTF *cough* the general public will have no idea. They're already introducing themselves as doctors this and that, with patients often less the wiser.

Furthermore, in a world where mid levels outnumber doctors, and I don't see that being too far off considering the speed of training and current high relative compensation, their bargaining position will go up to the point where as long as they're not exactly the same pay as a doctor they will be a discount. IMO this is why nurses seem to run every hospital I've ever been in, there are just so many of them.

A recent article about this topic, but the comment section has been overrun by nurses.

When Your Doc Is Not a Doc: Should Nurse Practitioners Be Autonomous?

Its a good article, but a little too late, no?

Obviously the practice rights thing has to spread to bigger states, but at the same point pandora's box is current gaping.

If our salaries go way down or our jobs are given to NPs and PAs..how do we pay back out student loans?

I am an incoming MS1 and am pretty concerned..


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Your guess is as good as anyone's. What will happen if we get a blue president in 2020 & we go straight socialized? Who knows.
 
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I think the important aspect is the ratio of mistakes per provider, not the raw number across all providers. I would imagine an NP vs an MD would have somewhere between a 10 to 1 or 50 to 1 ratio of misdiagnoses/mistakes. My numbers are pure conjecture, but the point remains that an NP/PA will mess up far more frequently than a competent physician, on average.

I will admit, and it's sad to say, that the top 5% of midlevels are probably equal to or better than the bottom 5% of physicians. Again I'm making up random numbers, but a few amazing midlevels are likely better than the worst of physicians.
I dont think thats wht the public cares about
 
Least safe/wouldn't even consider if you offered me a $100k bonus right now:
Rads
Gas
Path

I know people like to crap on the job market issue in Pathology, but keep in mind that we don't have physician extenders like PA's or NP's. We have Pathology Assistants but their expertise is in grossing specimens, not microscopy. They save us time by finding the best specimens for our microscopy.

And as for AI in pathology, we have something called Cellavision for blood smears, and one of the biggest headaches we have is correcting it, literally taking up hours a day! Glass slides are immensely cheaper than whole slide imaging and generally preferred amongst the big wigs in the field.
 
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They could easily argue the same when a physician harms a patient and that is far more common given how much more frequent physicians are in the direct and leading care of patients

Imo the difference isn't even in the number of errors, but the type of errors being made. Sure, docs make mistakes, but I've never heard a physician prescribe only steroids for a case that has already been proven via culture to be bacterial pneumonia or try to prescribe an antidepressant to someone in a manic episode just because they said they have passive SI. I mean, most pre-clinical med students would know how wrong both of those are but I've seen NPs actually try and justify doing this with patients irl.

At the same time, I've never seen a physician just throw z-paks at every suspected sinus infection that walks into their office or run a rapid strep on anyone that comes in saying they've got a sore throat. I've seen both of these things done by more than one midlevel, which just racks up the bill from unnecessary testing. It completely contradicts the "midlevels are cheaper" argument.

The only field that is untouchable is Emergency Medicine because if a computer AI had to deal with the meth heads and drunkards that I deal with on a daily basis it would format its own damn hard drive.

You could say the same thing about psych in terms of technology though. I'd enjoy seeing what kind of diagnoses and treatments a computer would come up with after getting the history from someone in active psychosis.

It is, but unfortunately it seems as though we've already crossed that bridge considering the practice rights situation. I really don't understand how the AMA and other physician-advocacy bodies let this happen considering the group is largely stocked full of primary care doctors in the leadership.

I agree, but until studies are publicized regarding outcomes *cough* AMA WTF *cough* the general public will have no idea. They're already introducing themselves as doctors this and that, with patients often less the wiser.

Furthermore, in a world where mid levels outnumber doctors, and I don't see that being too far off considering the speed of training and current high relative compensation, their bargaining position will go up to the point where as long as they're not exactly the same pay as a doctor they will be a discount. IMO this is why nurses seem to run every hospital I've ever been in, there are just so many of them.

It happened because there are several states with large rural areas that no one wants to go to. The argument is that people in the boondocks are better off with mediocre medical care than no medical care at all. Unfortunately, the laws don't prevent nurses and other midlevels from practicing independently where physicians are available, which is the real problem imo.

Even with mid-levels outnumbering doctors, I'm still not that worried. Right now I see patients every day who say they're seeing an NP because the doc didn't have any openings but wish they were seeing an actual physician. I also see patients on a daily basis who come in because they're still having problems or their medications are causing problems because an NP gave them the wrong treatment. I also see patients who just flat out refuse to see midlevels and will only make appointments where they will be seen by a physician. So while the nursing lobby and NPs may have some people (including politicians) fooled, there are many people in the U.S. who still demand care from a physician. Plus as long as NPs keep making stupid mistakes (which isn't going to stop anytime soon given the poor quality of many NP programs), we'll still need someone (aka physicians) there to clean them up.
 
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Simultaneously the most and least future proof specialty is psychiatry.
 
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It happened because there are several states with large rural areas that no one wants to go to. The argument is that people in the boondocks are better off with mediocre medical care than no medical care at all. Unfortunately, the laws don't prevent nurses and other midlevels from practicing independently where physicians are available, which is the real problem imo.

Yeah I really wonder when the government just decided to stop funding residency training spots to match population growth. Probably an article out there on it but I'm too lazy to read...
 
-Pathology: Just feel like there's so many now with less work day-by-day.

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There is plenty of work to do in path. I don't see path being replaced by slide imaging anytime soon. It is not as black and white as a lot of people think it is. Also, my clinicians don't want to talk to a machine.
 
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Been in several countries in south america and asia. The specialties that always seemed to be the top earners were: anesthesia, ophthalmology, otolaryngologists and plastic surgeons.
 
I don't think neurosurgery belongs on the "safe" list. Much of the income of community neurosurgeons comes from spine stuff as opposed to intracranial, and a lot of spine surgery is being replaced by image-guided percutaneous interventions, which can be learned by doctors from other specialties. I know an interventional pain-trained anesthesiologist who does percutaneous placement of spinal spacers for spinal stenosis.

Aside from 2-3 level lumbar fusions and ACDFs, a lot of spine surgery is already BS enough as it is however laser spine surgery is even a bigger scam. The majority of those patients end up under going fusions. Thus, spine surgeons are gonna be quite busy for the foreseeable future.


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Hi
I'm a danish medical student and I'm also worried about the future job security. It seems like every day I open a newspaper, there is a new studie that show that AI and deep learning are better at diagnosing and treating patients, than doctors. Today I read, that algorithms were better at identifying heart diseases than cardiologists. Yesterday I read that a new softwareprogram were just as good at identifying cancer as a pathologist.
Hospitals here in Denmark has already started to buy computers which are able to screen x ray pictures and we also have robots doing surgeries.
I read that a silicon valley investor by the name of Vinod Khosla said that maschines will replace 80 procent af all doctors. Its hard not to become pessimistic about the future, when you hear all of this.
I'm defently gonna chose a speciality which are the least vulnerable to AI.
In my perspective family medicine and psychiatry is the least vulnerable and have the best outlooks. Not only because machines prabably isnt gonna take our jobs, but also because there will be a increasing demand for these two specialties, because of the growing population and the incresing number mental disorders. I've read that WHO believes that mental illness will become the biggest health concern in the future.
But even in a speciality like psyciatry, machines are advancing. ELLIE, a talking robot, is able to read facial expression and the tone of our voice and is being used to screen soldiers for PTSD. Other software were able to identify suicidal candidats and depression. Also bio markers are able to identify areas in the brain which are associated with mental disorder, so maybe neurologist are taking over some of the jobs for psyciatrists.
Here in Denmark we also have started to train psychologists to replace psychiatrist, and we are starting to have nurses doing the diagnosing, so that also is a threat to our job safety.

I think you may be interested in reading this:

http://www.oxfordmartin.ox.ac.uk/downloads/academic/The_Future_of_Employment.pdf

It's an analysis on the susceptibility of different jobs being taken over by automation. If you wanna read the whole thing, great. If not you can ctrl+F "physicians" and you'll see in the appendix that physicians and surgeons were determined to have a relative probability of being replaced by automation of 0.0042. Essentially, according to the authors by the time we're replaced by robots, everyone else will have already lost their jobs before us. I am unsure how the field will be changed, but ultimately I don't think all of this doom and gloom over advancing AI is necessarily warranted.
 
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I can't help but wonder if radiology will ever be outsourced; judging by the amount of radiologists in India, for example.
 
I can't help but wonder if radiology will ever be outsourced; judging by the amount of radiologists in India, for example.
No, simply because they have to be US licensed in order to recieve reimbursement. If they train in the US it is a possibility but not otherwise.
 
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Anything that brings in patients will be safe. Surgery will be super safe just because culturally surgeons are 'gods' (really dumb but it is what it is). Other examples are medicine fields, etc.

Not safe: anesthesiology, radiology, pathology. Because those are consultants. As hospitals get pressed more and more for cash, they will try to cut corners with these specialties, meaning nurses to replace anesthesiologists, AI to replace radiologists in the future or possible telerads. AI may replace parts of pathology in the future as well.

EM would be questionable. Good for foreseeable future, but i can easily see mid levels replace ED docs. And we can't continue to have more and more ED visits or our system will just die and crash so who knows when that will change. I noticed being a ED doc can vary and really depend on how hard you try. You can be a crappy ED doc and still be fine if you recognize the main killers and just call consults on the rest.
Rad Onc would be questionable too, if a medical breakthru comes out. Field is too dependent on one type of technology.
 
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Aside from 2-3 level lumbar fusions and ACDFs, a lot of spine surgery is already BS enough as it is however laser spine surgery is even a bigger scam. The majority of those patients end up under going fusions. Thus, spine surgeons are gonna be quite busy for the foreseeable future.


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I agree, unless one day regulators decide to crack down on this BS. Evidence for spinal fusions is pretty god awful, yet spinal fusions are the most lucrative procedures, thus spine surgeons do a ton of them. I see patients getting fusions, then their surrounding back hurts, come back for more fusions, until they have one fused back.
 
I think the important aspect is the ratio of mistakes per provider, not the raw number across all providers. I would imagine an NP vs an MD would have somewhere between a 10 to 1 or 50 to 1 ratio of misdiagnoses/mistakes. My numbers are pure conjecture, but the point remains that an NP/PA will mess up far more frequently than a competent physician, on average.

I will admit, and it's sad to say, that the top 5% of midlevels are probably equal to or better than the bottom 5% of physicians. Again I'm making up random numbers, but a few amazing midlevels are likely better than the worst of physicians.

Its more about cost to the system. You can hire 2 NPs for the price of 1 MD, thus see more patients = more revenue for hospital, which is what administrators ultimately care about. Sure NPs make more mistakes, but NPs also are likely to simply refer for tougher cases to specialists. Also, if you mess up the treatment for eg hypertension, what exactly will happen? The patient may have a 2% chance of dying a bit earlier 50 years down the line or something
 
Everyone says AI will replace radiology, but does anyone have evidence of how well that is going for the programmers/developers? Will the hospital then have to take on liability of the machine (instead of the radiologist holding their own liability as I understand it)?

It's actually going pretty well. They are feeding hundreds of thousands of images to AIs to get them to learn. Ive heard some places have even hired radiologists to help with the learning process. And I am guessing yes regarding liability. But usually when a hospital employed doctor get sued, the hospital gets sued with it anyway. not a big difference, especially with a trend towards capping damage compensations
 
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If our salaries go way down or our jobs are given to NPs and PAs..how do we pay back out student loans?

I am an incoming MS1 and am pretty concerned..


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This is something you should have thought about before embarking onto this journey...
 
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LOL at the chicken****s in this thread worried about a bunch of nurses or midlevels taking their jobs.

"Ohh noo... my $300K job is in jeopardy because I only wanna work 40 hours a week and see 3 patients a day... have weekends off... never ever deal with call.. and want to go sail the coast of Italy every month... but I still want to be the main shot caller and get all the respect and people kissing my feet because I just can"

Here's an idea...

how about you buck up... work your azz off... and show why nurses are nurses and you are a phucking doctor.

You will work harder. You will have more stress. You deserve more pay IF you do a good job and put forth the goddamn effort.

Nobody is gonna kiss your ass just because you have a goddamn MD or DO behind your name. Seriously. NOBODY.

What matters is you can relate to people, respect them, if you can offer SOLID and PROFESSIONAL advice and be a badass doctor. That's it!

This is why people have been saying for YEARSSS...

DO NOT DO MEDICINE ONLY FOR THE MONEY.

As a millenial... I only have one thing to say to all of y'all other goddamn millenials who have been coddled and never worked for anything and want everything to fall in their frickin' lap ...

You cannot have something for nothing in this country and in life. This is not how **** works.

Tired of these threads popping up everytime the new batch of med students are about to start school.

Medicine is cyclical. **** changes... and **** happens.

Deal with it or shut up... get out... and go into NP/PA/CRNA if you can't cut it homie.

Simple.



Moderator note: please keep it professional, avoid insults, avoid flames, and do not use swear words either filtered or purposely misspelled to avoid the filter.
 
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LOL at the chicken****s in this thread worried about a bunch of nurses or midlevels taking their jobs.

"Ohh noo... my $300K job is in jeopardy because I only wanna work 40 hours a week and see 3 patients a day... have weekends off... never ever deal with call.. and want to go sail the coast of Italy every month... but I still want to be the main shot caller and get all the respect and people kissing my feet because I just can"

Here's an idea...

how about you buck up... work your azz off... and show why nurses are nurses and you are a phucking doctor.

You will work harder. You will have more stress. You deserve more pay IF you do a good job and put forth the goddamn effort.

Nobody is gonna kiss your ass just because you have a goddamn MD or DO behind your name. Seriously. NOBODY.

What matters is you can relate to people, respect them, if you can offer SOLID and PROFESSIONAL advice and be a badass doctor. That's it!

This is why people have been saying for YEARSSS...

DO NOT DO MEDICINE ONLY FOR THE MONEY.

As a millenial... I only have one thing to say to all of y'all other goddamn millenials who have been coddled and never worked for anything and want everything to fall in their frickin' lap ...

You cannot have something for nothing in this country and in life. This is not how **** works.

Tired of these threads popping up everytime the new batch of med students are about to start school.

Medicine is cyclical. **** changes... and **** happens.

Deal with it or shut up... get out... and go into NP/PA/CRNA if you can't cut it homie.

Simple.

Great speech brah. Bob your friendly local hospital CEO couldn't have said it better himself.

In all seriousness, I don't know what you're ranting about. This thread has nothing to do with the idea that we all want to work derm hours and get our arses kissed by the lay public every time we expel unicorn farts. Who are you even directing this straw-man at?

Nobody here is complaining about the enormous time investment we devote to medical training and the grueling hours we will work. We all knew this was part of the game going in and it always has been. The purpose of this thread is not to figure out how to avoid putting in the massive effort, it's to figure out how to avoid getting shafted out of the reward for this effort. If you have a problem with people not wanting to be chumps left holding the bag, the problem is yours, not ours.
 
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Great speech brah. Bob your friendly local hospital CEO couldn't have said it better himself.

In all seriousness, I don't know what you're ranting about. This thread has nothing to do with the idea that we all want to work derm hours and get our arses kissed by the lay public every time we expel unicorn farts. Who are you even directing this straw-man at?

Nobody here is complaining about the enormous time investment we devote to medical training and the grueling hours we will work. We all knew this was part of the game going in and it always has been. The purpose of this thread is not to figure out how to avoid putting in the massive effort, it's to figure out how to avoid getting shafted out of the reward for this effort. If you have a problem with people not wanting to be chumps left holding the bag, the problem is yours, not ours.

Check yourself little homie.
Like I said, everything in medicine is cyclical. If anybody could predict what fields will be hot and what won't be in the next decade, don't you think we'd frickin know by now hotshot?

That's the thing. You don't know. Nobody does. We can all sit and pretend like we know wtffff we are talking about but it don't meant jack ****.

Everything changes. Hopefully you buy low and sell high.

Which is why... Once again... I will state you better choose something you like for 30-40 years or else you're gonna be another "shoulda-woulda-coulda" miserable brat some attendings are.

If you're afraid of being "shafted", then sucks to be you amigo. Medicine is full of uncertainty. Get used to it.
 
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It's actually going pretty well. They are feeding hundreds of thousands of images to AIs to get them to learn. Ive heard some places have even hired radiologists to help with the learning process. And I am guessing yes regarding liability. But usually when a hospital employed doctor get sued, the hospital gets sued with it anyway. not a big difference, especially with a trend towards capping damage compensations

Thousands of images!

I enjoy reading about radiology on SDN. It's so distorted that it's kind of like playing around with a funny mirror.

AI is at the top of its hype cycle right now. There's a full court press to attract venture capital. Were we able to run thousands of lab tests on a single drop of blood?

AI will probably affect everyone in a somewhat distant future. AI extensions will speed human radiologists up first, reduce some of the more repetitive parts of the job, and markedly increase the number of incidental findings (which will lead to overall cost to the system, I bet). If AI were ever to completely replace radiology, that would be so far down the road that the whole medical landscape would have changed. Rads has always been a tech-driven field and it has had its share of dead ends. We don't do video kymography or pneumoencephalograms any more and MRI spectroscopy is not magic answer for everything... yet imaging takes place more than ever. If you're interested in rads, you have to be interested in tech and developing tech.

The medical world is in flux, which obv worries everyone in training since it's supposed to be a *safe* lucrative career. Indeed, one would be a fool to take on that much debt if the career and salary prospects were not stable. But it's not safe if you want to just find a niche and hide there. They will find you. Surgical specialties are relatively safe, but you're gonna pay and pay to get into that safety zone and only you can know if that price is worth it.

Ultimately, the most futureproof *specialist* is one who embraces the change and tries to drive the change. The least futureproof specialist is a rigid one who wants to score well on a few exams and then get paid more than the average for repeating the same task over and over.
 
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Thousands of images!

I enjoy reading about radiology on SDN. It's so distorted that it's kind of like playing around with a funny mirror.

AI is at the top of its hype cycle right now. There's a full court press to attract venture capital. Were we able to run thousands of lab tests on a single drop of blood?

AI will probably affect everyone in a somewhat distant future. AI extensions will speed human radiologists up first, reduce some of the more repetitive parts of the job, and markedly increase the number of incidental findings (which will lead to overall cost to the system, I bet). If AI were ever to completely replace radiology, that would be so far down the road that the whole medical landscape would have changed. Rads has always been a tech-driven field and it has had its share of dead ends. We don't do video kymography or pneumoencephalograms any more and MRI spectroscopy is not magic answer for everything... yet imaging takes place more than ever. If you're interested in rads, you have to be interested in tech and developing tech.

The medical world is in flux, which obv worries everyone in training since it's supposed to be a *safe* lucrative career. Indeed, one would be a fool to take on that much debt if the career and salary prospects were not stable. But it's not safe if you want to just find a niche and hide there. They will find you. Surgical specialties are relatively safe, but you're gonna pay and pay to get into that safety zone and only you can know if that price is worth it.

Ultimately, the most futureproof *specialist* is one who embraces the change and tries to drive the change. The least futureproof specialist is a rigid one who wants to score well on a few exams and then get paid more than the average for repeating the same task over and over.
Loved this. Good stuff, @Gadofosveset!
 
Loved this. Good stuff, @Gadofosveset!

From my impression, AI will help Radiology first before hurting it. It seems that many radiologists have the same problems. They work SO hard reading a never ending que of scans. By the time they read one there are 3 more, especially when on call.

With basic AI wouldn't the machine be able to read basic CXRs and other scans and provide an initial report which the radiologist would then review and approve? I'm sure there are complex cases with many subtleties that only an attending radiologist would catch, right?

I'm not a tech guy but everyone says "AI is all about pattern recognition" but how similar are all these patterns really when all human anatomy is slightly different? I've seen rad onc docs go through scans and the anatomy of different patients looks crazy different. Maybe in 50 years AI will be better but by that time I'll be retired
 
At the same time, I've never seen a physician just throw z-paks at every suspected sinus infection that walks into their office or run a rapid strep on anyone that comes in saying they've got a sore throat. I've seen both of these things done by more than one midlevel, which just racks up the bill from unnecessary testing. It completely contradicts the "midlevels are cheaper" argument.
Really? I see that all the time.
 
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From my impression, AI will help Radiology first before hurting it. It seems that many radiologists have the same problems. They work SO hard reading a never ending que of scans. By the time they read one there are 3 more, especially when on call.

With basic AI wouldn't the machine be able to read basic CXRs and other scans and provide an initial report which the radiologist would then review and approve? I'm sure there are complex cases with many subtleties that only an attending radiologist would catch, right?

I'm not a tech guy but everyone says "AI is all about pattern recognition" but how similar are all these patterns really when all human anatomy is slightly different? I've seen rad onc docs go through scans and the anatomy of different patients looks crazy different. Maybe in 50 years AI will be better but by that time I'll be retired
I hope an attending radiologist can comment on this, but personally I think it'd actually really help radiologists if a Silicon Valley wizard or someone else can get a machine to properly read basic CXRs someday. At least where I am there's a huge backlog of scores and scores of "basic CXRs" that won't be read any time soon. Eventually one of the radiologists will get to each of them, but it's an open secret that the clinicians who ordered the CXR don't expect a report on it any time soon (otherwise, if they do, they will call or come down in person and ask one of the radiologists). I suppose ordering the CXR is more to cover themselves than anything else since they've usually already started treating/managing the patient. So I think it'd really help if radiologists didn't have to read basic CXRs, but could let a machine do it. Let the radiologists focus on more significant aspects of their work. Just my opinion.
 
Ah, so typical. What you are describing is the tired old tale of the sellout. Yes, a handful of physicians will become big winners by selling their field down the drain. They'll oversee armies of midlevels from the comfort of their McMansions while 90% of their colleagues face plunging salaries and job prospects. Yes, we should all embrace this wonderful world of yours. What a surprise that this rosy picture is coming from "Academic Neurosurgy." Planning any residency expansions lately? However bright the future might be with armies of midlevels, surely it will be even more bright if we pump out ever more residents as well, no?

I encourage you to learn about the current medical climate in this country, especially with regards to GME issues and physician shortages in medically under-served populations. In many places, we are seeing a decline in salaries in popular cities (e.g. East/West coasts) and an increase in salaries for people willing to move to rural areas. This is simple economics - supply and demand. I think much of the problem comes from the misinformed belief that as physicians, we dictate how the medical sector behaves and since we have gone through rigorous training, we deserve to live in the Bay Area and get paid $1M/year. This is not the case and physicians are not above the supply and demand of the market.

That issue aside, I don't buy into your prediction that midlevels will take over everything and be overseen by a few physicians leading to less physician jobs, etc. Here is something to chew on - if midlevels are successfully taking over our jobs as you claim, who is to say we deserve the pay we are receiving? Look at it from the other side (i.e. the perspective of hospital executives). If a PA can adequately manage the bread and butter cases for a fraction of the cost of employing a physician, why would hospital executives not take that offer? This is why it is important that we as physicians continue to provide a unique set of skills that makes us valuable. It is the same concept in other industries such as when you are applying for a job, starting a new business, pitching an entrepreneurial venture, etc. - your competitive advantage is what determines your value to those who pay you. There is no reason why a PA can't go see a consult for NPH and start a basic workup. A neurosurgeon can now use the 30 minutes he/she saved for something only he/she has the training to do, such as cranking out another peripheral nerve case that may have otherwise gone to another hospital/delayed care.

My point is this - more and more midlevels are taking over responsibilities once held solely by physicians. If they do these tasks adequately, I have no problem with it and for those who do have a problem, tough luck because cheaper labor will always win. At the same time, modern-day medical advancements are giving physicians new responsibilities that only they are uniquely qualified to learn and to implement. If you stay up to date with new guidelines/procedures, continue to hone your skills every day, and never stop learning, you will continue to be valuable in the health care sector.
 
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If you can get a good 15 to 20 years right now (and manage money well), you won't have to worry about the future of any medical field at all when you're 50 and retired :)

I resent that outlook on life... It almost makes it seem like we study, we work, we retire. Kinda depressing if you ask me.

I just want to hammer home the staggering magnitude of the midlevel tsunami that is going to wash over us.

There are currently 23,000 NPs graduating each year.
Assuming a 30 year average career and no further growth in the number of NP slots, this will lead to a workforce of 700,000 Nurse Practitioners. But the number of graduating NPs is growing each year.

In 2008 there were roughly 800,000 physicians and only 86,000 NPs. Today there are roughly 130,000 NPs, and we have seen them noticeably encroach on physician territory as a result of this ~50,000 increase. But in the coming decades their number will go up by an additional 600,000. If we are noticing the effects of midlevel creep from a paltry 50k increase, what can we expect when ten times that number is pumped into the labor market?

This is only the NPs. The PAs are a similar tale. We are moving from a world where there are 10 times more physicians than midlevels to a world where the numbers are equal. This is not going to end well.

Who needs doctors anyway? We've already given em longer white coats, might as well just give them a doctorate and call them physicians. Meanwhile, confuse the absolute Sht out of patients.
 
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swear words either filtered or purposely misspelled to avoid the filter.

This describes like 20% of my lifetime SDN posts. :angelic:

For what it's worth, even psychiatry isn't without attempts at automation. There are efforts out there to use algorithms to stratify and determine suicide risk. See the VA's REACHVET program, as well as a rather good article about what the NIH is doing in the most recent The Atlantic.

...though so far all REACHVET has been able to do is inform me about the patients I'm already well aware of and admitted myself, then cause me more paperwork to fill out about them.
 
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Really? I see that all the time.

In my experience, I haven't. I've seen a few that are a bit more prone to give rapid strep tests, but not like the NPs/PAs I've worked with, most recently an NP who ran 15+ strep tests in one day and only 1 came back positive (this is the same NP who asked me, an MS3 at the time, if I thought 3 different patients had impetigo in the same day). She was seeing patients independently in the clinic I was rotating through and has since been fired. I'm sure there are doctors out there who do fall into that category, as no profession is safe from inadequate workers, but from my experiences those inadequacies seem to be the norm among NPs and the ones doing the job right are the exception.

I resent that outlook on life... It almost makes it seem like we study, we work, we retire. Kinda depressing if you ask me.

To be fair, that's how most people live their lives. They prepare for a job, work doing something they enjoy or more often can tolerate, then retire as soon as their benefits kick in. The only difference is the amount of time and effort required to actually start being fully paid as a physician. The other point I think @Dermpire was making was that if you want to retire at 50 as a physician you can, which is a luxury that very few other fields are capable of providing.

For what it's worth, even psychiatry isn't without attempts at automation. There are efforts out there to use algorithms to stratify and determine suicide risk. See the VA's REACHVET program, as well as a rather good article about what the NIH is doing in the most recent The Atlantic.

...though so far all REACHVET has been able to do is inform me about the patients I'm already well aware of and admitted myself, then cause me more paperwork to fill out about them.

Is that the "The Smartphone Psychiatrist" article? If not would you mind linking the one you're referring to as I didn't see any others.
 
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In my experience, I haven't. I've seen a few that are a bit more prone to give rapid strep tests, but not like the NPs/PAs I've worked with, most recently an NP who ran 15+ strep tests in one day and only 1 came back positive (this is the same NP who asked me, an MS3 at the time, if I thought 3 different patients had impetigo in the same day). She was seeing patients independently in the clinic I was rotating through and has since been fired. I'm sure there are doctors out there who do fall into that category, as no profession is safe from inadequate workers, but from my experiences those inadequacies seem to be the norm among NPs and the ones doing the job right are the exception.



To be fair, that's how most people live their lives. They prepare for a job, work doing something they enjoy or more often can tolerate, then retire as soon as their benefits kick in. The only difference is the amount of time and effort required to actually start being fully paid as a physician. The other point I think @Dermpire was making was that if you want to retire at 50 as a physician you can, which is a luxury that very few other fields are capable of providing.



Is that the "The Smartphone Psychiatrist" article? If not would you mind linking the one you're referring to as I didn't see any others.

yeah, that was it. I take a strong behaviorist approach to mental health care, so I like the idea behind it, but with a lot of technology in mental health I'm a bit of a Luddite until there's good data that it's worth my time to use.
 
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I encourage you to learn about the current medical climate in this country, especially with regards to GME issues and physician shortages in medically under-served populations. In many places, we are seeing a decline in salaries in popular cities (e.g. East/West coasts) and an increase in salaries for people willing to move to rural areas. This is simple economics - supply and demand. I think much of the problem comes from the misinformed belief that as physicians, we dictate how the medical sector behaves and since we have gone through rigorous training, we deserve to live in the Bay Area and get paid $1M/year. This is not the case and physicians are not above the supply and demand of the market.

That issue aside, I don't buy into your prediction that midlevels will take over everything and be overseen by a few physicians leading to less physician jobs, etc. Here is something to chew on - if midlevels are successfully taking over our jobs as you claim, who is to say we deserve the pay we are receiving? Look at it from the other side (i.e. the perspective of hospital executives). If a PA can adequately manage the bread and butter cases for a fraction of the cost of employing a physician, why would hospital executives not take that offer? This is why it is important that we as physicians continue to provide a unique set of skills that makes us valuable. It is the same concept in other industries such as when you are applying for a job, starting a new business, pitching an entrepreneurial venture, etc. - your competitive advantage is what determines your value to those who pay you. There is no reason why a PA can't go see a consult for NPH and start a basic workup. A neurosurgeon can now use the 30 minutes he/she saved for something only he/she has the training to do, such as cranking out another peripheral nerve case that may have otherwise gone to another hospital/delayed care.

My point is this - more and more midlevels are taking over responsibilities once held solely by physicians. If they do these tasks adequately, I have no problem with it and for those who do have a problem, tough luck because cheaper labor will always win. At the same time, modern-day medical advancements are giving physicians new responsibilities that only they are uniquely qualified to learn and to implement. If you stay up to date with new guidelines/procedures, continue to hone your skills every day, and never stop learning, you will continue to be valuable in the health care sector.

I got some issue with this sentiment. If you are in academic neurosurgery, you are in a secure turf and PA/NP can increase your earnings.

However, how do you define "simple"?

Is placing an EVD a simple procedure? I suppose you will tell me no. Is placining a central line or mediport simple procedure? You may say, sure, it's simple. Let's train PAs to do it.

Before you know it, it's a few academic physicians and an army of PAs. When you already got your job, it's not a big deal, but to declare things simple (things like consult or "basic workup"), you are handing away medicine to mid levels and decrease demand for physicians, ultimately decreasing demand for physicians.

In that world, I am sure you and me, from the ivory tower to the next, will be fine. But what about the majority of posters here who don't go to an big ivory tower? What about the vast majority of DOs? Are most of their jobs so simple that a NP can do?

Here's the deal. You can train NP and PAs to do ANY Procedure. Hell, if you argue that work up for NPH is simple, I can counter and say basic stroke endovascular work is simple too.

However, you never know whether a work up or a problem or a procedure is going to be simple, and I am sure you know that very well.

NPs and PAs, due to limitations of their training, don't know what they don't know and will not recognize when a problem is no longer "simple". That will lead to patient harm.

As a result, we simply cannot declare things as "simple" and hand them away to mid levels. This happened already, to anesthesia.

Alternatively, we can give most things to mid levels, close most med schools instead of the top 30, and train enough physicians only to staff academic centers and a few to lead private pracicss. Is that the future you would like to see?
 
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LOL at the chicken****s in this thread worried about a bunch of nurses or midlevels taking their jobs.

"Ohh noo... my $300K job is in jeopardy because I only wanna work 40 hours a week and see 3 patients a day... have weekends off... never ever deal with call.. and want to go sail the coast of Italy every month... but I still want to be the main shot caller and get all the respect and people kissing my feet because I just can"

Here's an idea...

how about you buck up... work your azz off... and show why nurses are nurses and you are a phucking doctor.

You will work harder. You will have more stress. You deserve more pay IF you do a good job and put forth the goddamn effort.

Nobody is gonna kiss your ass just because you have a goddamn MD or DO behind your name. Seriously. NOBODY.

What matters is you can relate to people, respect them, if you can offer SOLID and PROFESSIONAL advice and be a badass doctor. That's it!

This is why people have been saying for YEARSSS...

DO NOT DO MEDICINE ONLY FOR THE MONEY.

As a millenial... I only have one thing to say to all of y'all other goddamn millenials who have been coddled and never worked for anything and want everything to fall in their frickin' lap ...

You cannot have something for nothing in this country and in life. This is not how **** works.

Tired of these threads popping up everytime the new batch of med students are about to start school.

Medicine is cyclical. **** changes... and **** happens.

Deal with it or shut up... get out... and go into NP/PA/CRNA if you can't cut it homie.

Simple.



Moderator note: please keep it professional, avoid insults, avoid flames, and do not use swear words either filtered or purposely misspelled to avoid the filter.

This type of mentality is exactly why we are losing and will lose the battle if it continues. For some some reason some of MDs out there think if you work hard, harder than a nurse, better than a nurse, it will be OK. Well i think that's just stupid. Times have changed. It's no longer a paternalistic model where the doc is the boss. Now it's the team healthcare, with administrators as the boss. It's all about how much money you cost and make for the hospital. Nurses will be winning the legal battles, the lobbying, the increased independence, takeover of medical fields, where you will be stuck in your little corner working your face off, winning battles that probably only matter to you. Got to look at the big picture. Your job may be safe cause you are working 100 hr weeks, for the cost of 1 MD, so theres no reason to replace you. But its dumb to tell every doc to work 100 hr weeks to keep our jobs. thats how we got into this mess in the first place. we don't play smart.
 
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I got some issue with this sentiment. If you are in academic neurosurgery, you are in a secure turf and PA/NP can increase your earnings.

However, how do you define "simple"?

Is placing an EVD a simple procedure? I suppose you will tell me no. Is placining a central line or mediport simple procedure? You may say, sure, it's simple. Let's train PAs to do it.

Before you know it, it's a few academic physicians and an army of PAs. When you already got your job, it's not a big deal, but to declare things simple (things like consult or "basic workup"), you are handing away medicine to mid levels and decrease demand for physicians, ultimately decreasing demand for physicians.

In that world, I am sure you and me, from the ivory tower to the next, will be fine. But what about the majority of posters here who don't go to an big ivory tower? What about the vast majority of DOs? Are most of their jobs so simple that a NP can do?

Here's the deal. You can train NP and PAs to do ANY Procedure. Hell, if you argue that work up for NPH is simple, I can counter and say basic stroke endovascular work is simple too.

However, you never know whether a work up or a problem or a procedure is going to be simple, and I am sure you know that very well.

NPs and PAs, due to limitations of their training, don't know what they don't know and will not recognize when a problem is no longer "simple". That will lead to patient harm.

As a result, we simply cannot declare things as "simple" and hand them away to mid levels. This happened already, to anesthesia.

Alternatively, we can give most things to mid levels, close most med schools instead of the top 30, and train enough physicians only to staff academic centers and a few to lead private pracicss. Is that the future you would like to see?

First and foremost, I am not a practicing academic neurosurgeon nor have I ever claimed to be one. I will probably never work in the 'ivory towers' and don't care to. With regards to my comment about NPH, I said the initial workup for a patient is pretty standard, not that putting in a shunt is something a PA can do. I am not saying the PA is going to make the diagnosis, take the patient to the OR, and stick a shunt in. What they can do is go see the patient, do an H&P, assess the patient's stability, put in preliminary orders, etc. The neurosurgeon being consulted will obviously go see the patient but the process is streamlined by a PA initially going to see the patient. As I alluded to in my previous post, knowing appropriate boundaries is important and of course making the decision to operate/placing a shunt is outside the scope of a PA's training. If we can refine midlevel education and define their roles in a clearer way, they can truly be an asset to any patient's care team. Finally, I am not sure why you are connecting academic physicians with a large army of PAs. I would argue the reality is quite the opposite, PAs are more valuable/more common in community settings. Very generally speaking, people go to academic centers for non-routine issues and are seeking care from highly specialized physicians. In areas with less resources, however, PAs can fill a significant gap in health care services. Further, many rural areas are desperate for physicians and offer very competitive salaries. Aside from not wanting to live in a rural area, another reason these jobs are hard to fill is because there are such limited resources in rural areas and you may be on call 365. I am speculating here but maybe having midlevel support may be enticing enough to draw some physicians to rural areas. I listed several examples in my previous posts about community physicians (neurosurgeons and internists) who all independently hired PAs. The local neuro group in my area has something like 6 neurosurgeons and 5 neurologists, each of whom hired their own PA. Maybe I am biased by my glass-half-full life perspective and what I have personally witnessed during my training.

We can beat a dead horse all day long but midlevels aren't going anywhere. If the kinks regarding the quality of training programs get worked out and clear boundaries are set, I still believe we will all be better off. But, only time will tell.
 
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I've been thinking a lot about midlevel encroachment in dermatology. The vast majority of what you treat in derm clinic could easily be treated by a NP/PA (acne, warts, eczema). The rare zebra cases definitely do take a higher level of education. However, the issue is that derm cases for the most part are very low acuity. I would actually expect something like anesthesia to be one of the last fields to go to midlevels as each decision you make can have such drastic consequences...however this is clearly not the case (CRNAs). I understand that mohs and dermpath would not likely be taken over by midlevels. However, what are everyone's thoughts on general dermatology?
 
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I've been thinking a lot about midlevel encroachment in dermatology. The vast majority of what you treat in derm clinic could easily be treated by a NP/PA (acne, warts, eczema). The rare zebra cases definitely do take a higher level of education. However, the issue is that derm cases for the most part are very low acuity. I would actually expect something like anesthesia to be one of the last fields to go to midlevels as each decision you make can have such drastic consequences...however this is clearly not the case (CRNAs). I understand that mohs and dermpath would not likely be taken over by midlevels. However, what are everyone's thoughts on general dermatology?

See my post earlier in this thread. This terrifies me the most.
 
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I've been thinking a lot about midlevel encroachment in dermatology. The vast majority of what you treat in derm clinic could easily be treated by a NP/PA (acne, warts, eczema). The rare zebra cases definitely do take a higher level of education. However, the issue is that derm cases for the most part are very low acuity. I would actually expect something like anesthesia to be one of the last fields to go to midlevels as each decision you make can have such drastic consequences...however this is clearly not the case (CRNAs). I understand that mohs and dermpath would not likely be taken over by midlevels. However, what are everyone's thoughts on general dermatology?

Derm is going to reap what they sowed. The consequences of not increasing the size of the field in previous decades creates the unintended consequence that other tentacles of the medical profession reach around to meet the unmet demand.

If I'm an NP advocate type, I'm gunning hard for derm as an area to invade...
 
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If you guys only focus on the potential threat from technology such as AI, and not midlevel workforce, then how futureproof do you consider psychiatry and family medicine?
 
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If you guys only focus on the potential threat from technology such as AI, and not midlevel workforce, then how futureproof do you consider psychiatry and family medicine?
I doubt psych will be threatened by future tech unless future tech can read minds and diagnose mental illnesses. If anything, the mind (as distinct from the brain) will likely be medicine's last frontier.
 
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Derm is going to reap what they sowed. The consequences of not increasing the size of the field in previous decades creates the unintended consequence that other tentacles of the medical profession reach around to meet the unmet demand.

If I'm an NP advocate type, I'm gunning hard for derm as an area to invade...

It's unfortunate that a dermatologist who supposedly had to graduate at the top of his/her class with 250+, AOA, honors, research etc... may loose out to an NP who got a degree from an online university. Sad world we live in. At least there are no midlevels doing moh's and dermpath.
 
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It's unfortunate that a dermatologist who supposedly had to graduate at the top of his/her class with 250+, AOA, honors, research etc... may loose out to an NP who got a degree from an online university. Sad world we live in. At least there are no midlevels doing moh's and dermpath.

Very thankful for this as well, however from what I've heard the job market is pretty terrible for both of these, at least for anyone looking to do full time.
 
There isn't going to be any specialties that disappear or are overrun by midlevel providers, physicians will always be more desirable. In my opinion, basing a career choice on speculation isn't wise. If you truly enjoy a specialty, don't avoid it because you're uncertain of how the future will impact that specialty.

Yes and no, yes to a degree (Physician specialists do adapt) but also in large part "no" because physicians arent in control as to what they do, where, when, nor why.

Medicine is a business. Physicians need to embrace this joyfully. Otherwise, the lashings will continue. Every large established business has a business plan that uses metrics to decide how to turn a profit. Regardless if CMS, 3rd party payers or private cash is floating the business, a health care facility will not run gratis. Physicians will not work gratis. As long as a sector / department is contributing in the positive to the overall business plan, then they are retained. If they are a cost, then they will be eliminated unless if their existence is essential to the overall business in spite of it being a cost, e.g. a hospital must have an ER, an OR, an ICU. They may merely exist but will not be eliminated. Few hospitals offer Level 1 Trauma Centers for a reason. Some hospitals have minimal number of OR rooms while others depend on 30+ suites in OR for their revenue.

e.g. Today interventional cardiologists are a dime a dozen. Hospital billboards litter the nation with promotional efforts of their having the #1 stroke / heart center. Not so 20 years ago. Cardiothoracic Surgeons were the top dogs through the 1990s. Then along came the bare metal stent. The CT surgeons complained about the CDs suddenly having new skillsets / toys. The CDs adapted. Now they both coexist. However, the CT surgeon was at one time practically revered while the CD was "meh" in the eyes of CT surgery (NB: I worked as a clinical perfusionist team member for 9 years). The same applies to oncology: cancer centers 30 years ago were largely morgues. Today not many hospitals can afford to operate a state of the art cancer center even if there exists a need (supply/demand) but one can find multiple cancer centers in one major city. Again, the oncologists had to adapt - new toys (targeted therapies). Ditto for Infectious Diseases 40 years ago. The ID physicians then were a rare find. Their work was largely limited to nosocomial infections unless if they were situated in a major city with much travel (NYC, San Francisco, etc) and they addressed the rare bug that entered from travelers. Then came AIDS in the 90s, and the ID physicians exploded in their importance, i.e. they adapted. Today HIV/AIDS is treated by GP, FP, IM physicians because they too had to adapt. Meanwhile ID physicians lost prominence. So they adapted to "global health initiatives", chase bugs across the globe. In my state university hospital, the ID physicians are essentially HIV /Hep docs. We don't have much travel to our region, and nosocomial infections are just that.

Depending on the region of the country, certain areas of medicine can thrive while others are not offered in great numbers. So the physician must go where ever the business is certain. Since the business leaders have to turn a profit, if the jobs can be done by skilled workers at a lower cost, then the higher paying jobs will be reduced in number or eliminated. Ask Anesthesiologists what Nurse Anesthetists have done to their profession. They are losing in State Legislatures across the country. Physicians beware. Learn from the plight of the Anesthesiologists. Adapt or be reduced.

We see this at pharmacies. At one time a pharmacy was largely staffed by multiple Pharmacists. Not so today. Pharmacy techs are mainly running the business while 1 pharmacist does most of the "official" dispensing.

As long as the current business model reigns (third party payers), physicians should think like business professionals. Since a business is run at a 30,000 feet level, those on the ground won't notice the changes that need to be done as to business direction. However, the business leaders see the horizon all too well. If an NP or PA can do what an MD can, the business has no reason to employ the MD. Thus the MD should continually be justifying their existence, developing their skills and promoting themselves as invaluable to the overall health care industry. Their brandishing their MD Degree is laughable b/c it doesn't work in the business model. Evolve or become extinct. Given that physicians largely are complaining, moaning, whining and not playing ball with the business / hospital admins (like this thread), they are losing their shirts....literally. First came their salaries, then came their titles, slowly their job descriptions exploded to which brings us to the current discussion

TL;DR: If you don't like the threat of NP/PAs encroaching on what a physician can do, when, where and why, then you need to play ball with the hospital / business leaders. Otherwise offer your own competing medical business paradigm. I vote for the latter.

Happy selling
 
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It's unfortunate that a dermatologist who supposedly had to graduate at the top of his/her class with 250+, AOA, honors, research etc... may loose out to an NP who got a degree from an online university. Sad world we live in. At least there are no midlevels doing moh's and dermpath.

Though if Derm hadn't been so insistent on not expanding the number of residency slots over the years, you wouldn't need that 250, and the NPs wouldn't have such an easy time encroaching because of how difficult it is to get a derm appointment...
 
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Physicians in different specialties will adapt, there won't be one profession that dries up overnight. Just look at what specialties looked like 50 years ago vs today, they're ever evolving. The first EM residency wasn't even until 1970.

I don't want to dive into the NP issue too much, but two things:
1. Any pro-midlevel arguement comes back to the idea that they can identify their limitations and will refer correctly and timely (before someone dies). Unless this is a gross pathology staring them in the face, if they miss a Dx/Tx/anything, they miss it. Medical error, not a referral, due to their lack of knowledge. However these errors can can be unapparent (as one poster alluded to decreasing their life span decades down the road).
2. I would argue physicians are trained more heavily to be classical clinical medicine physicians at most med schools, not administrative/clinical supervisors of an allied health army. This is a doom and gloom speculation as I think physicians will adapt, but; If we let corporate health push us into this role, there could be tighter job prospects for these jobs which we are not ideally suited for (I could also see this entailing doctors taking the most difficult pathology for the same pay). Medicine is very much a business run often by business people, most with no science background or appreciation for it. The politicians (that make rules we and the hospitals often have to play by) have even less scientific knowledge or respect for it. If you think they wouldn't potentially cut doctor positions in favor of a cheaper midlevel option with a few physician directors or department chiefs, believe it. Just look at what administrators did to PhD university professors, students are paying 100x in tuition to be taught by a 29 year-old adjunct Masters grad while an 80 year-old PhD department chair "oversees" the course.
 
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