In this scenario, wouldn't the fewer physicians and their expertise become even more valuable? Which theoretically should lead to higher prestige and compensation?
Not necessarily, but I do think this provides some job security in our field given the ability to run a cash-only practice. There will always be people willing to pay for quality, which is something to consider in terms of job path/security.
Doubtful. This assumes there aren't forces from insurance companies, CMS, politicians [with good intentions, but bad implementation like we are currently seeing with balanced billing legislation]. With this vain of thought we should already be seeing it for physicians against the back drop of these mid-levels fields - but we aren't - only the same rate of descent into the cold icy Atlantic waters as the Titanic creaks downward.
1) fellow citizens don't even know the difference of the alphabet soup. Continually people say, "My doctor..." but when you google them, its an ARNP or PA.
2) Hospitals and health systems have been laying off physicians during covid to extract more work out of them, while prepping the job adds to replace the fired physicians with a midlevel.
Again, I don't doubt this is the general path, but I do think psychiatry is a bit more insulated than some other fields (see FM, peds, even derm) in terms resilience to non-cash market factors (insurance, CMS). The only major fear imo would be if we moved to a single-payer system which did not allow cash-only practices, but this would essentially mark the complete destruction of the US healthcare system.
NP is a major issue. I have physician friends who run NP-focused practices: NPs have lower quality but better profit margin and are slated to expand. MDs need to innovate and have a pitch, as well as collectively bargain hard. His opinion is facilities-based publicly funded MD jobs will die out. This will affect a lot of lower-tier trained MDs. Higher tier MDs will still get hired/be partnered to do medical director oriented jobs to manage multiple NP case loads.
Commercial insurance and cash practices will still favor MDs--as a patient, if I can find and afford an MD I wouldn't go to an NP, though there is downward pressure--commercial insurance-driven practices are increasingly unable to find in-network MD providers. So most MDs will be chasing after 30-40% of the market that's cash-based.
Currently this is not affecting job market because the demand has grown astronomically, but I think in the next 20 years if you are a lower tier/DO/FMG trained at community programs, you'll be either offered a job that's not very desirable or be prepared to start your own practice. Cush state/non-profit community jobs will be very rare and tend to be reserved for prestige residency grads and will have a large admin component. Current med students who are interested in a long term sustainable career in psychiatry should plan to work hard and match into as good a residency program as possible to hedge against this. The current state where anyone with a pulse can waltz into a community job that pays 250k for 35 hours a week will end sooner than you think.
I can see the first two paragraphs occurring, but partially disagree with the third. I don't think lower-tier MD/DO is going to see a huge hit anytime soon. The demand for psychiatrists is still high enough that true saturation will take a while and given the poor treatment quality of many mid-levels, true saturation may never occur. Good psychiatrists will always be needed, and I think there will be a place for almost all (at least in the outpatient setting) well past 20 years. That being said, I do agree with the last sentence that pay may take a fair hit and that you'll need more than a pulse to get a common clinical job.
You mentioned low tier/DO/FMG.
What about DO/FMG that train at university programs? As a follow-up question, are DOs at a disadvantage for cash practice even if they train at strong programs?
Depends. Prestige and image certainly matter to some demographics. If you're known in the community as a good physician though, you'll get referrals. There are a couple cash-only DOs in my area who don't even take new patients. For now, I think our field still has some insulation (at least in the geographic areas I'm familiar with).
Change is inevitable. People have been predicting doom since the 80's (or maybe even earlier) and yet for decades physicians have no trouble finding jobs and making more money every year. Predicting doom sounds smart and attracts attention.
So I'm going to sound stupid. Change will continue. But things will be ok and physicians will continue to have no trouble finding jobs and will continue to make more money every year.
But this is how you prepare in case I am wrong. I would encourage you to learn how private practice works and how to document and how to bill. Because at the very least, if the doomsday scenario does occur, you can always start your own practice and take Medicare and by being a physician, you have a huge marketing advantage over NPs. (And when you have enough work, then you may expand by overseeing NPs.) And it will benefit you now because in many scenarios, the knowledge will help you maximize income so you can put away more money today in preparation for the future.
I don't think it's stupid. Things aren't as good now in many areas as they were in the 80's and there may still be doom, it just is unlikely to come in the form of an explosive crash and more likely to be a slow descent into hell. The making more money aspect is all relative to inflation as well. Salaries may continue going up, but what is the actual value of those dollars?
I do agree with your last paragraph. I think that anyone currently in residency will have plenty of time to safely set themselves up for financial security as long as they're being responsible in the first 10 years out of residency. The other protective factor to mention is specialization. Find a niche that others can't do or that makes you high demand (forensics, addiction, ASD/ID) and you'll hold onto job security and financial freedom longer.
I’m not sure about psychiatry’s image taking a hit since we have arguably the least prestige associated with our field compared to every other one.
But I do think our pay will take a hit due to mid levels. We can’t even find moonlighting in our program’s city because the inpatient units have moved to hiring mid levels for weekend coverage.
As someone with little interest in outpatient psychiatry I feel that I’ve made a massive mistake choosing the field. I feel that mid levels will soon replace inpatient psychiatrists as a cheaper alternative
Until NPs gain FPA in all states, inpatient jobs will remain secure (at least as supervisory positions). Academic positions will remain open and quality will still matter in a lot of places. Even in the VA system where NPs have had FPA for quite a while, I don't know any inpatient psych units that aren't staffed by physicians (I've worked in or with 5 separate VA inpatient units). That being said, as someone who also loves inpatient psych I am making contingency plans for myself should inpatient become an invalid option in the future.
You'd be wrong. Somewhere around half of states allow an unrestricted license about 1 year of post-graduate training. If you have a full license in a state, you can get a normal DEA number.
I should addend that. I'm not surprised that they can technically call themselves psychiatrists. I am surprised that there are that many states that allow an unrestricted DEA license with only 1 year of residency.