Salaries of specialists adjusted for overhead expenses

[medigeek]

11 hours ago, marrakech said:

It's not as if most physicians wouldn't like to make more money.  Half will be below the median and half will be above.  Only looking at the highest earners misses an important part of the picture, especially before even beginning residency.  

FM also has the most specialists - and more likely to have outliers.  The relative proportion of high earning FM docs is much lower compared to high earning specialists.  

You can gear your practice towards maximizing revenue. Most practices are not run like that and most doctors are not nearly that efficient. Sure most people want to make more money. But doing it well and executing is a different story than wanting. 

In Ontario, those who want to make more have set up capitation based practices. Most doctors however work in a FFS model which pays the least and simply can't see too many patients per day without compromising quality of care. 

[indefatigable]

9 minutes ago, medigeek said:

You can gear your practice towards maximizing revenue. Most practices are not run like that and most doctors are not nearly that efficient. Sure most people want to make more money. But doing it well and executing is a different story than wanting. 

In Ontario, those who want to make more have set up capitation based practices. Most doctors however work in a FFS model which pays the least and simply can't see too many patients per day without compromising quality of care. 

Yeah but I'm not convinced by the first implication that FPs are somehow unable to set up their practices efficiently compared to high earning specialists.  I do agree that there are limitations on how much FPs can bill - FFS is not as lucrative in FM as it is in some other specialties.    

 

[medigeek]

7 minutes ago, marrakech said:

Yeah but I'm not convinced by the first implication that FPs are somehow unable to set up their practices efficiently compared to high earning specialists.  I do agree that there are limitations on how much FPs can bill - FFS is not as lucrative in FM as it is in some other specialties.    

 

Most people (which includes doctors) don't have a great business sense or business acumen. Academic intelligence and business intelligence are entirely differently. You might have both, in which case you kill it with billings, non billing income, various investments and so on. Or you might work at a modest pace and live a decent upper-middle class lifestyle in comparison. 

My point is, not everyone is built to make a lot of money. Otherwise everyone would indeed be doing it. One doctor I've seen was having serious financial trouble despite working long hours. Simply because he was running his practice and hospital role in a very inefficient manner. In comparison another doctor can run his clinic with minimal overhead and laser efficiency. 

[indefatigable]

7 minutes ago, medigeek said:

Most people (which includes doctors) don't have a great business sense or business acumen. Academic intelligence and business intelligence are entirely differently. You might have both, in which case you kill it with billings, non billing income, various investments and so on. Or you might work at a modest pace and live a decent upper-middle class lifestyle in comparison. 

My point is, not everyone is built to make a lot of money. Otherwise everyone would indeed be doing it. One doctor I've seen was having serious financial trouble despite working long hours. Simply because he was running his practice and hospital role in a very inefficient manner. In comparison another doctor can run his clinic with minimal overhead and laser efficiency. 

I agree completely - it's something I've seen too.  I just don't think that some specialties have a greater proportion of physicians with much better business sense.

[medigeek]

7 minutes ago, marrakech said:

I agree completely - it's something I've seen too.  I just don't think that some specialties have a greater proportion of physicians with much better business sense.

Well precisely. Business acumen is pretty random. Certain fields are more business friendly though. For example FM's general license makes it business friendly by definition. Derm & plastics for obvious reasons. Many other fields can have pretty much 0 business potential. 

[bloh]

1 hour ago, humhum said:

It is still true. The different figure you have changes nothing about the original point regarding scaling.

What you need to understand is the ability to scale up or not. An ENT can't scale up, no matter how badly he wants to - the hospital dictates when and where he can operate and how often. And once a surgeon has a full-time position with solid ER time, he is a slave to it. He can't scale down either. Hence the poor 65 year-old general surgeons still covering 1 in 3 call.

A GP can book his practice booked solid from 8am to 8am the next morning. The next week he can go to Hawaii.

That is called scaling. I don't think you have any idea what the work hours of a surgeon are like. The brutality of a 24 hour call shift is not equivalent to two 12 hour work days of a GP.

I do 72 hour call shifts at least once a month. And I don't have resident scutmonkeys to help me. Thank's for assuming things.

Also, no one I know does 12 hour work days as a GP and it's for an exhausting reason that you can't appreciate.
 

I would work 2-3 days a week to make an equivalent 5 day income anytime. That's the part you don't get. That someone's time is worth exponentially more

 

[TheBoss]

2 hours ago, humhum said:

What you need to understand is the ability to scale up or not. An ENT can't scale up, no matter how badly he wants to - the hospital dictates when and where he can operate and how often. And once a surgeon has a full-time position with solid ER time, he is a slave to it. He can't scale down either. Hence the poor 65 year-old general surgeons still covering 1 in 3 call.

Generally true for surgical specialties, that it can be hard or almost impossible to scale. ENT is one of the more scalable surgical specialties though, since they are not as OR dependent for work, and have more private work they can do.

[Hanmari]

10 hours ago, bloh said:

I do 72 hour call shifts at least once a month. And I don't have resident scutmonkeys to help me. Thank's for assuming things.

Also, no one I know does 12 hour work days as a GP and it's for an exhausting reason that you can't appreciate.
 

I would work 2-3 days a week to make an equivalent 5 day income anytime. That's the part you don't get. That someone's time is worth exponentially more

 

Hey hey I know we are this but you don't need to rub it in our simian faces 

[GrouchoMarx]

pathology SHOULD be the most scalable, but because of the spinelessness of our forebears and intrusive government control, it has become the LEAST scalable.

the monetary goal in pathology is therefore to find a job with the least amount of work since the pay is the same everywhere. kind of like communism.

it is so unpopular as a specialty, even in the current match climate, partly because all control over your earning potential is forfeited.

also not mentioned in the original debate of FM vs derm income is that although the mean seems to be 300k for both, what it isnt saying is that the derms who are billing that low are probably part timers doing mommy track schedules. i think most derms are female. doing a full time schedule probably nets double.

[bloh]

52 minutes ago, Hanmari said:

Hey hey I know we are this but you don't need to rub it in our simian faces 

We all had to do it.

40 minutes ago, GrouchoMarx said:

pathology SHOULD be the most scalable, but because of the spinelessness of our forebears and intrusive government control, it has become the LEAST scalable.

the monetary goal in pathology is therefore to find a job with the least amount of work since the pay is the same everywhere. kind of like communism.

it is so unpopular as a specialty, even in the current match climate, partly because all control over your earning potential is forfeited.

also not mentioned in the original debate of FM vs derm income is that although the mean seems to be 300k for both, what it isnt saying is that the derms who are billing that low are probably part timers doing mommy track schedules. i think most derms are female. doing a full time schedule probably nets double.

Which is why net income per day is the most relevant statistics and it shows absurd variability between groups. The ability to 'scale' is at best a minor issue but most likely a fallacy. If that was true why is the wait time to see an ENT surgeon for tinnitus in my city now more than 6 months? Those are non-surgical issues that they see merely to comfort patients, because they somehow don't believe the truth when they hear it from a non-specialist.

[indefatigable]

2 hours ago, GrouchoMarx said:

pathology SHOULD be the most scalable, but because of the spinelessness of our forebears and intrusive government control, it has become the LEAST scalable.

the monetary goal in pathology is therefore to find a job with the least amount of work since the pay is the same everywhere. kind of like communism.

it is so unpopular as a specialty, even in the current match climate, partly because all control over your earning potential is forfeited.

also not mentioned in the original debate of FM vs derm income is that although the mean seems to be 300k for both, what it isnt saying is that the derms who are billing that low are probably part timers doing mommy track schedules. i think most derms are female. doing a full time schedule probably nets double.

It could be a management issue in pathology too - most people in the workforce are not self-employed.  Incentives like bonuses for meeting and exceeding targets, quality, etc..   could help improve motivation.

Although it's now true that women make up more of the youngest derm workforce, this is more of a recent phenomenon.  Women now form the majority of medical students too.  The CMA specialty profile gives a detailed breakdown of gender by age (p. 10 source).  

The stats from almost a decade ago indicated that even then the median income of FP and derm was the same in Ontario.  FPs in ON now have a significantly higher mean income, and derm has probably increased as well.  Happy women's day, btw!

1 hour ago, bloh said:

We all had to do it.

Which is why net income per day is the most relevant statistics and it shows absurd variability between groups. The ability to 'scale' is at best a minor issue but most likely a fallacy. If that was true why is the wait time to see an ENT surgeon for tinnitus in my city now more than 6 months? Those are non-surgical issues that they see merely to comfort patients, because they somehow don't believe the truth when they hear it from a non-specialist.

Net income per day does illustrate variability between groups succinctly, but doesn't capture the variability within groups.  It's essentially: (avg gross - overhead) / day.  One issue is that a given specialty might have a high avg income, but a lot of variability which means the median income could be quite a bit lower (see for example source p.101-2 for ophth).  So net income might be misleading when considering a typical specialist rather than a high earner, not to mention provincial differences.

 

[distressedpremed]

2 hours ago, Hanmari said:

Hey hey I know we are this but you don't need to rub it in our simian faces 

[Hanmari]

8 hours ago, bloh said:

We all had to do it.

And that totally makes it okay! The fact that you can even type the word "scut" without curling up from PTSD is a sheer marvel for my monkey brain. Bill away, ubermensch!

[medigeek]

On 3/7/2018 at 0:02 PM, marrakech said:

It's not as if most physicians wouldn't like to make more money.  Half will be below the median and half will be above.  Only looking at the highest earners misses an important part of the picture, especially before even beginning residency.  

FM also has the most specialists - and more likely to have outliers.  The relative proportion of high earning FM docs is much lower compared to high earning specialists.  

I missed a statement I wanted to highlight. Thing is, I'm not so sure this is true.

A few months ago, we had a few hundred doctors signing something in support of that disastrous federal liberal tax proposal. That would effectively slice future income for all doctors. Now we got Quebec doctors (small minority) protesting a pay raise. 

Unfortunately, we have some socialist minded people in our profession. The fortunate part, is that most doctors do not think like that (as shown by how intensely doctors mobilized after the ridiculous Ontario liberal cuts). Otherwise we would be making Europe level money for our services. 

[Aconitase]

On 2018-03-07 at 11:16 PM, humhum said:

These are good questions that I wondered as well. I think with nephrology, the big billings comes from the dialysis units. (and this is pure personal speculation). I think the amount they can bill for the "procedure" itself, and all the different complications that dialysis have bring in additional billing opportunities. But I really don't know for sure; interested to hear from someone with direct knowledge about this.

Thing to keep in mind, from what I do know, nephrology positions are very hard to come by these days. Many go years before stable employment after graduation.

It’s very simple actually. 

 

Putting in IHD lines pays nothing. It’s all chronic dialysis fees. Once you roster a patient for dialysis then you are paid a set amount by the government each year for that patient. That covers their chronic IHD management for the year. 

 

Most busy community nephrologists are starting the year around 400-600k before they do anything based on these fees. Now add in out patient work as well as the in patient consult and acute dialysis billing’s and it adds up fast. 

 

The rush to roster them is real. The reason a lot of new grads don’t have jobs is because no one wants to let anyone else’s roster a patient. They would rather do it themselves and keep the chronic fee 

[humhum]

23 hours ago, bloh said:

I do 72 hour call shifts at least once a month. And I don't have resident scutmonkeys to help me. Thank's for assuming things.

Also, no one I know does 12 hour work days as a GP and it's for an exhausting reason that you can't appreciate.
 

I would work 2-3 days a week to make an equivalent 5 day income anytime. That's the part you don't get. That someone's time is worth exponentially more

You sound disgruntled, and under-appreciated. If you think the flexibility, portability, and years you saved from your youth NOT slaving  as a resident is somehow not commensurate with the per-hour compensation you keep harping on, what is stopping you from going back into residency into a highly paid specialty you covet so much?

[ZBL]

1 hour ago, Aconitase said:

It’s very simple actually. 

 

Putting in IHD lines pays nothing. It’s all chronic dialysis fees. Once you roster a patient for dialysis then you are paid a set amount by the government each year for that patient. That covers their chronic IHD management for the year. 

 

Most busy community nephrologists are starting the year around 400-600k before they do anything based on these fees. Now add in out patient work as well as the in patient consult and acute dialysis billing’s and it adds up fast. 

 

The rush to roster them is real. The reason a lot of new grads don’t have jobs is because no one wants to let anyone else’s roster a patient. They would rather do it themselves and keep the chronic fee 

So what is stopping nephrologists from renting out a small space in some strip mall and setting up a bunch of dialysis stations? 

[snapmoster82]

3 hours ago, ZBL said:

So what is stopping nephrologists from renting out a small space in some strip mall and setting up a bunch of dialysis stations? 

The insane costs?

15 hours ago, GrouchoMarx said:

pathology SHOULD be the most scalable, but because of the spinelessness of our forebears and intrusive government control, it has become the LEAST scalable.

the monetary goal in pathology is therefore to find a job with the least amount of work since the pay is the same everywhere. kind of like communism.

it is so unpopular as a specialty, even in the current match climate, partly because all control over your earning potential is forfeited.

also not mentioned in the original debate of FM vs derm income is that although the mean seems to be 300k for both, what it isnt saying is that the derms who are billing that low are probably part timers doing mommy track schedules. i think most derms are female. doing a full time schedule probably nets double.

I have always wondered why pathologists aren't billing the same as radiologists. Their diagnostic consultations are just as valuable. I assume if they were remunerated like Rads , it would be just as competitive.

[Aconitase]

9 hours ago, ZBL said:

So what is stopping nephrologists from renting out a small space in some strip mall and setting up a bunch of dialysis stations? 

I believe the spots are funded by government and they won’t fund more unless approved 

[indefatigable]

1 hour ago, rmorelan said:

I should also mention I guess one other factor that I suspect is at play - with say derm, optho, rads, plastics, cardiology....... -  because they are high paying often have attracted the top residents (globally speaking - and definitely in the US with the standardized scores), 

The most competitive residencies in the US are surgeries - ortho, neuro, plastics, ophth, ENT,..  Rads is definitely less competitive these days and IM isn't nearly as competitive.  Derm is also very competitive.  Basically - one can't match into surgeries or derm without attending a US med school.  Cardiology matching is through performance during IM residency.

A great example of difference between US & Canada is neurology (besides standardized tests) - it's quite competitive here, but not in the US (even though outside Québec it doesn't pay that well). 

[GrouchoMarx]

3 hours ago, rmorelan said:

well a major part of the high fees for radiology is simply a quirk of history - you set a fee level at X and then adjust it by percentages every year. A CT used to take hours and hours to read because PACS didn't exist (it was actually billed effectively as 30 X rays because nothing scaled - you had to read them like they were so many plain fllms - hanging film on a wall and reading them, and hanging all the priors after you got them from the film library). So the fee reflected that - CTs were a pain in the ass . Then we invented things to make it much faster - like PACS systems, digital imaging (wonderful for radiology!), followed by then adding 1000s of extra slices/reconstructions/new techniques to make it harder again ha (a CT head used to be 1cm thick, 10 axial slices or 10 pictures - now it is 100s in a CT head and you have to look at every one. More and more every year but the fee is the same - bad for radiology). MRI fees are based on CT fees so they are both high paying, because again they were originally a big deal - now they are not a big deal to do and process at least. 

Same with optho - a cataract removal used to take hours to. Now 15 mins. It is the these tech improvements that made the difference, and that is why they get paid so well (same fee, procedure takes 1/6 the time). That  matters because for rads if you don't read CTs or MRIs - which is quite possible - you will get paid quite poorly relatively. One rad I knows earns 250-300K a year doing that - comparatively quite low doing out patient x ray and US. Rad procedures pay little as well. So you cannot just say drop all rad fee codes by 20% (which they keep trying to do) as it would destroy critical imaging centres and that imaging is actual quite important. 

Pathology hasn't had that "tech that speeds us up by a factor of 5 to 10" event. It is not much different than it was 20 years ago in that sense.  If they did then absolutely go billing and make a killing. They won't make that much different by going fees - the only thing I will mention is that they may make more because as salaried people, which most are,  over time the hospitals have been asking them to do more and more but not paying them any differently (just like any other boss would be trying to do - fixed salary means squeeze them hard to get the most work out of them). The flip side of that is good luck trying to get a path person to say after the end of their shift (yeah,...not going to happen) while rads are often there now rather late (left at 7 yesterday). The payment system supports that - I WANT to read studies just like a surgeon wants to operate - their is a pavlov response their (read study make X dollars, read another make X dollars....its like giving your dog a treat every time they do a trick). I suppose in theory great pathologists day would be just enough work to not be bored and getting to go home an hour early ha. Our best day would be a huge number of very easy CT scans (renal colic, renal colic, PE study is a perfectly healthy person, CT head for " general weakness"x100.........)

So to be clear it isn't about "value" - that assumes there are no politics and things are fair (or even can and some would argue should be fair). Cardiologists don't make a lot because it is fair - they make a lot because they work hard to have good PR/press, are very political, and yes back it up by working their asses off at all times - and good luck to you if you threaten any of that for them for they will respond, and respond hard. Rads makes a lot because of the history involved, the shear volume of imaging we read now (which honestly is a bit insane), because no one basically can do squat anymore without imaging to back it up, and like everyone else is active marketing ourselves.

I should also mention I guess one other factor that I suspect is at play - with say derm, optho, rads, plastics, cardiology....... -  because they are high paying often have attracted the top residents (globally speaking - and definitely in the US with the standardized scores), and that creates this kind of right or wrong inherit justification for them them earning more in some people's minds - what I am saying is fewer people argued about they pay differences because they saw the top people in the classes etc going into those fields, and on some level thought the top people "should" get paid more. A lot of these fields take pains to make sure that pattern continues to hold and to project that their fields are technically or intellectually the most challenging areas of medicine.  

Keep in mind that the Ontario government tried to rope radiologists into a primarily salaried model around the same time they did it to pathology, except the radiologists resisted or ignored the change, while pathologists embraced it.  This event illustrates the huge difference in personalities between radiologists and pathologists. Both are booksmart, but radiologists are also aggressive, while pathologists are too agreeable.

In some centers, particularly the larger ones in nice cities, pathologists will stay late to finish work because the administration will talk down to them if their "turn around times" are too long. And rather than the dept head or colleagues supporting their own, they team up against them. Pathologists are like crabs in a bucket.

Also keep in mind that the standards for pathology recruitment are dismal and the field is therefore made up of many practitioners who are questionably competent or unqualified. As they may or may not be practicing on fraudulent medical degrees, they keep their heads down and mouths shut so as not to be discovered. Pathologists who speak up regarding matters of patient care or overwork are bullied into submission by their peers and administrators. The suck-ups and mutes are promoted so as to maintain the status quo. It becomes a toxic corporate environment, not a medical one.

I think if the general public knew that their cancer diagnoses were being rendered by people who may not know what they're doing, they'd be a lot more concerned about the way the field is right now. But as we are "lab" and nobody gives a shit about that, all of these problems persist.

 

 

 

 

[snapmoster82]

It's fascinating how politics, and payment fees can lead to such different perceptions of specialties. Pathology in my view is largely under-appreciated and dismissed. It's too bad there's a seeming issue with training of pathology. It's also very very under-reprented in medical school. At my medical school, we aren't taught histology at all. Any discussion of its relevance is usually dismissed. However, I have been pimped 7000x times on the JVP. 

I will say that in Canada there is no pattern of "smartest" medical students going into the ROAD specialtiies. The smartest people from my class went into FM or more commontly IM. To get into a ROAD, you need to gun from day 1 really. Canadian medical school training favors gunning vs book smarts. 

[rmorelan]

19 minutes ago, snapmoster82 said:

It's fascinating how politics, and payment fees can lead to such different perceptions of specialties. Pathology in my view is largely under-appreciated and dismissed. It's too bad there's a seeming issue with training of pathology. It's also very very under-reprented in medical school. At my medical school, we aren't taught histology at all. Any discussion of its relevance is usually dismissed. However, I have been pimped 7000x times on the JVP. 

I will say that in Canada there is no pattern of "smartest" medical students going into the ROAD specialtiies. The smartest people from my class went into FM or more commontly IM. To get into a ROAD, you need to gun from day 1 really. Canadian medical school training favors gunning vs book smarts. 

I was trying to be careful with my wording and I really don't want to give the wrong impression - I didn't say that ROAD is the smartest (although I suppose specifically for the US if you believe board scores are directly related to book smarts then perhaps they are..maybe..as that is the primary selection tool). Other than sounding arrogantly self serving, I think that is also flat out wrong. In Canada with our pass fail system being a top student doesn't mean book smart as you rightly say - "gunning" is in my mind what it takes because that will get you whatever the Canadian criteria is to get that specialty (and gunning involves a lot of work, which probably the common denominator there). In my opinion the two smartest person in my class went into internal medicine, and the third smartest went into family medicine.  

Some parts of ROAD as well aren't that hard to get into. Radiology shouldn't even be in ROAD lifestyle-wise as it stands now, and has roughly 80% success rate - others not in ROAD are much harder to get into and can have a much better lifestyle. Ha, maybe just the O and D parts are gunning level hard  (not that getting into any field is completely trivial)

I think part of the reason by pathology slides under the radar is you will simply never have to look at a slide unless you are in fact a pathologist. In other words it is possible to be almost ignorant of how that all works and get on just find. You cannot get away from X rays that cleanly as they are used by a lot of fields, and used for critical things (kind of like how you cannot get away from EKGs). They aren't just for radiologists ha. Plus by definition they are almost never "emergent" in terms of findings. 

To truly horrify residents they should add a LMCC part 2 pathology station - just to watch almost everyone squirm for 10 minutes.  

 

 

[rmorelan]

7 minutes ago, marrakech said:

The most competitive residencies in the US are surgeries - ortho, neuro, plastics, ophth, ENT,..  Rads is definitely less competitive these days and IM isn't nearly as competitive.  Derm is also very competitive.  Basically - one can't match into surgeries or derm without attending a US med school.  

True - the "sexy factor" comes into play there as well - and surgery does pay well as well. 

Radiology in the US for instance pay is lower than here. There is a corresponding lack of interest and in particular lack of interest in the lower paying areas (like pediatrics unlike say MSK which can be quite well paying). 

 

1 hour ago, GrouchoMarx said:

Keep in mind that the Ontario government tried to rope radiologists into a primarily salaried model around the same time they did it to pathology, except the radiologists resisted or ignored the change, while pathologists embraced it.  This event illustrates the huge difference in personalities between radiologists and pathologists. Both are booksmart, but radiologists are also aggressive, while pathologists are too agreeable.

In some centers, particularly the larger ones in nice cities, pathologists will stay late to finish work because the administration will talk down to them if their "turn around times" are too long. And rather than the dept head or colleagues supporting their own, they team up against them. Pathologists are like crabs in a bucket.

Also keep in mind that the standards for pathology recruitment are dismal and the field is therefore made up of many practitioners who are questionably competent or unqualified. As they may or may not be practicing on fraudulent medical degrees, they keep their heads down and mouths shut so as not to be discovered. Pathologists who speak up regarding matters of patient care or overwork are bullied into submission by their peers and administrators. The suck-ups and mutes are promoted so as to maintain the status quo. It becomes a toxic corporate environment, not a medical one.

I think if the general public knew that their cancer diagnoses were being rendered by people who may not know what they're doing, they'd be a lot more concerned about the way the field is right now. But as we are "lab" and nobody gives a shit about that, all of these problems persist.

Yeah we didn't fall for that trap (at least not yet) - and the salary model in particular doesn't work for us as it is hard to get someone on salary to randomly do things at odd hours on the night. 

You have greater exposure to path than I ever will - I will say that like radiology, pathology is a field that requires intense focus and training to do well. I deserves similar recognition and needs people of great skill.  

Also where you are, and whatever you do support your profession as you can. Anything you do to short cut things just comes back to bit you personally in the ass at some point 10 years later.  The fields with the best situation in medicine has learn somehow to have a bunch of type A personalities to actually work together in a united fashion. The field of medicine as a whole can learn something from that. 

[Lactic Folly]

10 hours ago, rmorelan said:

MRI fees are based on CT fees so they are both high paying, because again they were originally a big deal - now they are not a big deal to do and process at least. 

rmorelan do you have a source for this? In the days of film, I remember seeing all the images for an MRI brain printed out on two sheets. Now, even a routine MR brain easily has hundreds of images. It's not an exaggeration to say that it probably takes me 10x longer to scroll through all the images, than it did for the radiologist at that time to inspect those two sheets.  Or are you saying that there was a time when CT/MRI were available, but it was not possible to print multiple images on a sheet?