Have the lucrative specialties changed?

[AR]

The White Coat Investor wrote:

Longevity probably matters more than pay. Better to be a pediatrician for 30 years than burn out of dermatology in 10.

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The anecdotes in this thread notwithstanding, I think that burning out of derm in 10 years is an incredibly rare phenomenon.  Virtually impossible given how easy it is to find a part-time, well-paying derm job in almost any city in the US.

I suppose it could be a definition problem.  If you say someone who wants to go from 50 pts 5 days a week down to 30 pts three days a week is doing so because of "burn out", then I guess I can give you that.  I'd just say it's someone who wants to cut back.

 

 

[VagabondMD]

AR wrote:

The White Coat Investor wrote:

Longevity probably matters more than pay. Better to be a pediatrician for 30 years than burn out of dermatology in 10.

Click to expand…

The anecdotes in this thread notwithstanding, I think that burning out of derm in 10 years is an incredibly rare phenomenon.  Virtually impossible given how easy it is to find a part-time, well-paying derm job in almost any city in the US.

I suppose it could be a definition problem.  If you say someone who wants to go from 50 pts 5 days a week down to 30 pts three days a week is doing so because of “burn out”, then I guess I can give you that.  I’d just say it’s someone who wants to cut back.

 

 

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Lots of anecdotes. Pediatricians burn out, too, just not as frequently as ER docs, for example, 72% vs. 46%, according to this study: https://wire.ama-assn.org/life-career/medical-specialties-highest-burnout-rates.

Given the disparity in pay between the derm and the pediatrician, and the relative burn out chance, 67% vs. 46%, it's probably better to make hay in derm while you can, all other things being equal. Of course, how the burnout manifests and what is the recourse or solution matters a lot, too.

Someone mentioned Moh's surgery earlier. I would be concerned about hitching a career 10 years from now to the Moh's gravy train. Procedures that pay excessively and skyrocket in volume tend to get squashed back down over time (volume and reimbursement), sometimes very suddenly.

[AR]

Vagabond MD wrote:

AR wrote:

The White Coat Investor wrote:

Longevity probably matters more than pay. Better to be a pediatrician for 30 years than burn out of dermatology in 10.

Click to expand…

The anecdotes in this thread notwithstanding, I think that burning out of derm in 10 years is an incredibly rare phenomenon.  Virtually impossible given how easy it is to find a part-time, well-paying derm job in almost any city in the US.

I suppose it could be a definition problem.  If you say someone who wants to go from 50 pts 5 days a week down to 30 pts three days a week is doing so because of “burn out”, then I guess I can give you that.  I’d just say it’s someone who wants to cut back.

 

 

Click to expand…

Lots of anecdotes. Pediatricians burn out, too, just not as frequently as ER docs, for example, 72% vs. 46%, according to this study: https://wire.ama-assn.org/life-career/medical-specialties-highest-burnout-rates.

Given the disparity in pay between the derm and the pediatrician, and the relative burn out chance, 67% vs. 46%, it’s probably better to make hay in derm while you can, all other things being equal. Of course, how the burnout manifests and what is the recourse or solution matters a lot, too.

Someone mentioned Moh’s surgery earlier. I would be concerned about hitching a career 10 years from now to the Moh’s gravy train. Procedures that pay excessively and skyrocket in volume tend to get squashed back down over time (volume and reimbursement), sometimes very suddenly.

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Interesting link, but I think it brings up the question that I alluded to in my post.  It really depends on how you define burnout.  I skimmed your link and didn't see that they actually defined it (I could have missed it though).  The post I was responding to made it sound like it was referring to burn out to the point of not practicing any longer. In that sense, I think derm burn out would be rare.  With a broader definition of burn out, I'd guess that derm would have some just like every other specialty.

[ENT Doc]

Strider_91 wrote:

ENtdoc,
Interesting thought about being a more generalized physician, I wouldn’t have thought about that on my own. I think a “generalized specialist” is probably the best bet in terms of expertise yet still having maneuverability. I have read a post from you about a head and neck surgeon being done for if they cured a certain type of carcinoma that makes up about 90% of their practice.

It is my understanding that this is what happened to cardiac surgeons when interventional cardiologists started putting in stents.

It is counter intuitive to realize that being general can be better especially when you factor in the opportunity costs of some fellowships. I also remember reading about this in Dr. Dahle’s book.

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Look at it like the market (to some degree).  Could a niche ETF soar?  Could it perish?  Sure for both.  The market portfolio only has systematic risk, scrubbing out the idiosyncratic risk of those niche investments.  Like Tom Cruise said in The Firm, "It's not sexy, but it's got teeth."  Maybe the generalist doesn't have his picture on a billboard, but he also doesn't lose his job when a CRISPR therapy dries up his practice.

As for the Enlitic study, no doubt I am skeptical too about their (unpublished) results.  But the question is, where do you see this going?  If enlisted in a supportive capacity to start it's only a matter of time before someone tests its independent abilities.  Computers have a habit of getting better, not worse.  The more complex issue is that of malpractice.  If the techies want to tread into the medical realm and disrupt the industry I would also welcome them to absorb the downside risk of the lawyers and their class action suits.  As Bruce Willis famously said, "Welcome to the party, pal!"  Oddly, our greatest adversary (other than disease) historically may be our biggest ally moving forward.

[WallStreetPhysician]

Strider_91 wrote:

As an incoming M1 I get the advice to do what you love because who knows what the future holds but I know I can enjoy many specialties and given the choice I’m taking the one that pays more with a better lifestyle every time. My interest seems to be leaning towards a surgical sub-specialty, EM or Anes because I want to do procedures.

 

When you were in school what were the top paying specialties and how have they changed? When did you graduate? What are the “odds” ortho, urology, or ENT just start paying less than other specialties in the future? What is the chance that FM or pediatrics starts to become compensated more than other specialties?

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To give some perspective, here was a summary of the MGMA report in 1997, and Becker's summary of compensation review in 2016. Things have mostly not changed (perhaps a bump for dermatology).

I would note that anesthesiologists still make more than general surgeons (both in 2016 and in 1997). Maybe that's why the surgeons feel the need to be so bossy to the anesthesiologists in the OR...

[Miss Bonnie MD]

Vagabond MD wrote:

Someone mentioned Moh’s surgery earlier. I would be concerned about hitching a career 10 years from now to the Moh’s gravy train. Procedures that pay excessively and skyrocket in volume tend to get squashed back down over time (volume and reimbursement), sometimes very suddenly.

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Some Mohs surgeons have ruined it for the rest. I'm sure this happens in other fields too.. Mohs is still cheaper (than any GA surgical procedure) and the most effective at curing skin cancer for the right skin cancer, size, and location.

I interviewed at a private practice and saw this guy literally Mohs anything. I couldn't believe it. Maybe he was seeing if I'd be ok with sending him any case. There are established criteria when to use Mohs. Then there is the reconstruction - using a graft, flap etc - not always justified. Sad to see this happen - since it really does ruin it for the ones that really need it.

[VagabondMD]

Miss Bonnie MD wrote:

Vagabond MD wrote:

Someone mentioned Moh’s surgery earlier. I would be concerned about hitching a career 10 years from now to the Moh’s gravy train. Procedures that pay excessively and skyrocket in volume tend to get squashed back down over time (volume and reimbursement), sometimes very suddenly. 

Click to expand…

Some Mohs surgeons have ruined it for the rest. I’m sure this happens in other fields too..

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Absolutely! And that's why I brought it up. Basing a career decision, ten years down the road, on the reimbursement of a particular (lucrative) procedure is unwise, IMO.

Third party payers (especially CMS and the RUC) are constantly reviewing these anomalies for overutilization and overpayments and forcing down both, usually with a heavy hand.

In my field (IR), IVC filters were for a long time ridiculously overcompensated. The reimbursement was established on an ancient code for operatively ligating the IVC. In round numbers, Medicare was paying the operator about $700 per procedure. These usually take about 10-15 minutes to place.

This anomaly flew under the radar for most of my career. About 5 years ago, it was recoded and now pays about $200 for the proceduralist. I personally think that the pendulum swung a bit too far as these are often very ill patients, and there is a higher than average demand for off-hours procedures. Nonetheless, the change in reimbursement was swift and substantial, and this can happen for any procedure. (I have numerous other examples for IR.)

[Strider_91]

This happened with the TFESI for interventional pain. Cataract surgery for ophthalmologist etc. I find it very interesting that these types of things have not "changed" the lucrative specialties. I guess people adapt and overcome.

For interventional pain, where my mentor works, his practice bought into a surgical center because the facility fees are still decently reimbursed for TFESI and this offsets their losses for the declined reimbursement. Interesting that all of our TFESI are done in a surgery center but not a single facet injection will ever be done there. As I get more involved with medicine I see that it is a constant game of cat and mouse with the government/ insurance companies for the physician trying to make a living and in most cases patient care is not improved (sad realization for this doey eyed Pre-med).

This goes along with what ENT doc is saying. It is unwise to hitch your wagon to a very narrow specialty wherever of your practice is based on one procedure or pathology because all it takes is CMS slashing reimbursement or a cure to be found and you're in trouble.