1) Have you found that any ONE region in the US pays more/less? I plan to be in the Northeast, so that does make me somewhat geographically restricted. I don't particular need to be in any one city. Or is it a crapshoot among different hospitals/private practice groups?
Already in my city, over 50% of endovascular work is done by interventional radiology, and now cardiologists are doing endovascular AAA, so of course the vascular surgeons are pissed because they are handling all the middle-of-the-night crap without the elective perks.
Is there a possibility that breast surgeons may start doing some minor reconstruction procedures(tissue expanders/implants)? This seems pretty easy to learn and patients may prefer to have one surgeon to take care of everything.
I can't imagine a primary care physician referring a patient with a breast mass to a radiologist. Sure, a radiologist can do a biopsy, but then what? Eventually the patient should be seen by a breast surgeon who understands the pathology report and who can take care of the patient. It doesn't make sense for a radiologist to provide care for this patient population.
in reply to Dr. Viejo's self-serving statements about radiologists being "bottom dwellers", not only are they better trained to do imaging guided procedures, but there wouldn't be imaging guided procedures if it wasn't for them. Both vascular and cards should have benefited from rads without having to do much work to come up with those procedures. The ability to schedule a follow-up after a procedure hardly qualifies or justifies someone performing a procedure, and going to a 1-week course to learn a procedure does not equate to 6 or 7 years of training. Furthermore, the caliber of students going into rads is signficantly higher then those going into surgery, and before someone quotes lifestyle, I do not think the "lifestyle" does not cross people's minds when they pick breast surgery, having one of the best lifestyles in surgery, and those that think radiology is a lifestyle specialty do not know much about it. if surgeons want to do breast biopsies then, they should go ahead and do the diagnostic/screening mams too, deal with that patient population, deal with the shadow of a lawsuit with every missed lump 10 years after a screen was done.
Then you don't know PCPs and radiologists. Out here the radiologists have started to aggressively market themselves. A patient comes in and is found to have an abnormal mammogram. While the patient is in the facility, they are scheduled for a biopsy by the radiologist and an order for the biopsy is faxed to the PCP.
in reply to Dr. Viejo's self-serving statements about radiologists being "bottom dwellers", not only are they better trained to do imaging guided procedures, but there wouldn't be imaging guided procedures if it wasn't for them. Both vascular and cards should have benefited from rads without having to do much work to come up with those procedures. The ability to schedule a follow-up after a procedure hardly qualifies or justifies someone performing a procedure, and going to a 1-week course to learn a procedure does not equate to 6 or 7 years of training. Furthermore, the caliber of students going into rads is signficantly higher then those going into surgery, and before someone quotes lifestyle, I do not think the "lifestyle" does not cross people's minds when they pick breast surgery, having one of the best lifestyles in surgery, and those that think radiology is a lifestyle specialty do not know much about it. if surgeons want to do breast biopsies then, they should go ahead and do the diagnostic/screening mams too, deal with that patient population, deal with the shadow of a lawsuit with every missed lump 10 years after a screen was done.
SDN is about developing collegial relationships amongst practitioners and different specialties. However, we all realize that there are turf battles and at times, arguments will spring up between different specialties.
eekthecat, you must realize that you are welcome to join in on any discussion here in the Surgery Forums. However, it is a Terms of Service violation to enter a specialty specific forum with the express intent to bash those practitioners there. You are welcome to join in on the discussion and offer a unique perspective; you are not welcome to post about the superiority of radiology residents in an attempt to derogate surgerons and surgical residents.
Now for some history:
- stereotactic biopsy was not developed by radiologists by rather by a neurosurgeon and an engineer;
- the first stereotactic biopsy to be performed in the US was not by a radiologist, but by Dr. Kambiz Dowlat, a surgeon at Rush University in Chicago, who has also pioneered other percutaneous biopsies and treatments
- the American College of Radiology, in conjunction with the American College of Surgeons and the American Society of Breast Surgeons, developed guidelines for the performance and certification process involved in percutaneous image guided biopsies for the breast. Those are guidelines that I happen to exceed on every point (as a matter of fact, I perform more stereotactic biopsies yearly here than any of the radiologists).
If you have a problem with surgeons doing image guided biopsies, then you need to take it up with the ACR as they were the ones who developed guidelines for proficiency and credentialing. Surgeons cannot meet those guidelines with a "1 week course", nor can a radiologist.
In addition, no one doubts that radiologists are excellent at what they do but to claim that "6-7" years of training encompasses 6-7 years of image guided biopsy training is simply false; the vast majority is DR of all forms. The ACR has decided what the requirements are for doing those biopsies and it does not require a full radiology residency or fellowship (which is where I assume the 6-7 years comes from).
The issue of physicians performing procedures and not following up on complications, pathology results or a management plan is not unique to radiology; we have the same issues with GI. However, the problems are not ones that I have identified, but rather PCPs have. I think I offer more than the "ability to schedule a follow-up." That really belittles what I and other practitioners do. Again, if you are willing to post a reasonable and thoughtful argument, you are welcome here, but insulting us is not.
Finally, if you think that radiologists are the only ones being sued for missing a lesion, think again. Not a day goes by when I and my colleagues see a patient with a "breast mass" and normal imaging, an area that feels like normal fibroglandular tissue to me. I loose sleep at night wondering how many of those might turn out to be a malignancy that I missed and that I will be sued for. Its a very real problem and one of the reasons why my malpractice rates are higher than the local radiologists.
So I'll ask that everyone play nicely in the sandbox and realize the relative contributions we make to taking care of patients. But there is no need to rewrite history or insult each other.
in reply to Dr. Viejo's self-serving statements about radiologists being "bottom dwellers", not only are they better trained to do imaging guided procedures, but there wouldn't be imaging guided procedures if it wasn't for them. Both vascular and cards should have benefited from rads without having to do much work to come up with those procedures. The ability to schedule a follow-up after a procedure hardly qualifies or justifies someone performing a procedure, and going to a 1-week course to learn a procedure does not equate to 6 or 7 years of training. Furthermore, the caliber of students going into rads is signficantly higher then those going into surgery, and before someone quotes lifestyle, I do not think the "lifestyle" does not cross people's minds when they pick breast surgery, having one of the best lifestyles in surgery, and those that think radiology is a lifestyle specialty do not know much about it. if surgeons want to do breast biopsies then, they should go ahead and do the diagnostic/screening mams too, deal with that patient population, deal with the shadow of a lawsuit with every missed lump 10 years after a screen was done.
The ability to schedule a follow-up after a procedure hardly qualifies or justifies someone performing a procedure, and going to a 1-week course to learn a procedure does not equate to 6 or 7 years of training.
This thread is an example of why I think all doctors should get paid the same, regardless of specialty. No more turf wars, or certain specialties feeling superior over other specialties. People can actually pick what they would be happy doing instead of being distracted by $$$ and prestige.
This thread is an example of why I think all doctors should get paid the same, regardless of specialty. No more turf wars, or certain specialties feeling superior over other specialties. People can actually pick what they would be happy doing instead of being distracted by $$$ and prestige.
This thread is an example of why I think all doctors should get paid the same, regardless of specialty. No more turf wars, or certain specialties feeling superior over other specialties. People can actually pick what they would be happy doing instead of being distracted by $$$ and prestige.
I agree, comrade!! These capitalist pigs need to be taught a lesson.
Why stop there? Perhaps all healthcare workers should get paid the same. That way people who really want to be nurses or patient care techs won't be distracted by the $$$ and prestige and instead will pick what they would be happy doing (nursing, patient care teching) and forgo the hassle and expense of medical school/residency.
I see the point you are trying to make. As a med. student I felt the same way you did the first two years. When I hit rotations I began to realize that no matter what specialty you are in, you are first and foremost taking care of patients which is a huge responsibility in itself. No matter what specialty you go into you will be responsible for someone else's health and physical/mental wellbeing. Secondly, I don't think any specialty is inherently more difficult or intricate than any other to master. For example surgery residents on average work more hours than medicine residents, but medicine residents should be using that time to study. 12-16 hour days on surgery are tiring, but I feel just as wasted spending just 8 hours in medicine clinic seeing patient after patient. I am not against physicians making a very good living. Notice I said all specialties should get paid the same, but I never said how much. I think most docs are underpaid for all the crap they have to go through. But I think the pay inequalities create a hiearchy in medicine that is detrimental to collaboration between physicians and therefore patient care. And I think it causes some people to go into some specialities for the wrong reasons which is why some specialties are full of unsavory people.
Your viewpoint is naive and unrealistic. Sure, most doctors work pretty hard....and most doctors make a pretty good living. However, there's no doubt that the number of years and number of hours spent becoming board certified in different specialties are not the same. Risk and liability are different as well.
Most reasonable people are not going to voluntarily work harder and take on more professional risk if there's no monetary reward for the decision...especially not the general surgeon, where the pain:benefit ratio is already so poorly balanced.
I think orthopedic surgeons already consider themselves beast surgeons.Even taking into account malpractice and overhead there are large disparities in salaries between specialties. When did I say general surgeons should make less? If anything, they should make more. I also think internal medicine doctors should make as much as radiologists. Beast surgeons should make as much as orthopedic surgeons. How about that?
which is why some specialties are full of unsavory people.
For example surgery residents on average work more hours than medicine residents, but medicine residents should be using that time to study.
nice try, undercover pediatrician!
And all this still does not address the logical extension of what you're proposing: PAs, NPs, and RNs are all
- taking care of patients which is a huge responsibility in itself
- responsible for someone else's health and physical/mental wellbeing
- likely feel wasted after 8 hours of answering call buttons and putting up with patients' crap (as they deal with them more intimately than most docs do)
You have already conceded that there are unsavory people in medicine. This illustrates the point. These unsavory folks are not going to work hard without incentives. This is also true for savory people. It is the rare individual in any field (medicine or other) who works harder just for kicks. Why would I spend my Saturday seeing abdominal pain complaints when I could be at home with my daughter, and still get paid the same?
The lack of incentives is already killing medicine as it is. For instance, at my hospital, the EM docs are all salaried (as are the residents). Thus there is no incentive for them to see more patients. Why would I work hard to move patients through the system when those discharged patients are just going to be replaced with more patients that I need to work up? Now, if they were paid more for seeing more patients, I think our ER would have much shorter wait times.
The same goes for admitting patients. Turns out that no one (including medicine) wants to admit patients, but everyone wants to consult. I saw a fight the other day between vascular surgery, transplant surgery, and nephrology about who was going to be the admitting team for a fistula abscess and who was going to consult. No one wanted to admit because it's more work with no incentive. This is census protection. If you got paid more for being the admitting team, I think the conversations would have been different.
The same goes with consults in a university hospital: residents groan when they get new consults because it's more work but no benefit (except potentially learning, but we all know that education is the only commodity where people will pay more for less). On the other hand, I rotated at a large community hospital where all the consultants are private attendings. Those docs love consults and never, ever refuse them--because they get paid more for seeing those patients. And they're always extremely pleasant about the whole thing.
I do concur with what may be your underlying sentiment: the reimbursement structure as it is right now is unfair to cognitive tasks in favor of procedures. Optimizing a difficult patient's diabetes regimen can be a challenging cognitive task for which those docs are probably not properly reimbursed because it's not as easy to quantify and measure as doing a spine injection.
But to think even that all docs in the same field (such as all breast surgeons) should make the same regardless of how many breast biopsies or mastectomies they do--much less that all physicians should make the same, regardless of whether they're just triaging in the ER or doing a 26-hour free flap--is plainly ludicrous and would destroy medicine with sloth.
And all this still does not address the logical extension of what you're proposing: PAs, NPs, and RNs are all
- taking care of patients which is a huge responsibility in itself
- responsible for someone else's health and physical/mental wellbeing
- likely feel wasted after 8 hours of answering call buttons and putting up with patients' crap (as they deal with them more intimately than most docs do)
So on that basis, why begrudge them the same pay as a primary care doc (who happens to make the same as a pediatric surgeon under your scheme)?
And maybe you honestly don't know this, but I'm pretty sure that surgery residents have as much or more to study than medicine residents--and still work on average more hours. Go figure.
I think orthopedic surgeons already consider themselves beast surgeons.
Obviously those who work more should make more. I never said all physicians should be salaried employees (although I have met salaried docs who are very happy with their situation).
I would be careful of where you are going with this argument with midlevel encroachment becoming a bigger issue in medicine. NP's can take history and physicals just as well as CRNAs can do ASA1/2 cases just as well as PAs can harvest saphenous veins endovascularly.
My point is that 1hr of procedural work is not any more intrinsically difficult than 1hr of cognitive tasks. I would also argue that mastering the skills in procedures vs. cognitive tasks takes the same amount of time and effort. You have to work hard regardless of whether you are diagnosing and managing someone's illness or doing a procedure on them.
I'm a little surprised that no one here has pointed out the obvious fallacy that "procedural work" occurs exclusive of "cognitive work." The current discussion occurs to be set in the framework that surgeons are little more than technicians and we leave all the complex "cognitive work" up to the medicine folks.
Additionally, it should be pointed out that not all specialties carry the same level of inherent risk and more goes into reimbursement than the number of hours worked.
I think this is my line as the junior surgery resident.Why u no think me smart? me cut when told. me good cutter.
I must have been too busy employing my procedural typing skills to notice with my cognitive skills.me say already.
I guess you lost me, so perhaps you could clarify a few things.
You said "all doctors should get paid the same." Now you say that people who work more should get paid more--which means they won't get paid the same, by the way. I assumed that for all doctors to get paid the same, they'd all have to be salaried, but apparently not.
Can you describe the reimbursement scheme you favor that would pay all doctors the same but also pay more to those who work more (and pay them even more extra to take call)?
Exactly. It's not my argument, it's your argument that emboldens NPs, PAs, and CRNAs. This is not something you can stop with partway, and I've only articulated it to its logical (and inevitable) conclusion.
If, as you say above, 1 hour of cognitive work equals one hour of procedural work, then the NP/PA who makes a diagnosis of viral URI in the office is working just as hard as a PCP that does the same thing, who is in turn working just as hard as an anesthesiologist who does a cervical block for arm surgery, who, finally, is working just as hard as the breast surgeon who does a U/S-guided needle biopsy of the breast. Those are the wages of 1 hour of cognitive work = 1 hour of procedural work. Is that not your point? Or have I misunderstood?
The simplest reimbursement scheme to achieve this would be to raise the reimbursement for cognitive work.
My argument was for the equalization of reimbursement across specialties and had nothing to do with midlevel providers. You are taking my argument out of context and applying it to the battle between docs and midlevel providers, where there are different variables to consider....I believe the key for midlevel providers is proving that they can achieve the same outcomes despite less training.
But if you are a surgery resident now, tell me you won't be pissed if you become a general surgeon and you spend all day in the OR just like the spine surgeon next door, except that he makes 700k/year and you make 250k/year.
And I though I'm not a surgeon of any kind, I wouldn't be any more upset about the spine surgeon making 700K because I can't (and am not) doing what he does. Maybe it's a lot harder than what I'm doing. And if not, the reimbursement should be re-evaluated, but not simply because we're both working the same number of hours in the OR, but because one task (cognitive or procedural) really isn't harder (or doesn't require any more expertise to master) than the other[/B].
Andi it's a far cry from your original lament of "all doctors should get paid the same," which you have now totally backed away from.
I think you are NOT putting your argument in PROPER context. What are midlevel providers but another class of specialists? I'm not sure why your argument would not apply to them, but would apply to specialties as different as radiology and dermatology and primary care internal medicine. If midlevels do the same cognitive work, they should get the same pay, a point you concede yourself in principle by supporting equalized pay as long as midlevels have the same outcomes. And I think that oftentimes PAs and CRNAs are doing the same work as PCPs and attending anesthesiologists.
But you hit upon a key point: less training. There is a reason that PCPs do only 3 years of IM or FM, and general surgeons do 5 years (and some argue should train longer). To say that the tasks performed by a PCP should be reimbursed at the same rates as those performed by a GS, you would really need to show that those tasks are equivalent in difficulty. I think that the length of training suggests that those tasks are not equivalently difficult (even though PCPs are just as tired after a day of clinic as a surgeon is after a day of operating).
Actually, the inchoate system you just described is the system we have now. That is how medicare reimbursements are determined currently. And private insurance reimbursement rates follow medicare's lead. Look up Specialty Society Relative Value Scale Update Committee (RUC). I am just proposing that reimbursements become more equal across specialties. You have just been arguing against me, but what is your stance? Are you happy with the way reimbursement rates are structured now?In any event, by the time you get through quantifying how comparatively different various cognitive tasks performed by physicians are, you end up with exactly the same system we currently have, with just as much disparity, but distributed slightly differently (and probably skewing even more in favor of those who simultaneously do procedures and cognitive tasks...like surgeons).
Similarly, some surgical subspecialists who do complicated surgeries will still, under your proposed (but admittedly inchoate) scheme, make more than breast surgeons who do lumpectomies and axillary lymph node dissections all day long.
I am just proposing that reimbursements become more equal across specialties.
Yeah. We're obviously not communicating on this issue and not going to make any headway on these issues. I basically don't agree with your characterization of anything you've said, but I'm apparently not articulate enough to make the necessary points.
Let me just note that making reimbursements across specialties more equal without somehow showing that the current inequity is unjustified (not just saying that a priori you think it's unjustified) is, in fact, socialism.
Arguing that the current reimbursement structure is extremely arbitrary and proposing a change is not socialism.
Some tasks are easy, so much so that even mid-levels can perform them with only a little training. And some tasks are challenging even with rigorous training. Such tasks should be differentially reimbursed.
(like paying PM&R docs bookoo bucks for spine injections and nothing for complex medical decision making).
.
what is bookoo?
what is bookoo?
= beaucoup
Originally Posted by Svidrillion View Post
(like paying PM&R docs bookoo bucks for spine injections and nothing for complex medical decision making).
what is bookoo?
something that PMR-Pain docs somehow can spell---despite their apparent lack of complex medical decision making........