One in six newly graduated medical specialists can’t find work

[Dongzhuo]

Hum hum, what about general surgeon dealing with cancer or acute and often life-threatening surgical conditions?

 

It is very difficult to compare specialties between them using the "importance of the organ" factor, compensation should be based on length of the training, rigor of the training, average hrs/week and patients, degree of responsibility on the life-limb and nature of the call.

 

Since this thread is talking about the fact that too many are going into specialities and not enough into primary care..... Shouldnt the logical approach be to increase incentives (financial or otherwise) for primary care the the opposite for specialties?

[RunningGuns]

I think that the honour associated with a job is compensation in a sense. That's why everyone wants to be US President when it only pays 400k. For example, even if a surgeons salary was 200k...people would still do it. Its only GP and other jobs that people are not really wanting to do that needs additional financial incentive to entice people to do it. View it like rural incentives.

 

Since this thread is talking about the fact that too many are going into specialities and not enough into primary care..... Shouldnt the logical approach be to increase incentives (financial or otherwise) for primary care the the opposite for specialties?

 

I think that your two post contradict each other a little bit, but please correct me if I'm wrong. Let's say they drop the salary of specialists to obscenely low numbers. I know that I'd still become a specialist, not a generalist. In fact, I'd pick another profession all together over becoming a GP. I'm sure there are other people that don't feel that strongly about it, but others may also agree.. I'm not sure what the solution is by any means, but it has to be more than financial incentives.

[ArchEnemy]

I think that ophthalmology may have been the wrong specialty to use as an example. I, personally, really value my sight and would almost be willing to pay anything for it. I don't really feel the same way about any of my GPs services. Therefore, I think it's fair that ophthalmologist's be compensated significantly more then them. Even a salary of, let's say, $800,000.00/year seems low when I consider the gift of being able to see again!

 

I agree that compensation isn't perfect, or ideal, on the whole though.

 

I think this really shows how disconnected you are with finances.

[uwodesperate]

I think that your two post contradict each other a little bit, but please correct me if I'm wrong. Let's say they drop the salary of specialists to obscenely low numbers. I know that I'd still become a specialist, not a generalist. In fact, I'd pick another profession all together over becoming a GP. I'm sure there are other people that don't feel that strongly about it, but others may also agree.. I'm not sure what the solution is by any means, but it has to be more than financial incentives.

 

How can you logically and reasonably make these conclusions without even spending a day as a medical student?

[uwodesperate]

I think that ophthalmology may have been the wrong specialty to use as an example. I, personally, really value my sight and would almost be willing to pay anything for it. I don't really feel the same way about any of my GPs services. Therefore, I think it's fair that ophthalmologist's be compensated significantly more then them. Even a salary of, let's say, $800,000.00/year seems low when I consider the gift of being able to see again!

 

I agree that compensation isn't perfect, or ideal, on the whole though.

 

How about surgeons who perform transplant surgeries? I say the gift of lengthening lifespan triumphs the gift of being able to see again so transplant surgeons should get paid significantly greater than $800,000.00/year?

[RunningGuns]

I think this really shows how disconnected you are with finances.

 

I think you intentionally took my comment out of context.

 

The monetary value of something isn't necessarily equivalent to its intrapersonal value. That's not to say that ophthalmologists, for example, can be excessively subsidized in reality. Rather I, personally, would assign a value to their skill, and my eyesight, that far exceeds what is financially feasible.

[RunningGuns]

How can you logically and reasonably make these conclusions without even spending a day as a medical student?

 

... You're right I've never been a medical student.. But I was a DPM for ten years prior to committing to undergraduate full-time to pursue an MD. So, I'd like to think that I've got a decent idea of what I'm getting myself into.

 

How about surgeons who perform transplant surgeries? I say the gift of lengthening lifespan triumphs the gift of being able to see again so transplant surgeons should get paid significantly greater than $800,000.00/year?

 

Again, I was referring to monetary vs. intrapersonal value. If someone values a specialist and/or a procedure more than its financial value, then I think it's fair to voice that opinion. I'm not saying that the financial reality of the situation will, or can, change, but I do think that we should actively try and prevent things from being further undervalued. Within reason, of course...

 

You're, of course, free to disagree with me as well. This' just my own opinion.

[LifeIGuess]

... You're right I've never been a medical student.. But I was a DPM for ten years prior to committing to undergraduate full-time to pursue an MD. So, I'd like to think that I've got a decent idea of what I'm getting myself into.

 

 

 

Again, I was referring to monetary vs. intrapersonal value. If someone values a specialist and/or a procedure more than its financial value, then I think it's fair to voice that opinion. I'm not saying that the financial reality of the situation will, or can, change, but I do think that we should actively try and prevent things from being further undervalued. Within reason, of course...

 

You're, of course, free to disagree with me as well. This' just my own opinion.

 

interesting..what makes you think monetary valuation is fixed or doesnt need change? there're so many factors involved that reassessing the value of service is an important ongoing need that is currently being ignored...as an example, rather than internalizing the benefits of say a breakthrough technology by ignoring the need to revalue the fee for service to take into account the fact that the service may no longer reflect the same effort that it once did, we need to externalize those benefits so a larger community can benefit..while we like to think of it as business sometimes when it comes to salaries and financial incentives, unfortunately decisions in healthcare trickle down and impact the public...often in worse ways than other services

[rmorelan]

One thing I've noticed over the years is that the fee codes tend to favor procedures that involve the use of state-of-the-art (aka relatively new to market) technologies over old-school methods. It's one thing that explains why an ophthalmologist gets paid more than a general surgeon, or why radiologists get paid so well.

 

The valuation has nothing to do with impact on patient health.

 

Whichever entity sets the fee codes is probably heavily influenced by corporate lobby groups who want to see returns on their investments into the development and marketing of new gadgets. Inflating the fee codes increases the likelihood that these new techs will be bought, utilized, and made the standard of care.

 

If what I say is true, then we will never see GP, psych or other E&M-style fields reach any type of respectable pay level, and we will never see the fields with the overinflated fee codes see any substantial reductions.

 

Probably hard to drop a fee in an area (no one complains if you increase it but if you drop one you get yelled at). Rads old school CT scan reading was slower - you actually had all these plates to read, and comparing to prior required well going to get the old primaries from a filing cabinet somewhere etc. Sounds painful Fees were based on that originally and fees are "sticky".

 

Same with optho - removing cataracts used to take a long time. The billing was based on that. Of course along some newer tech and now something takes 1/5 as long. However the code wasn't adjusted down.

 

This happens all the time in medicine, and the government slowly gets wind of it and adjusts things (usually due to some outside pressure of course - often other docs are the source). It just takes time - too much time in my mind, but time none the less. If there was NO payoff through for advancing tech then docs would be more resistant to change and that wouldn't help us much either. Balance is good - although again we swing too far over on the reward side of things I think. Right now rads is getting very serious pressures to drop fees and in the US in particular they have kind of crashed a bit (30% reductions almost across the board).

 

Rads is not going to be the high money maker it used to be and that isn't a bad thing (it probably should bottom out I would hope around where internal medicine is). Ha - now some are arguing it is swinging too far the other way as with tech advances and thinner and thinner slices it is actually taking LONGER to read scans now as there is a shear image explosion. Pay cuts plus longer reading times are making for grumpy doctors

 

Side note: one rads in the US are some of the most sued doctors and argue they do need to earn more to simply pay the insurance. The reason is simply that there is always a permanent record of everything you did or should have seen. No room for subjective interpretation. Plus there is rarely a backup to catch any of your mistakes - it is just you at 3am looking at a scan.

[Med0123]

One thing I've noticed over the years is that the fee codes tend to favor procedures that involve the use of state-of-the-art (aka relatively new to market) technologies over old-school methods. It's one thing that explains why an ophthalmologist gets paid more than a general surgeon, or why radiologists get paid so well.

 

The valuation has nothing to do with impact on patient health.

 

Whichever entity sets the fee codes is probably heavily influenced by corporate lobby groups who want to see returns on their investments into the development and marketing of new gadgets. Inflating the fee codes increases the likelihood that these new techs will be bought, utilized, and made the standard of care.

 

If what I say is true, then we will never see GP, psych or other E&M-style fields reach any type of respectable pay level, and we will never see the fields with the overinflated fee codes see any substantial reductions.

 

100% agree with you.

[Lactic Folly]

Probably hard to drop a fee in an area (no one complains if you increase it but if you drop one you get yelled at). Rads old school CT scan reading was slower - you actually had all these plates to read, and comparing to prior required well going to get the old primaries from a filing cabinet somewhere etc. Sounds painful Fees were based on that originally and fees are "sticky".

 

Sounds a bit like that controversial commentary by Will Falk...

 

Although I never trained on film, in years past I spent time in the radiology department collecting said films from the printer, as well as observing the radiologists reporting on film.

 

To me, I cannot see any clear advantage in terms of speed since switching to PACS. On film, you had a finite number of images to look at - I remember being impressed by the speed of a radiologist who viewed an entire routine MR head on all of two sheets of film, and was able to dictate a normal report in seconds. Now with new technology, there are literally thousands of images in different planes and sequences, and viewing all of them takes significantly longer.

 

In the past, prior examinations were pulled by the film library staff, so they would be included with the examination for reporting. I am sure films went missing then, but PACS is not failproof either. Often, more remote studies are archived, so it now falls to the radiologist to click on them at the time of interpretation, spend minutes waiting, and not infrequently receive some sort of incomplete retrieval failure error.

 

In addition, with the advent of voice transcription and doing-away-of human transcriptionists in many centres, it now falls to the radiologist to proofread and edit their reports, which also represents a decrease in efficiency.

 

Of course, I am not saying that advances in technology have not been incredibly beneficial - obviously we can gain more information with new MR sequences, transmit studies across long distances using PACS, and turnaround time is decreased with voice recognition. I also agree that it is the direction of change in fees that can be more contentious than what the fee actually is. However, it is just not definitely clear to me that today's radiologist can read at any greater speed than in the past.

[rmorelan]

Sounds a bit like that controversial commentary by Will Falk...

 

 

someone I have actually never heard about Google has him as some sort of a policy strategist?

[Lactic Folly]

http://www.longwoods.com/content/22475

Yes, this article has been used by the Ontario government in fee negotiations, and been the subject of much rebuttal by radiologists and others.

While it's difficult to have a fruitful debate on what fees should be in absolute terms, increased department efficiency in performing studies does not make it any faster for radiologists to interpret those studies, so statements such as "It is as if we paid Air Canada pilots by the miles flown and gave them a jet to replace their turboprop." reflect at best an inaccurate understanding of what physicians actually do.

[bloh]

Since this thread is talking about the fact that too many are going into specialities and not enough into primary care..... Shouldnt the logical approach be to increase incentives (financial or otherwise) for primary care the the opposite for specialties?

 

Because money grows on trees and we can just harvest some more and throw it at everyone....

 

Everyone is once again arguing the wrong detail. The more problematic part is that we are simply training too many physicians overall. There's multiple reasons why family medicine is becoming more popular and job prospects are one of them.

 

It will all be a moot point in ~10 years when we are over-saturated with family physicians as well. Even now when people say they can't fight a GP, I tell them they're not looking hard enough. There's a ton of physicians accepting new patients in major cities.

[rmorelan]

http://www.longwoods.com/content/22475

Yes, this article has been used by the Ontario government in fee negotiations, and been the subject of much rebuttal by radiologists and others.

While it's difficult to have a fruitful debate on what fees should be in absolute terms, increased department efficiency in performing studies does not make it any faster for radiologists to interpret those studies, so statements such as "It is as if we paid Air Canada pilots by the miles flown and gave them a jet to replace their turboprop." reflect at best an inaccurate understanding of what physicians actually do.

 

gah - well I certainly wasn't proposing extremes of improvements that guy is in his paper. In particular the idea that PACS was primarily a cost savings measure seems really odd to me. It was to improve access to data, and improve thus patient care - the scans turnaround can be faster without actually doing anymore scans in the same amount of time - that is organization structuring not productivity gains. He is assuming the total investment somehow is going to improvements in productivity. A human beings don't obey Moore's Law (which even isn't a law - it is merely an observation that we all know will end relatively soon as you can only pack so much in so much space before you go atomic ) I keep waiting for the point where he proved sustainable improvements in reading time - rather than short term gains in productivity with step wise tech advancement.

 

I also cannot say I like the idea of turning radiologists in the "production factories" - that is the wrong direction. Having your radiologist centralized no where near the hospital reinforces the idea that a radiologist isn't a part of the care team at all, and discussing a case would be impossible. As someone potentially going the interventional route I find that concept a bit scary.

 

That being said I find reading scans after someone went home or underwent the procedure that a scan was ordered for a bit silly.

[rmorelan]

Because money grows on trees and we can just harvest some more and throw it at everyone....

 

Everyone is once again arguing the wrong detail. The more problematic part is that we are simply training too many physicians overall. There's multiple reasons why family medicine is becoming more popular and job prospects are one of them.

 

It will all be a moot point in ~10 years when we are over-saturated with family physicians as well. Even now when people say they can't fight a GP, I tell them they're not looking hard enough. There's a ton of physicians accepting new patients in major cities.

 

10 years sounds about right I guess - the current estimates are complete total end of shortage in 5 years in Ontario overall for FM. There is estimated as about 300 too many in the province by 2023. To put that in perspective it was estimated that we were 800 short in 2008. All this is off of that needs model, which is just one study on things of course. Bottom line is no field in medicine can indefinitely absorb the surplus we are currently generating. We need at least some logical plan for where we are going with all of this rather than just screaming - more and more and more (is it ever going to be enough? )

 

Of course again distribution problems will remain.

[Hockeynut]

10 years sounds about right I guess - the current estimates are complete total end of shortage in 5 years in Ontario overall for FM. There is estimated as about 300 too many in the province by 2023. To put that in perspective it was estimated that we were 800 short in 2008. All this is off of that needs model, which is just one study on things of course. Bottom line is no field in medicine can indefinitely absorb the surplus we are currently generating. We need at least some logical plan for where we are going with all of this rather than just screaming - more and more and more (is it ever going to be enough? )

 

Of course again distribution problems will remain.

 

 

 

Is this not a problem when you have some overseeing entity planning the market/field?

[Der Kaiser]

Because money grows on trees and we can just harvest some more and throw it at everyone....

 

Everyone is once again arguing the wrong detail. The more problematic part is that we are simply training too many physicians overall. There's multiple reasons why family medicine is becoming more popular and job prospects are one of them.

 

It will all be a moot point in ~10 years when we are over-saturated with family physicians as well. Even now when people say they can't fight a GP, I tell them they're not looking hard enough. There's a ton of physicians accepting new patients in major cities.

 

I know a big problem where I live is that many patients would rather be without a family doc than settle for some of the family docs that moved here. They can find a GP, just not the one they want. In Canada people act like healthcare consumers, but everybody seems to believe that healthcare is not something to be consumed.

[seeking1]

NLengr, what specialty are you in, if you don't mind my asking? Its interesting and even positive to hear that some associations are matching up with reality. You had a really good post there.

 

Why didn't NLengr answer my question? Its been like an additional 7 pages of flame war!

[seeking1]

Haha, I love it when you go on the war path against the CCFP brooksbane! I kind of agree, although I'm sure there's a million reasons people will bring up to prevent the return to GP's.

 

brooksbane, are you an FP? I'm not trying to paint you as a hypocrite or whatever, I'm just interested because I keep forgetting your specialty.

 

(PS I think we should have people on this forum indicate clearly what specialty/residency type they're in in their sigs, it would make it easier to talk about stuff.)

 

Same with brooksbane.

[Lactic Folly]

Both have contributed a great deal of personal opinions to this forum, as well as expressed a wish for anonymity. In order that this forum can still benefit from their contributions, it would be best that we respect such wishes...

[LifeIGuess]

One thing I've noticed over the years is that the fee codes tend to favor procedures that involve the use of state-of-the-art (aka relatively new to market) technologies over old-school methods. It's one thing that explains why an ophthalmologist gets paid more than a general surgeon, or why radiologists get paid so well.

 

The valuation has nothing to do with impact on patient health.

 

Whichever entity sets the fee codes is probably heavily influenced by corporate lobby groups who want to see returns on their investments into the development and marketing of new gadgets. Inflating the fee codes increases the likelihood that these new techs will be bought, utilized, and made the standard of care.

 

If what I say is true, then we will never see GP, psych or other E&M-style fields reach any type of respectable pay level, and we will never see the fields with the overinflated fee codes see any substantial reductions.

 

actually i was saying the some thing earlier. however to be clearer, i do think it impacts healthcare delivery. if you're able to hire more specialists due to adjustment of fees, it definitely helps with ensuring a wider pt base is being served in the same amount of time which translates into less waiting time/back log at surgeries, scans etc what about an ideal envt, where some specialty docs end up moving rural where there was a need going unfilled? wouldnt that improve healthcare as sick pts have to travel less distance to reach care?

[rmorelan]

Both have contributed a great deal of personal opinions to this forum, as well as expressed a wish for anonymity. In order that this forum can still benefit from their contributions, it would be best that we respect such wishes...

 

and that is total fair. It is usual for anyone to known in real life on the forum after all. I don't think knowing someone's specialty helps that much really - a) it could be wrong most people on the forum aren't doctors and c) the few that are are really, really early in their training so aren't that much different than anyone else

[NLengr]

Both have contributed a great deal of personal opinions to this forum, as well as expressed a wish for anonymity. In order that this forum can still benefit from their contributions, it would be best that we respect such wishes...

 

Pretty much this.

 

There are many topics that we discuss here that are controversial. It's safer for everyone, and better for discussion openess, for people to remain somewhat anonymous.

 

I agree with the opinion we are training too many people overall right now. There are two solutions as far as I can see:

 

1. Cut seats in med schools and residencies to meet current availability of positions

2. Increase healthcare system funding in order to increase the number of physicians that will be coming into the system in the future.

[seeking1]

Both have contributed a great deal of personal opinions to this forum, as well as expressed a wish for anonymity. In order that this forum can still benefit from their contributions, it would be best that we respect such wishes...

 

Fair enough.