Most and least futureproof specialties.

[Brahnold Bloodaxe]

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?

---

Members don't see this ad.

 

[AcademicNeurosurgery]

Here we go again...sigh.

 

[bashwell]

1) The further out you try to predict, the less accurate it is likely to be. If we're talking 25 years from now, who can really tell? Even 10 years from now is hard to predict. For example, 10 years ago rads was one of the most highly coveted specialties since it seemed to have a great future. Especially in light of the internet and tech boom.

2) Safety is relative. It's not like physicians are as replaceable as McDonalds cashiers or even investment bankers who are often let go in a bad economy. Every specialty will likely still have a job in the future. Maybe not a great job, maybe not a job in whatever desired location, maybe not a fairly compensated job, etc., but a job that can most likely at least still afford a middle class lifestyle. Even radiology will likely be fine and not entirely replaced by A.I. At least not in the next decade. Again, harder to tell beyond that.

3) If future job security or safety is the only criterion, and not for instance whether you actually enjoy the specialty, then I think the safest specialties are those specialties that are patient facing and procedural. The more you own your patients, and the more you can develop and master a highly technical and difficult to replicate and replace skill set, the more unique you are, and the more you don't have to deal with layers of middlemen before dealing with a patient (e.g., midlevels, bean counters), the less likely you are to be replaced.

4) Healthcare in the US is up in the air. Who knows where things will land. Will Obamacare get repealed? Will there be a replacement? If so, what will the replacement look like? How will it affect us as physicians? And many other questions are undetermined so far. Yet they can significantly impact our future. But again if you own your patients directly, and you have a unique skill set that can't be replicated, then whatever happens you'll be in a secure a position as anyone is likely able to be in. Just my opinion.

 

[deleted407021]

Why is anesthesiology abbreviated "gas"? Is it bc they use gas? Is it for "general anesthesiology"? What?

 

[Brahnold Bloodaxe]

1) The further out you try to predict, the less accurate it is likely to be. If we're talking 25 years from now, who can really tell? Even 10 years from now is hard to predict. For example, 10 years ago rads was one of the most highly coveted specialties since it seemed to have a great future. Especially in light of the internet and tech boom.

2) Safety is relative. It's not like physicians are as replaceable as McDonalds cashiers or even investment bankers who are often let go in a bad economy. Every specialty will likely still have a job in the future. Maybe not a great job, maybe not a job in whatever desired location, maybe not a fairly compensated job, etc., but a job that can most likely at least still afford a middle class lifestyle. Even radiology will likely be fine and not entirely replaced by A.I. At least not in the next decade. Again, harder to tell beyond that.

3) If future job security or safety is the only criterion, and not for instance whether you actually enjoy the specialty, then I think the safest specialties are those specialties that are patient facing and procedural. The more you own your patients, and the more you can develop and master a highly technical and difficult to replicate and replace skill set, the more unique you are, and the more you don't have to deal with layers of middlemen before dealing with a patient (e.g., midlevels, bean counters), the less likely you are to be replaced.

4) Healthcare in the US is up in the air. Who knows where things will land. Will Obamacare get repealed? Will there be a replacement? If so, what will the replacement look like? How will it affect us as physicians? And many other questions are undetermined so far. Yet they can significantly impact our future. But again if you own your patients directly, and you have a unique skill set that can't be replicated, then whatever happens you'll be in a secure a position as anyone is likely able to be in. Just my opinion.

Can't quibble with anything you wrote aside from the part about a middle class lifestyle. You can study accounting or engineering or business and have a middle class lifestyle at 22 years old right after college. We're investing an additional 7 to 10 post-college years into this profession, so a middle class lifestyle just isn't going to cut it at least as far as I'm concerned. My point in creating this thread is to discuss which specialties give you the best odds of achieving a lifestyle that is better than mere "middle class."

 

[bashwell]

Can't quibble with anything you wrote aside from the part about a middle class lifestyle. You can study accounting or engineering or business and have a middle class lifestyle at 22 years old right after college. We're investing an additional 7 to 10 post-college years into this profession, so a middle class lifestyle just isn't going to cut it at least as far as I'm concerned. My point in creating this thread is to discuss which specialties give you the best odds of achieving a lifestyle that is better than mere "middle class."

Cool, fair enough. I just meant the worst case scenario in my opinion is doctors making middle class lifestyle money. Hopefully we won't ever get to that point.

But also in my opinion, never say never, because that seems to be what's happened in some European countries for example.

On a related note, look at what's happening now with the NHS in the UK. Google all the doctor strikes, UK junior physicians moving in droves overseas to places like Australia and NZ, some people in the UK are ironically even hoping the NHS will be privatized to save it or at least save certain hospitals. I assume a lot of it might be sensationalized by the British media, but still there's a lot of upset physicians especially junior physicians in the UK. It's possible (though I hope very unlikely) our healthcare system heads down a similar road and we all end up underpaid and overworked even though it's not at all fair to us.

But as for now, most specialties will allow you to have a better than middle class lifestyle. Even traditionally low paid specialties like PCPs such as peds, outpatient IM, FM, psych, etc. The key isn't so much the specialty per se, though that's obviously important, but other factors such as geography and payor mix. For e.g. I personally know a general pediatrician making about $150k in Southern California and another general pediatrician making about $350k (seriously) in Texas, both working similar hours (40-50, rare nights and rare weekends, limited call) and seeing a similar number of patients. Both recent grads too. The guy in TX is in a nice suburb of a major city too, not at all some place out in the middle of nowhere. That's a great lifestyle and great pay for a pediatrician, and $350k goes a long way in TX, definitely not just middle class. Of course that's nothing compared to most or maybe all surgical specialties, especially if they're also in a great practice environment like TX apparently (e.g., consider working in states with tort reform). But still it's above just middle class. The question is how long will all this last? That's the same question for almost all specialties. Hence why lots of people are trying to make hay while the sun is still out, because no one knows when or if it will end depending on what happens in the future with healthcare.

 

[Brahnold Bloodaxe]

The question is how long will all this last? That's the same question for almost all specialties. Hence why lots of people are trying to make hay while the sun is still out, because no one knows when or if it will end depending on what happens in the future with healthcare.

Yeah, and that's the gist of this thread. There are many different threats to the continued viability of pediatricians making 350k in Texas or hospitalists pulling north of $400k in the rural midwest, with midlevels being probably the number one threat. The number of NPs graduating each year has more than doubled in the previous 10 years. There are now more NP slots than medical school slots, which seemed unthinkable even a few years ago. And the rate of growth shows no sign of abating! In addition, their scope of practice continues to expand.

For that reason, I don't think any of the non-surgical specialties can make any "futureproof" list. Even procedural fields where the procedures are relatively minor, such as GI or derm, cannot be considered to be completely safe. If you think the nurses and PAs are uppity about encroaching on physician turf now, just wait till the "traditional" midlevel job market becomes saturated and they need to expand scope just to find jobs to feed their exploding numbers.

I really wanted to do EM, but I'm starting to seriously reconsider any specialty which is already facing midlevel problems today. The growth in midlevels is just staggering, I think people are seriously underestimating the impact it will have once the job market tipping point is reached and they start pushing into our turf in earnest. And the big dogs-hospitals, insurance, and government-all have an incentive to enable them in this push: the the hospitals to skim more from the top and the insurance and gov to decrease prices. It will suck to do a surgery residency and hold off on life for an additional 3 years but it's increasingly looking like the one safe bet.

 

[bashwell]

Honestly, primary care specialties (e.g., peds, IM, FM) are likely quite safe, because they're already at the lower end of compensation (relatively speaking, still better than most Americans) and so likely won't fall further even if healthcare becomes all bundled payments like it looks like is already happening. They're also in much more demand than most other specialties in most parts of the nation and that's not projected to change in the next decade or actually longer. They also own their patients directly. They don't need referrals like subspecialties often do. They don't even need to depend as much on insurance companies or hospital systems. I don't see midlevels being a threat just yet because of the huge and tremendous shortage and need in most places, but of course things could change in 10 years or more, who knows. Of course, you have to like the work, outpatients, mostly chronic disease management, etc., which a lot of people don't.

From what I can tell, the future of critical care medicine also looks bright or at least promising. ICUs are often a big sink hole of cash for hospitals, but ICU physicians are likely going to be needed in the future, especially if there are more and more closed ICUs, as should be the case in my view, and with newer ICU models coming out too. But you have to like the ICU which a lot of people hate. It's a tough lifestyle too, but I hear it's becoming more shift work, so things may be improving. Couple CCM with pulm and that's got a good future too it seems to me, since pulm can be outpatient or inpatient, you can transition from the ICU to pulm if you want a change of pace later in your career, you can build a practice seeing pulm patients, or however you want really since IM/pulm/CCM gives you so many options, etc.

Most surgical specialties will likely be fine too. That probably is the safest but I couldn't stomach a surgical residency, but if you can, then that's great.

A good if rough gauge to determine how much in demand a particular specialty currently is would be to search a popular physician job site and see how many jobs are being offered in that specialty.

 

[bashwell]

Maybe another way to think about all this is that medicine is your day job so to speak. So for example do a short (3 year) residency like EM if you like EM, maybe do something that is shift work so you don't have to carry a pager, when you're off you're off, and instead use your free time to do something else like start a business, invest in real estate, whatever, so you can eventually make money elsewhere and leave medicine. Or at least be able to work just a few shifts when you feel like it because you have FU money saved up and could leave anytime. That's what some doctors seem to be doing now. Sad to say if you really love medicine or your specialty though, and want to make a long career out of it, but that might be another option for you/me/all of us. Anyway, it's been nice chatting with you all about this, but back to the grinder for me now.

 

[Staphylococcus Aureus]

There are now more NP slots than medical school slots

There literally aren't enough qualified nurses for that many slots to gain that much practice freedom, how long before this explodes? (I would say implode, but it's gonna get messy).

 

[Oh_Gee]

Why is anesthesiology abbreviated "gas"? Is it bc they use gas? Is it for "general anesthesiology"? What?

this whole time i've been on sdn, i thought gas was for gastroenterologist...

 

[DrfluffyMD]

Radiation oncology may not be around in 200 years. There will be a time when the benefit of radiation therapy for most things are outweigh by the risk of secondary malignancy due to advent in gene and targeted therapy. I don't know when that day will come, but it will come.

 

[deleted407021]

this whole time i've been on sdn, i thought gas was for gastroenterologist...

But that's GI. I'm so confused!

 

[Oh_Gee]

Radiation oncology may not be around in 200 years. There will be a time when the benefit of radiation therapy for most things are outweigh by the risk of secondary malignancy due to advent in gene and targeted therapy. I don't know when that day will come, but it will come.

that's for the class of 2120 to worry about

 

[Oh_Gee]

But that's GI. I'm so confused!

i'm so immature i thought "gas" was slang for gastroenterologist because fart jokes, that's why lol

 

[Redpancreas]

Here are my BS predictions. Warning, I'm pulling this all out of my a**:

I think IM subspecialties (and Neurology) are fairly safe as they require a good mix of diagnostics, patient interaction, and procedures. There may or may not be relative declines in GI/Cards/Heme/CCM compensation but I have absolute confidence in the security given the people I see applying. Derm is also safe as IM because of the willingness to pay out of pocket. The tie between immobility and mortality in today's age means Orthopedics is probably the safest and I agree other areas of surgery are very safe. Family also pretty safe because preventative medicine is so huge.

What people say is not safe, but is safe IMO:

Radiology: Just looking at the people going into this field, the field is too smart to fail. Computers still have not mastered the EKG yet and people are saying crying big-data/IBM Watson, etc. Even if machine-learning becomes a thing, it will only be a tool that revolutionize Radiology and makes it far more advanced. Some forget that while MRIs/CTs/CXRs may become easier to read with technology, who knows what other kind of imaging radiology will come up with. Also, they're poised to come up with new image guided procedures.

Anesthesiology: People still haven't figured out some of what may seem to be the simplest fluid management questions, and while that's mostly CCM territory, anesthesia is highly rooted in physiology that I just don't see many willing to learn.

What I think is not as safe IMO:

-Psychiatry: I really feel like Neurology (and deservedly so) should gain a good chunk of the inevitable advances we'll encounter in these next decades. I hope and believe they will. I feel that while Psychiatry is interesting, I don't see it as much more as it is today and feel it should be managed by clinical psychologists who are more willing to talk to the patients along with pharmacists to assist them.

-PM&R: I just don't see it lasting.

-Pathology: Just feel like there's so many now with less work day-by-day.

----
Undecided: EM.

 

[WingedOx]

-Psychiatry: I really feel like Neurology (and deservedly so) should gain a good chunk of the inevitable advances we'll encounter in these next decades. I hope and believe they will do. I feel that while Psychiatry is interesting, I don't see it as much more as it is today and feel it should be managed by clinical psychologists who are more willing to talk to the patients along with pharmacists to assist them.

This is a pretty typical opinion about the future coming from medical students. It's wrong for a couple reasons.

1. The "neuro-based" advances in psychiatric care have generated a lot more pipe dreams (and useless fMRI studies) than actual results.

2. Walk into a resident room full of neurologists and ask how many of them want to see more psych patients. You'll get your answer there.

 

[justabanana]

This is fun.

Why wouldn't PM&R survive? America is getting older and fatter every year. For some reason I see PM&R booming, especially if we do something like go single payer. Why would the government pay for a surgery when they could pay a fraction of that?

I'm a lowly M3, and I've scrubbed in for a whopping 7 surgeries so far. But I haven't seen one anesthesiologist. Literally 7 surgeries, all CRNAs. Maybe there's one hiding somewhere in the ceilings watching over though. Honestly anesthesia seems like a cool job and it was what I originally thought I might want to do, but yeah, that just doesn't comfort me.

EM is what I want to go, but I'm also terrified it will just be eaten my mid-levels. I'll probably still go EM anyway and just try to be really good at my job, see how far that gets me. Even though I'd agree that surgery is probably safest and slightly cooler, I'd probably end up jumping out a window during the residency.

Lastly, I think psych has the possibility for some major changes in the next 20 years. There's a really effective class of drugs (LSD, psilocybin, random other 'psychedelics') that aren't being used to their potential because of the fears caused by the 60's. Once other countries start proving that they're more effective than anything else we have for certain conditions, I wouldn't be surprised if they become a psychiatry niche. Seems like there's been a resurgence of research into them for addiction and PTSD and even mood disorders. I imagine psychiatrists would have a firm hold on psychedelic therapy or whatever if the stigma ever fades enough to allow good enough research. Guess we'll see.

 

[cellsaver]

1. The "neuro-based" advances in psychiatric care have generated a lot more pipe dreams (and useless fMRI studies) than actual results.

You don't like the fMRI studies, eh?

"....an fMRI scan is about as useful at detecting neuronal activity as your dad's "brain sucking alien" hand trick." Wired

 

[738177]

CRNA's have been around for ~30 years. Is there a reason why Gas is more doomed now than they were before? In recent years, has there been a big increase in CRNA students or have they been gaining more autonomy? I know i'm not contributing anything to the thread but i was just curious.

 

[AcademicNeurosurgery]

CRNA's have been around for ~30 years. Is there a reason why Gas is more doomed now than they were before? In recent years, has there been a big increase in CRNA students or have they been gaining more autonomy? I know i'm not contributing anything to the thread but i was just curious.

No, no one is doomed due to allied health care professionals. Medical students love to complain about "midlevel encroachment" 24/7, especially when they "scrub into 7 surgeries and don't see an anesthesiologist" like the person above.

There are two kinds of physicians: 1) the ones who constantly stare at the rearview mirror and talk about the good ole days and 2) the ones who are adaptable and embrace change. The latter group will be successful and happy regardless of what the future holds, the former will always find a reason to complain. I know several surgeons and an IM physician who hired "midlevels" and absolutely rave about them. These physicians now carry more patients, have more flexible schedules, and provide more effective/efficient care to their patients. I am sure there are isolated cases of poor, avoidable outcomes due to some of the allied folks overstepping boundaries but this is just part of growing pains as they become more and more involved in the health care team. I imagine future studies in several decades will show a trend toward improved outcomes and quality of life (especially for physicians) for all who embrace "midlevel encroachment".

The future is bright.

 

[ERDOC555]

I'll say something controversial, and that is that Derm and GI aren't the untouchable fields people like to pretend they are.

I think the biggest threat to both fields is changes in compensation and billing codes. There is already some wonky stuff in derm where you can't bill for things you used to be able to. I don't know the exact details, but things like doing 2 things in the same day, not getting paid for certain services if you don't wait some amount of time between them, changes to Mohs etc. I'd love to hear the derm members chime in on any coding changes they know about. With just a few procedure code changes to things like Endoscopy, ED&C, biopsy etc, basically all the well compensated procedures, I think both fields would take a hefty pay cut. I doubt they'd drop down to pediatrics pay checks but they would probably end up where a typical specialist is right now. Not saying procedural codes will get slashed, just saying that if it did Derm and GI would be the first to see large hits.

The second thing that scares me about derm is mid levels. I've already watched midlevels who run their own clinic and see their own patients pretty much without any supervision, and in one case without an MD even on site. The bread and butter of derm aren't that hard to pick up, but being a good dermatologist requires probably 10-20x as much knowledge as a PA/NP because of the slew of rare things that a dermatologist will see over the course of a year. I doubt PA/Nps even would recognize the names of 80% of the dieseases in derm. Pretty sure that derm MDs currently outnumber midlevels, but what if that changes in the coming years, and midlevels start taking the bread and butter acne, psoriasis, warts, eczema, tumors, etc.? Simply put midlevels are doing this now, just not in large numbers. They'd be pretty poor dermatologists overall, but they could probably treat 9/10 patients on their own and then refer out or completely mismanage the care of the 1/10. And in derm mistakes are farless deadly than in a lot of fields, so I don't think these cases of gross incompetence would become known to the public. If you put steroids on a fungus, you'll have an angry patient, but you won't be defending yourself in court over that or having to settle a lawsuit.

 

[ERDOC555]

Yea I'm scared about GI too but I'm too far in to turn back now

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 🙂

 

[Stagg737]

Yeah, and that's the gist of this thread. There are many different threats to the continued viability of pediatricians making 350k in Texas or hospitalists pulling north of $400k in the rural midwest, with midlevels being probably the number one threat. The number of NPs graduating each year has more than doubled in the previous 10 years. There are now more NP slots than medical school slots, which seemed unthinkable even a few years ago. And the rate of growth shows no sign of abating! In addition, their scope of practice continues to expand.

For that reason, I don't think any of the non-surgical specialties can make any "futureproof" list. Even procedural fields where the procedures are relatively minor, such as GI or derm, cannot be considered to be completely safe. If you think the nurses and PAs are uppity about encroaching on physician turf now, just wait till the "traditional" midlevel job market becomes saturated and they need to expand scope just to find jobs to feed their exploding numbers.

I really wanted to do EM, but I'm starting to seriously reconsider any specialty which is already facing midlevel problems today. The growth in midlevels is just staggering, I think people are seriously underestimating the impact it will have once the job market tipping point is reached and they start pushing into our turf in earnest. And the big dogs-hospitals, insurance, and government-all have an incentive to enable them in this push: the the hospitals to skim more from the top and the insurance and gov to decrease prices. It will suck to do a surgery residency and hold off on life for an additional 3 years but it's increasingly looking like the one safe bet.

The problem with the midlevel argument for many fields is that they are so poorly trained and poorly equipped to handle what they're supposed to be doing, that half their patients end up going to a physician for the proper treatment anyway. I can't tell you how many patients I've seen on rotations who came in to see us after seeing a NP who completely f***ed up their initial treatment. While I do think the encroachment is something to be concerned about, I'm more concerned about mid-levels providing inadequate care than I am about them taking my future job right now.

-Psychiatry: I really feel like Neurology (and deservedly so) should gain a good chunk of the inevitable advances we'll encounter in these next decades. I hope and believe they will do. I feel that while Psychiatry is interesting, I don't see it as much more as it is today and feel it should be managed by clinical psychologists who are more willing to talk to the patients along with pharmacists to assist them.

To add to what Ox said, I don't think psychologists have the training or breadth of pharmacological knowledge required to prescribe meds adequately. There's a lot more to it than just throwing the right class of meds at a patient until something sticks (though from the perspective of those not interested in psych, I can understand why it might seem like that). At the same time, a pharmacologist isn't going to have the training at the interpersonal level to adequately understand the patient history in order to give the right drug. I think you need someone with a working knowledge of both aspects to do the job properly, and outside of psychiatrists I don't think that exists.

Additionally, a lot of the pyschologists I've worked with (especially on the inpatient side) are so stretched with the administrative and social work aspect of their jobs that they have no desire to add any more responsibilities to their workload. Maybe that's different in other places, but that's been my experience so far.

 

[JPSmyth]

I'm curious to see other people's thoughts about more safe/unsafe fields ten years from now. Procedure heavy/surgical fields are safest but I don't see myself being a surgeon

 

[Stagg737]

I'm curious to see other people's thoughts about more safe/unsafe fields ten years from now. Procedure heavy/surgical fields are safest but I don't see myself being a surgeon

Before reading, I should say these are just my opinion and I'm inferring stuff that makes sense from my personal experiences. Others with much more experience may completely disagree and have much better insights.

Safe Fields:

Anything procedure heavy that can be done in the outpatient setting (plastics/cosmetic medicine, elective ortho, . If you can have a private surgical practice that accepts mostly private insurance or cash will still be fine. I also think anything that is procedure heavy that performs "essential" procedures that people would die without will still do well. Aka cardiothoracic surgery, neurosurg, trauma surgery, etc. Anything where someone would die without your services.

Optho: I don't see much changing in this field very much. People will always need to see and problems with vision can destroy careers. Insurance and the gov will pay to keep people working.

Urology: This is a huge quality of life field. I don't think most people realize how important it is to have normal urinary and distal GI functioning until there's a problem. Like ophtho, people will pay for quality of life.

Pediatric oncology: Because anyone who wouldn't pay to save really sick kids is obviously completely evil. Whether it's through a foundation or insurance, if it's a curable cancer and a kid's got it, the docs will have a job (that pays bank).

Psych: The biggest threat here is from mid-level encroachment, but I've addressed why that's not a huge issue already. It's also a field that most other docs just don't want to deal with, and there's no threats from technology (the idea of a paranoid schizophrenic voluntarily giving info to a machine makes me lol a bit). On top of that, it may be a lower paying field, but it's largely because a lot of psychiatrists work a fraction of the hours of other fields.


Unsafe fields:

PM&R: There's a lot of crossover with other areas of medicine and I feel like a lot of their fellowships either have crossover with other fields of medicine or midlevel positions. Plus the most lucrative area (pain medicine) may be coming under fire from the gov. With the increased attention towards the opioid epidemic, I feel like the field of pain management will have to change if they want to keep pulling in the kind of money some of the guys pull in.

Pathology: From what I've always heard, there's already saturation in the field. Add new technologies into the mix and think it's a field that's going to face even more problems going forward.

OB/Gyn: I actually saw far more mid-level encroachment in this field than any other. The hospital I rotated at even had midwives available to deliver babies for people looking for a more "natural" birthing experience. On top of mid-level encroachment, there's some encroachment from FM docs who want to focus on OB. Talked to a few families that preferred that because the doc who delivered their baby could then be the baby's physician as they grew up (another doc at the hospital was an FM doc that delivered babies and would keep them as patients until they turned 18). Some parents loved the idea of having 1 doc who really knew their kid treating them from conception to adulthood. Add in the ridiculous rates for malpractice and the fact that many parents think that any problem with their baby must have been the docs fault and it's not the safest field imo.


Neutral/unsure:

EM: I think things will stay good for EM. It's shift work that pays well and is needed. The biggest issues I see is the increasing popularity of the field along with potential encroachment by mid-levels. I think this field is more susceptible to mid-levels than others because so many patients are just triage and admission/referral and actual emergencies make up a relatively small portion of the patients seen (this obviously varies a lot based on location).

FM: IMO this is totally dependent on how far mid-level encroachment is allowed to go. I don't think it'll be as large of an issue as many people here make it out to be. That being said, they're the first line before specialists, and the encroachment is already there more than in other fields. I don't see too much changing, but if things did shift in terms of "provider" rights, I think this would be one of the first fields to take a hit.

Gas: Yes, the CRNA encroachment is there. Yes, it will continue to be there. Yes, anesthesiologists will still be needed for many procedures including ones outside of surgery. Would worry a bit, but I don't think the field has as much doom and gloom as people here portray it.


As I said before, these are all just opinions and this is by no means a comprehensive list. Just what comes to mind based off of what I've seen and heard about the fields mentioned above. Regardless of the field, I think medicine as a whole is a pretty safe career choice and will continue to be a great career path unless there is some massive shift towards a government run single-payer system that slashes reimbursement across the board. However, as others have said it's really difficult to predict the future of medicine too far into the future, but I don't see it being a poor choice anytime soon.

 

[CharlieBillings]

.

 

[Levo]

In my opinion...

Safest:
1) Ortho
2) Neurosurg

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.

 

[zoopers]

Plus the most lucrative area (pain medicine) may be coming under fire from the gov. With the increased attention towards the opioid epidemic, I feel like the field of pain management will have to change if they want to keep pulling in the kind of money some of the guys pull in.

I don't understand this. With the opioid epidemic, pain medicine specialists are going to be more necessary, and that is not a field that midlevels can take over. IMO, it seems to be an incredibly challenging field with an obviously very challenging patient population, nothing that people are trying to take over anyways. Treating chronic pain with opioids is easy, but a pain medicine specialist's job is pretty much to avoid that as much as possible (according to my understanding of what they do). If anything, I think this would point to pain medicine being one of the more important (and therefore "futureproof") specialties in the future, particularly with the crackdown on opioids plus an aging population and blah blah blah.

 

[JP2740]

I don't understand this. With the opioid epidemic, pain medicine specialists are going to be more necessary, and that is not a field that midlevels can take over. IMO, it seems to be an incredibly challenging field with an obviously very challenging patient population, nothing that people are trying to take over anyways. Treating chronic pain with opioids is easy, but a pain medicine specialist's job is pretty much to avoid that as much as possible (according to my understanding of what they do). If anything, I think this would point to pain medicine being one of the more important (and therefore "futureproof") specialties in the future, particularly with the crackdown on opioids plus an aging population and blah blah blah.

Yea hes just ignorant on what pain docs do. It's more than just give opioids.

 

[Dr jones]

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.

 

[DrfluffyMD]

So a little bit about radiology.

The field itself is very cyclic. I've already seen my first cycle.

When I was a med student and signed up for rads, the word hasn't been out for job market as well and I was one of the last class where competition was relatively stiff.

Now 5 years later, the radiology job market has been growing, with search on Merrill Hawkins doubling each year since 2015 and is now back to the top 10 most searched for specialty.

Of course, a few med student picked up here and there, but I bet it'll be another 2 years before med student really pick up radiology again, and those who pick up last maybe ones who graduate into a lean market.

It usually take 4-5 years for job market info to filter down to students.

As for why the job market got better, a lot of it has to do with mid levels. Some of the mid level "specialist" have no idea how to manage their patients. As a result, they rely on imaging and having us telling them what to do, which strengthen radiology.

Radiology is sufficiently difficult so that mid levels typically cannot read diagnostics or perform complex IR.

 

[Mad Jack]

Why is anesthesiology abbreviated "gas"? Is it bc they use gas? Is it for "general anesthesiology"? What?

It's because they use gas, or pass gas as they say in the field. And they're the only doctors that do so, even if nurses are stepping all over their turf.

 

[Osteoth]

Cool, fair enough. I just meant the worst case scenario in my opinion is doctors making middle class lifestyle money. Hopefully we won't ever get to that point.

The question becomes though, what happens to our educational costs? In terms of pure numbers the average medical student comes out with ~$160k in debt, and those are the individuals who take out educational loans.

Lets say the government forgives all educational loans (pipe dream because they make a ton of money off of them, but w/e). Then what about the people whose families invested in their education because of the conclusion that they would be earning a substantial amount and would be able to provide going forward? Do they get shafted on their investment?

No good answers from what I can see.

I really wanted to do EM, but I'm starting to seriously reconsider any specialty which is already facing midlevel problems today. The growth in midlevels is just staggering, I think people are seriously underestimating the impact it will have once the job market tipping point is reached and they start pushing into our turf in earnest. And the big dogs-hospitals, insurance, and government-all have an incentive to enable them in this push: the the hospitals to skim more from the top and the insurance and gov to decrease prices. It will suck to do a surgery residency and hold off on life for an additional 3 years but it's increasingly looking like the one safe bet.

I'm more worried about EMTALA & Press-Ganey + administration/corporatization in EM than I am midlevel encroachment. Liability seems too high in a lot of cases + speed is such a factor in the game (door to bed time, admit time, discharge time etc etc).

Honestly, primary care specialties (e.g., peds, IM, FM) are likely quite safe, because they're already at the lower end of compensation (relatively speaking, still better than most Americans) and so likely won't fall further even if healthcare becomes all bundled payments like it looks like is already happening. They're also in much more demand than most other specialties in most parts of the nation and that's not projected to change in the next decade or actually longer. They also own their patients directly. They don't need referrals like subspecialties often do. They don't even need to depend as much on insurance companies or hospital systems. I don't see midlevels being a threat just yet because of the huge and tremendous shortage and need in most places, but of course things could change in 10 years or more, who knows. Of course, you have to like the work, outpatients, mostly chronic disease management, etc., which a lot of people don't.

I wonder why all specialties where the provider is generally not providing a service that can directly harm the patient if not done perfectly (non-surgical basically) can't move toward the anesthesiology model in general.

Why wouldn't every hospital have 1 FM/IM/Peds doc + a host of PAs/NPs? Obviously much cheaper and theoretically would provide "the same level" of care from the business side of things.

Maybe another way to think about all this is that medicine is your day job so to speak. So for example do a short (3 year) residency like EM if you like EM, maybe do something that is shift work so you don't have to carry a pager, when you're off you're off, and instead use your free time to do something else like start a business, invest in real estate, whatever, so you can eventually make money elsewhere and leave medicine. Or at least be able to work just a few shifts when you feel like it because you have FU money saved up and could leave anytime. That's what some doctors seem to be doing now. Sad to say if you really love medicine or your specialty though, and want to make a long career out of it, but that might be another option for you/me/all of us. Anyway, it's been nice chatting with you all about this, but back to the grinder for me now.

The problem with that is those of early in our training still have 4+ years to get through, plus we need to pay off our loans. If you can only make $150k at as EM doc coming out (theoretically obviously), and have $150k+ of loans. Where do you find the money to invest?

There are two kinds of physicians: 1) the ones who constantly stare at the rearview mirror and talk about the good ole days and 2) the ones who are adaptable and embrace change. The latter group will be successful and happy regardless of what the future holds, the former will always find a reason to complain. I know several surgeons and an IM physician who hired "midlevels" and absolutely rave about them. These physicians now carry more patients, have more flexible schedules, and provide more effective/efficient care to their patients. I am sure there are isolated cases of poor, avoidable outcomes due to some of the allied folks overstepping boundaries but this is just part of growing pains as they become more and more involved in the health care team. I imagine future studies in several decades will show a trend toward improved outcomes and quality of life (especially for physicians) for all who embrace "midlevel encroachment".

The future is bright.

In my opinion its not about the argument that midlevels are bad, because I think in general they are as dedicated and hard-working as their titles and training allow them to be, but the problem is what happens to the doctors?

If you have 1 anesthesiologist + 5 mid-levels, then they're taking the job of lets say 2 other anesthesiologists, right?

Furthermore, what happens when mid-levels are taking all the bread and butter stuff from doctors and we're left with all the high-acuity/complex/difficult cases all day every day for an entire career? If burn-out is high now I can't imagine that situation.

I think the biggest threat to both fields is changes in compensation and billing codes. There is already some wonky stuff in derm where you can't bill for things you used to be able to. I don't know the exact details, but things like doing 2 things in the same day, not getting paid for certain services if you don't wait some amount of time between them, changes to Mohs etc. I'd love to hear the derm members chime in on any coding changes they know about. With just a few procedure code changes to things like Endoscopy, ED&C, biopsy etc, basically all the well compensated procedures, I think both fields would take a hefty pay cut. I doubt they'd drop down to pediatrics pay checks but they would probably end up where a typical specialist is right now. Not saying procedural codes will get slashed, just saying that if it did Derm and GI would be the first to see large hits.

The second thing that scares me about derm is mid levels. I've already watched midlevels who run their own clinic and see their own patients pretty much without any supervision, and in one case without an MD even on site. The bread and butter of derm aren't that hard to pick up, but being a good dermatologist requires probably 10-20x as much knowledge as a PA/NP because of the slew of rare things that a dermatologist will see over the course of a year. I doubt PA/Nps even would recognize the names of 80% of the dieseases in derm. Pretty sure that derm MDs currently outnumber midlevels, but what if that changes in the coming years, and midlevels start taking the bread and butter acne, psoriasis, warts, eczema, tumors, etc.? Simply put midlevels are doing this now, just not in large numbers. They'd be pretty poor dermatologists overall, but they could probably treat 9/10 patients on their own and then refer out or completely mismanage the care of the 1/10. And in derm mistakes are farless deadly than in a lot of fields, so I don't think these cases of gross incompetence would become known to the public. If you put steroids on a fungus, you'll have an angry patient, but you won't be defending yourself in court over that or having to settle a lawsuit.

Not an expert but super interesting that your entire life (mortgage, loan repayment, kids schools etc etc) can change based on one administrative change to a bread and butter procedure.

Also, thats a big question to me too. Why isn't every big hospital group hiring new derm docs with big fat juicy 600k salaries (obviously a 10 year contract) and then putting them in charge of 10 NPs/PAs in a clinic and working them to the bone?

The problem with the midlevel argument for many fields is that they are so poorly trained and poorly equipped to handle what they're supposed to be doing, that half their patients end up going to a physician for the proper treatment anyway. I can't tell you how many patients I've seen on rotations who came in to see us after seeing a NP who completely f***ed up their initial treatment. While I do think the encroachment is something to be concerned about, I'm more concerned about mid-levels providing inadequate care than I am about them taking my future job right now.

I don't think anyone is arguing that they're as good as doctors, but its being accepted, both inside medicine and outside, that NPs/PAs are integral parts of the care delivery team. I mean Jesus they have FULL PRACTICE RIGHTS in some places. Everyone always talks about people wanting to be doctors without going to medical school but NPs have succeeded! They are literally doing the same work without the same training. The last domino to fall will be the same compensation, and I can't imagine they're not fighting every minute of every day for that as well.

 

[LoGo]

I actually think surgical specialties are not as "safe" as one might think. And i think it's more a matter of encroachment by non-surgical specialties than anyone else. Derm could take on some of plastics more minor stuff and even some bigger stuff if there are advancements in tissue engineering thus preventing the need to harvest big donor tissues. Rheum or IR could start doing "joints" once biological implants gain more traction (for preliminary, see here: http://www.pnas.org/content/113/31/E4513.full.pdf, http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(16)31658-0/fulltext), cardio and neuro could do more trans catheter stuff as the tech becomes available, and even GI could in theory gain more procedures that take away from Gen surg.

People don't want surgery. It's cool, but somewhat archaic. Innovation is in the non-invasive, so while there will always be a need for the big dissections and polytrauma stuff, my thought is 20-30 years down the road many non-surgical specialties will have approaches that render some of the current surgical approaches obsolete.

 

[Brahnold Bloodaxe]

No, no one is doomed due to allied health care professionals. Medical students love to complain about "midlevel encroachment" 24/7, especially when they "scrub into 7 surgeries and don't see an anesthesiologist" like the person above.

There are two kinds of physicians: 1) the ones who constantly stare at the rearview mirror and talk about the good ole days and 2) the ones who are adaptable and embrace change. The latter group will be successful and happy regardless of what the future holds, the former will always find a reason to complain. I know several surgeons and an IM physician who hired "midlevels" and absolutely rave about them. These physicians now carry more patients, have more flexible schedules, and provide more effective/efficient care to their patients. I am sure there are isolated cases of poor, avoidable outcomes due to some of the allied folks overstepping boundaries but this is just part of growing pains as they become more and more involved in the health care team. I imagine future studies in several decades will show a trend toward improved outcomes and quality of life (especially for physicians) for all who embrace "midlevel encroachment".

The future is bright.

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?

 

[Doctor-S]

No, no one is doomed due to allied health care professionals. Medical students love to complain about "midlevel encroachment" 24/7, especially when they "scrub into 7 surgeries and don't see an anesthesiologist" like the person above.

There are two kinds of physicians: 1) the ones who constantly stare at the rearview mirror and talk about the good ole days and 2) the ones who are adaptable and embrace change. The latter group will be successful and happy regardless of what the future holds, the former will always find a reason to complain. I know several surgeons and an IM physician who hired "midlevels" and absolutely rave about them. These physicians now carry more patients, have more flexible schedules, and provide more effective/efficient care to their patients. I am sure there are isolated cases of poor, avoidable outcomes due to some of the allied folks overstepping boundaries but this is just part of growing pains as they become more and more involved in the health care team. I imagine future studies in several decades will show a trend toward improved outcomes and quality of life (especially for physicians) for all who embrace "midlevel encroachment".

The future is bright.

@AcademicNeurosurgery ... well stated.

 

[Brahnold Bloodaxe]

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.

 

[JPSmyth]

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.

...s**t lol

 

[DrfluffyMD]

This midlevel gravy train is one stop away from a well planned expose from New York times where an ill trained mid level butcher someone.

 

[theonlytycrane]

that feeling when your desired speciality is on the unsafe list 😱

 

[Staphylococcus Aureus]

This midlevel gravy train is one stop away from a well planned expose from New York times where an ill trained mid level butcher someone.

All you would have to do is look at the comment section on that expose to see that nurses have already won the propaganda war. That and "elitist doctors are discriminating against NPs who want equal access to physician jobs".

 

[DrfluffyMD]

All you would have to do is look at the comment section on that expose to see that nurses have already won the propaganda war. That and "elitist doctors are discriminating against NPs who want equal access to physician jobs".

Again, it's about patient safety. The general population wants the most qualified to care for them if they are aware of the difference.

 

[bannie22]

this whole time i've been on sdn, i thought gas was for gastroenterologist...

Young one

 

[Staphylococcus Aureus]

Again, it's about patient safety. The general population wants the most qualified to care for them if they are aware of the difference.

I agree, but most laypeople don't know. Often people are in a situation where they are simply given a provider and they assume that is the correct white coated person they are supposed to see.

 

[bannie22]

I think the biggest threat to physician compensation is mid level encroachment. Therefore, nonsurgical subspecialties are going to be affected more so that surgical subspeciaties.

The government will move towards paying less for something they see tht even NPs can provide. Add to that there is now an increased supply of practitioners...

Not a good time for physicians at all. But wht can you do? Physicians dont stand up for their own regardless of the situation.

 

[Stagg737]

I don't understand this. With the opioid epidemic, pain medicine specialists are going to be more necessary, and that is not a field that midlevels can take over. IMO, it seems to be an incredibly challenging field with an obviously very challenging patient population, nothing that people are trying to take over anyways. Treating chronic pain with opioids is easy, but a pain medicine specialist's job is pretty much to avoid that as much as possible (according to my understanding of what they do). If anything, I think this would point to pain medicine being one of the more important (and therefore "futureproof") specialties in the future, particularly with the crackdown on opioids plus an aging population and blah blah blah.

Yea hes just ignorant on what pain docs do. It's more than just give opioids.

I'm not ignorant to the field, but as zoopers said, opioids are the easy route and I've encountered quite a few people who use them as a go to option for a lot of issues. Yea, there are plenty of other treatment options, but several of the guys I've heard of will be losing a pretty hefty chunk of change if they have to cut back or stop prescribing opioids (I'd add, some of these guys don't sound like the most ethical docs in the first place, but they're there). My point was that because of the opioid epidemic and how critical people are about it now, I wouldn't be surprised if pain specialists were put under the microscope for a while. Maybe my logic was backwards there as I could also see further scrutiny keeping mid-levels away. I also think you're right about the difficult patient population, so guess I'd have to move that out of the unsafe area.

I don't think anyone is arguing that they're as good as doctors, but its being accepted, both inside medicine and outside, that NPs/PAs are integral parts of the care delivery team. I mean Jesus they have FULL PRACTICE RIGHTS in some places. Everyone always talks about people wanting to be doctors without going to medical school but NPs have succeeded! They are literally doing the same work without the same training. The last domino to fall will be the same compensation, and I can't imagine they're not fighting every minute of every day for that as well.

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.

 

[popopopop]

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?

 

[ERDOC555]

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?

Fantastic article, however the comments made me want to vomit.

We need more of these articles. Every time an NP misdiagnoses a case or maims patient, the families should speak out and media should pick up these stories. Considering all the anecdotal accounts here on SDN we're likely talking about 1000s of medical errors made each day by NPs.

 

[bannie22]

Fantastic article, however the comments made me want to vomit.

We need more of these articles. Every time an NP misdiagnoses a case or maims patient, the families should speak out and media should pick up these stories. Considering all the anecdotal accounts here on SDN we're likely talking about 1000s of medical errors made each day by NPs.

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