Most and least futureproof specialties.

[naus]

Surgical specialties have a lot of midlevels as well, but so far culturally most patients want their elective surgery to be done by a real surgeon and not a nurse practitioner. It's a big life event. Whereas people generally don't mind taking a z-pak from a nurse. The danger is if nomenclature and semantics changes: the PA being called a "physician associate" or the surgical NP being called a "surgical associate" or some other Orweillian name like "surgicist" or "proceduralist." This has happened in anesthesiology, where the CRNA is often called an "anesthetist" (which laypeople do not know difference with anesthesiologist). If that happens, then even surgical fields are not immune to encroachment.

The reason why primary care isn't screaming too much is because physician pay and midlevel pay in that field is already comparable, so there's still a huge demand for primary care physicians because groups and practice systems know the value add of primary care physicians versus midlevels. My wife is a primary care physician, and her job is VERY secure, believe me. I'm ortho and I worry more about midlevels (not necessarily in job security but in the admin push to increase my volume and run two OR rooms). But I think the fields with the biggest dangers are those without their own patient panels and where much of the diagnosis is done by imaging/tests and the follow-through is done by specialists. That is the low hanging fruit for midlevels. Emergency medicine comes to mind. For instance it doesn't take a lot of brain cells to diagnose and treat an ankle fracture when patient has pain in the ankle, you get XR, radiology calls you and says there's a fracture, and the extent of your treatment is to consult ortho. Midlevels would love that job for 100k.

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[ERDOC555]

Surgical specialties have a lot of midlevels as well, but so far culturally most patients want their elective surgery to be done by a real surgeon and not a nurse practitioner. It's a big life event. Whereas people generally don't mind taking a z-pak from a nurse. The danger is if nomenclature and semantics changes: the PA being called a "physician associate" or the surgical NP being called a "surgical associate" or some other Orweillian name like "surgicist" or "proceduralist." This has happened in anesthesiology, where the CRNA is often called an "anesthetist" (which laypeople do not know difference with anesthesiologist). If that happens, then even surgical fields are not immune to encroachment.

In what aspect are PAs or NPs operating? I understand they can be first assist, and do simple things like closing and whatever else you tell them to, but I've never heard of a midlevel doing a surgery. Holding retractors and closing doesn't qualify them to do a surgery, and I find it very hard to believe we will ever get to the point where midlevels do surgery, unless they make up a new degree similar to how CRNAs came about.

 

[wegh]

I'm going into Rads. No idea what will actually happen in the future or if the world won't be in crisis mode from nuclear war. Gotta do what you like most and hate the least. Can't speculate who and what will get automated first and last.

Besides, I would rather be obsolete in 20 years than do 10 of things like surgery, derm, psych. Just not for me

 

[nimbus]

How "hard" ie technically demanding and knowledge intensive are IR procedures, anyway? I was watching an aneurysm embolization video yesterday and it didn't seem like a very difficult procedure. You literally thread a catheter into the aneurysm and stuff a bunch of string through it until there is a big lump of string inside the aneurysm. It seemed like something you could teach a freshly released felon how to do in a day or two, with the most challenging part being having him commit the route through the vasculature to memory.

That's the impression I got from watching the video. I'm not even remotely trying to suggest that it really is as easy as that but rather I want to ask people with first hand experience how challenging these procedures really are that you can't glean from watching a youtube video.

It is hard. I once worked once at a place where a couple vascular surgeons were trying to learn endovascular stents. They were not dumb guys. Now I work with actual well trained and experienced IR docs. What they do may look simple but it is not. The good ones just make it look easy. No fuss, no muss, no drama. Those X-ray skills and wire skills take years to develop and not everyone gets there in the end. I've seen good and bad. I'm fortunate to be working with wizards now

 

[Treebeard]

Medical Oncology is very safe I think. Nurses don't want actual accountability, responsibility for creating complicated treatment plans, or to have to constantly tell people they are out of options and are going to pass away soon.

Some NPs/PAs are already doing the strictly management stuff (ie - a patient was prescribed a particular chemo course and checks in every 1-3 weeks for symptom management), but they run and hide the second there is a weird problem or a bad scan.

 

[rabbott1971]

Merritt Hawkins most recent study found that the highest absolute demand* was for pulmonology. Anyone do that?
*absolute demand = (total number of placement requests/total number of docs in same specialty)

 

[bashwell]

Merritt Hawkins most recent study found that the highest absolute demand* was for pulmonology. Anyone do that?
*absolute demand = (total number of placement requests/total number of docs in same specialty)

I saw that. Pulm/crit care is indeed on the rise now. Good specialty. Fun procedures. COPD is the third leading cause of mortality in the US (after heart disease and cancer) so pulm/crit care will be needed in the foreseeable future (though obviously pulm/crit care isn't only COPD). I think it's safe from midlevels, though I also think that's true for other IM subspecialties too. However, the ICU is very difficult in terms of lifestyle. Hard work, long hours, sickest of the sick, etc. Maybe fun to do more crit care when younger, then transition into pulm when older. In the future, pulm and crit care might become separate subspecialties, so perhaps one could focus on the one or the other as alternatives too.

 

[PlutoBoy]

Surgical specialties have a lot of midlevels as well, but so far culturally most patients want their elective surgery to be done by a real surgeon and not a nurse practitioner. It's a big life event. Whereas people generally don't mind taking a z-pak from a nurse. The danger is if nomenclature and semantics changes: the PA being called a "physician associate" or the surgical NP being called a "surgical associate" or some other Orweillian name like "surgicist" or "proceduralist." This has happened in anesthesiology, where the CRNA is often called an "anesthetist" (which laypeople do not know difference with anesthesiologist). If that happens, then even surgical fields are not immune to encroachment.

The reason why primary care isn't screaming too much is because physician pay and midlevel pay in that field is already comparable, so there's still a huge demand for primary care physicians because groups and practice systems know the value add of primary care physicians versus midlevels. My wife is a primary care physician, and her job is VERY secure, believe me. I'm ortho and I worry more about midlevels (not necessarily in job security but in the admin push to increase my volume and run two OR rooms). But I think the fields with the biggest dangers are those without their own patient panels and where much of the diagnosis is done by imaging/tests and the follow-through is done by specialists. That is the low hanging fruit for midlevels. Emergency medicine comes to mind. For instance it doesn't take a lot of brain cells to diagnose and treat an ankle fracture when patient has pain in the ankle, you get XR, radiology calls you and says there's a fracture, and the extent of your treatment is to consult ortho. Midlevels would love that job for 100k.

If your wife is getting paid the same as a midlevel you may want to look into that. I make over $100,000 more than the midlevels in my office.

They consult me 10x day for antibiotic selection, diagnosis, "come and see this rash with me" questions, management of hypertension, and a plethora of other things.

This is fine but it leads me to believe that your average midlevel should not and cannot manage anything other than a few urgent care visits and wellness exams so I believe my higher salary is justified.

While carrying my own patient panel I provide "on the spot" consultation and patients appreciate it when an MD walks in the room when the midlevel is in over their head. It adds another layer of safety to patient care.

If midlevels cannot (or rather, should not) take over primary care, I really don't see midlevels taking over emergency medicine. I have nothing but respect for that field. Is your typical midlevel going to be able to handle a polytraumatized patient needing immediate intubation, hemodynamic stabilization, chest tube, etc? EM docs do much more than ordering XRAYS and picking up a phone for a consult.

The midlevels in the ER are there to handle the simple complaints, not the actual emergencies.

Our culture has degraded the ER to urgent care but the specialty is much more than that. I want a MD/DO EM doc if either I or my loved ones are facing an emergency.

I also wanted to see the MD/DO OBGYN for my pregnant wife when we thought we were not feeling the baby kick (first baby - we are nervous). And I will certainly demand an actual MD/DO pediatrician for our baby check ups.

Granted, I am not the general public neither do I represent the body of politicians that actually make the decisions in this country and I cannot prevent them from drowning in their own ignorance but so far it seems to me that doctors provide a very particular and important service that cannot be easily replaced.

 

[Menander's Bust]

Pathology seems safe to me as a specialty though I'll agree they may be saturated with people now. But pathology is widely used in surgical sub specialties and it is very hard to image a computer doing it.

 

[Treebeard]

Pathology seems safe to me as a specialty though I'll agree they may be saturated with people now. But pathology is widely used in surgical sub specialties and it is very hard to image a computer doing it.

Hasn't this field already been crushed by consolidation and outsourcing?

 

[CDI]

ER for sure. Our fairly large hospital system has granted full scope to PAs and NPs in the ERs. It's a numbers game and metrics drive everything. The "time to see a provider" and ship them out the ER is all the suits care about. So within 5 minutes into the eval they know if the patient is likely going home within a few hours, or they will be placed in observation or fully admitted. If the patient is going to be observed or admitted, then the consult goes out to the hospitalist or crit care team, who is there in house (often in the ER) to take over. The ER group partners keep more in their pocket by hiring the ER PA/NP then they do the ER MD. The ER MD exclusively handles all intubations, other than that, nothing really separates them. Since they hardly spend any time with the patient, if you have a team of solid hospitalists who can admit the numbers or an efficient ICU team to clean up the mess. Now this all goes south, fast, if the ER, floor & ICU nurses are below par and are more of a burden rather than an asset as I have seen hospitalists quit in a matter of weeks because of this.

-

 

[badasshairday]

How "hard" ie technically demanding and knowledge intensive are IR procedures, anyway? I was watching an aneurysm embolization video yesterday and it didn't seem like a very difficult procedure. You literally thread a catheter into the aneurysm and stuff a bunch of string through it until there is a big lump of string inside the aneurysm. It seemed like something you could teach a freshly released felon how to do in a day or two, with the most challenging part being having him commit the route through the vasculature to memory.

That's the impression I got from watching the video. I'm not even remotely trying to suggest that it really is as easy as that but rather I want to ask people with first hand experience how challenging these procedures really are that you can't glean from watching a youtube video.

Well one wrong move and you can rupture or dissect an artery causing intracranial hemorrhage and stroke. You can knock off plaque and cause a stroke. Coils can migrate or deploy in the wrong place. You can take a perfectly health patient coming in for elective aneurysm coiling and turn them into a vegetable. So yes, it is technically challenging.

 

[rabbott1971]

How "hard" ie technically demanding and knowledge intensive are IR procedures, anyway? I was watching an aneurysm embolization video yesterday and it didn't seem like a very difficult procedure. You literally thread a catheter into the aneurysm and stuff a bunch of string through it until there is a big lump of string inside the aneurysm. It seemed like something you could teach a freshly released felon how to do in a day or two, with the most challenging part being having him commit the route through the vasculature to memory.

That's the impression I got from watching the video. I'm not even remotely trying to suggest that it really is as easy as that but rather I want to ask people with first hand experience how challenging these procedures really are that you can't glean from watching a youtube video.

Any time you watch a highly skilled person performing a difficult thing, they tend to make it look easy.

 

[rabbott1971]

Well one wrong move and you can rupture or dissect an artery causing intracranial hemorrhage and stroke. You can knock off plaque and cause a stroke. Coils can migrate or deploy in the wrong place. You can take a perfectly health patient coming in for elective aneurysm coiling and turn them into a vegetable. So yes, it is technically challenging.

OK how about the reverse, are there many IR procedures that are less risky, or less technically demanding?

 

[DrfluffyMD]

OK how about the reverse, are there many IR procedures that are less risky, or less technically demanding?

Yes, a paracentesis, where if you don't look at the abdomen wall before hand you can stick through an epigastric or bowel if you pushed needle too deep. That's literally one of the "easiest" procedure we do and take about 30 seconds.

 

[CDI]

Yes, a paracentesis, where if you don't look at the abdomen wall before hand you can stick through an epigastric or bowel if you pushed needle too deep. That's literally one of the "easiest" procedure we do and take about 30 seconds.

They do paras blind all over the world.
We like to over exaggerate a bit over here.

Turn pt to side.
Percuss, and poke.
Drain into cut-open, empty 2L Coke bottle.
Gravity.
Done.


Sent from my iPhone using SDN mobile

 

[DrfluffyMD]

They do paras blind all over the world.
We like to over exaggerate a bit over here.

Turn pt to side.
Percuss, and poke.
Drain into cut-open, empty 2L Coke bottle.
Gravity.
Done.


Sent from my iPhone using SDN mobile

And we used to blood let?

 

[VA Hopeful Dr]

They do paras blind all over the world.
We like to over exaggerate a bit over here.

Turn pt to side.
Percuss, and poke.
Drain into cut-open, empty 2L Coke bottle.
Gravity.
Done.


Sent from my iPhone using SDN mobile

Still a fair number of people here do them blind as well. Heck, apparently I'm pretty rare in that I do my carpal tunnel injections blind.

We don't need to US everything we stick a needle into

 

[CDI]

And we used to blood let?

What do you mean "used to"?


Sent from my iPhone using SDN mobile

 

[CDI]

Still a fair number of people here do them blind as well. Heck, apparently I'm pretty rare in that I do my carpal tunnel injections blind.

We don't need to US everything we stick a needle into

We don't need to do a lot of things, but we do anyways...cause lawyers.


Sent from my iPhone using SDN mobile

 

[SpecializedSurgeon]

Medical training is an enormous investment with the potential payoff being well over the time-horizon and thus invisible at the early stages of training. We have no idea what kind of job market and compensation will await us 7 or 10 years down the road, which is a bit dispiriting as we try to motivate ourselves to keep cramming endless minutiae and working endless shifts to ever so slowly move towards our destination. So it makes sense to consider which specialties are most and least likely to provide the pot of gold at the end of the rainbow.

In my opinion...

Safest:
1) Ortho
2) Neurosurg

The surgical specialties are obviously safer than the nonsurgical specialties from both the midlevel and AI boogeymen. They are also safer from residency expansion because it's just not that easy to open up or expand a surgical program, and most institutions with enough volume to host a surgical residency already have one. The reason I selected ortho over neurosurg is that ortho is at least theoretically able to survive outside of the corporate hospital/third party payor system whereas neurosurg is not. If the sheit hits the fan and reimbursement is slashed to European levels or hospitals merge to form one massive Wall Street Health System Inc to depress wages, ortho at least has the option to shift entirely to ASCs and charge cash for the professional fee (you get around $1500 for a knee replacement which frankly is about what an endodontist charges for a freakin' root canal and endodontists survive on cash).

Least safe/wouldn't even consider if you offered me a $100k bonus right now:
Rads
Gas
Path

Do I know for sure that rads and anesthesia will be decimated by AI and midlevels respectively? No, there can obviously be no certainty about the future but those fields face threats that are so specific and well defined that I would never risk staking my entire career on the hope that the worst-case-but-reasonably-likely scenario will not come to pass. As for path, it's been crap for decades.

Agree? Disagree? Any other fields to add to the two lists?

My wife and I discuss this all the time, and we're pretty certain we have the most protected specialties out there.

She's an OB, I'm a Trauma Surgeon.

If you think about the two things people will never stop doing, we are golden.

 

[Rads312]

My wife and I discuss this all the time, and we're pretty certain we have the most protected specialties out there.

She's an OB, I'm a Trauma Surgeon.

If you think about the two things people will never stop doing, we are golden.

Yeah, but then you have to be an OB or a trauma surgeon. Even worse, you have to do those residencies.

 

[wegh]

Again, it just doesn't come down what procedures or what population you deal with. Being an OB or Trauma surgeon doesn't guarantee future-proof specialities just because people will keep having babies and experiencing trauma. What if family practitioners start hanging on to their pregnant patients and even do the delivery? What if robot surgeons are developed and mid level providers can operate them? I am just throwing random things out there, but a lot of specialities that suffer end up suffering for different reasons than expected. For example, cardiologists started running into problems competing with interventional cardiologists etc

 

[Rads312]

Again, it just doesn't come down what procedures or what population you deal with. Being an OB or Trauma surgeon doesn't guarantee future-proof specialities just because people will keep having babies and experiencing trauma. What if family practitioners start hanging on to their pregnant patients and even do the delivery? What if robot surgeons are developed and mid level providers can operate them? I am just throwing random things out there, but a lot of specialities that suffer end up suffering for different reasons than expected. For example, cardiologists started running into problems competing with interventional cardiologists etc

What? Guessing that is a typo.

Robot surgeons and mid level operators seems kind of far fetched, even for the paranoia of the SDN forums.

 

[Dr jones]

Robots are starting to perform surgeries better than humans. I dont think the procedure heavy specialities are so futureproof anymore.

 

[DrfluffyMD]

Robots are starting to perform surgeries better than humans. I dont think the procedure heavy specialities are so futureproof anymore.

Source?

 

[VA Hopeful Dr]

Source?

I suspect that someone thinks The DaVinci is doing the procedures by itself

 

[jhamaican]

Robots are starting to perform surgeries better than humans. I dont think the procedure heavy specialities are so futureproof anymore.

This is the silliest thing I have ever heard. 100% not true. Surgery is perhaps the most protected of any job, not just medicine.

 

[Dr jones]

I can't post links but google "Autonomous Robot Surgeon Bests Humans".

I think the most futureproof specialities is someone that combines a lot of different tasks, patient interactions og procedures. Most IM specialities and FM is looking pretty safe imo.

 

[SpecializedSurgeon]

I can't post links but google "Autonomous Robot Surgeon Bests Humans".

I think the most futureproof specialities is someone that combines a lot of different tasks, patient interactions og procedures. Most IM specialities and FM is looking pretty safe imo.

In Flesh-Cutting Task, Autonomous Robot Surgeon Beats Human Surgeons


This is a long way from what happens in Surgery. Not saying it couldn’t be true one day, but there is a lot of decision making and adjustment for even the easiest of operations.

 

[DrfluffyMD]

In Flesh-Cutting Task, Autonomous Robot Surgeon Beats Human Surgeons


This is a long way from what happens in Surgery. Not saying it couldn’t be true one day, but there is a lot of decision making and adjustment for even the easiest of operations.

Oh great, a article published in a non-medical journal talking about how they will replace xyz physician by cutting a better straight line...

This is similar to AI citing better sensitivity than radiologist at detecting calcification in mammo, ignoring the fact that it’s specificity that matters.

Surgeons are paid based on their decision making ability, not their abilities to cut in a straight line.