Rise and Fall of Competitiveness in specialties

[Psai]

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There is concern that with reimbursement claw back other specialties will keep patients to themselves rather then refer to IR, in speaking with a few physicans it seems like jobs are difficult to come by in the desirable locations , and indications for some of the bread and butter cases may become more limited. Also some ir folks don't have enough volume so they end up reading a whole bunch. At least this is the impression I got.

Lol our surgical residents are busy trying to tell us to send patients with obvious surgical indications to IR instead. Maybe it's different outside of academic centers.

 

[libertyyne]

Lol our surgical residents are busy trying to tell us to send patients with obvious surgical indications to IR instead. Maybe it's different outside of academic centers.

Yeah, there was a thread about how if surgical volume decreased people would just stop sending to IR. It is a difficult position to be in if you end up competing for procedures with the people sending them to you.
Welcome back!

 

[jqueb29]

What makes you think the future is bright? Asking because I am interested in this field but all I ever hear about is CRNAs and automation.

And the question I would have for you is: who do you hear this from? In talking to anesthesiologists all over the country, whether they be old and about to retire or residents just entering the field, nobody I've met is really worried a lick about CRNAs or automation.

 

[Warderino92]

What uncertainty have you heard about rad onc? Not challenging you, just curious because I'm very interested in the field.

The residents and attendings regularly discuss how the field keeps expanding residency positions while there is no corresponding increase in supply of jobs. Thus the programs keep pushing more people out and increasing competition for jobs after residency graduation. The general consensus is that you can't really have a all or nothing geographical preference anymore for where you want to work after residency.

Also look at job board posts on places like Merritt Hawkins, there's 6 pages worth of jobs for GI docs and only 1 single posting for a rad onc at the moment. I realize this doesn't represent all the recruiters that don't post jobs online or jobs that only come from cold emailing places or connections, but I do believe that it represents overall trends.

 

[ChrisMack390]

And the question I would have for you is: who do you hear this from? In talking to anesthesiologists all over the country, whether they be old and about to retire or residents just entering the field, nobody I've met is really worried a lick about CRNAs or automation.

Point taken that it's mostly online articles and SDN. I'm not really trying to argue with you - I already said I am interested in this field. I'm just wondering what makes you say the future is "bright" for the field? Just that you don't expect any significant change? Or is it expanding?

 

[Man o War]

Work enough shifts with CRNAs and you will understand why the docs aren't worried....
Ask for a central line and see what they say.
Give them a sick patient to manage and watch the "Alpine anesthesia" ensue.
They're technicians, and fairly mediocre ones most of the time.
God forbid someone actually craps out....

 

[libertyyne]

What uncertainty have you heard about rad onc? Not challenging you, just curious because I'm very interested in the field.

Look at the Rad Onc Resident forums for more nuanced opinion, http://www.redjournal.org/article/S0360-3016(16)33385-5/fulltext

 

[jqueb29]

Point taken that it's mostly online articles and SDN. I'm not really trying to argue with you - I already said I am interested in this field. I'm just wondering what makes you say the future is "bright" for the field? Just that you don't expect any significant change? Or is it expanding?

Sorry if I sounded argumentative, I def wasn't trying to sound that way. I was just pointing out that the people who are actually intimately involved and affected by the situation are also the people who aren't worried at all. Here's a few reasons why we're not worried:

1. The utter incompetence of CRNAs for anything but extremely simple cases. They're not going to ever meaningfully encroach on anesthesia's territory.
2. Pain management is going to become insanely huge. Get in now before the crowd figures out and catches up. These data are a few years old, but just look at this: http://www.beckershospitalreview.co...sician-specialties-by-hospital-ownership.html . All those other specialties on here have pretty atrocious lifestyles. But pain management: predictable hours, less stressful work, $500k, and demand for your services only going to grow and grow? I'm in.
3. Anesthesia in general continues to look for ways to expand the role of the anesthesiologist. The perioperative surgical home is a big new movement in the field that will also help ensure the future is bright.

 

[jw3600]

Work enough shifts with CRNAs and you will understand why the docs aren't worried....
Ask for a central line and see what they say.
Give them a sick patient to manage and watch the "Alpine anesthesia" ensue.
They're technicians, and fairly mediocre ones most of the time.
God forbid someone actually craps out....

I hope you are right but doesn't it seem like the public will never truly understand this and eventually the nursing lobby will squeeze some legislation by? I know there was recently a win in the VA with not allowing CRNAs equal scope or whatever but they are literally going to try every year for the next 50 years.

 

[Man o War]

I hope you are right but doesn't it seem like the public will never truly understand this and eventually the nursing lobby will squeeze some legislation by? I know there was recently a win in the VA with not allowing CRNAs equal scope or whatever but they are literally going to try every year for the next 50 years.

They actually have been able to get laws passed eliminating the need for an anesthesiologist in many places, and yet it is extremely rare to come across CRNA only practice.
I attribute this to surgeons who won't work in that type of arrangement and administrators who realize the risk of allowing them to practice on their own.

 

[ChrisMack390]

Sorry if I sounded argumentative, I def wasn't trying to sound that way. I was just pointing out that the people who are actually intimately involved and affected by the situation are also the people who aren't worried at all. Here's a few reasons why we're not worried:

1. The utter incompetence of CRNAs for anything but extremely simple cases. They're not going to ever meaningfully encroach on anesthesia's territory.
2. Pain management is going to become insanely huge. Get in now before the crowd figures out and catches up. These data are a few years old, but just look at this: http://www.beckershospitalreview.co...sician-specialties-by-hospital-ownership.html . All those other specialties on here have pretty atrocious lifestyles. But pain management: predictable hours, less stressful work, $500k, and demand for your services only going to grow and grow? I'm in.
3. Anesthesia in general continues to look for ways to expand the role of the anesthesiologist. The perioperative surgical home is a big new movement in the field that will also help ensure the future is bright.

Can you describe or point to a good resource re: what a pain management doctor does? I've always thought of anesthesiology strictly in terms of OR stuff.

 

[PL198]

Can you describe or point to a good resource re: what a pain management doctor does? I've always thought of anesthesiology strictly in terms of OR stuff.

manage pain

but really, lot of procedures with pain relief as end goal

 

[deleted564680]

Sorry if I sounded argumentative, I def wasn't trying to sound that way. I was just pointing out that the people who are actually intimately involved and affected by the situation are also the people who aren't worried at all. Here's a few reasons why we're not worried:

1. The utter incompetence of CRNAs for anything but extremely simple cases. They're not going to ever meaningfully encroach on anesthesia's territory.
2. Pain management is going to become insanely huge. Get in now before the crowd figures out and catches up. These data are a few years old, but just look at this: http://www.beckershospitalreview.co...sician-specialties-by-hospital-ownership.html . All those other specialties on here have pretty atrocious lifestyles. But pain management: predictable hours, less stressful work, $500k, and demand for your services only going to grow and grow? I'm in.
3. Anesthesia in general continues to look for ways to expand the role of the anesthesiologist. The perioperative surgical home is a big new movement in the field that will also help ensure the future is bright.

Pain management can be done by multiple specialties though so there will be a lot of competition if it becomes extremely lucrative. Anesthesia, PM&R, Neurology, and Radiology all have pretty easy access and training for it.

Also, those patients man....

 

[libertyyne]

Pain management can be done by multiple specialties though so there will be a lot of competition if it becomes extremely lucrative. Anesthesia, PM&R, Neurology, and Radiology all have pretty easy access and training for it.

Also, those patients man....

Lines stretching out the door with drug seekers, addicts, high risk patients. I bet malpractice insurance is going to be through the roof for pain management.

 

[823683]

Residency choice IMHO should be based on what problems/culture/patients/procedures you like. The economics will take care of itself. Too many burnt-out docs working decades in a field they chose based on economic predictions, which sacrifices the psychic income of doing what you love. Economics has always and will continue to change, but I have never seen a licensed doc starve. Your degree and license have always guaranteed a reasonable living if not riches. Market forces incentivize otherwise relatively undersupplied services (e.g. rural locations, long highly selective fellowship requirements) and each doc makes a calculation including sum of psychic (work, setting, hours) and economic income vs. alternatives. Not enough providers in one specialty/place? Wage will rise, docs respond, hole filled. Too many? Wages fall, docs leave, those who remain find net income is worth it, resources optimally allocated, the market at work! Other players seek to redistribute income (from providers to health care organizations, insurors, etc) but overall we are well compensated and comfortable, my colleagues who complain otherwise have an exaggerated sense of entitlement. Do what you love. If you don't love anything, do what feels ok and learn to love it.

 

[alcoholdehydrogenase69]

Lines stretching out the door with drug seekers, addicts, high risk patients. I bet malpractice insurance is going to be through the roof for pain management.

Just give them all a medical marijuana prescription and see them on their way.

 

[libertyyne]

Just give them all a medical marijuana prescription and see them on their way.

With my luck I will have the first documented case of death due to marijuana overdose.

 

[ChrisMack390]

manage pain

but really, lot of procedures with pain relief as end goal

Gee thanks.....😵


Really though, what types of procedures are done for pain in this setting? Other than writing opioid scripts.

 

[libertyyne]

Gee thanks.....😵


Really though, what types of procedures are done for pain in this setting? Other than writing opioid scripts.

Probably nerve blocks, epidural injections, joint injections. I am unsure if they would manage intrathecal pumps, or spinal cord stimulators.

 

[823683]

Just give them all a medical marijuana prescription and see them on their way.

Pain Med practices run by anesthesiologists are the most restrictive in opioid prescribing of all practices that provide this service. Patients are routinely referred to pain management by PCP's who wish not to rx chronic narcs. These practices generally provide interventions (blocks) and will assume chronic narc rx if and only if patients are pristine. Inconsistent urine tox, abuse flags, non-compliance->fired patient. I have never seen an anesthesia pain practice accept a u-tox THC + patient, let alone actively rx medical MJ.

 

[libertyyne]

Pain Med practices run by anesthesiologists are the most restrictive in opioid prescribing of all practices that provide this service. Patients are routinely referred to pain management by PCP's who wish not to rx chronic narcs. These practices generally provide interventions (blocks) and will assume chronic narc rx if and only if patients are pristine. Inconsistent urine tox, abuse flags, non-compliance->fired patient. I have never seen an anesthesia pain practice accept a u-tox THC + patient, let alone actively rx medical MJ.

I feel like the MJ prescribers are pcps and tend to prescribe a high volume of them. I believe in my small region there are two doc's that are responsible for something like greater than 60% of the medical MJ cards.

 

[jqueb29]

With my luck I will have the first documented case of death due to marijuana overdose.

well you shouldn't have injected them with so many marijuanas

 

[alcoholdehydrogenase69]

Pain Med practices run by anesthesiologists are the most restrictive in opioid prescribing of all practices that provide this service. Patients are routinely referred to pain management by PCP's who wish not to rx chronic narcs. These practices generally provide interventions (blocks) and will assume chronic narc rx if and only if patients are pristine. Inconsistent urine tox, abuse flags, non-compliance->fired patient. I have never seen an anesthesia pain practice accept a u-tox THC + patient, let alone actively rx medical MJ.

I was partially kidding, but it is nice to know that there is a side of pain management that is set up to avoid opiod over-prescription and abuse. I really didn't know about the anesthesia pain practice side of things.
My perspective previously was through a community health center that had a handful of PCPs dealing with disgruntled pain management patients. Medical MJ just became legal in my state so it will be interesting to see how this changes care for this demographic.

 

[IslandStyle808]

Pain management can be done by multiple specialties though so there will be a lot of competition if it becomes extremely lucrative. Anesthesia, PM&R, Neurology, and Radiology all have pretty easy access and training for it.

Also, those patients man....

It still a very competitive field today. The ones with the largest ease in matching is Anesthesia since the majority of fellowships are under anesthesia. The next is PM&R, which as some but not a lot, and even the anesthesia residency will pick a PM&R resident over other specialties such as neuro or psych. I have no idea how easy it is for radiology, since none of the pain trained docs on here talk about it.

 

[zero0]

It still a very competitive field today. The ones with the largest ease in matching is Anesthesia since the majority of fellowships are under anesthesia. The next is PM&R, which as some but not a lot, and even the anesthesia residency will pick a PM&R resident over other specialties such as neuro or psych. I have no idea how easy it is for radiology, since none of the pain trained docs on here talk about it.

Never even heard of rads doing pain, but if psych and EM can get it...

 

[IslandStyle808]

Never even heard of rads doing pain, but if psych and EM can get it...

They can, but it is on the harder side of the spectrum.

 

[cowme]

Never even heard of rads doing pain, but if psych and EM can get it...

We have a pain fellowship in radiology. It's called mammography

 

[bashwell]

I believe good Dr. Fred Weiss (@freddydpt) knows about radiology doing pain. 🙂

 

[cowme]

In all seriousness, you guys are all about 5-7 years from looking for your job. Any field you apply to is going to be drastically different when you are at the other end.

Don't chase the field that is hot right now and avoid the field that has recently dipped in popularity, go with whatever field you think you would enjoy the most.

I applied to radiology During the nadir of the recent dip in popularity--everyone told me I was an idiot, and I would have to take a job in farm country as you all alluded to in this thread. Yet throughout the "down years" every senior resident of mine got jobs in a location of their choice from New York to California. Now the market is starting to heat up again...

Point is, things will be different in 6 years in every field. Do what you love despite what Internet forums may say

 

[Slack3r]

With my luck I will have the first documented case of death due to marijuana overdose.

Saw a kid with pneumomediastinum presumably from puffing a J.

 

[deleted564680]

With my luck I will have the first documented case of death due to marijuana overdose.

5 minute lit. search. Not overdose but death I guess 😛

Cancer:
- Callaghan, R.C., Allebeck, P. & Sidorchuk, A. Cancer Causes Control (2013) 24: 1811. doi:10.1007/s10552-013-0259-0
- Cannabis use and risk of lung cancer: a case–control study
S. Aldington, M. Harwood, B. Cox, M. Weatherall, L. Beckert, A. Hansell, A. Pritchard, G. Robinson, R.Beasley
European Respiratory Journal Feb 2008, 31 (2) 280-286; DOI: 10.1183/09031936.00065707

Adverse Effects in general:
- Adverse Health Effects of Marijuana Use. Nora D. Volkow, M.D., Ruben D. Baler, Ph.D., Wilson M. Compton, M.D., and Susan R.B. Weiss, Ph.D. N Engl J Med 2014; 370:2219-2227June 5, 2014DOI: 10.1056/NEJMra1402309


There are tons of studies about marijuana. I find it odd that we have pushed out tobacco cigarettes culturally due to lung cancer/respiratory toxins and now marijuana will just take its place.

 

[libertyyne]

5 minute lit. search. Not overdose but death I guess 😛

Cancer:
- Callaghan, R.C., Allebeck, P. & Sidorchuk, A. Cancer Causes Control (2013) 24: 1811. doi:10.1007/s10552-013-0259-0
- Cannabis use and risk of lung cancer: a case–control study
S. Aldington, M. Harwood, B. Cox, M. Weatherall, L. Beckert, A. Hansell, A. Pritchard, G. Robinson, R.Beasley
European Respiratory Journal Feb 2008, 31 (2) 280-286; DOI: 10.1183/09031936.00065707

Adverse Effects in general:
- Adverse Health Effects of Marijuana Use. Nora D. Volkow, M.D., Ruben D. Baler, Ph.D., Wilson M. Compton, M.D., and Susan R.B. Weiss, Ph.D. N Engl J Med 2014; 370:2219-2227June 5, 2014DOI: 10.1056/NEJMra1402309


There are tons of studies about marijuana. I find it odd that we have pushed out tobacco cigarettes culturally due to lung cancer/respiratory toxins and now marijuana will just take its place.

Or you know, you could just eat it, most of those studies are about the impact of the combustion products of the drug.

 

[zero0]

5 minute lit. search. Not overdose but death I guess 😛

Cancer:
- Callaghan, R.C., Allebeck, P. & Sidorchuk, A. Cancer Causes Control (2013) 24: 1811. doi:10.1007/s10552-013-0259-0
- Cannabis use and risk of lung cancer: a case–control study
S. Aldington, M. Harwood, B. Cox, M. Weatherall, L. Beckert, A. Hansell, A. Pritchard, G. Robinson, R.Beasley
European Respiratory Journal Feb 2008, 31 (2) 280-286; DOI: 10.1183/09031936.00065707

Adverse Effects in general:
- Adverse Health Effects of Marijuana Use. Nora D. Volkow, M.D., Ruben D. Baler, Ph.D., Wilson M. Compton, M.D., and Susan R.B. Weiss, Ph.D. N Engl J Med 2014; 370:2219-2227June 5, 2014DOI: 10.1056/NEJMra1402309


There are tons of studies about marijuana. I find it odd that we have pushed out tobacco cigarettes culturally due to lung cancer/respiratory toxins and now marijuana will just take its place.

But bro, like, marijuana doesn't have any of those, like, harsh chemicals that the tobacco companies put in cigarettes