Winged Scapula

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It can be.

I know some who took jobs under $200K because they were limited geographically. Of my fellowship class, most of us were offered jobs ranging from $200K to $375K.

I can tell you that I personally make more than that. However, I am fairly aggresive in biopsying and following patients up. My money is NOT made in the OR but rather in the office. The key in breast surgery is volume and image guided procedures. It remains to be seen what the new CMS proposals on imaging in medicine will do to these but be aware that the typical reimbursement for breast procedures without imaging is low.

It is not clear to me who the AGMA surveyed for this data; I didn't get one. Many breast surgeons work less than full-time, not sure if this was accounted for in the survey. But you shouldn't go into breast surgery with the idea that you'll be making as much as other subspecialists.
 
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I definitely understand that breast surgery has lower RVUs per procedure, but that low $200,000 as a "median" is ridiculous. It's almost HALF as much as the median as a general surgeon on that survey as well as any other surgeons. Training for 6-7 years after med school and possibly only making that much seems depressing.

Winged Scapula-thanks for all your posts and responses about breast surgery. I read all your past posts and based on them, breast surgery still sounds like an encouraging field. Speaking to other breast surgeons in private practice, it seems that they still work significant hours (over 50/week). So yes, spending time in a hospital past 6 or 7pm is a rarity, the cummulative hours imply that per hour of work, breast surgeons can make a lot less than general surgeons (unless you're savvy at office-based procedures andcoding/billing). A couple of questions:

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?

2) So the salary is mainly based on image-guided office-based procedures. Is there a positive or negative relationship between radiologists and breast surgeons currently and will this improve or get worse? My chairman predicts that in ten years, the majority of breast care will be taken over by radiologists except for those that need to get a full mastectomy. He thinks that family practice docs/internists will refer patients to the radiologists, and they will do the biopsies/ultrasounds/mammosite placement/etc. So if this is a possibility, I do worry about my future role as a breast surgeon.

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.
 

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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?
As a fellow Northeasterner (though I'm playing the part of a Midwesterner at the moment... :scared:), I can tell you that if you're dead set on going back to the Boston-NY-DC corridor you're going to have to be ready to take a pay cut. And I mean a real pay cut compared to your peers in the Midwest, the West Coast (excluding LA and SF -- but Central California to some extent), and especially the South.

The various groups and hospitals in any particular region know what everyone else is offering and what the going rate is, especially for fresh-outta-fellowship/residency graduates. If you interview in 10 spots in the same area, you're likely to get pretty much the same offer. The bigger differences seem to come when considering academic vs. private practice.

I'm relatively new to the job search thing as I'm in the middle of it right now, but this is what I've read and what I've seen so far...

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.
I think both Breast Surgeons and Vascular Surgeons suffer from the same manpower issues -- there just aren't enough of them to go around, so bottom-dwellers like Cards and IR will take up cases and leave the surgeons to deal with all the middle of the night BS and their iatrogenic complications. It's not a good situation. I think it'll be like this for quite some time until surgeons wise up and 1) shorten the length of training, thereby increasing the number of people attracted to the discipline and 2) pick up the procedures that Cards and IR do and hit them back where it hurts.
 

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On a completely unrelated issue -- this is proof positive that CMS monitors these surveys to see where cuts can be made to be "just" and "fair".... just remember that when deciding whether to participate in these surveys.
 

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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.
 

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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.
Sure its possible. However, you may be limited by your malpractice coverage (ie, you have to have a separate rider for any plastics cases) and your hospital privileges (ie, you won't be privileged to do reconstruction at most places without showing that you have been adequately trained - whatever that means).Finally, even if you were covered and privileged, you may wish to consider that without significant additional training to do reconstruction, what happens if you have a complication and are sued? Can you protect yourself when the plaintiff's attorney asks why you didn't refer the patient to a *real* plastic surgeon? If you live in an isolated community without a plastic surgeon, you might be able to get away with it.

You should realize that reconstruction doesn't pay much. If you're doing it at the time you do a mastectomy, since it will be a multiple procedure, you're looking at 50% or less reimbursement. Not much when you consider all the above factors.

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.
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.

PCPs or office staff who don't know that the surgeons can do the biopsies AND offer the follow-up (including follow-up complications from a biopsy performed by the radiologist), will sign the order and send it back in. Its easy.

I have a good relationship with our PCPs and they prefer that I do the biopsy, call the patient with the results (not all radiologists do, leaving it to the PCP to figure out the patient has had a biopsy, to locate the biopsy results, interpret them (have seen two patients this week told they had cancer when they had a benign result of LCIS) and inform the patient), and arrange follow-up and education of the patient. But it took some work, marketing and education on my part.

It makes sense for radiologists to do image guided procedures and I don't begrudge them doing so, especially if they can do it sooner than I can. However, most PCPs "get it", as I've outlined above and do prefer the patient see the surgeon. However, many aren't aware that it can be done percutaneously by the surgeon or trained in an environment where the surgeons didn't do needle biopsies other than FNAs. Not all patients with a breast mass need to see a surgeon. Its preferable, to me at least, that I see the patient to discuss the options for management of a benign mass, but many patients are fine doing nothing and do not want to see a surgeon.
 
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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.
 

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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.
Castro made that comment 7 months ago, so your comeback is a little delayed.

Also, be careful about coming onto a surgical forum and declaring your superior caliber. You'll start a war that you're unlikely to win. I suggest you take a deep breath, grab a cup of coffee, and head back to your dark room.
 

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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.
Agreed, this is the case at our institution too. By the time they've come to the breast center, they've had mammos, U/S, biopsies, and often MRIs and BSGIs. All they need is a sticker on the breast saying "cut here."

Sometimes we have to explain to the patients why they need a different operation than the radiologists said they needed.
 

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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.
I think the point is not that "you can schedule a follow-up"... the point is, and what upsets Surgeons about when radiologists do procedures, is that radiologists in general (I don't want to imply that all of them do this) perform the procedure and then have no ownership of it afterwards. As Winged Pointed out, not all radiologists even convey the results of these tests to patients, and not all radiologists understand what results mean, so essentially radiologists are serving as technicians performing the procedures but not serving as doctors analyzing data and conveining what it means and what options there are to patients. Many times, if rads does a procedure and patient needs observing or to be admitted overnight, it gets "dumped" onto a surgical team... conversely though, surgeons take for granted that IR will do PICC lines or other "procedures" for them that they have no interest in doing. Turf wars are funny things
 

Winged Scapula

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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 lose 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. I work very closely professional and socially with radiologists and anesthesiologists and respect them as they do me. There is no room for such antagonistic behavior in the real world.

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.
 
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SLUser11

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Geez....it's going to be hard for eek to develop a comeback from that one. It might take him another 7 months or so.....









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.
 

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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.
Well since the caliber of students going into plastic surgery is significantly higher than those going into radiology, does that mean it's okay for me to call you a "bottom-dweller"? Bottom-dweller. ;):thumbup:
 

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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.
I think that this comment alone demonstrates that, as a radiologist, you still have a lot to learn about clinical medicine and the day-to-day care of patients.

As a resident in a primary care specialty, I would say that 40% of the care of the patient is actually performing the procedure, 60% of it is making sure that the patient doesn't get "lost to followup." What's the point of doing the procedure if you aren't going to do something about a positive result?

Whoever is better at following up on the patient's results is, for me, the person who should be doing the procedure.
 
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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.
 

Elach

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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.
Nice try, undercover pediatrician! :D
 

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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 $$$ and prestige.
Why stop there? Perhaps all healthcare workers should get paid the same. That way people who really want to be nurses or patient care techs won't be distracted by the $$$ 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.
 

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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.
 
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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.

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.
 

SLUser11

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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.
 
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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.
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?
 

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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?
I think orthopedic surgeons already consider themselves beast surgeons.
 

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which is why some specialties are full of unsavory people.
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
  1. taking care of patients which is a huge responsibility in itself
  2. responsible for someone else's health and physical/mental wellbeing
  3. 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)?

For example surgery residents on average work more hours than medicine residents, but medicine residents should be using that time to study.
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.
 
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I think we think alike on many points. I agree that the financial incentives in medicine are poorly structured. And we also agree that reimbursement system favors procedures over cognitive tasks which contributes a lot to salary inequalities between specialties. 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 don't think anyone should take call for free. 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). But even taking into account number of hours worked there are certain specialties that get reimbursed at a far higher rate than other specialties. That is what I am against. This exists even among surgical subspecialties. Why should a urologist make more than a breast surgeon? Why should a spine surgeon make more than a transplant surgeon?

The 26 hour surgeries happen at academic centers where surgeons make less than in private practice...

And all this still does not address the logical extension of what you're proposing: PAs, NPs, and RNs are all
  1. taking care of patients which is a huge responsibility in itself
  2. responsible for someone else's health and physical/mental wellbeing
  3. 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)
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.
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
  1. taking care of patients which is a huge responsibility in itself
  2. responsible for someone else's health and physical/mental wellbeing
  3. 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.
 
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Svidrillion

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I guess you lost me, so perhaps you could clarify a few things.

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).
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)?

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.
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?
 

LucidSplash

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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.
 

SLUser11

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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.
Why u no think me smart? me cut when told. me good cutter.

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.
me say already.
 

LucidSplash

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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)?
Ok I was unclear. What I meant was that all specialties should get paid the same. By pay I am looking at the average salaries across specialties which already factors in malpractice (liability). Even when controlling for # of hours worked there are large inequalities across specialties. The simplest reimbursement scheme to achieve this would be to raise the reimbursement for cognitive work. I realize that docs will get paid differently if they do private practice, work at the VA, take cash only, or do academia etc but I am looking at average salaries and average # of hours worked.

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?
That is an entirely different argument. 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. Just because it is valid or invalid in one situation does not mean it is valid or invalid in this case. I believe the key for midlevel providers is proving that they can achieve the same outcomes despite less training. When looking at salaries across specialties, it does not make sense to look at outcomes of a urologist vs. a radiologist. I am basing my argument on the merit of work and I am saying that there is no reason why the work of one specialty should be valued more than another's work in terms of monetary reimbursement.

I have nothing against surgeons and I am well aware that they do "cognitive" work as well. I see general surgeons as internal medicine docs who also do surgery. And as a trauma surgeon once told me, the actual doing surgery part is easy but the hardest part is the preop/postop/deciding whether or not to do surgery, which is all cognitive. I have repeatedly said that I would favor raising reimbursements for nonprocedural work vs. cutting reimbursements for procedural work. i get the feeling that surgeons feel like they are being attacked or having something taken away from them. 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.
 
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Svidrillion

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The simplest reimbursement scheme to achieve this would be to raise the reimbursement for cognitive work.
I don't oppose this, but it still does nothing to correct the gross disparities among the surgical specialists that you are so worried about. 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.

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.
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).

Likewise, not all cognitive tasks are created equally: I submit that diagnosing chicken pox and working up a complex patient that turns out to have abdominal pain induced by porphyria are not equivalently difficult, nor are these tasks equivalently difficult for different people. Some young practitioners nowadays may have never seen a case of chicken pox and might mis-diagnose it, whereas my mother diagnosed us kids when we were little because she'd seen it so many times before. The question is, what are you paying for?
As a consumer, as you paying for the difficulty of the task? How much energy the task takes? Or are you paying for expertise, which requires years of training, after which certain tasks become relatively easy (even though they are impossibly difficult without that training)?

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). And the PCP who works 50-60 hours a week prescribing HTN meds and antibiotics for viral URIs, as well as doing routine physical examinations, will still make much less than his/her specialized peers.

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.

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.
 
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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].


Exactly my point. I think that reimbursement rates should be re-evaluated for a lot of things.

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 tried to clarify my point but if you think I am just trying to "back away" then there is nothing I can do about it. I think you think I am a socialist!

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.
I did not take say I supported midlevels. I just said that the key to their argument is proving that they have the same outcomes. Yes they are doing the same work but do they achieve the same outcomes? I think that is still up for debate. I did not think about viewing midlevels as another class of specialists but I don't really have a strong opinion (besides my own bias as a future MD) on how they should reimbursed.

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).
I do not really agree. I think the difference in length of training has more to do with getting # of cases under your belt rather than difficulty. Cases don't just magically appear and even then how many can you do a day? I would rather be in the OR on autopilot with music in the background than in clinic working up back pain. But given length of training there are still inequalities across specialties. For example EM vs. IM. Another example is pediatrics subspecialties (3 years peds + 3 year fellowships=6 years).

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.
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?
 
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Svidrillion

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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.
 

DoctwoB

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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. Even within specialties, there are procedures that pay more relative to the work and skill required then others, and those differences are even larger between specialties. That's just a fact of the current reimbursement system. As WS was saying here, if she could sit and do stereotactic biopsies all day instead of mastectomies, she'd be much richer, despite the fact that biopsies may not require more "skill."

How do you fix this? I have no idea. The entire system is so heavily invested in the current payment structure that significant changes will cost billions in lost capital. Also, the fact that some procedures are "over-reimbursed" allows docs to perform more of the underpaid procedures/consults or take more medicare/caid patients without going bust.

And while it could be argued that its "not fair" that specialists make more money then generalists, one could also argue that people going into different specialties make an informed decision with the knowledge of likely salaries. It is equally "not fair" to change that system after people have made nearly irreversible specialty choices based on the current system.
 

Svidrillion

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Arguing that the current reimbursement structure is extremely arbitrary and proposing a change is not socialism.
The premise proposed by Senor/Senorita Copes was not a simple proposal for change to the current reimbursement structure, but that "all doctors should get paid the same." That is the part that is socialist (and I make no value judgement about socialism--it is a system used with varying degrees of success in various places at various times.) It was my contention (if you read the whole thread) that reimbursement probably ought to be adjusted to remove obvious inequities (like paying PM&R docs bookoo bucks for spine injections and nothing for complex medical decision making).

The bottom line is that not all tasks performed by different doctors are equally challenging or equally valuable, even within the same specialty. Some tasks are easy once you gain the expertise, but require more years of training to obtain that expertise. 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.

Diagnosing and treating hypertension will never be as difficult or require as much training as removing a gallbladder, and thus removing a gallbladder will (or should) always garner more remuneration. The inequity of pay will (and should) always exist, and thus doctors will (or should) not ever "get paid the same". The real question is how to properly assess the proper reimbursement for various tasks.
 

Toennis

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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.
in a way this is a socialist statement as well
 

thedrjojo

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I happened to see one of the SICU nurse's W2's while on call last night (we have digital w2's and she was asking me to help her access hers and print it out...) Lets just say, I was depressed the rest of the night with the current career choice... :eek: she was making 3 times what I make (granted she has like 20yrs experience in this hospital)
 

Buzz Me

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They get paid extra for nights, weekends, overtime, holidays, etc. Then extra for ICU. Then extra for years of seniority/experience.

Some of our experienced ICU nurses here make over $120k a year.
 

bedrock

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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........
 
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