What would happen if...

[inthezone2]

Endoscopy and colonoscopy reimbursements were suddenly struck down like what happened with dialysis? Does GI have anything else or will compensation plummet?

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[JoeBiden69]

Endoscopy and colonoscopy reimbursements were suddenly struck down like what happened with dialysis? Does GI have anything else or will compensation plummet?

GI will turn into a more boring version of Allergy medicine, and their pay will reflect that.

 

[Scope guy]

Endoscopy and colonoscopy reimbursements were suddenly struck down like what happened with dialysis? Does GI have anything else or will compensation plummet?

endoscopy alone wont go down. it ll bring down echo, cath, ENT scopes, etc etc. the reason HD rates went down is coz most ended up as medicare patients once they were needing HD. dont see that happening in endoscopies or other surgeries

 

[deleted941485]

endoscopy alone wont go down. it ll bring down echo, cath, ENT scopes, etc etc. the reason HD rates went down is coz most ended up as medicare patients once they were needing HD. dont see that happening in endoscopies or other surgeries

But HD patients automatically qualify for Medicare no? Hasn’t that been the case for a while now?

 

[Redpancreas]

Endoscopy and colonoscopy reimbursements were suddenly struck down like what happened with dialysis? Does GI have anything else or will compensation plummet?

Lemme guess...recently matched IM and now debating between Cards vs. GI vs. other?

1.) Procedural rates rise and drop together. With dialysis, medicare got involved and mass-negotiated prices (similar to how Amazon/Costco drive down prices). If endoscopy falls, that's not just GI. Now that you've committed to IM, it's not like choosing Cards will save you.
2.) They won't be struck down. One is a USPSTF Grade A recommendation. In addition, you didn't ask this but if you're worried about FIT/FOBT future tests, know that those will only expand the amount of colonoscopies needed.
3.) Really wish there was a GI equivalent to @bronx43. He really did Cardiology applicants over the past few years a favor.
--

4.) I predict more interventional motility stuff for GI and potentially selective ablative procedures in lieu are bariatric surgery. It's not really become a thing or hit the new yet so it's not exactly on the horizon but I think GI's fine.

 

[Scope guy]

But HD patients automatically qualify for Medicare no? Hasn’t that been the case for a while now?

ya but in 2000s they figured out how ridiculously expensive HD were and how much nephrologists were raking in. enter Davita and Fresnius who took over the HD practices. Imaging paying equal to an EGD or colon 3 times a week or 150 times a year

 

[hemosuccus]

Lemme guess...recently matched IM and now debating between Cards vs. GI vs. other?

1.) Procedural rates rise and drop together. With dialysis, medicare got involved and mass-negotiated prices (similar to how Amazon/Costco drive down prices). If endoscopy falls, that's not just GI. Now that you've committed to IM, it's not like choosing Cards will save you.

Thank you for this @BacktotheBasics. While this may be a reasonable question for some, like you I didn't think this was it. Seeing this in the GI applicant pool, applicants who would normally be in the Cards/ Gen Surg pool making their way to GI.

If reimbursements go down, all the more reason we hope you picked GI because you (at least really) liked the subject matter so that even endoscopy wasn't the big feature you would still like it. Other notable things, blood based CRC screening probably coming in our lifetimes, much longer surveillance intervals, NP/ PAs doing endoscopy. No one can predict what happens 25 years on, that's why you should go with what you like... or just do Derm

 

[HatTricks01]

NP/ PAs doing endoscopy.

I just threw up in my mouth.

 

[sallyhasanidea]

Lemme guess...recently matched IM and now debating between Cards vs. GI vs. other?

1.) Procedural rates rise and drop together. With dialysis, medicare got involved and mass-negotiated prices (similar to how Amazon/Costco drive down prices). If endoscopy falls, that's not just GI. Now that you've committed to IM, it's not like choosing Cards will save you.
2.) They won't be struck down. One is a USPSTF Grade A recommendation. In addition, you didn't ask this but if you're worried about FIT/FOBT future tests, know that those will only expand the amount of colonoscopies needed.
3.) Really wish there was a GI equivalent to @bronx43. He really did Cardiology applicants over the past few years a favor.
--

4.) I predict more interventional motility stuff for GI and potentially selective ablative procedures in lieu are bariatric surgery. It's not really become a thing or hit the new yet so it's not exactly on the horizon but I think GI's fine.

Could you give some examples of how bronx43 helped cardiology applicants over the past few years a favor? I'm interested in cardiology

 

[GastriqueGraffin]

Endoscopy and colonoscopy reimbursements were suddenly struck down like what happened with dialysis? Does GI have anything else or will compensation plummet?

You can literally say that about anything. The result will be less people doing GI and worse patient outcomes.

 

[ChessMaster3000]

I just threw up in my mouth.

i still dont think the NP/PAs doing endoscopy will happen. who will train them? I never would.

 

[Redpancreas]

Could you give some examples of how bronx43 helped cardiology applicants over the past few years a favor? I'm interested in cardiology

It was a joke.

 

[1Cor1557]

They already have been declining steadily for a long time, the medicare facility fee for colonoscopy in 2021 is lower than it was in 2005 and yet still here we are talking about the end of GI, the only difference is the senior guys can reminisce about how few procedures they had to do back in the day and now we have to do more n more to keep pace, sort of like..... everyone else in medicine

 

[sallyhasanidea]

It was a joke.

Could you please explain?

 

[Redpancreas]

Could you please explain?

The poster was just someone who used to post lots of doom and gloom about Cardiology for a while.

 

[hemosuccus]

i still dont think the NP/PAs doing endoscopy will happen. who will train them? I never would.

Hopkins.

Experience of nurse practitioners performing colonoscopy after endoscopic training in more than 1,000 patients - PMC

Background and study aims  The demand for screening colonoscopy has continued to rise over the past two decades. As a result, the current workforce of gastroenterologists is unable to meet the needs for colorectal cancer (CRC) screening. Therefore, ...

www.ncbi.nlm.nih.gov

Inside Tract - Who's traversing the tract?

Nurse practitioners can rescue colonoscopist shortage.

www.hopkinsmedicine.org

An NP's Journey to Credentialing for Colonoscopy

:scared: An NP's Journey to Credentialing for Colonoscopy Blazing a trail for a training fellowship By Jordan Hopchik, MSN, FNP-BC, CGRN Posted on: September 3, 2012 Timing is often a key ingredient and of critical importance in determining whether or not a personal or professional...

forums.studentdoctor.net

 

[1Cor1557]

Not only cards, there are posts of bronx from ten years ago explaining the end rads and GI as well, a classic

 

[bronx43]

Lol, glad to see my name pop up here. I admit being wrong on rads, as the system has shifted towards more imaging and training spots haven’t expanded.

Cards lost significant market position over the past decade. Tons of practices were bought up by hospitals, though market forces haven’t destroyed the non invasive market. Still not sure I would recommend it given the work to money ratio.

GI is good in relative terms. Don’t think I ever had much negative about the field other than being over reliant on colonoscopy reimbursement, which isn’t going to go higher in the future.

in general, idk how anyone can look at medicine and not be bearish as a whole. We are all just arranging deck chairs on the Titanic. Some specialties are towards the front of the ship while others are near the back.

 

[bronx43]

Hopkins.

Experience of nurse practitioners performing colonoscopy after endoscopic training in more than 1,000 patients - PMC

Background and study aims  The demand for screening colonoscopy has continued to rise over the past two decades. As a result, the current workforce of gastroenterologists is unable to meet the needs for colorectal cancer (CRC) screening. Therefore, ...

www.ncbi.nlm.nih.gov

Inside Tract - Who's traversing the tract?

Nurse practitioners can rescue colonoscopist shortage.

www.hopkinsmedicine.org

An NP's Journey to Credentialing for Colonoscopy

:scared: An NP's Journey to Credentialing for Colonoscopy Blazing a trail for a training fellowship By Jordan Hopchik, MSN, FNP-BC, CGRN Posted on: September 3, 2012 Timing is often a key ingredient and of critical importance in determining whether or not a personal or professional...

forums.studentdoctor.net

Colonoscopy shortage? They’re scheduling like two weeks out where I am. In bigger cities, you can drop your pants and find a GI doc behind you. But of course the NPs are in clinic making medical decisions...

 

[blue.jay]

Lol, glad to see my name pop up here. I admit being wrong on rads, as the system has shifted towards more imaging and training spots haven’t expanded.

Cards lost significant market position over the past decade. Tons of practices were bought up by hospitals, though market forces haven’t destroyed the non invasive market. Still not sure I would recommend it given the work to money ratio.

GI is good in relative terms. Don’t think I ever had much negative about the field other than being over reliant on colonoscopy reimbursement, which isn’t going to go higher in the future.

in general, idk how anyone can look at medicine and not be bearish as a whole. We are all just arranging deck chairs on the Titanic. Some specialties are towards the front of the ship while others are near the back.

What speciality do you think has a promising years ahead ?

Cards is too much work/stress for the money.
GI relatively good.
AI is somewhat small speciality and saturated in big cities.
Nephro has it's issues which is well discussed about.
ID/Endo aren't well reimbursed compared to plain IM.
Rhem?
Pulmonary/Critical care? Seems there will be more providers in ICU (MD, NP, PA) eventually and with tele-ICU also decreasing staffing needs.

 

[bronx43]

What speciality do you think has a promising years ahead ?

Cards is too much work/stress for the money.
GI relatively good.
AI is somewhat small speciality and saturated in big cities.
Nephro has it's issues which is well discussed about.
ID/Endo aren't well reimbursed compared to plain IM.
Rhem?
Pulmonary/Critical care? Seems there will be more providers in ICU (MD, NP, PA) eventually and with tele-ICU also decreasing staffing needs.

Honestly, my worldview (pertaining to medicine) has changed in the past decade. I don’t actually think there’s a “good and safe” field per se going forward. There are too many forces acting against the medical industrial complex, which has already peaked. On the way down, it will be largely unpredictable. Midlevels, training volume, reimbursement changes, legislation are all confounding factors. Inflation is another elephant in the room - I think a very likely scenario is one where inflation picks up and physician income stagnates or drops off in real terms.

But to answer your question, I would probably go with a field that isn’t completely tied to hospitals. Also pick one where there isn’t exponentially expanding midlevel presence.

 

[blue.jay]

Honestly, my worldview (pertaining to medicine) has changed in the past decade. I don’t actually think there’s a “good and safe” field per se going forward. There are too many forces acting against the medical industrial complex, which has already peaked. On the way down, it will be largely unpredictable. Midlevels, training volume, reimbursement changes, legislation are all confounding factors. Inflation is another elephant in the room - I think a very likely scenario is one where inflation picks up and physician income stagnates or drops off in real terms.

But to answer your question, I would probably go with a field that isn’t completely tied to hospitals. Also pick one where there isn’t exponentially expanding midlevel presence.

Midlevel are everywhere these days..All non-procedural specialities - Psych, EM, IM, FM, Peds, Anesthesia, ICU. Most specialities are hospital dependant. Allergy/Rhem/Psych/PCP can do well in private practice.
I lost faith in the insitution of medicine. Even top academic centers are using midlevels and creating residency/fellowships without any concern about it's impact on the job market (like in EM, RadOnc, and Nephrology). Established academic boomer attendings want to earn well and live comfortably while residents/fellows do their scut.
Personally, I don't think it's worth pursuing any fellowship other than cardiology, GI at this point or alternatively a psych residency.

 

[bronx43]

Midlevel are everywhere these days..All non-procedural specialities - Psych, EM, IM, FM, Peds, Anesthesia, ICU. Most specialities are hospital dependant. Allergy/Rhem/Psych/PCP can do well in private practice.
I lost faith in the insitution of medicine. Even top academic centers are using midlevels and creating residency/fellowships without any concern about it's impact on the job market (like in EM, RadOnc, and Nephrology). Established academic boomer attendings want to earn well and live comfortably while residents/fellows do their scut.
Personally, I don't think it's worth pursuing any fellowship other than cardiology, GI at this point or alternatively a psych residency.

Cards is fine. GI is fine. Endo is fine. Rheum is meh, prob fine if you live in tier 4 or below. Psych is fine. Most important thing going forward for young docs is flexibility and tempering of expectations. Don’t expect a medical specialty to save you or provide you with guaranteed luxuries and security.

 

[blue.jay]

Cards is fine. GI is fine. Endo is fine. Rheum is meh, prob fine if you live in tier 4 or below. Psych is fine. Most important thing going forward for young docs is flexibility and tempering of expectations. Don’t expect a medical specialty to save you or provide you with guaranteed luxuries and security.

Why do you say Endo is fine and Rhem is meh..Rhematology is more competitive than Endo. There are more threats from Endo midlevels/NPs pleasing pts giving hormones, testosterone, armour thyroid and supplements. Rhematology is more specialized with unique diseases and newer treatments. I think you are a rheumatologist yourself, aren't you ?

 

[bronx43]

Why do you say Endo is fine and Rhem is meh..Rhematology is more competitive than Endo. There are more threats from Endo midlevels/NPs pleasing pts giving hormones, testosterone, armour thyroid and supplements. Rhematology is more specialized with unique diseases and newer treatments. I think you are a rheumatologist yourself, aren't you ?

Unique but exceedingly rare (thankfully) diseases. There is over saturation of rheum in any reasonably sized metro. Even with midlevels, there isn’t even close to saturation for endo. If midlevels want the thyroid and hormone patients, I think every endo in the country would rejoice.

 

[sallyhasanidea]

But to answer your question, I would probably go with a field that isn’t completely tied to hospitals. Also pick one where there isn’t exponentially expanding midlevel presence.

Which fields do you think fulfill this criteria?

1) isn't completely tied to hospitals --- aren't all IM subspecialties theoretically not completely tied to hospital as you can do outpt private practice in all? I suppose interventional cardiology is tied to hospital, you would not recommend interventional cardiology?

2) expanding midlevel presence --- Looks like increased midlevels in every field. Including heme onc which you have said you liked in a previous post. Mid levels are seeing all survivorship visits etc

Thanks for your posts by the way, you're one of the few that back up thoughts with real data points we appreciate it

 

[bronx43]

Which fields do you think fulfill this criteria?

1) isn't completely tied to hospitals --- aren't all IM subspecialties theoretically not completely tied to hospital as you can do outpt private practice in all? I suppose interventional cardiology is tied to hospital, you would not recommend interventional cardiology?

2) expanding midlevel presence --- Looks like increased midlevels in every field. Including heme onc which you have said you liked in a previous post. Mid levels are seeing all survivorship visits etc

Thanks for your posts by the way, you're one of the few that back up thoughts with real data points we appreciate it

All IM specialties have their weak and strong points. I don't think there's a way to fully hedge for the unknown over the next several decades. I wholly expect physician income to drop in real terms (perhaps nominal as well) with continued degradation of autonomy for most of us. However, nearer term threats are mainly volume of trainees as well as midlevel expansion, as both can completely devastate a specialty. This is why EM is in the position they are in. They are also hurt tremendously by the fact that their specialty is tied to hospitals by its very nature. IM specialties are safer in the latter regard as only a small handful are tied to hospitals (certain cards and hospital medicine). Midlevel expansion is a potential crisis that affects doctors asymmetrically. Young docs are hurt, while older docs are either protected or outright benefit from cheap labor. *One of the docs I used to work with employed a small army of midlevels and easily made 7 figures.
The question is when will midlevel expansion get to a point in a specialty where the negative consequences are readily palpable. If you get in and establish yourself before that point, then you're golden. If not, then you'll be SOL.

All in all, I would probably recommend my younger self to strongly consider heme onc and GI. The latter has more flexibility than anything else in IM, and the former is just a very protected, highly publicized specialty that's more or less in its own world. There's cancer care... then there's everything else.

 

[HatTricks01]

Hopkins.

Experience of nurse practitioners performing colonoscopy after endoscopic training in more than 1,000 patients - PMC

Background and study aims  The demand for screening colonoscopy has continued to rise over the past two decades. As a result, the current workforce of gastroenterologists is unable to meet the needs for colorectal cancer (CRC) screening. Therefore, ...

www.ncbi.nlm.nih.gov

Inside Tract - Who's traversing the tract?

Nurse practitioners can rescue colonoscopist shortage.

www.hopkinsmedicine.org

An NP's Journey to Credentialing for Colonoscopy

:scared: An NP's Journey to Credentialing for Colonoscopy Blazing a trail for a training fellowship By Jordan Hopchik, MSN, FNP-BC, CGRN Posted on: September 3, 2012 Timing is often a key ingredient and of critical importance in determining whether or not a personal or professional...

forums.studentdoctor.net

Precisely why I didn't even bother applying to Hopkins for fellowship. Funny how the Hopkins NP mentions that she didn't feel any resistance from the GI fellows as I'm sure they were all livid but were swiftly silenced by their boomer overlords. Haven't started fellowship yet but I can't even imagine the ire I'd feel having gone through 7 years of grueling medical education/training before touching a scope only to have a nurse proverbially take it out of my hands.

 

[ChessMaster3000]

Precisely why I didn't even bother applying to Hopkins for fellowship. Funny how the Hopkins NP mentions that she didn't feel any resistance from the GI fellows as I'm sure they were all livid but were swiftly silenced by their boomer overlords. Haven't started fellowship yet but I can't even imagine the ire I'd feel having gone through 7 years of grueling medical education/training before touching a scope only to have a nurse proverbially take it out of my hands.

agreed, the Hopkins NP endoscopist thing is well known among these forums. if you read the paper though, they were trained in 2010, 2011, 2012. this paper is recent, but the relevant NPs were all trained a decade ago. thus, this has yet to actually go anywhere. I think the vast, vast, majority of GIs will never ever train an NP. hopkins is an exception because it's hopkins. and yeah, im sure the fellows actually hated it.

however, that is not a reason not to go to hopkins. as it does not appear they are actively training NPs to do colonoscopy.

 

[hemosuccus]

agreed, the Hopkins NP endoscopist thing is well known among these forums. if you read the paper though, they were trained in 2010, 2011, 2012. this paper is recent, but the relevant NPs were all trained a decade ago. thus, this has yet to actually go anywhere. I think the vast, vast, majority of GIs will never ever train an NP. hopkins is an exception because it's hopkins. and yeah, im sure the fellows actually hated it.

however, that is not a reason not to go to hopkins. as it does not appear they are actively training NPs to do colonoscopy.

This is getting long and off topic, but given how there plenty of GI docs who train/ employ MLPs to take care of very complex IBD, panc-bil, liver (even liver transplant) new clinic referrals and high acuity hospital consults with minimal oversight, it is not surprising that MLPs will ask to do scopes, especially with current 'scope of practice' creep/ laws and what is happening in ER and Anesthesia. APP equivalents already do scopes in other countries. Their increase in grads outpaces MD increases/ traning spots. When we talk about what happens in 25 years I'm not sure how one can not see this as a possibility in the grand scheme of things- which was the OPs actual question.

Also, go to Hopkins lol, they are fantastic.

 

[ChessMaster3000]

This is getting long and off topic, but given how there plenty of GI docs who train/ employ MLPs to take care of very complex IBD, panc-bil, liver (even liver transplant) new clinic referrals and high acuity hospital consults with minimal oversight, it is not surprising that MLPs will ask to do scopes, especially with current 'scope of practice' creep/ laws and what is happening in ER and Anesthesia. APP equivalents already do scopes in other countries. Their increase in grads outpaces MD increases/ traning spots. When we talk about what happens in 25 years I'm not sure how one can not see this as a possibility in the grand scheme of things- which was the OPs actual question.

Also, go to Hopkins lol, they are fantastic.

I agree with all you said. Is it possible? yes. should it change one's decision to do or not do the field of gI? no. if you dont want to do GI, that's fine, but this is not that reason.

the only thing i dont agree with is just because MLPs are trained to take care of complex patients medically, that really is not analogous to teaching someone a procedure. it is normal for doctors to train MLPs for cognitive decision making, even though they tend to be poor at it, but training them to do EGD/colon on a mass scale is plenty of years away, ,if it ever happens. I just wont want pre med,s med students, and residents on this forum who arent in the field of GI, to be leaving this forum thinking that NP-endoscopists are the way of the future. as it stands right now, it is not.

 

[Redpancreas]

The reason I personally like GI is because it's a procedural field encompasses the broadest range of pathology in IM. There's the esophagus and then there's the liver and love how general clinic can still be. You do get a ton of bread/butter and chronic abdominal pain seekers, but you also get the opportunity to lower morbidity for a large number of people as well. In addition, the procedural component allows you to gain mastery in something. Developing relationships with patients while mixing in scopes is pretty awesome in my opinion. The relative pay's likely to go down like all fields, but I think the field's future is bright with low supply, mix of clinic, definitive treatments, expertise in specific area with insulation from midlevels, and new stuff on the horizon for IBD, weight loss, motility, etc.