Oversupply is mainly due to the largest proportional increase in resident numbers among all specialties. Resident numbers more than doubled over the past 20 years while indications declined slightly.
forums.studentdoctor.net
I guess I’m still sort of confused; what’s stopping PE from expanding other residencies such as anesthesiology or even surgery to drive up supply and drive down wages?USACS Denver pays EM docs 20 bucks an hour
https://sullivanlegal.us/denver-hospital-offering-emergency-physician-21-per-hour/?fbclid=IwAR1jH61iPEoisF9nKuQPQOncEijMRtKroUhSSqsFk3_uj_xGbVMVRAMNI2M Wow such a competitive wage
A lot has to do with the culture and leadership of the specialty. Some specialties like urology have always carefully regulated their numbers. Does the leadership see themselves as custodians of the specialty for future generations?
They’re trying. HCA has opened a number of surgery programs recently, but it’s simply a different ballgame for surgeons. The roadblocks for this happening to surgeons is that they have to show they have enough case volume. You can’t just do 1000 gall bags and have a surgery residency. And then there is the fellowship component, 80% of general surgery residents do a fellowship. The job market for a true general surgeon is huge because of it.
Interesting about 80% of general surgery residents doing fellowship. At some point when do some surgeons and subspeciality surgeons (ENT/Ortho/Urology etc) push back and forego the fellowship year? I imagine there’s plenty of work for acute care surgery and trauma, which any surgery resident should be prepared to handle after a 5 year residency.
Seems surgery is pretty well insulted from PE and mid-levels👀 And pretty low-risk in general.
www.medpagetoday.com
Derm can actually get pretty saturated easily. There's been a pretty good expansion of derm residencies (though not nearly as much as EM or rad onc), and a lot of IM/FM docs are competing with dermatologists to do many of the same simple elective cosmetic derm procedures that they do, but instead do it in their primary care office since (many are cash based with high profit margins whether done by a dermatologist or IM/FM doc). Sure, the complication rates will likely be higher when these procedures are done by IM/FM docs as expected, but when that happens they will then refer the patient to a dermatologist or plastic surgeon, but are still only held to the standard of care of a general practitioner. Mid level encroachment in derm is a mixed bag - they can get into it do more medical dermatology, but I suspect that for most of the cash based elective procedures most people who have the money and want these elective procedures will specifically request a dermatologist to perform instead of their NP/PA.
It's interesting you mention "push back and forego the fellowship year." These threads are always full of attendings that have interesting insight into attending salary and their specialty's grip on the field. That's relevant for attendings, but for a med student extra years of training may be the #1 factor in terms of earning potential and mitigating the chance of financial disaster.
I get your point but your numbers are pretty off for the surgeon… a colon and rectal surgeon is not making 440k their entire career, they will likely hit that 2 years after graduating fellowship. I don’t know a mid career CRS surgeon making less than 500k… many of them make quite a bit more.
I used the 2019 MGMA median for CRS to get to $440K. EM's median is $363K. I'm sure it's a bit higher now, but so is EM.
The 440k median is 2 years out of training… your numbers are off. And this analysis doesn’t even touch the fact the EM doc coming out of residency right now is going to have little geographic flexibility or ability to change jobs without a pay cut, while the surgeon can live just about anywhere and find a job, and unless things change significantly will have an email inbox of job offers waiting for the moment they want a location change
When I live somewhere that has a wait time for new derm patients under 4 months, then I'll be concerned.
It’s under that in New England and Mid Atlantic.
This. And don't forget the major impact of taxes have on your income, especially as an attending. When you're in the 35-37% federal income tax bracket plus an additional 1.45% for Medicare and another 5-10% of state taxes, that's about an extra 37-47% of your additional income going to taxes. So the higher paid specialist that makes $150k per year more pretax than a lower paid specialty will be taking home only around $85k more post-tax. And if they spent 3-5 years more in training than someone who did a 3-year EM, IM, or FM residency, it may take 10-20 years post-training for them to catch up financially. They may still come out slightly ahead late career, but the difference is a lot smaller than what it makes seem like on the surface by simply seeing that Physician A makes $500k per year while Physician B only makes $350k per year. This is especially the case once you considering the head start in investing savings that also happens when you start making the attending paycheck sooner.
My initial post was not about EM vs. surgery, more about the issue of over-specialization in many specialties. IMO most (>80%) of general surgeons, ortho surgeons, radiologists, should seriously question why they’re doing a fellowship. Academics love to blather on about “questioning dogma”, well what about the current dogma they sell to naive residents about fellowship?
Yup, FWIW I accounted for all of this in my numbers. I built a calculator years ago (out of pure masochism) to see how much I was losing by going the MD/PhD route. Over the years I've added to it piece by piece and so far it's done fairly well when testing it against real scenarios. So I think it's an okay tool. I basically have Python read an excel sheet that has inputs year by year like salary, loan payments, loan interest, post-tax savings rate, etc... It accounts for federal and state taxes, though right now it just picks a middle ground, and it let's you pick a rate for interest on investments (I chose 6%, inflation adjusted).
Well the thread is about risk. Sorry if I piggybacked off your comment to make a tangential point, it just seemed relevant, and it's a soapbox of mine I guess. I'm actually quite okay with my choices, but when I signed up for MD/PhD I didn't really understand the full impact of a long training horizon. I like to communicate that to med students often, because we have an epidemic of senior leadership stealing our time.
Ah, I thought CRS was a two year fellowship. So mea culpa there. FWIW it changes the outcome very little (CRS surgeon retires with $5.8M). However, the MGMA 2019 median is $440K, and that's for all years of experience. Like I said, I'm sure the numbers are different since the data was collected 4 years ago, but I'm comparing from the same source for EM vs. CRS. Again, the actual number is completely irrelevant, and I'm fully aware it's off.
The reason to do fellowship varies by specialty. It’s not usually about the money You can’t do meaningful cards, gi, pulm or icu without a fellowship. Could probably do some ID, rheum and endocrine but not at the level of someone with years more of training on that one subject.
forums.studentdoctor.net
Wait until have you kid and need child care.
I think you're both right, ultimately, but it depends on the physician. It's easy to become quietly wealthy, having already adjusted to a very humble standard of living as a med student/resident. It's also easy to lose all financial sense once you have a real income.
Present Housing costs and inflation throws so much of this into doubt. well finished 4 bedroom home easily over one mill in most desirable locations. propery tax on that alone is 20+k. hard to know if that is a good investment or not.
There is perhaps no specialty in medicine with a greater combination of demand plus APP insulation than neuro - we have subspecialists with new patient wait times of 12-16 months where I work - but the issue is always going to be absolute salary. Med students are going to look at median salary numbers and say "neurology makes less than EM" not realizing that those EM jobs are hard to find whereas the neurology job market is hot.
I have spoken to them. They don't care. It's all about lobby money. And midlevels have much more.
Isn’t it more of an issue of class consciousness that is lacking within physicians compared to np/pa. AMA is only outspent by a few lobbying orgs, none of which are np/pa. Even outspent Amazon
| Lobbying Client | U.S. Chamber of Commerce |
|---|---|
| Total Spent | $66.4 million |
| Lobbying Client | National Association of Realtors |
| Total Spent | $44 million |
| Lobbying Client | Pharmaceutical Research & Manufacturers of America |
| Total Spent | $30.4 million |
| Lobbying Client | Business Roundtable |
| Total Spent | $29.1 million |
| Lobbying Client | Blue Cross/Blue Shield |
| Total Spent | $25.1 million |
| Lobbying Client | American Hospital Association |
| Total Spent | $25.1 million |
| Lobbying Client | Meta |
| Total Spent | $20 million |
| Lobbying Client | American Medical Association |
| Total Spent | $19.5 million |
| Lobbying Client | Amazon.com |
| Total Spent | $19.3 million |
| Lobbying Client | American Chemistry Council |
| Total Spent | $16.6 million |
The state by state lobbies midlevels beat us. Heck psychologist have prescription rights in some states.Isn’t it more of an issue of class consciousness that is lacking within physicians compared to np/pa. AMA is only outspent by a few lobbying orgs, none of which are np/pa. Even outspent Amazon
Top spenders on federal lobbying, 2021
Source: Opensecrets.org
Lobbying Client U.S. Chamber of Commerce Total Spent $66.4 million Lobbying Client National Association of Realtors Total Spent $44 million Lobbying Client Pharmaceutical Research & Manufacturers of America Total Spent $30.4 million Lobbying Client Business Roundtable Total Spent $29.1 million Lobbying Client Blue Cross/Blue Shield Total Spent $25.1 million Lobbying Client American Hospital Association Total Spent $25.1 million Lobbying Client Meta Total Spent $20 million Lobbying Client American Medical Association Total Spent $19.5 million Lobbying Client Amazon.com Total Spent $19.3 million Lobbying Client American Chemistry Council Total Spent $16.6 million
THE WASHINGTON POST
My understanding is that EM experienced the combination of aggressive residency expansion and diminished volume due to midlevel work in the ER. Midlevels can't do anything to your job security if the people who move the levers on residency spots tighten up when they see midlevels taking a slice of the pie. However, if you have weak leadership in the field, you're going to have problems.
Wouldn’t this lead to midlevels crashing and burning? Even in the next decade? I imagine their salaries would take a major hit from saturation. Not to mention the malpractice insurance they’ll take on from independent practice.
Yep. NP schools are generally easier to get into than PA schools just because there are a lot more NP programs out there. PA school is actually somewhat competitive to get into with an overall national acceptance rate in the low 30s% (which btw is lower than the recent USMD school acceptance rate). Many RNs are doing it just to get away from bedside nursing, which is adding to the already ongoing nursing shortage across the board. It won't be long until hourly salaries for RNs and NPs equal out.
I am going to say that for medical students that are reading this thread. It is NOT difficult to make 300k+ as a FM/IM doc. It's actually EASY if you know where to look.
Unless you are hellbent on academia, I would definitely aim for ID/crit care.
Makes sense. With hospital epi, antimicrobial stewardship and the opportuntity to further subspecialize into transplant ID or something if the going gets rough I hope the field will be okay. Still going to try to aim for the combo fellowship, board eligible for critical care for just one extra year is a good deal.
but then why not just ...do crit care?
For me personally, I primarily want to do ID, so that's not negotiable for me. What I've read is that when you add the crit care there's a few different setups that physicians with the dual training do, either mostly CCM with some ID or vice versa. I'm mostly thinking having CCM training could be a good backup?
academic.oup.com
In most cases, you will end up practicing primarily one over the other... If you do ID, IM is already your backup.For me personally, I primarily want to do ID, so that's not negotiable for me. What I've read is that when you add the crit care there's a few different setups that physicians with the dual training do, either mostly CCM with some ID or vice versa. I'm mostly thinking having CCM training could be a good backup?
Synergy, Salary, and Satisfaction: Benefits of Training in Critical Care Medicine and Infectious Diseases Gleaned From a National Pilot Survey of Dually Trained Physicians
A survey of physicians trained in critical care medicine (CCM) and infectious diseases (ID) suggested this combination is synergistic and satisfying. However, m
thats fair then! sometimes when people ask these questions they're really more focused on the money in which case i think it's not the best choice (vs cc alone), but if you think you really may do both it would be worth it. I've heard mixed things on what people actually do with it but if it interests you then go for it. You may end up doing mostly one in the end, but that doesn't have to be a bad thing if it feels worth it to your goalsFor me personally, I primarily want to do ID, so that's not negotiable for me. What I've read is that when you add the crit care there's a few different setups that physicians with the dual training do, either mostly CCM with some ID or vice versa. I'm mostly thinking having CCM training could be a good backup?
Synergy, Salary, and Satisfaction: Benefits of Training in Critical Care Medicine and Infectious Diseases Gleaned From a National Pilot Survey of Dually Trained Physicians
A survey of physicians trained in critical care medicine (CCM) and infectious diseases (ID) suggested this combination is synergistic and satisfying. However, m
