Most "future proof specialty"; or one with the least likely chance to have to deal with BS in the future

[madiso30]

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I shadowed a PMR doc who focused on pain management and worker's comp cases, it was pretty depressing and he genuinely seemed to hate his job lol

PM&R is so wide range in practice setting and focus that its hard to nail down how good or bad they have it. Unfortunately PM&R docs dealing with SCI and TBI, it is going to be a depressing practice setting. The pain guy I shadowed in undergrad loved his job and had surprisingly decent patients with good outcomes.

 

[madiso30]

This is fine in their world. If they fall, there’s always a safety net. As a result, they typically are more cavalier about stuff than physicians since the consequences for messing up are at most a slap on the wrist.

It's funny you mention that. My sister in law was thinking about becoming a CRNA. Her sister currently is a CRNA. I love both of them but one time when I was visiting, they asked what I had been thinking about, specialty wise. I mentioned that pain is on my radar and the sister said I should totally open a practice and hire them. At the time I wasn't aware of how much autonomy CRNA's were pushing for so I said, "Oh. Well, what would you guys do?" And she said, "The same procedures as you." My sister-in-law said, "How could we do the same procedures?" and I kid you not, her sister responded with, "madiso30 can teach it to us and take the liability." I just kind of changed the subject and now avoid the topic. But I was dumbfounded that she actually said that non-sarcastically.

 

[fldoctorgirl]

PM&R is so wide range in practice setting and focus that its hard to nail down how good or bad they have it. Unfortunately PM&R docs dealing with SCI and TBI, it is going to be a depressing practice setting. The pain guy I shadowed in undergrad loved his job and had surprisingly decent patients with good outcomes.

Agreed. He was just so disenchanted with his patients, after walking out of every room he would be like "so, this is how I knew they were lying about being in pain and just trying to get drugs from me". He had a pretty negative outlook on his patients and his job...I've seen other PMR docs working in the physical rehab sphere that love what they do and get so much fulfillment from it.

 

[madiso30]

Agreed. He was just so disenchanted with his patients, after walking out of every room he would be like "so, this is how I knew they were lying about being in pain and just trying to get drugs from me". He had a pretty negative outlook on his patients and his job...I've seen other PMR docs working in the physical rehab sphere that love what they do and get so much fulfillment from it.

It's a weirdly vast field. Worth noting for anyone reading this that PM&R was in the top 5 (I think) for most burnt out specialties from last years reporting. Take that for what you will.

 

[Sardonix]

-FM: Listen to your nurses talk to each other. I'm betting on average at least 30% of hospital nurses are in NP school right now. We went from about 3-4k NPs/year in the early 2000s, now it's ~40k/year graduating from these online degree mills (More than MD/DOs combined). They're already flooding FM first before anything.

*Sigh

They flood FM because there are no FM doctors to fill the role and institutions are desperate for warm bodies to do the job. Primary care is still the lynchpin for medical care coordination and cost control. As such, you cannot operate a hospital without IM/FM. Given there really is a VAST shortage in primary care docs, naturally midlevels are stepping in to fill in... as they can.

But the ability of NPs/PAs to fill the role is the key. Which do you think is easier/more appealing: trying to master the whole breadth of knowledge required to operate as an effective PCP or transferring to a subspecialty where the RVUs are better and the span of knowledge required is much more manageable? See BQ's post that I mostly agree with:

Apparently the top specialties that employ over 25% of NPs/PA are Derm,Cardiology,OB/GYN,Ortho and Gastroenterology Number of NPs/PAs in Specialty Care Rises 22% Over a Decade . You're probably right they are out there I've just never been in contact with any. I think neuro is like psych doesn't attract that many NPs.

... except for the bolded part. Go to the psych section of SDN. I was dabbling with psych last year and I happened to see a post where an attending's contract at a hospital was DC'd because they had trained in x4 Psych NPs and no longer had interest in keeping the x2 psychiatrist MDs. There are some places where they really DO straight up turn down docs in favor of midlevels.

It bears mentioning in any discussion of being "future proof" specialties that plenty of the untouchable surgical specialties are only a reimbursement change away from huge income fluctuations. Obviously everyone on SDN gets super jazzed about Medicare for All, but even within the context of our current system all it takes is CMS deciding to change the reimbursement for certain procedures to suddenly make derm the new FM, or deciding that screening colonoscopies are over reimbursed to make GI the least competitive IM subspecialty or whatever. Simultaneously, reimbursement changes could suddenly make ID or nephro lucrative. None of this has anything to do with job markets, NPs/PAs, or oversupply--though obviously those can have an effect too.

If you try and predict the future too closely it's probably 50/50 whether you look like a genius or an idiot, and that's probably being generous. My extremely uneducated opinion (about the same level as everyone else here, I'd guess) is that the more hyperspecialized and small your field is the more you're vulnerable to new technology, job market changes, and reimbursement changes (for example pathology and rad onc).

(Also there are 100% NPs in neuro, the stroke team at the last hospital I was at was one or two NPs and sometimes a neuro resident.)

Really love this perspective, as it goes with what I said earlier: there's no point himming and hawing with med students about future trends of specialties, as it's hard to predict and ultimately up to preference.

My advice: if you are interested in a specialty go to its featured SDN section here on reddit and see what they are worried about. Otherwise it's just med students talking smack.

 

[Rekt]

*Sigh

They flood FM because there are no FM doctors to fill the role and institutions are desperate for warm bodies to do the job. Primary care is still the lynchpin for medical care coordination and cost control. As such, you cannot operate a hospital without IM/FM. Given there really is a VAST shortage in primary care docs, naturally midlevels are stepping in to fill in... as they can.

But the ability of NPs/PAs to fill the role is the key. Which do you think is easier/more appealing: trying to master the whole breadth of knowledge required to operate as an effective PCP or transferring to a subspecialty where the RVUs are better and the span of knowledge required is much more manageable? See BQ's post that I mostly agree with:



... except for the bolded part. Go to the psych section of SDN. I was dabbling with psych last year and I happened to see a post where an attending's contract at a hospital was DC'd because they had trained in x4 Psych NPs and no longer had interest in keeping the x2 psychiatrist MDs. There are some places where they really DO straight up turn down docs in favor of midlevels.



Really love this perspective, as it goes with what I said earlier: there's no point himming and hawing with med students about future trends of specialties, as it's hard to predict and ultimately up to preference.

My advice: if you are interested in a specialty go to its featured SDN section here on reddit and see what they are worried about. Otherwise it's just med students talking smack.

You're very sadly mistaken if you think they care even one iota about the complexity of primary care. FNP is the easiest and most abundant certification, thus readily available and where they head to first because its the "easiest". The first thing out of their mouths when LLPs are talking about transitioning to a 'provider' role is salary and $/hr. Nothing about interest or complexity. They also don't have a clue what they don't know so PCP is easy mode to them.

Just look at their A/Ps. They include thousands of dollars of unecessary testing and multiple specialist referrals. Sure, there's "need", but boy it sure doesn't hurt to make a lot of people a lot of money along the way. Whereas an actual trained physician wouldn't put the patient through that because they aren't clueless. Plenty of actual research showing they order statistically significantly more tests and referrals than an avg physician.

 

[BorderlineQueen]

*Sigh

They flood FM because there are no FM doctors to fill the role and institutions are desperate for warm bodies to do the job. Primary care is still the lynchpin for medical care coordination and cost control. As such, you cannot operate a hospital without IM/FM. Given there really is a VAST shortage in primary care docs, naturally midlevels are stepping in to fill in... as they can.

But the ability of NPs/PAs to fill the role is the key. Which do you think is easier/more appealing: trying to master the whole breadth of knowledge required to operate as an effective PCP or transferring to a subspecialty where the RVUs are better and the span of knowledge required is much more manageable? See BQ's post that I mostly agree with:



... except for the bolded part. Go to the psych section of SDN. I was dabbling with psych last year and I happened to see a post where an attending's contract at a hospital was DC'd because they had trained in x4 Psych NPs and no longer had interest in keeping the x2 psychiatrist MDs. There are some places where they really DO straight up turn down docs in favor of midlevels.



Really love this perspective, as it goes with what I said earlier: there's no point himming and hawing with med students about future trends of specialties, as it's hard to predict and ultimately up to preference.

My advice: if you are interested in a specialty go to its featured SDN section here on reddit and see what they are worried about. Otherwise it's just med students talking smack.

Only 5.4% of nps specialize in psych so it’s not a whole percentage. What you’re talking about is a whole different issue. What is a Psychiatric Nurse Practitioner?

 

[Chibucks15]

You're very sadly mistaken if you think they care even one iota about the complexity of primary care. FNP is the easiest and most abundant certification, thus readily available and where they head to first because its the "easiest". The first thing out of their mouths when LLPs are talking about transitioning to a 'provider' role is salary and $/hr. Nothing about interest or complexity. They also don't have a clue what they don't know so PCP is easy mode to them.

Just look at their A/Ps. They include thousands of dollars of unecessary testing and multiple specialist referrals. Sure, there's "need", but boy it sure doesn't hurt to make a lot of people a lot of money along the way. Whereas an actual trained physician wouldn't put the patient through that because they aren't clueless. Plenty of actual research showing they order statistically significantly more tests and referrals than an avg physician.

Once the payment model changes (as it kinda seems to be) to focus on value based and not fee for service, theoretically wouldn't this practice by NPs kinda screw them over?

 

[Sardonix]

You're very sadly mistaken if you think they care even one iota about the complexity of primary care. FNP is the easiest and most abundant certification, thus readily available and where they head to first because its the "easiest". The first thing out of their mouths when LLPs are talking about transitioning to a 'provider' role is salary and $/hr. Nothing about interest or complexity. They also don't have a clue what they don't know so PCP is easy mode to them.

Just look at their A/Ps. They include thousands of dollars of unecessary testing and multiple specialist referrals. Sure, there's "need", but boy it sure doesn't hurt to make a lot of people a lot of money along the way. Whereas an actual trained physician wouldn't put the patient through that because they aren't clueless. Plenty of actual research showing they order statistically significantly more tests and referrals than an avg physician.

You raise some good points... which seem to actually support my argument that institutions will prefer FM physicians instead of NPs/PAs given their ability to control costs, decrease unnecessary work, and increase patient satisfaction. Meanwhile, I will again defer to BorderlineQueen's post about midlevels seeking high paying specalties like Cardio/Ortho/OB etc. Sure, midlevels may start in primary care (the link I refer to even mentions PC NPs grew by 24% compared to 22% in specialties in the same timeline)... but then they transfer to specialties. I've seen it happen x5 times in the last year alone.

Like you said, they are primarily concerned with dollar bills. And specialties offer that with lifestyle.

 

[BorderlineQueen]

Psychiatry is the only field that has a large and easy to sustain cash only market. Cosmetic plastic surgery is a close second, but that tends to require a lot more marketing and hustle than a psych practice. People tend to not want to shell out cash for NPs. It's also a field that is unlikely to suffer much intrusion from AI. Most midlevels also have a hard time functioning independently due to lack of ability with regard to challenging patients, the sort of patients that tend to find themselves being seen by psych rather than PCPs to begin with.

Yep I agree with you. It pisses me off when psych nps have nursing experience in something other than psych nursing. Yeah I’m pretty sure your ob/gyn experience in nursing will help you in psych (sarcasm). I think some of them go into it to try to work through their own issues. I’ve seen the curriculum for them and I have no clue how one can safely diagnosis and prescribe with that curriculum. I volunteered at a psych hospital the psych NP would only ask like five questions. How is your sleep/mood/SI/side effects or whatever. I’m pretty sure a high schooler would be able to do that.

 

[BorntobeDO?]

I personally just find the CRNA thing overblown. I'm about as certain as one can be without actually looking that if you go back 20 years on SDN, there are people saying anesthesiology is doomed from CRNAS. In the following 20 years, what has happened to anesthesiology? A quick google from a variety of years shows me that their salary has done nothing but go up despite more and more CRNAs entering the market.

As for anesthesiologists warning people not to go into that field, I take that with a grain of salt as well. There's this humorous phenomenon on here where if you go into just about any specialty section on SDN, someone, somewhere is comparing their field to another and saying "those guys have it right and we're doomed". You look at anesthesiology and they all say they should have been surgeons or emergency docs. You look at emergency med and they're all saying to look at some other specialty because they're over-expanding their own residencies and their salaries will never be the same. Look at critical care and they think they're doomed to oversupply due to NPs filling spots. I never look at the derm threads but they're probably the only ones not saying this, lol.

I think the take-away from this thread is that all of this is purely conjecture and no one can predict the future of any specialty. At the end of the day, doctors, in general, will always be in demand. I'm not going to base my future around worrying about clinics hiring NPs or PAs to do their follow-up med checks and whatnot, but that's just me. In my work experience prior to med school, I have found the physician:NP/PA model actually works well despite what you read on SDN. When it takes 5 months to see a specialist, it's hard to argue that it's a bad thing that they hire an NP/PA to do med check appointments and whatnot to free up their time for the people who really need to see them.

The bolded and underlined is completely wrong. The salary has not absolutely gone up. Anesthesia was a million dollar a year field in the 90's fairly easily. I doubt anyone is making that much now unless they are a senior partner.

 

[Hippocrates II]

The bolded and underlined is completely wrong. The salary has not absolutely gone up. Anesthesia was a million dollar a year field in the 90's fairly easily. I doubt anyone is making that much now unless they are a senior partner.

I said the past 20 years (1999-present), not throughout the 90's. The median anesthesiology salary in 1998 (per MGMA 1999) was $250,200 ($397k today's dollars). Too lazy to find current MGMA data but I recall anesthesiology was low-mid 400's today. Not saying it's huge growth, but it is an increase in salary in spite of a growing number of CRNAs.

Not only that, but what you're referring to is not anesthesia-specific; Many areas of medicine used to make significant sums of money that aren't made today. That is probably more of a consequence of insurance companies than it is anything else, but I don't want to get in the way of SDN blaming everything on midlevels. Not long ago, you went to the doctor and paid your bill. Today, you pay a biller a sizeable salary to haggle with insurance companies for reduced payments. Doctors used to make millions (says you, I have no idea what they made). Today, insurance companies make millions. Coincidence? Hmm.. So, I'll have to respectfully disagree that anesthesia salaries have gone down over the past 20 years (from my research, at least), and it certainly has not fallen off due to CRNAs like certain doom and gloom SDNers love to parrot on here.

 

[BorntobeDO?]

I said the past 20 years (1999-present), not throughout the 90's. The median anesthesiology salary in 1998 (per MGMA 1999) was $250,200 ($397k today's dollars). Too lazy to find current MGMA data but I recall anesthesiology was low-mid 400's today. Not saying it's huge growth, but it is an increase in salary in spite of a growing number of CRNAs.

Not only that, but what you're referring to is not anesthesia-specific; Many areas of medicine used to make significant sums of money that aren't made today. That is probably more of a consequence of insurance companies than it is anything else, but I don't want to get in the way of SDN blaming everything on midlevels. Not long ago, you went to the doctor and paid your bill. Today, you pay a biller a sizeable salary to haggle with insurance companies for reduced payments. Doctors used to make millions (says you, I have no idea what they made). Today, insurance companies make millions. Coincidence? Hmm.. So, I'll have to respectfully disagree that anesthesia salaries have gone down over the past 20 years (from my research, at least), and it certainly has not fallen off due to CRNAs like certain doom and gloom SDNers love to parrot on here.

Let me first acknowledge that your statement about the median going up for basically 20 years is correct. However, I think there is good reason to think it will not keep doing so.

On the million dollar thing: I knew a guy who was doing it even as late as 2007. But he was hardly unique. All you have to do is talk to any Anesthesiologist about what the field was like in the 90's vs now and they will tell. Ask the old guys if they were in your shoes as a medical student, would they still go into anesthesia and do they think that current anesthesiologist have the same kind of opprotunities they did. I have done that, and the answer was not affirmative. If they are being honest, all of them know that its not the same, and the outlook is not good. They may like the job, but the market is changing.

 

[BorderlineQueen]

The bolded and underlined is completely wrong. The salary has not absolutely gone up. Anesthesia was a million dollar a year field in the 90's fairly easily. I doubt anyone is making that much now unless they are a senior partner.

N=1 does not equal N=3000. You're giving an anecdote about one man who was very successful . But the average states that salary was lower for anesthesia back then. Anecdotes are not facts or data.

 

[DennisReynolds]

Medicine's future in it's entirety is bleak af.

 

[Drrrrrr. Celty]

Psychiatry is the only field that has a large and easy to sustain cash only market. Cosmetic plastic surgery is a close second, but that tends to require a lot more marketing and hustle than a psych practice. People tend to not want to shell out cash for NPs. It's also a field that is unlikely to suffer much intrusion from AI. Most midlevels also have a hard time functioning independently due to lack of ability with regard to challenging patients, the sort of patients that tend to find themselves being seen by psych rather than PCPs to begin with.

I think most PCPs don't want to be dealing with personality disorder patients or general psych patients aside from moderate anxiety/depression. Also I wouldn't be surprised if more prescriptions for antipsychotics are written by NPs than Psychiatrists in a lot of major cities with average wait times extending towards 3-6 months.

Psych isn't at risk of AI mostly because pharmacotherapy probably is the least effective part of it.

 

[BorderlineQueen]

Medicine's future in it's entirety is bleak af.

Lol to quote from the anesthesiology forum. "Until then, this profession will keep going to hell, with anesthesiology leading the way. " I found this quote surprisingly funny.

 

[goldsummer]

I know 3 in neuro at our hospital for 2 neurologists

I also have been at 2 different major medical centers where they only had 2 Neurologists on staff, 1 week on, 1 week off, supervising 3-4 NP's to see all the Neuro consults...which was a lot.

Neuro is not safe from mid level encroachment. Think its heading that direction across the board. Though I do feel like physician's job security isn't in as much danger as we sometimes feel...I say that to make the point: Dont make a decision based on what you think has the best job security...do what you like 🙂

 

[Sardonix]

I also have been at 2 different major medical centers where they only had 2 Neurologists on staff, 1 week on, 1 week off, supervising 3-4 NP's to see all the Neuro consults...which was a lot.

Neuro is not safe from mid level encroachment. Think its heading that direction across the board. Though I do feel like physician's job security isn't in as much danger as we sometimes feel...I say that to make the point: Dont make a decision based on what you think has the best job security...do what you like 🙂

But don't you want to needlessly panic and speculate?

 

[Postictal Raiden]

Neurology has its fair share of midlevels. Most don’t function autonomously though. May change in the future.

To be completely insulated you need to subspecialize. Neuroimmunology, movement disorder, neuro oncology, neuro Opthalmology, neuro otology, neuromuscular, etc.

Such fields are too specialized even for general neurologists, let alone other physicians or much less midlevels, to tap into.

But then you start losing some geographical and work environment flexibility when you specialize too deeply.

Choose your flavor of BS I guess.

 

[libertyyne]

It's a fools errand to predict the future. Reimbursement could change overnight. AI could change many specialties and nurses could start doing surgery. The only thing for certain is that the future is uncertain. Do what you love and leave the rest to fate , because you could predict wrong and end up in a field you hate leading to being miserable.

 

[deleted407021]

Seriously though, what’s the state of midlevels in PICU/NICU? I imagine these are specialized such that physicians are preferred.

 

[Ho0v-man]

Neurology has its fair share of midlevels. Most don’t function autonomously though. May change in the future.

To be completely insulated you need to subspecialize. Neuroimmunology, movement disorder, neuro oncology, neuro Opthalmology, neuro otology, neuromuscular, etc.

Such fields are too specialized even for general neurologists, let alone other physicians or much less midlevels, to tap into.

But then you start losing some geographical and work environment flexibility when you specialize too deeply.

Choose your flavor of BS I guess.

Ain’t medicine great? Nothing quite like training to be a doctor for 7+ years to then find out you might need a fellowship to outcompete a nurse with an online degree.

BS indeed...

 

[BorntobeDO?]

Ain’t medicine great? Nothing quite like training to be a doctor for 7+ years to then find out you might need a fellowship to outcompete a nurse with an online degree.

BS indeed...

We need to be more aggressive in marketing how much more training we have than NP's. I rotated with a psychiatrist who actively did this. She would correct the patients any time they called their NP a doctor and explain that the NP probably had very little experience prescribing the meds she was . This NP had given something which would have caused a drug drug interaction without telling the psych doc, so my attending was a bit PO'd.

If we didn't hire midlevels and we aggressively compared our training the public would get the idea pretty fast. The problem is that enough boomer docs love having midlevels as extra income generators so they will make BS claims and downplay their lack of training. We can't do that kind of stuff. With 40k midlevel providers coming out a year the threat is much different than it was 20 years ago when there was only 4k a year and no online schools.

 

[madiso30]

We need to be more aggressive in marketing how much more training we have than NP's. I rotated with a psychiatrist who actively did this. She would correct the patients any time they called their NP a doctor and explain that the NP probably had very little experience prescribing the meds she was . This NP had given something which would have caused a drug drug interaction without telling the psych doc, so my attending was a bit PO'd.

If we didn't hire midlevels and we aggressively compared our training the public would get the idea pretty fast. The problem is that enough boomer docs love having midlevels as extra income generators so they will make BS claims and downplay their lack of training. We can't do that kind of stuff. With 40k midlevel providers coming out a year the threat is much different than it was 20 years ago when there was only 4k a year and no online schools.

This starts at all our representing bodies for each specialty. I have not heard of any going to bat for us in the same way CRNA or NP lobbying groups have. What is the point of paying for memberships and participating in these groups when they readily allow us to be bulldozed by aggressive midlevel political lobbies?

 

[BorderlineQueen]

This starts at all our representing bodies for each specialty. I have not heard of any going to bat for us in the same way CRNA or NP lobbying groups have. What is the point of paying for memberships and participating in these groups when they readily allow us to be bulldozed by aggressive midlevel political lobbies?

Home - Physicians for Patient Protection Physicians for patient protection is a pretty good group. But the AMA is pretty spineless when it comes to mid-levels the nursing lobby is a lot more powerful I assume. Also nurses have a better PR than physicians. Whenever MDS/DOs piss on nurses/nps/midlevels it makes it look like greedy physicians are protecting turf. While the poor nurses are working so hard.

 

[BorntobeDO?]

Home - Physicians for Patient Protection Physicians for patient protection is a pretty good group. But the AMA is pretty spineless when it comes to mid-levels the nursing lobby is a lot more powerful I assume. Also nurses have a better PR than physicians. Whenever MDS/DOs piss on nurses/nps/midlevels it makes it look like greedy physicians are protecting turf. While the poor nurses are working so hard.

Agree completely. We can't do what some of my boomer attendings say and 'just give up on primary care.' The midlevels will not stop with full independent practice at FM. They will try and find thier way into every other specialty as well. I just had a PA student tell me they want to work in Inteventional Radiology. They were saying that some idiot attending was actually training PA's to do this in the midwest somewhere. There truly are no safe harbors. Some greedy boomer somewhere will sell out surgery too as well. The only way to fight this is on an organizational level, because there are enough old docs just looking for one more cash grab who will literally do whatever the politicians allow for an extra 20k a year. These attendings will never support us, they will be the ones claiming that they think their NP's are better than their primary care doc cause they 'empathize more' etc.

On the one hand, I think any doc with tons of midlevels should be forced to see midlevels when they actually need care. But on the other, I don't want my family seeing solo NPs or PAs ever. We have the moral highground. We need to stop letting some greedy bad apples give away the field.

 

[BorntobeDO?]

Once the payment model changes (as it kinda seems to be) to focus on value based and not fee for service, theoretically wouldn't this practice by NPs kinda screw them over?

It will, and it already is in hospitals where they don't get paid without justification. Hence why I think hospitalist are relatively safe. Unfortunately primary care doesn't have a controlling mechanism like bundled payments. NP's can prescribe inappropriately all over and the only one who gets the shaft is the patient who does those inappropriate diagnostics and ends up with large bills.

 

[KeikoTanaka]

To be honest I think Primary Care will have a pendulum swing back to having more need for physicians, even with FNPs flooding the market. People will realize if they have only one single provider to trust for all their medical needs, they're gonna want a trusted physician. At least I hope haha

 

[madiso30]

Agree completely. We can't do what some of my boomer attendings say and 'just give up on primary care.' The midlevels will not stop with full independent practice at FM. They will try and find thier way into every other specialty as well. I just had a PA student tell me they want to work in Inteventional Radiology. They were saying that some idiot attending was actually training PA's to do this in the midwest somewhere. There truly are no safe harbors. Some greedy boomer somewhere will sell out surgery too as well. The only way to fight this is on an organizational level, because there are enough old docs just looking for one more cash grab who will literally do whatever the politicians allow for an extra 20k a year. These attendings will never support us, they will be the ones claiming that they think their NP's are better than their primary care doc cause they 'empathize more' etc.

On the one hand, I think any doc with tons of midlevels should be forced to see midlevels when they actually need care. But on the other, I don't want my family seeing solo NPs or PAs ever. We have the moral highground. We need to stop letting some greedy bad apples give away the field.

Its ashame that the door to inappropriate autonomy has been opened by greedy physicians looking for a quick buck with no care for patient safety.

 

[Postictal Raiden]

... And this is why a lot of attendings tell their students/residents to specialize.

Keep in mind, academicians usually are clueless about what happens in the real world outside their bubble. I'd take their advice with a grain of salt.

You can still find many, many jobs in neurology without a fellowship.

Also, fearing midlevels should never be the reason to subspecialize. They are, literally, in every field. Plenty of them are in surgical fields. Yes, they don't do surgeries yet, but they do a lot of the other work that surgeons should be doing (following up on postop pts, writing notes, etc). This increases surgeon's efficiency and will eventually lead to decrease need.

Very few subspecialties in Neurology, and in medicine in general, that make good financial sense. When you decide on pursuing a fellowship, you are sacrificing attending salary for X amount of years. Therefore, in neurology, unless you're going to do NIR or interventional pain fellowship, no fellowship will result in a meaningful boost to your income to offset the opportunity loss of doing a fellowship.

Look at the following two extremes to get the idea:

John goes into FM, finishes 3 years training, and gets a job paying 230k right out of residency
Jane goes pursues a training in interventional cardiology (8 years long). Gets a job paying 500k right out of fellowship
During the 5 years of the extra training that Jane endured, Johan produced $1,150,000 while Jane produced $300,000 (60k/year in fellowship).
This puts Jane $850k behind John. Given the gap between their salaries, it'd take Jane 3-4 years after her training to catch up to John.

Keep in mind, I didn't account for the difference in work hours during fellowship and beyond. From what I observe at my institution, cardiology fellowship regularly work 80+hrs/week. Most FM docs work less than 45hrs/week. Therefore, if we want to adjust for this, the opportunity loss Jane would endure can be much more than what the calculations above showed.

 

[Postictal Raiden]

Ain’t medicine great? Nothing quite like training to be a doctor for 7+ years to then find out you might need a fellowship to outcompete a nurse with an online degree.

BS indeed...

That's because despite having the second best job security (prostitutes come first 🙂 ), physicians are very insecure when it comes to salary and job prospects.

 

[scoopdaboop]

The pathology section of SDN does NOT seem to be all that encouraging, for various reasons lol

always wondered why that is. anatomical pathologists make above 300k based on the previous mgma salaries. there are path fellowships that offer jumps in salaries as well.

 

[madiso30]

That's because despite having the second best job security (prostitutes come first 🙂 ), physicians are very insecure when it comes to salary and job prospects.

Well of course I'm gonna be insecure. How am I supposed to avoid homelessness while making $200k a year? That's quite the difficult feat.

 

[Dreamstoo]

Well of course I'm gonna be insecure. How am I supposed to avoid homelessness while making $200k a year? That's quite the difficult feat.

To be honest - you would be surprised how many doctors complain about it. I've had a med school friend scoff at the idea of becoming a generalist in peds/FM for the "low pay." Keep in mind, said student has two parents who are in those fields making a combined 500K+. Even my friend's parents tell him to specialize unless he wants to "just settle" for $200K. I've seen something similar happen to someone whose father was a PCP and they went into an ultra competitive specialty that pays on average 400K+ (personally makes ~500K 5-10 years into practice with great hours). Said person's father thinks they should double their hours and try to make millions. It's the same type of "mentality" that makes me not stand the majority of the 5-10 ortho applicants I personally know applying this year.

I personally know a surgeon who makes millions but said surgeon has an amazing personality and simply loves his job. The money is just a perk to him.

 

[Sardonix]

I am really glad to see this thread swinging a bit back into sane territory.

I get that there's lots to be worried about with the future of medicine, but some of stuff people have been posting here basically amounts to "It's all over now!" or "I wish I never went to medical school because being a DO is literally worse than cancer."

Am I exaggerating? Sure. But sweet baby jesus there's been a lot of cringe inducing, neckbeard talk on this forum recently.

 

[RangerBob]

Any specialty with a lot of bread and butter is particularly vulnerable. That’s pretty much all of us. FM (not hard to manage DM), psych (not hard to manage depression/anxiety), peds (well child checks are pretty much simple algorithms), gen surg (plenty of surgeons already have surgical assistants), and even my “unicorn specialty” (love the nickname) PM&R. 80% of what most of us do can be done by midlevels. They don’t know what they don’t know, but our healthcare system doesn’t seem to care.

The more specialized you are, the more protected you are from any encroachment. Otherwise, we may see midlevels handling all the simple stuff, with physicians handling the more complicated stuff-you already see this. Psych NPs are sometimes running psych units after the psychiatrist does the intake, after which they just “oversee” the NPs. Rehab units can be the exact same. IM/FM use midlevels to handle the easy stuff. Every surgical specialty uses NP/PAs to manage the floor.

Midlevels are already here, whether we like it or not. But there’s plenty of room at the table, and you can be sure that if the need for healthcare declines, we’ll be in higher demand than midlevels (patients almost always prefer us if they know the difference-and most do).

I’m sure a lot of people would rather talk to an AI about their anxiety, STI, or ED, etc., than a real person, but most people want a real human connection. There was a pretty infamous case of a “robot doctor” (which was a real doctor via telemedicine) delivering bad news. It didn’t go well. I don’t see AI going anywhere with much of medicine anytime soon due to public demand/perception.

When robots replace doctors, we probably have bigger things to worry about, because I’m sure by then they’ll have replaced cops and soldiers as well.

More likely is we’ll see AI implemented to “help” clinical decision making. We’ll see how that goes...

In the meantime-as a plug for my own specialty: I have no idea why burnout in PM&R is so high. We’re rarely included in any pan-specialty surveys (we’re so small), so perhaps it’s sample size? It’s nice we got included for once... I guess.

Or maybe it’s true. Who knows? In my n=1 experience, the happiest PM&R docs I meet, on average, are doing the things that sound more depressing-SCI/TBI/peds. They are among the most grateful patients/families you’ll ever meet. Pain seem to be the least happy (though the happiest/nicest guy I know in PM&R did pain, so there are clearly exceptions).

 

[BorderlineQueen]

Any specialty with a lot of bread and butter is particularly vulnerable. That’s pretty much all of us. FM (not hard to manage DM), psych (not hard to manage depression/anxiety), peds (well child checks are pretty much simple algorithms), gen surg (plenty of surgeons already have surgical assistants), and even my “unicorn specialty” (love the nickname) PM&R. 80% of what most of us do can be done by midlevels. They don’t know what they don’t know, but our healthcare system doesn’t seem to care.

The more specialized you are, the more protected you are from any encroachment. Otherwise, we may see midlevels handling all the simple stuff, with physicians handling the more complicated stuff-you already see this. Psych NPs are sometimes running psych units after the psychiatrist does the intake, after which they just “oversee” the NPs. Rehab units can be the exact same. IM/FM use midlevels to handle the easy stuff. Every surgical specialty uses NP/PAs to manage the floor.

Midlevels are already here, whether we like it or not. But there’s plenty of room at the table, and you can be sure that if the need for healthcare declines, we’ll be in higher demand than midlevels (patients almost always prefer us if they know the difference-and most do).

I’m sure a lot of people would rather talk to an AI about their anxiety, STI, or ED, etc., than a real person, but most people want a real human connection. There was a pretty infamous case of a “robot doctor” (which was a real doctor via telemedicine) delivering bad news. It didn’t go well. I don’t see AI going anywhere with much of medicine anytime soon due to public demand/perception.

When robots replace doctors, we probably have bigger things to worry about, because I’m sure by then they’ll have replaced cops and soldiers as well.

More likely is we’ll see AI implemented to “help” clinical decision making. We’ll see how that goes...

In the meantime-as a plug for my own specialty: I have no idea why burnout in PM&R is so high. We’re rarely included in any pan-specialty surveys (we’re so small), so perhaps it’s sample size? It’s nice we got included for once... I guess.

Or maybe it’s true. Who knows? In my n=1 experience, the happiest PM&R docs I meet, on average, are doing the things that sound more depressing-SCI/TBI/peds. They are among the most grateful patients/families you’ll ever meet. Pain seem to be the least happy (though the happiest/nicest guy I know in PM&R did pain, so there are clearly exceptions).

The thing about psych is most patients with bread and butter disorders will choose to see a psychiatrist. Only around 55% of psychiatrists accept insurance.People who are middle-to upper class with bread and butter disorders will most likely pay cash for a physician. The ones who can't afford it who have severe schizophrenia and Bipolar will see an NP/PA.

 

[RangerBob]

The thing about psych is most patients with bread and butter disorders will choose to see a psychiatrist. Only around 55% of psychiatrists accept insurance.People who are middle-to upper class with bread and butter disorders will most likely pay cash for a physician. The ones who can't afford it who have severe schizophrenia and Bipolar will see an NP/PA.

I really like psych. But one thing that always bothered me about the specialty however was how few psychiatrists accept insurance compared to every other specialty, and in general. I understand it’s easier, they earn more this way, and quite simply they can-in large part because there’s a shortage of psychiatrists. But I think it’s immoral-physicians have a duty to serve others. I have some issues with concierge medicine too, but at least it’s clear they’re serving the wealthy.

The people who need psychiatrists the most are those with schizophrenia and bipolar disorder. Bread and butter depression/anxiety can easily be handled by midlevels, or PCPs. What is a psychiatrist offering those patients that midlevels/PCPs can’t? If it’s refractory or complicated depression/anxiety then perhaps quite a bit, but for bread and butter not much. Psychiatrists are kind of making themselves obsolete if they aren’t handling the complicated cases they’re best suited to treat if you ask me...

Take PM&R for example. One could argue an NP or hospitalist could do most of what we do, and perhaps run the inpatient unit. And in some areas hospitalists do serve as primary. As patients get more medically complicated we see more and more hospitalist support, with them covering the “medical” issues and PM&R covering the “rehab” issues. For general debility and even a lot of trauma cases, you could argue these other providers can do most of what I do.

But they can’t take optimal care of a patient with a TBI, SCI, or stroke. These are the “hardcore” rehab patients. If I stop treating these patients, then what good am I? What am I really offering patients that someone with less experience, whether a hospitalist or NP, couldn’t offer? I’d be making myself obsolete as well.

 

[RangerBob]

I get where your coming from but why is it only physicians that are the bad guy when it comes to only taking cashh? Any other service profession only takes cash. Cast the blame on insurance and government for not paying enough not the doctors. I wouldn’t personally only do a cash practice but after shelling out some insane amount for tuition and seeing how patients treat doctors a lot of times we aren’t often the bad guy.

The guess the car technician and contractor are bad guys too for only accepting cash

They don’t work in systems where most people rely on insurance to afford astronomical prices. Nor did they take oaths. Our profession is a noble one, with a long history of service and sacrifice, and I (along with most of the public) see us as “above” most other professions. We’re up there with nurses, teachers, firefighters, and clergy. We’re the only high-paying profession that people actually respect and look up to.

We used to all be cash-based (or we accepted chickens). Then care became more expensive and ultimately most people got insurance one way or the other (work or gov’t).

How many physicians accept state Medicaid? The program was set up so physicians would get some compensation for cases we used to take on as charity as part of our professional/moral obligation. But now a lot of us don’t accept it because it pays so little. That is a moral tragedy. We are better than that, and doing things like limiting Medicaid and only accepting cash, diminishes the noble stature of our profession.

I can understand the urge-I half a million in debt and am living in a high COL area. But I can still afford a roof over my head, and I am proud of the work I do.

 

[BorntobeDO?]

They don’t work in systems where most people rely on insurance to afford astronomical prices. Nor did they take oaths. Our profession is a noble one, with a long history of service and sacrifice, and I (along with most of the public) see us as “above” most other professions. We’re up there with nurses, teachers, firefighters, and clergy. We’re the only high-paying profession that people actually respect and look up to.

We used to all be cash-based (or we accepted chickens). Then care became more expensive and ultimately most people got insurance one way or the other (work or gov’t).

How many physicians accept state Medicaid? The program was set up so physicians would get some compensation for cases we used to take on as charity as part of our professional/moral obligation. But now a lot of us don’t accept it because it pays so little. That is a moral tragedy. We are better than that, and doing things like limiting Medicaid and only accepting cash, diminishes the noble stature of our profession.

I can understand the urge-I half a million in debt and am living in a high COL area. But I can still afford a roof over my head, and I am proud of the work I do.

'The worker is worth his wage.' Medicaid doesnt even cover the cost of keeping a practice open in most cases. I think its highly immoral to suggest that a physician should work well below thier market value to the point of going broke or for free. I am not a slave and I have no problem charging near the same level as a mechanic for my services when they took a much longer and more difficult path to get those skills. Sorry not sorry, I don't work for free and my job deserves to be compensated.

 

[Neopolymath]

The issue for me is that these essentially no pay patients can still sue your ass. Why take the risk/liability (depending on what you do)? If it wasn't so litigious I would likely feel differently.

 

[Chibucks15]

The issue for me is that these essentially no pay patients can still sue your ass. Why take the risk/liability (depending on what you do)? If it wasn't so litigious I would likely feel differently.

Honestly a large cause of many of the costs/other issues is the predatory lawyers and stupid litigious society we live in. Burn yourself on HOT coffee because there wasn't a label warning you it was hot? Win millions.
Don't like how someone talked to you, but don't really have anything bad that happened other than inconvenience? Waste everyone's time and money to sue their ass, whether or not you win. Sure there are definite instances of malpractice, but many of the real ones get drowned out by useless ones (in my limited experience)

 

[BorntobeDO?]

The issue for me is that these essentially no pay patients can still sue your ass. Why take the risk/liability (depending on what you do)? If it wasn't so litigious I would likely feel differently.

Medicaid patients rarely understand that thier coverage basically is charity. Medicare is better, but with the huge expansion of medicaid that population is ridiculous. I know psychiatrist that work with the medicaid population in Federally qualified healthcare centers, all of them work for salary not reembursement and they made sure it was that way due to massive noncompliance and puny reembursement.

 

[Candidate2017]

... except for the bolded part. Go to the psych section of SDN. I was dabbling with psych last year and I happened to see a post where an attending's contract at a hospital was DC'd because they had trained in x4 Psych NPs and no longer had interest in keeping the x2 psychiatrist MDs. There are some places where they really DO straight up turn down docs in favor of midlevels.

We have low level providers at our psych ward. They do the stuff no one wants to do, like take insane amounts of call. They take moonlighting hours away from residents but I don’t think they affect attending pay since attendings dont want that job. 90% of psychiatrists are outpatient anyway.

On the outpatient side, psych NPs are walking advertisements for psychiatrists. NPs are still nurses and their training is geared towards doing (prescribe something, anything in the name of patient care) rather than constant learning and thinking about differentials, medication choices, risks, side effects, alternatives (practice medicine, manage the disease process). Psych patients also undervalue, overvalue, and misreport various symptoms. NPs are not able to tease out nuances that dictate treatment. Their process is: Sad? SSRI. Can’t sleep? Hypnotic. Irritable? Mood stabilizer. Strange thoughts? Antipsychotic. Can’t focus? Stimulant. Anxious? Benzo. This leads to ineffective polypharmacy, terrible side effects, patient dissatisfaction and tremendous appreciation when they finally get to see a psychiatrist after 12 months of terrible treatment and a 3 month wait.

 

[Candidate2017]

The thing about psych is most patients with bread and butter disorders will choose to see a psychiatrist. Only around 55% of psychiatrists accept insurance.People who are middle-to upper class with bread and butter disorders will most likely pay cash for a physician.

That is my experience too. Psych patients in the ambulatory setting tend to have comorbid anxiety and personality traits/disorders (narcissistic/histrionic/borderline/schizoid/obsessive etc) that are exquisitely sensitive to detecting, challenging and calling people out on their BS. They have a low tolerance for NPs' lack of knowledge. I would hazard to say the average psych outpatient is more likely than the general population to know the differences between doctor vs NP, psychiatrist vs psychologist.

 

[Ho0v-man]

They don’t work in systems where most people rely on insurance to afford astronomical prices. Nor did they take oaths. Our profession is a noble one, with a long history of service and sacrifice, and I (along with most of the public) see us as “above” most other professions. We’re up there with nurses, teachers, firefighters, and clergy. We’re the only high-paying profession that people actually respect and look up to.

We used to all be cash-based (or we accepted chickens). Then care became more expensive and ultimately most people got insurance one way or the other (work or gov’t).

How many physicians accept state Medicaid? The program was set up so physicians would get some compensation for cases we used to take on as charity as part of our professional/moral obligation. But now a lot of us don’t accept it because it pays so little. That is a moral tragedy. We are better than that, and doing things like limiting Medicaid and only accepting cash, diminishes the noble stature of our profession.

I can understand the urge-I half a million in debt and am living in a high COL area. But I can still afford a roof over my head, and I am proud of the work I do.

I’m like premed level inspired after reading this post. I have nothing to add. Thank you.

 

[Hippocrates II]

I really like psych. But one thing that always bothered me about the specialty however was how few psychiatrists accept insurance compared to every other specialty, and in general. I understand it’s easier, they earn more this way, and quite simply they can-in large part because there’s a shortage of psychiatrists. But I think it’s immoral-physicians have a duty to serve others. I have some issues with concierge medicine too, but at least it’s clear they’re serving the wealthy.

The people who need psychiatrists the most are those with schizophrenia and bipolar disorder. Bread and butter depression/anxiety can easily be handled by midlevels, or PCPs. What is a psychiatrist offering those patients that midlevels/PCPs can’t? If it’s refractory or complicated depression/anxiety then perhaps quite a bit, but for bread and butter not much. Psychiatrists are kind of making themselves obsolete if they aren’t handling the complicated cases they’re best suited to treat if you ask me...

Take PM&R for example. One could argue an NP or hospitalist could do most of what we do, and perhaps run the inpatient unit. And in some areas hospitalists do serve as primary. As patients get more medically complicated we see more and more hospitalist support, with them covering the “medical” issues and PM&R covering the “rehab” issues. For general debility and even a lot of trauma cases, you could argue these other providers can do most of what I do.

But they can’t take optimal care of a patient with a TBI, SCI, or stroke. These are the “hardcore” rehab patients. If I stop treating these patients, then what good am I? What am I really offering patients that someone with less experience, whether a hospitalist or NP, couldn’t offer? I’d be making myself obsolete as well.

I personally think disdain towards doctors not accepting insurance should be redirected to the insurance companies themselves - they have bred this uprising to not accept insurance by throwing up as many roadblocks to reimbursement as possible. Several years ago I was working with a doctor who had to close her clinic early one day for a meeting with BCBS because they were 4 months and tens of thousands of dollars behind on paying her. No doctor should have to put up with that. I am going through medical school because I want to work with patients, not so that I can sit on the phone fighting with insurance companies for a portion of my day. I'm sure I'm preaching to the choir given that you probably deal with this yourself as a physician, but I personally do not think a doctor should be looked down upon because they choose not to play into this obviously corrupt and one-sided payment model that insurance companies have devised.

 

[Ho0v-man]

'The worker is worth his wage.' Medicaid doesnt even cover the cost of keeping a practice open in most cases. I think its highly immoral to suggest that a physician should work well below thier market value to the point of going broke or for free. I am not a slave and I have no problem charging near the same level as a mechanic for my services when they took a much longer and more difficult path to get those skills. Sorry not sorry, I don't work for free and my job deserves to be compensated.

I see your point. But bruh it’s psych. It’s not like they’re using tons of fancy equipment they have to pay off. The overhead is barely anything compared to other fields.

Honestly a large cause of many of the costs/other issues is the predatory lawyers and stupid litigious society we live in. Burn yourself on HOT coffee because there wasn't a label warning you it was hot? Win millions.
Don't like how someone talked to you, but don't really have anything bad that happened other than inconvenience? Waste everyone's time and money to sue their ass, whether or not you win. Sure there are definite instances of malpractice, but many of the real ones get drowned out by useless ones (in my limited experience)

You should look into that case. Lots of misconceptions surround it. It wasn’t the first time they’d been warned about the temperature of their coffee. The burns on that lady’s leg were so severe she legitimately almost died. She also only requested that McDonalds pay the amount that wasn’t covered by Medicare and McDonald’s decided to put up the big fight. They were given multiple opportunities to settle for much less than what was awarded ($640,000).Liebeck v. McDonald's Restaurants - Wikipedia

 

[Ho0v-man]

That is my experience too. Psych patients in the ambulatory setting tend to have comorbid anxiety and personality traits/disorders (narcissistic/histrionic/borderline/schizoid/obsessive etc) that are exquisitely sensitive to detecting, challenging and calling people out on their BS. They have a low tolerance for NPs' lack of knowledge. I would hazard to say the average psych outpatient is more likely than the general population to know the differences between doctor vs NP, psychiatrist vs psychologist.

My n=1 experience is that they don’t care as long as the benzos keep flowin’.