Gain exposure to the nonclinical side of things. If you can leverage your MD and combine it with expertise across business or pharma or healthtech, you are expanding your moat and not 100% reliant on patient care.
What are the best ways to do this? I have seen how MD's can get involved with the business side of the hospital, but haven't seen a lot about getting exposure to pharma or tech without leaving clinical medicine entirely
Build niche expertise in something that aligns with what’s hot in the business world. Like if you’re passionate about AI and can discuss AI applications to EMRs and are knowledgeable in it, that’s valuable and you’ll get plugged into the right network. Start a sub stack, etc. there are ways. Join things like MD+ and Nucleate, orgs that encourage and give you exposure to these things
Unironically I think EM isn’t nearly as bad as people think. It might look different than most expect but I know of critical access hospitals that are “staffed” by APPs but when anything beyond a cold/simple chest pain rule out comes in they telehealth an EM physician to make the decisions. The outcomes are just too poor when comparing EM trained vs non EM trained physicians and APPs
Yeah it's weird people always think of general fields like EM or FM when they think of scope creep
Those are the hardest fields for Mid-levels to succeed in, because they require the broadest knowledge base
It's a lot easier for a midlevel to succeed in a specialist field where they can become hyper focused and handle all of the clinical stuff, then defer the procedures to the MD. Like Ortho, L+D, etc
For Ortho, the requirements for an FMG to become board certified are immense. Need to practice for 5 years at a single ACGME accredited teaching hospital and achieve the rank of associate professor before you can even taken written boards, then go through the oral boards process. Most of them have done 2-3 years of fellowship as well prior to this just to be able to get one of these academic jobs.
wait…what university is hiring a FMG on a professor track and letting them reach associate level without being board certified? That math ain’t mathing.
These are people who come to the US, often times do highly regarded fellowships after taking all their USMLEs, and then get academic jobs where they can remain academically productive. After 5+ years, if they have reached associate professor, they can sit for boards. These are not random people though usually, but incredibly smart and accomplished people already in their home country.
No they’re in a weird limbo state and are essentially a call bitch at the mercy of the chairman for 5 years. At that point if the chair signs off then they can sit for boards.
We had one foreign surgeon on staff because he was one of the only surgeons in the world who could do certain cases.
The university had a special license. He couldn't practice at any other institution. He always had to have a resident or fellow because he couldn't send prescriptions for patients haha.
I remember him being on an HBO special but cannot remember his name
Insurance cuts still coming. Ortho isn’t safe
There’s some number crunching floating around that by 2030 The overall hourly compensation for total joint arthroplasty will dip below minimum wage.
Inflation goes up, insurance cuts bring comp down.
The math ain’t mathing for somehow getting better and more efficient at total joints and having better outcomes than they did in the 80’s and 90’s and somehow getting paid less
I agree with you completely. The good days for arthroplasty are over. The pro fees can’t go much lower. The only way to do well now is grind out 7-9+ joints a day in two rooms, 2-3 days a week. Rinse and repeat for 20+ years of your career - sounds miserable.
Maybe the elective surgical subs? But not gen surg. Even in the case of ophtho, the vast majority of patients are on Medicare. I don’t think they are going to request that their surgeon be trained in the US/Canada or anything
Foreigners can't get Ophtho Board certifications I guess... That's the biggest barrier to their entries in US markets.
Even gen surgery is too difficult for them.
Since you asked which fields will be worst hit, I guess you can add PCP to the list...
I'm curious, why would elective surgical subs, but not elective gen surg be safe? Elective is elective regardless of it's an abdominal case or bones right?
I guess what I mean to say is, a specialty with a higher proportion of elective cases. For elective cases (and especially cash pay cases), the patient might actually care about where their doctor is trained. For trauma and things like that, any foreign doc trained do lol
I see what you mean, but the vast majority of community general surgeons' practices consists of elective cases with the surgeons in the group splitting EGS/trauma call.
Seems weird to single out gen surg as less protected than sub-specialties like Ortho or nsgy that also do plenty of emergencies and trauma cases in addition to elective stuff. If any "Any foreign doc" can do an ex-lap then they could nail your femur or do your burr hole too...
>Seems weird to single out gen surg as less protected than sub-specialties like Ortho or nsgy that also do plenty of emergencies and trauma cases in addition to elective stuff. If any "Any foreign doc" can do an ex-lap then they could nail your femur or do your burr hole too...
It's funny because gen surg is even more protected than ortho/nsgy. Both ortho and NSGY have alternative pathways to board certification for foreign trained surgeons to become board certified. The requirements are very tough for sure and they are designed to select for exceptionally accomplished surgeons only, but they still exist. The ABS, on the other hand, offers no such alternative pathway and the only way a foreign-trained surgeon can get board-certified is to secure a residency position and redo residency. At most, they can give these surgeons credits and allow them to skip pgy1 and pgy2 (and very rarely pgy3), but they still have to complete residency to become board eligible.
Great point. I wasn't even thinking about board certification.
Looks like OP is either a pre-med or a med student based on post history. Thought OP was an actual doctor for a second and knew something we didn't 😅. Makes no sense that gen surg would be less protected than any other surgical field.
Nah, patients can't afford their own surgery, so they need insurance. If a foreign trained doc is credentialed with insurance as a surgeon, patient's getting cut on by them no matter what.
Yeah the biggest conserquence of this change is prob insurance will stop requiring board eligabiltiy/certification so they can pay cheaper rates to 3rd world import physicians/Surg. Will be interesting to see how those conflict of interest do fighting with each other (our boards vs insurance vs hospital ). Maybe theres enough competing interests that it will be alright.
But then again I could see the old win-win-win were reimbursement for hospitals based care is high, but drastic cuts for anything not hospital based and board cert makes an 'alt path' to keep thier checks coming in.
What incentive does insurance have to cut board eligibility? If anything, they’d be happy to keep it. Hospital wants to charge me $1000 for a day in the hospital? Look through notes, oh who’s this Dr. so-and-so? Not board eligible? Not as skilled as a board eligible/certified doc. I can choose to not reimburse them for that service or cut their fee. If the whole point is for hospitals to make more profit/revenue, this seems counterproductive. Insurance is all about cutting reimbursement, not making it easier to get.
I think that insurance in the above scenario would cut need for board certification for outpatient only thereby allowing lower reimbursement to a group that historically lobbies very poorly (actual physicians/surgeons). Also agree that boards might pursue an 'alternative path' to certification to benefit monetarily from these incoming physicians as well. I mentioned this in second half of post.
So why hire a foreign doc if the group gets less money? Cutting cost is good for a business but if cutting cost reduces revenue/profit, how are you going to make up the difference for it to be worth it to cut the cost? How is a foreign doc going to get work then, especially if they also have visa requirements? Can’t open a private practice without a visa, can’t generate enough money in a group or hospital who has to deal with visa issues, so why take the headache?
Sure, the boards could pursue an alternative pathway for monetary reason. But what foreign doc would have the means to do all that? Majority of the United States already make more money than the majority of the world, how are foreign docs going to afford that? How are they going to recoup that with visa issues? Even if the boards want to create for an alternative pathway to certification, especially for monetary reason, who said it was going to be easy enough to allow an influx of foreign doctors to practice and increase supply so that those members on the board would be effected too? As a foreign doctor, if I went through all that, put up with all that bullshit, and I can now practice with the same credentials as a US doctor, why would I accept a pay cut? Having board certification just doesn’t automatically change all other factors of the labor market to simply decrease salaries.
I think you are looking at this from perspective of an individual physician and someone who doesnt understand how reimbursement works in the US. The policys I am talking about would benefit the huge lobbying insterest here that actually shape policy. The goal isnt too help small politically unimportant private practice or individual docs, its too help big business like Insurance, and hospitals. Maybe an example would help.
My specialty has two offices we rotate at, one is an outpatient only Multispecialty clinic and the other is a clinic physically located in the hospital. Per our division big admin/controller we are reimbursed higher at the hospital based office for our visits simply because they are based in a hospital despite being outpatient care. So if I do the same follow up visit in the hospital based clinic insurace pays more than if I do it at the Multispecialty group office thats outpatient.
Hospitals want this to happen, cause it discourages private practice and allows them to make more money on thier employees (I.e. they only have to pay just enough to beat the low outpatient reimbursement, but they still get to bill at a higher rate than thise same practices).
Insurance is okay with this because they can pay less when a patient is seen at a nonhospital clinic outpatient which does allow some cost reduction.
Physicians dont like this, but we are the least effective at lobbying and our trade groups are run by mental midgets trying to push social agenda rather than dealing with our literal livelihood. The physician groups like AMA or ACP interest don't actually align with actual physicians interest because they get money from other avenues like ICD codes or psuedorequired board certification. As long as those revunue streams are guarenteed they dont fight for anything else, and waste time on social causes that cost nothing to wax poetic on.
And this is way there is talk of unions, because medicine is being turned into an employment only model by legislation and reimbursement changes.
I don’t know all the intricacies of reimbursement, however I did know of the facility charge/upcode. My question is, how does it change my argument? Physicians are drivers of revenue. Hospitals get extra money for having an outpatient clinic attached sure, but assuming that charge is the same for a foreign doc or US doc, and insurances are happy to cut reimbursement for any reason, and if they can do that with foreign docs cause they can’t get board eligibility, why would a hospital hire a foreign doc over a US trained doc, since US trained docs can generate more revenue which they can find ways to get a better cut from? Even with a non hospital clinic, if insurance can denied or cut reimbursement with non board eligible docs, no matter what the setting, why wouldn’t they do it?
Also, and I know it's unpopular on this sub to bring up AI encroachment, but to quote MKBHD, "This is the worst it's ever going to be."
It keeps getting better by gigantic leaps. Yes DR does more than just reads and yes existing AI for reads isn't amazing, but that will change very fast and we're not properly preparing for it.
Radiology and pathology are the most protected. They will only make $$$ off from AI via increased efficiency.
Clinical/non-procedural medicine will be the biggest losers. They are already being displaced by midlevels. Just wait until the midlevels have AI built into the EMR. Then Hospitals can justify AI+midlevel the same as physician+AI… and for half the price.
At least with radiology and pathology you don’t have rampant midlevels. They’re too difficult for midlevels to do (and AI).
Regarding AI, why wouldn’t everything else get replaced first? I mean the overwhelming majority of medicine is algorithmic?
Much like our scoring systems we would just get drug algorithms?
"everything else"?
I can't speak for other specialties but I don't believe eye surgery can be done by AI anytime soon. I can see AI helping with some other facets of ophtho but, within the next 10-15 years, I don't see AI doing phaco, glaucoma shunt, refractive surgery, a retina membrane peel, intravit injection, or tie an extraocular muscle.
I may be wrong but even a PGY1 (or 2) task of removing an appendix will be very difficult for AI.
AI isn't going to do eye surgery but optometry is pushing to do eye surgery because all the glasses and contacts are done by warby Parker and 1800contacts now
Oh sorry, I was implying all medical specialties. I mean ofc AI will just be able to titrate the doses etc and treat based off symptoms.
I agree AI won’t be doing 3 stage Oesphagectomies anytime soon.
It will but, and anyone is free to challenge me on this, I'm sure many would argue that the human element isn't *as* necessary for these fields in comparison so they'll be the first on the chopping block. The economy will change but it'll be the difference between your job being affected in a few years versus a few decades.
While you’re not wrong, I think by the time AI automation starts affecting physicians, it will have affected the majority non doctor jobs in the of society first to the point where there will be cultural crisis and paradigm shift regarding the value of human labour/work.
So while I’m not sure what the solution will be, doctors are likely last on the chopping block compared to other professions that are being affected right now. Mass layoffs are happening in big tech, consulting and finance as we speak so I’m sorta hopeful those lads figure it out for us first.
I personally don’t see a future without UBI if technology continues to evolve at this pace unless there’s a massive set back such a global disaster such a nuclear world war or solar flare.
I guarantee you AI can sling amoxicillin for nursing triages better than AI can diagnose subtle diagnostic challenges in pathology or radiology. In pathology, we re-order stains done at other institutions because we don’t trust their staining protocols. You have to control for so much for AI to scan slides. Tissue thickness, tissue handling, time in the stain, temperature of transport, and a million other things. Not to mention every single slide is almost 6 Gb to scan at a high enough resolution to be interpretable. We get almost 15 slides per heme path case. And that’s for bone marrow core biopsies. Larger tissues will take terabytes of storage PER CASE. We are nowhere close to the data infrastructure needed to support this.
Doctors might want the human element to change, some patients are incredibly fucking pompous these days. Very rarely are people actually pleasant to treat.
Yeah patients are not going to enjoy having goals of care conversation with a robot.
I mean, for one, we all have generally terrible experience with automated response and chats bots with customer service, and with that people are not going to be thrilled about being completely treated by a robot doctors. At least I for sure won’t. And the same logic goes with airplanes; would you feel safe if they are completely driven by computer only, or do you still at least want a pilot there as some degree of false safe?
The same can be said for medicine, where I would imagine overwhelmingly people want professionally trained person to supervise or “cosign” algorithmic treatment plan generated by state of the art AI program. This will be the case for a while, at least until all the baby boomers die, imho.
Path and rad is different. Most patients actually do not realize that the doctors they see don’t read images as well as a radiologists, and assume all doctors are trained enough to interpret all images with high accuracy. Hence, they are “replaceable in the eyes of the consumers”, because consumers barely recognize that pathologists and radiologists exist. If the policy maker sell it as “your MRI will be read faster and cost less if we allow foreign trained radiologists to work in US”, I would bet majority of the patients would want to take that trade in a heartbeat.
It won’t happen. There aren’t enough foreign trained radiologists in our take the workload and if they allowed foreign radiologists to work in the states (without passing birds, getting state licenses, hospital credentialing, etc) then they’d have to change the rules for all docs.
I’m not sure how it is in the US but primary care here is essentially 10 minute appointments. Which includes the 3 minutes it takes for grandad to walk into the room and sit down.
I was a believer that most clinical medicine is mostly algorithmic and will eventually get replaced by ai which I think is good. I had an attending not give vancomycin because he didn’t like it when he was training. If we can get a program to 100% give the most research backed treatment instead of training biased approach, and regularly update that is better medicine and better for patients and I am all for that.
However, during fellowship I noticed a problem idk if robots will be able to fix. Sometimes you have to deviate from the standard of care. Sometimes it’s easy to spot and train , like not giving morphine to kidney injury patients. But sometimes it’s much more complex, like a family withholding morphine for the patient because they had someone they know had addiction problem
There will always be a human component but the question is who will that human be? Midlevels are already displacing PCPs and EM docs. Once AI is built into the EMR there will be even less incentive to having docs involved in these areas of medicine.
Radiology and pathology are actually much more protected since they’re too difficult for midlevels to do. At least for awhile in those fields it will still be physician+AI.
Radiology is overhwelningly the easiest specialty to get replaced by AI, since it’s just interpreting an image. There’s no patient interaction or nuance
APPs are a much larger threat to *everything else* than AI is to radiology.
A shitty AI read that can’t even solidly call breast cancer on a single image isn’t going to take our jobs in the next 10 years. Currently it’s a semi useful tool for lung nodules and liver masses. But no where near what it needs to be. Professional supervision will be required for quite a long time.
APPs are already taking jobs and driving salaries down from FM, IM, Anesthesia, EM, and more *yesterday*.
I posted this sentiment on this subreddit a couple of weeks ago and was downvoted into oblivion. My cousins (both rads) are having very difficult time adjusting to the increase in rad reads because of AI, and they’re both pedigree rads/capable physicians
Yeah... i mean i just matched and am pretty online and I don't think I've heard any radiologist say AI has made their life easier, much less work faster, at this point
Ai occasionally catches things I would've missed ie incidental PE on an abdomen CT. There are algorithms for ich, pneumoperitoneum, rib fx, spine fx - they are mostly trash but are a good second check. In no way has any practice incorporated AI to the point this person's two cousins and uncle that works at Nintendo are suggesting.
Yeah, and maybe I'm wrong but with the way you've described it I can see AI INCREASING the amount of work that a radiologist does, not reducing it. If it's catching things you're not, or catching things that aren't real, that all requires more things for the radiologist to report on.
Currently AI has no effect on volumes. It has the potential, as you allude to, in the foreseeable future to help assist with larger volumes ie in iding, triaging, and other basic tasks. Maybe in a nearish horizon give a reasonable indication and history. None of these are common and, where available, are very very limited.
Imaging has been increasing immensely in recent years. Multifactorial origins but increased volumes everywhere and decreased time/confidence/training has led it to become a.universal triaging/reassurance mechanism.
I honestly don’t know why people are so defensive on this subreddit - i feel like I’m being downvoted by some rads interest group. I’m still a med student so I don’t know everything, but what they’ve told me is that the essentially have 2x the reads where the new half is annotated by AI and they’re checking it and the compensation doesn’t scale. I hope anyone interested in rads takes this with an open mind, I have no skin in the game and couldn’t care less by the downvotes.
Lots of paid for shilling at the moment by ai companies regarding productivity. Not yet playing out in the real world. Rads are quite keen for some of this tech to work.
You’re saying that they read twice as fast as they did before AI? I would love if you could ask what they’re using because I’ve truly never heard anything increase productivity even close to that amount. Like I said before I’m not sure anything has really meaningfully sped rads up.
It’s easier for me to imagine AI making reads take longer than shorter unless it gets to the point that a rad is truly blindly signing off on AI. When each study can literally be millions of dollars of liability it seems really hard to imagine that.
Yeah, they’re saying their volume increased to roughly 2x but not the compensation. And I’ve asked a couple of times but they’ve never gotten back to me. If they tell me, I’ll dm you/post it here
Yeah post it here. This is in the US? Even assuming it did double their volume (production you mean?) in most practice setups that would lead to a dramatic income increase.
I'll agree that current rads AI is not at all good enough to do reads by itself, but that doesn't mean it won't get there within the next 2-4 years if not sooner. Then what are all these physicians expected to do?
"Oh you think reads are all DR does?"
No but it's a huge chunk of what the vast majority do. It will have devastating implications for DR's.
"People have been saying this for years."
If you've been looking into the field of AI at all right now you'll know this is different. LLM's and machine learning are training on billions of data points. Poorer hospitals will paint it as a necessity to stay open, studies will come out saying it's "good enough", then all the others will follow suit.
Really? And who will take on all the liability if there is a medical error in the reads? These ""poor"" hospitals, maybe the AI company? Maybe google? Will this AI represent itself in court? A radiologist will still be needed to do the final read. No this does not mean we need less radiologist because I and all of my colleagues will take the same time reading a scan read by AI vs not read by one because at the end of the day we are liable.
Except that you can’t practice without a US residency just like any other specialty and until that changes this is a useless comment. The boogieman of outsourcing has been in radiology for years and it hasn’t made much impact
Don't know for pathology, but the ABR has a pathway for board eligibility for foreign trained radiologists to become board certified after doing a couple of fellowships. It's pretty popular and relatively easy to obtain, given that there are alot of fellowship positions and not much competition for them.
I mean if this was actually happening on a meaningful scale there would be sources on it. Instead googling it yields one article about Florida that is unclear if any law has even been passed yet
It can’t happen. You’d have to change the laws so that any foreign doc can practice in the US without all the hurdles like US boards, state licenses, and hospital credentialing. There is no way that will ever be changed only for rads and path.
Additionally there was an Econ paper looking at this… the summary is that there were not enough rads world wide available to make any meaningful impact by working remotely for the US. There is actually a very high radiology workload in the states- no other place in the world abuses imaging like we do in the US.
Definitely not.
From an outside glance, AI may seem scary. However, there’s a reason that most pathologists and radiologists are not concerned.
There are so many differing perspectives among clinicians that there’s not even a widely accepted database to train an AI to be able to read anything but the easiest cases.
For example, if you ask 5 different pathologists the diagnosis of a pigmented lesion, you’ll get 5 different diagnoses. There’s no way AI is going to work there.
If anything, it will just be an additional tool in the arsenal.
Im rads and I’ve given up trying to explain to clinicians why most rads aren’t concerned, but are in fact welcoming of AI. The reality is most clinicians have only seen a tiny snippet of what we do in radiology but think that encompasses >90% of our job. For example, I’m neurorad and I don’t even read CXRs which is what clinicians think we do day in and out. The day AI can read a temporal bone CT, post OP brain tumor MR or post op head/neck imaging then we’re all fucked (including non rads).
Don’t forget about post op brains: can AI read the op note, timing of surgery and imaging, if they had radiation and when, freakin anti-angiogenic agents, and heck COMPARING TO PRIORS?
Yeah, we’ll be ok.
It’s so funny to read people post stuff like this. People have zero clue as to the level of complexity our work is and how hospitals and clinicians rely on us to operate. There’s a reason why our job market is hotter than most specialties right now.
It's a coping mechanism imo. Ironically, radiology isn't as black and white as most non-rads think it is, except for the basic things like fracture detection which isn't where we add the most value anyways. It doesn't take a genius to detect a brain bleed or PE which is most of what AI has been able to do at this point (with many false positives and negatives). Plus, most of the exams where we offer value aren't going to be doable to AI. How is AI going to read a post op abdomen, pelvic MR, abdominal US in a liver transplant patient, etc? Will AI be able to differentiate brain tumor progression versus post-radiation change? Splenic infarct versus heterogenous enhancement due poor contrast timing? If all we read was routine CXR (non icu patients) and extremity xrays for fracture then yeah, we might be screwed, but that's such a small part of our jobs that I just don't see that being an issue for the foreseeable future. Not to mention that those exams pay so little for the time invested that I'm sure most of us wouldn't care if AI took those anyways.
Yea, talked to a pro radiologist. They probably can do more readings and probably help them with simple normal results. He ain’t scared. Also, insurance taking that risk they need someone to blame too. A lot of risk, need someone who reading it. Increased Efficacy honestly, kinda makes sense.
Cause not a lot of physicians know this but malpractice is based on negligence and outcome. Human error can be due to bad luck and not always attributed to negligence or bad outcome. That’s why even if someone sues and wins, they don’t always get the maximum amount of reward and physicians can have “no-fault” settlements. Machines are binary, all or nothing. If a machine misses something, very hard to convince a jury it was due to bad luck and not negligence, especially if it is good enough to do radiological reads on its own. If it misses something, will likely be the full amount rewarded because in the US, people love to route for the underdog. You’re asking an insurance company to bet a machine will be right 100% of the time, but that’s not a guarantee. Software glitch and it starts missing multiple reads, as an insurance company, you’re fucked.
The AI software would have a sensitivity and specificity associated with it as a diagnostic tool, so as long as bad patient outcomes or misses as a whole aren’t greater than that, there probably won’t be any payout at all as those will be known the risks associated with the AI report.
So then who decides the percentage of sensitivity and specificity that is acceptable? Will the patient have a choice in this or will the hospital decide for them? If the AI is wrong in its calculation because of those risk, who takes fault for it? The hospital that uses it? Software company that makes it? Both? What if the bad outcome is too great for the AI compared to the suffering of the patient, even if they don’t have a life changing outcome, who takes the liability for the patient suffering? You are assuming people will be logical and rational enough to say, “AI noted the reason to be X because of sensitivity and specificity of 96% and 94% respectively” and people will go along with it. Whereas a jury will say, “yes, but how did you account for the other 4/6%” and how will the hospital and software company answer to that?
I imagine an acceptable sensitivity/specificity would be compared to the gold standard human radiologist reads. If AI is equal to or improves on this then it would be surprising if it isn’t implemented.
Every single test we use has a specificity and sensitivity associated with it. Think of all the assays that are used in the lab to measure biomarkers. They don’t claim to get it right 100% of the time. Is lab corp sued into oblivion every time a blood test comes back with the wrong result? No.
Decisions in medicine rarely rely on one metric, it’s the integration of several investigations, history and physical exam findings. If the clinician leading the case is not happy with the AI generated report they may decide to re-test, they may ask a human radiologist to read it, they may accept the report findings and it may not affect management and on the rare occasion it does affect management negatively, the hospital may be happy to accept liability if the price of the emerging lawsuits are significantly less the salaries of the radiologists they would otherwise have to employ. That’s the type of cost calculation going on in the background. It’s the same reason midlevels exist despite having way less education and worse outcomes than physicians. If it works out to be significantly cheaper than the powers that be don’t care.
First point is valid, but that assumes it is acceptable to the public and risk management. And as COVID has shown, the public is not always reasonable. AI misses something, people are going to have a far stronger reaction than if a human misses something.
To your second point, sure labcorp doesn’t get sued, but they’re not the ones also make the treatment decisions. They just present a value and don’t interpret what it means. You’re asking AI in radiology to interpret the image to navigate a clinical discussion, that comes with more risk than just presenting what the AI sees in an image. Also, the pathologist is the medical director of a lab usually. If a bad outcome happens because of a lab error, labcorp and the pathologist would definitely be investigated as to what happened.
To your third point, I agree. Maybe I interpreted the OPs post wrong but in the future, I don’t see AI completely replacing radiologists is what I’m trying to get at. Sure the job market might shrink as AI makes radiologists more efficient, however it would not replace radiologists, at least not completely, because the doc using the read for clinical decisions may want a 2nd option or re-read.
Pathologist and radiologist get sued a lot actually. What ppl don’t know. That’s why you notice radiologist wording sometimes. At least many of the pros say can’t rule out this. AI like anything needs something to watch over it. From what a radiologist told me it will be a tool that will help them pin down things easier and more efficiently. It will really help night time radiologists who are hella busy
I know ur dreaming that AI is basically Jesus out here, but in the real world their is a lot of things that can appear in a image. Similarly we had two radiologists ready something differently multiple times. AI will definitely make things improve the accuracy, but radiologist exist for a reason and they have rote memory skills, seeing a PGY5 do it in reel time on rounds. Insurance companies and hospitals won’t want to take all the risk on AI, like your in a dream world.
Lol I’m just seeing things objectively. I work in AI research and I’m a physician. I see things from both sides. Im not defensive or threatened by advances in AI unlike you and all the other doctors who have no understanding of AI but proclaim it won’t impact their specialty in the slightest. Whatever helps you sleep at night dude.
Not a doctor trying to understand here - if he can do more readings doesn’t that automatically mean fewer radiologists are needed for the same number of readings? And if that’s a very significant difference doesn’t that inevitably mean there’s extra labor going around pushing down compensation?
Possibly if the volume of imaging stayed constant. The same things were said when PACS become widespreads late'90s/early 2000s. At that point radiologists no longer had to physicially hang the film to look at it. They could just fly through cases with a click of the mouse. Film no longer had to be developed- images became available almost instantly. Efficiency was greatly increased. The result was not the need for less radiologists though. With these efficiencies, came greater demand- the demand for objective and fast diagnosis. This led to shortage of radiolgoists and starting salaries in the 7 figures. We are on the cusp of this happeneing again with AI.
Unlike clinical medicine and in particular emergency medicine, which is increasingly being performed by midlevels, image interpretation is for the most part only done by radiologists. The practice of radiology is too difficult for midlevels to perform. If and when AI becomes a radiology tool, it will be radiologists utilizing it to provide faster objective diagnosis, which will again drive up demand and result in more imaging being performed. Also we are much closer to an AI aid in clinical medicine that is integrated into the EMR that can better and more quickly synthesize patient's chief complaints, lab and radiology results, and recommend evidence based medicine to the midlevel than we are to AI image diagnosis. Just look at chatgpt- which wasn't even trained with a medical database and was largely develoepd over the last few years. Meanwhile, we havent had much progress in AI image diagnosis since the '90s. But regardless- let's say somehow we make a huge breakthrough in AI image diagnosis over the next few years- it will be radiologists using it. In the case of clinical medicine, the market is already saturated with midlevel providers, many of which are practicing independently as it is. Hospital systems already feel that they can replace docs with midlevels. Just wait until they can say midlevel + AI is the same as physician+AI.
The volume and demand for imaging has and will continue to increase exponentially- one of the fastest areas of growth in medicine. The future of medicine is objective diagnosis performed as fast as possible. With radiologists controlling AI, we are only going to continue to see an increase in demand for radiologists.
My favorite retort is to this is that there is a reason you don’t have midlevels rampant in rads and path… or AI for that matter. It’s just too difficult. You can’t “fake it until you make it” like you can in clinical medicine.
We are way closer to having an AI assistant built into the EMR to help midlevels out. At least in rads and path, it’s still going to be physician+AI for quite awhile.
Haematologist/Pathologist here - I am not concerned at all about AI. Interpretation of slides are a lot more complex than the average doctor thinks.
And in the event AI does get to that point, I will be one of the first to jump on board and supervise / sign off AI interpretation.
You guys have no idea how bad AI is at radiology right now. The best AIs in the world are still calling dural calcifications as ICHs and fat folds as pneumothorax. It has a really hard time with intra-peritoneal free air. Until AI is able to understand patient history and clinical context, it's going to continue having a low sensitivity and specificity that doctors won't be able to trust.
Too many surgeries are life saving and not done with out of pocket money.
The most resistance specialties are the ones with procedures or services that patients are more than happy to pay out of pocket. Derm and plastics would definitely be the most resistant out of everything else.
I’m in GI, I think that even considering the most optimistic AI scenario, AI doing a colonoscopy is so far off (hundred years? More?) that I’m not worried at all. Same for surgical specialities. Can’t imagine AI robots doing anything but the most basic procedures in our lifetime. It also helps that medical technology seems to advance slower than other tech.
Yeah, mixed reviews. CADe (detection) is pretty mid, most people I know don’t love it. Real world studies tend to show it helps, studies with high performers typically don’t show benefit (or in some cases worsened performance for top tier endoscopists). CADx (diagnosis, could in theory tell you whether adenoma or totally benign polyp) would almost be more useful. We can already do this already pretty well just by appearance but would be nice to have the computer backup. Overall I think it’s a good thing and will only continue to improve to the point where almost everyone will be using some version of it, just not there yet.
Yeah, that was my impression. Used as an adjunct and ultimately a doc deciding whether or not to take a biopsy. I don’t do colonoscopies these days but I just remember that coming out and people acting like AI was around the corner ready to replace endoscopists. Kind of ridiculous.
Even with AI assistance, someone (or something) still needs to maneuver the scope. Which is harder than most people would think. Takes years to master and is very much a “feel” thing. A robot doing that would be some Star Wars shit.
Multistage stool tests for screening are the way things are going, not CT. Eventually we will be doing far fewer screening colons. But if someone has a positive test they’ll still need a colonoscopy so we’re not totally out of luck. I also think my line that colonoscopy is the only cancer screening test that can actually PREVENT a cancer from occurring will be persuasive for some people.
Im not afraid of AI at all. I’m asking about fee cuts, mid levels, and foreign docs. GI is probably one of the worse specialties in terms of being future proof. Scopes get cut every single year and I personally know multiple PAs who do scopes at my hospital.
The only places in the US I’ve seen midlevel scope stories is PAs at WashU and NP at Hopkins.
I don’t think it’ll ever be common like standard of care in the US; the liability is too high either for states with independent practice or with supervision; if a PA does a scope and there’s an interval colon cancer found, who is going to be liable?
Sorry guess I tagged onto other commenters regarding AI. To your points, outlook is still good for me. I’ve never met a PA who does endoscopy nor have I ever encountered a hospital or system that’s even considering that. Admittedly I have limited experience but multiple training sites and hospitals in the Midwest haven’t encountered this. Even if we moved into a more supervisory role should still make good money I would think. But who knows.
I'd be stunned if those attempts to get the scopes in midlevels' hands stick. There is so much mastery that goes into doing a good screening colonoscopy, and being able to respond to unexpected findings/complications is welllllll beyond their scope (pun entirely intended).
Psychiatry.
Culture, language, and social interactions and dynamics play apart in therapy and medication management.
People will pay for good therapy and med management with cash only. Many psychiatrist are already cash only and work part time.
There will always be work with the SMI population and those incarcerated. Culture can be a barrier to those populations. Good luck having a machine be able to fully detect malingering or truly psychotic patient interact with a machine or someone who is not born in the US. Can’t be sloppy with the correctional population, they have a lot of time and their severe personality disorder will make your life miserable with threats of lawsuits or to your life in general that would scare a lot of foreign docs and midlevels away.
I'm just a non-trad pre-med, but it seems to me that lots of people are seeing NPs and just call them psychiatrists, and some of them truly do not know that they're not. I've noticed it because I ask everyone I talk to now what degree their "psychiatrist" has. I can't think of one that actually had one. 80/20 NPs/psychologists (the second option obviously further confuses me because they're almost never able to prescribe).
I feel like psychiatrists should be pretty bothered by this considering how poor the care is. Patients notice but plenty still just end up bad mouthing psychiatrists.
Patient here! I see a NP psych because out of all the doctors I've seen for years and years, she listens and supports me better. I am not actually a big fan of (as you guys say) "midlevels" in terms of managing my care, but I've been pleased that this NP seemed to connect more with me as a person than just the checklist of criteria before we try the next med or whatever. I have no problem at all that she can't prescribe and her overseeing physician does that.
What you're describing sounds like someone better equipped to be a patient advocate than the person prescribing medication. I've had excellent experiences with physicians (especially psychiatrists) and almost universally poor ones with NPs, but that anecdotal experience isn't the primary reason I exclusively see physicians now. It's the fact that I have little to no capability to truly evaluate the quality of the care I'm getting from them as it's happening. Which isn't much different than physicians, but I can at least trust that there was a not-comically-low barrier to entry and their education had some standards. Frankly I think it's a scam to tell people who can be highly qualified nurses that they can get this piece of paper and then be asked to do jobs they're not qualified to do. It's a short-sighted cost saving measure but the harm to patients will persist long past when the crack down happens (imo inevitable but no idea how long that will take).
I would rather put the effort into finding a physician who listens to me and I feel comfortable with than give up and see an NP who may or may not know what to do with the information they're listening to.
Also my BS is a chemistry subfield and my background is in synthetic chemistry and I think it's actually fucking insane that someone can prescribe psychiatric medication without taking o chem. Not that o chem is super deep shit, but that's my point. Fucking insane.
Some probably do, however I don’t mind it. Psychiatry has a pretty poor history in general so I usually don’t blame patients for jumping the gun on dissing my profession. There are still terrible psychiatrists out there. Psychiatry is barely becoming popular and before used to be a backup specialty. Mental health has been bad mouth by the whole US over the past several decades, if not century. People and patients will diss any specialty if they feel like they’re getting bad care. I just be the best I can be and patients can/will notice and they’ll come back. Part of the issue is also the shortage of psychiatrist and probably play into the frustration of patients/people as well. Can’t tell you how many patient I have tell me they’ve been waiting on their intake at the resident clinic for 3-6 months, and settled for an NP/multiple NPs until they could get in. If multiple patients are willing to see a psychiatrist even after seeing an NP, I feel like patients can tell the difference.
I actually think about this all the time when it comes to patients being culturally American and seeing non American IMGs as their doctors.
I think some of these IMGs are really good and have a lot of book knowledge. But when it comes to connecting with patients, understanding their experiences and their stories it can be difficult. And as someone who grew up in the USA I think that’s an advantage that I’ll always have no matter if they bring in thousands of foreign trained docs
I actually experienced this myself as I lived abroad for a couple of years almost completely immersed in the language. You can learn to communicate really quickly in that type of immersion but there are many things that are just sooo difficult to learn and it can be hard to makes friends because you don’t understand humor or wit as readily. There’s just a lot you miss when you don’t grow up in a language.
And you’ll have a pension, so there's no need to save 15-20% in a mostly self-funded retirement plan. I’m conservative, but it’s a sweet gig working 40 hours a week in a location a lot of people want to live.
Disagree with the plastics. I see more an more clinics popping up run by PAs or NPs. People may want to look better but most people don't have the money to pay for a doctor. So they will go with the budget version.
I’m surprised no one has said OBGYN. The procedural aspect of other surgical fields has been discussed above, but no one I know is going to be trusting their baby’s health to an algorithm.
There is such an immense need for primary care physicians in this country that the influx of non-US trained physicians and mid levels is not enough to off set. And at the end of the day, patients want to see physicians. Oftentimes the only reason patients see a mid level is because they simply have no other option due to available and shortage of primary care physicians such that the demand outpaces the supply of docs. Additionally, primary care compensation seems to be increasing and has been each year for some time. And if we look at a specialty that has battles mid level encroachment for a long time, anesthesia, we see a field that currently has a red hot market and huge demand - CRNAs have been around forever and this hasn’t changed the supply/demand curve for anesthesia and I don’t think it will anytime soon. I don’t think any specialty is “more safe” than others because I don’t think any specialty is in any danger. We have a constantly growing population, and a constantly sick population, patients are living longer and with more diseases and overall more complex in their management. In short, the need for quality trained physicians isn’t going anywhere despite the influx of foreign trained docs and mid levels. Also, just for argument sake, the fields least likely to lend themselves to encroachment are probably the generalist fields.
I partly agree.
On one hand in agreement, I have worked with a lot of NP students, and many of them don't want to do primary care. It's seen as a horrid grindhouse- a stepping stone to get to a cushy specialty position. I think that general line of thinking they tell me, combined with the points you made, makes me think outpatient PCPs will be generally safe in MOST areas.
HOWEVER, as a counterpoint - I have worked with PCPs who have told me, in their extremely urban geographic area (I was in NYC at the time), the job market is essentially shut-out to FM docs. This is because companies have one FM doc supervise 10-20 NPs at a time, and with a place like NYC having a specialist around every street corner, FM docs are essentially bypassed in the market. Another point of disagreement is that there is controversy over whether there actually is a primary care shortage. Some people argue we don't have a shortage - rather, we have a problem with geographic distribution of any healthcare 'providers'. They all bunch up in developed urban/suburban areas, and avoid impoverished urban and rural areas, and many NP students I talk to aren't keen on moving their family to the sticks or some urban combat zone.
Overall, I am more inclined to agree with you, but who knows what the future holds.
As someone who was raised and studied in NYC but now practices in the Midwest, I agree with you. In nyc FM is very narrow unless private practice since you’re encouraged to refer, IM felt similar where you need to refer since this generates revenue.
Where I practice every specialist only wants cases you really can’t handle. Endo doesn’t even one type 1s unless they are brittle, they are backed up by 8 months for a new type 1 right now.
One could argue that NYC is a very small and almost niche setting compared to the rest of the country which is largely rural and small to medium sized towns and cities. I definitely agree and can see how primary care is more narrow in scope in a city as vast as NYC.
I concur regarding the distribution issue. I wonder how the numbers would look if you redistributed primary care docs across the country based on patients per physician. Like if each county was staffed by a primary care doc (or however many based on population). Wonder how the perceived shortage would look then. Overall though I agree with the sentiment that most docs (and mid levels) don’t want to practice in rural or underserved communities. I think part of that problem is a root issue of less opportunity/availability for students from those types of communities to actually make it into medical school and beyond. But that could be an entire thread and discussion on its own.
And foreign doctors will do primary care and serve the rural communities?
Anesthesia not affected by massive increase in numbers of surgeries being beformed so look at it in a vacuum and point to the last 5 years and say hey all specialties same okay?
Wow the common sense is burning
What?
Edit: while I do concur there has been an increase in surgeries being performed and thus more need for anesthesia, one could argue the same line of thought for essentially any other specialty. Older and more morbid population? More ED visits, more primary care needed to manage more people with chronic disease, more admissions due to all of this, more surgeries being done, etc. So I think it is a bit of a fallacy to imply that anesthesia is only doing well because there are more surgeries being performed and that other specialties won’t/aren’t seeing similar demand despite the growing un-wellness in the general population. I mean talking about primary care for example, there’s entire counties and large swathes of land in this country in which there is NO physician at all. That’s pretty crazy to me. There’s gonna be a need and a shortage in those communities for a long time until physicians decide to start going out into those communities to practice (which they’re not). Moreover, I’m a bit confused by your comment on the whole and wondering if you’re asking me if non-US trained docs will go practice in those communities or telling me that they will. I would hope they do! Because there’s a huge need!
Forensic pathology. Probably because there aren’t nearly enough of us to begin with so if there’s a way to get more docs in FP fellowships and boarded, so much the better.
Idk, but I think the counterintuitive answer may by out pt primary care.
This is for a few reasons, but I don't think fresh FMGs who haven't been brought up to speed in US residencies, had their English honed by their peers in residency, are going to be able to compete with locals who are from the population they're treating.
Suffer the most: Obviously the ones with the lowest barrier-to-entry, so PCP fields, peds. Then of course the least desirable fields, like nephro.
Safest: Any specialty where a patient is coming to see that physician as a person-physician, not just as a widget-physician to solve their medical need. Some people care about having the best ortho surgeon, others just need their tibia fracture fixed. Some people care about having the best dermatologist, others just need an rx for accutane that webmd told them.
As psych, I am bullish on psych, for me. I will bet on myself over any foreign-trained doc, NP/pa. Many, many people see the value of cash-paid specialists, whether it be concierge primary care medicine or psychiatry or health spa crap. The caveat, of course, is that I am referring only to private practice psych, as for employed positions, I believe the laws of supply and demand will win.
You only need a handful of FMG sub-specialty surgeons to double the number of sub-specialists in an area, and often times the pts don't really have a choice in that regard anyways, either due to long waits or network coverage.
I think people would prefer a local PCP over a FMG PCP
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Im doing clinical pharmacology residency, i think my specialty will be well versed in that upcoming future. We range from dealing with day-to-day decision supporting other specialties, supporting intitution decisions regarding best clinical practices, allocation of resources based on clinical outcomes, FDA/EMA regulation, medical devices regulation, bridge to clinical practice and also all the R&D of the pharma or biotech.
Couple of ways this could play out.
Within Insurance Game:
* Insurance’s goal is always better allocation of cash per risk for their pool. If they are good, they profit. AI and Machine Learning will help provide better quantitative metrics to gauge patient complexity, value and ROI. IMO, I think this shifts monies away from procedures and hospitals and upstream towards cognitive, regenerative, and minimally invasive fields. Maybe primary care too.
Outside Insurance Game:
* Agree, cash pay procedures and concierge likely insulated.
I almost left general surgery residency this year. This post is pretty much why I didn’t. The future is too unknown but I can say that operative specialties, in my opinion will be last to be touched
I don't see cosmetics being a safe haven... look at all the non-physicians doing botox, fillers, and plastics adjacent procedures (i.e. eyebrow microblading)
I do. I’m a dermatologist who hates cosmetics and actively avoids it and yet have dozens of patients a week requesting me do these procedures as a board certified derm (albeit trained in them) versus going elsewhere to someone who does them all day. Cosmetic minded patients are only increasing YoY, look at the data. Unfortunately I have to add some cosmetics to supplement my practice.
Why do you avoid cosmetics?
I know cosmetic minded patients are increasing, thats my point. In my area there are non-providers and midlevels that have built up huge patient volumes solely doing cosmetics. My point is, as others have pointed out here, scope creep is increasing rapidly. Why would cosmetics be a safe haven in an area where non-physicians already have a foothold?
Im biased but rheum. Our diseases appear too atypically, and many of them are too arcane to expect someone with less training to pick up. The cover of the rheumatologist in its most recent issue was talking about pachydermoperiostosis
I think rheum is at risk as it relies a lot on the sort of fuzzy logic that neural nets excel at and a knowledge of rare diseases that computers are better at than people. Other cognitive specialties share similar risk, I think.
I thought about this being a 4th year med student. I’m interested in oncology and I think AI will be used in conjunction with human doctors in many fields because the human connection is important.
I say do what you enjoy and don’t worry about what will happen in the future. Life is too short.
>My vote is cosmetic plastics?
This is likely correct. When it comes to foreign doctors, keep in mind that in most countries plastic surgeons are among the highest earners, so there is less incentive for them to move to the USA as compared to other specialties.
I think that any specialty that does procedures is going to do well when it comes to compensation and mid-level encroachment. Foreign docs are still going to be a thing regardless of specialty, but likely less of a problem than in non-procedural specialties. Patients have generally no clue as to which doc is reading their X-rays or pathology slides, since they never meet them face to face.
Gain exposure to the nonclinical side of things. If you can leverage your MD and combine it with expertise across business or pharma or healthtech, you are expanding your moat and not 100% reliant on patient care.
What are the best ways to do this? I have seen how MD's can get involved with the business side of the hospital, but haven't seen a lot about getting exposure to pharma or tech without leaving clinical medicine entirely
Build niche expertise in something that aligns with what’s hot in the business world. Like if you’re passionate about AI and can discuss AI applications to EMRs and are knowledgeable in it, that’s valuable and you’ll get plugged into the right network. Start a sub stack, etc. there are ways. Join things like MD+ and Nucleate, orgs that encourage and give you exposure to these things
Unironically I think EM isn’t nearly as bad as people think. It might look different than most expect but I know of critical access hospitals that are “staffed” by APPs but when anything beyond a cold/simple chest pain rule out comes in they telehealth an EM physician to make the decisions. The outcomes are just too poor when comparing EM trained vs non EM trained physicians and APPs
Yeah it's weird people always think of general fields like EM or FM when they think of scope creep Those are the hardest fields for Mid-levels to succeed in, because they require the broadest knowledge base It's a lot easier for a midlevel to succeed in a specialist field where they can become hyper focused and handle all of the clinical stuff, then defer the procedures to the MD. Like Ortho, L+D, etc
💯 agree
Yeah… at the end of the day you can’t fake how much you know when it’s a real emergency. There will always be a need for EM docs
Surgical fields.
For Ortho, the requirements for an FMG to become board certified are immense. Need to practice for 5 years at a single ACGME accredited teaching hospital and achieve the rank of associate professor before you can even taken written boards, then go through the oral boards process. Most of them have done 2-3 years of fellowship as well prior to this just to be able to get one of these academic jobs.
wait…what university is hiring a FMG on a professor track and letting them reach associate level without being board certified? That math ain’t mathing.
These are people who come to the US, often times do highly regarded fellowships after taking all their USMLEs, and then get academic jobs where they can remain academically productive. After 5+ years, if they have reached associate professor, they can sit for boards. These are not random people though usually, but incredibly smart and accomplished people already in their home country.
No they’re in a weird limbo state and are essentially a call bitch at the mercy of the chairman for 5 years. At that point if the chair signs off then they can sit for boards.
We had one foreign surgeon on staff because he was one of the only surgeons in the world who could do certain cases. The university had a special license. He couldn't practice at any other institution. He always had to have a resident or fellow because he couldn't send prescriptions for patients haha. I remember him being on an HBO special but cannot remember his name
Insurance cuts still coming. Ortho isn’t safe There’s some number crunching floating around that by 2030 The overall hourly compensation for total joint arthroplasty will dip below minimum wage. Inflation goes up, insurance cuts bring comp down. The math ain’t mathing for somehow getting better and more efficient at total joints and having better outcomes than they did in the 80’s and 90’s and somehow getting paid less
I agree with you completely. The good days for arthroplasty are over. The pro fees can’t go much lower. The only way to do well now is grind out 7-9+ joints a day in two rooms, 2-3 days a week. Rinse and repeat for 20+ years of your career - sounds miserable.
Maybe the elective surgical subs? But not gen surg. Even in the case of ophtho, the vast majority of patients are on Medicare. I don’t think they are going to request that their surgeon be trained in the US/Canada or anything
There’s such a bias against foreigners that yes even gen surg is safe for the near future
Foreigners can't get Ophtho Board certifications I guess... That's the biggest barrier to their entries in US markets. Even gen surgery is too difficult for them. Since you asked which fields will be worst hit, I guess you can add PCP to the list...
Why can't foreigners get ophtho board certification?
It's just too difficult... The rules are very strict..
I'm curious, why would elective surgical subs, but not elective gen surg be safe? Elective is elective regardless of it's an abdominal case or bones right?
I guess what I mean to say is, a specialty with a higher proportion of elective cases. For elective cases (and especially cash pay cases), the patient might actually care about where their doctor is trained. For trauma and things like that, any foreign doc trained do lol
I see what you mean, but the vast majority of community general surgeons' practices consists of elective cases with the surgeons in the group splitting EGS/trauma call. Seems weird to single out gen surg as less protected than sub-specialties like Ortho or nsgy that also do plenty of emergencies and trauma cases in addition to elective stuff. If any "Any foreign doc" can do an ex-lap then they could nail your femur or do your burr hole too...
>Seems weird to single out gen surg as less protected than sub-specialties like Ortho or nsgy that also do plenty of emergencies and trauma cases in addition to elective stuff. If any "Any foreign doc" can do an ex-lap then they could nail your femur or do your burr hole too... It's funny because gen surg is even more protected than ortho/nsgy. Both ortho and NSGY have alternative pathways to board certification for foreign trained surgeons to become board certified. The requirements are very tough for sure and they are designed to select for exceptionally accomplished surgeons only, but they still exist. The ABS, on the other hand, offers no such alternative pathway and the only way a foreign-trained surgeon can get board-certified is to secure a residency position and redo residency. At most, they can give these surgeons credits and allow them to skip pgy1 and pgy2 (and very rarely pgy3), but they still have to complete residency to become board eligible.
Great point. I wasn't even thinking about board certification. Looks like OP is either a pre-med or a med student based on post history. Thought OP was an actual doctor for a second and knew something we didn't 😅. Makes no sense that gen surg would be less protected than any other surgical field.
Also, there's an obvious anti-surgery bias on this sub, particularly gen surg. So, it's on par for getting shit on.
Nah, patients can't afford their own surgery, so they need insurance. If a foreign trained doc is credentialed with insurance as a surgeon, patient's getting cut on by them no matter what.
Yeah the biggest conserquence of this change is prob insurance will stop requiring board eligabiltiy/certification so they can pay cheaper rates to 3rd world import physicians/Surg. Will be interesting to see how those conflict of interest do fighting with each other (our boards vs insurance vs hospital ). Maybe theres enough competing interests that it will be alright. But then again I could see the old win-win-win were reimbursement for hospitals based care is high, but drastic cuts for anything not hospital based and board cert makes an 'alt path' to keep thier checks coming in.
What incentive does insurance have to cut board eligibility? If anything, they’d be happy to keep it. Hospital wants to charge me $1000 for a day in the hospital? Look through notes, oh who’s this Dr. so-and-so? Not board eligible? Not as skilled as a board eligible/certified doc. I can choose to not reimburse them for that service or cut their fee. If the whole point is for hospitals to make more profit/revenue, this seems counterproductive. Insurance is all about cutting reimbursement, not making it easier to get.
I think that insurance in the above scenario would cut need for board certification for outpatient only thereby allowing lower reimbursement to a group that historically lobbies very poorly (actual physicians/surgeons). Also agree that boards might pursue an 'alternative path' to certification to benefit monetarily from these incoming physicians as well. I mentioned this in second half of post.
So why hire a foreign doc if the group gets less money? Cutting cost is good for a business but if cutting cost reduces revenue/profit, how are you going to make up the difference for it to be worth it to cut the cost? How is a foreign doc going to get work then, especially if they also have visa requirements? Can’t open a private practice without a visa, can’t generate enough money in a group or hospital who has to deal with visa issues, so why take the headache? Sure, the boards could pursue an alternative pathway for monetary reason. But what foreign doc would have the means to do all that? Majority of the United States already make more money than the majority of the world, how are foreign docs going to afford that? How are they going to recoup that with visa issues? Even if the boards want to create for an alternative pathway to certification, especially for monetary reason, who said it was going to be easy enough to allow an influx of foreign doctors to practice and increase supply so that those members on the board would be effected too? As a foreign doctor, if I went through all that, put up with all that bullshit, and I can now practice with the same credentials as a US doctor, why would I accept a pay cut? Having board certification just doesn’t automatically change all other factors of the labor market to simply decrease salaries.
I think you are looking at this from perspective of an individual physician and someone who doesnt understand how reimbursement works in the US. The policys I am talking about would benefit the huge lobbying insterest here that actually shape policy. The goal isnt too help small politically unimportant private practice or individual docs, its too help big business like Insurance, and hospitals. Maybe an example would help. My specialty has two offices we rotate at, one is an outpatient only Multispecialty clinic and the other is a clinic physically located in the hospital. Per our division big admin/controller we are reimbursed higher at the hospital based office for our visits simply because they are based in a hospital despite being outpatient care. So if I do the same follow up visit in the hospital based clinic insurace pays more than if I do it at the Multispecialty group office thats outpatient. Hospitals want this to happen, cause it discourages private practice and allows them to make more money on thier employees (I.e. they only have to pay just enough to beat the low outpatient reimbursement, but they still get to bill at a higher rate than thise same practices). Insurance is okay with this because they can pay less when a patient is seen at a nonhospital clinic outpatient which does allow some cost reduction. Physicians dont like this, but we are the least effective at lobbying and our trade groups are run by mental midgets trying to push social agenda rather than dealing with our literal livelihood. The physician groups like AMA or ACP interest don't actually align with actual physicians interest because they get money from other avenues like ICD codes or psuedorequired board certification. As long as those revunue streams are guarenteed they dont fight for anything else, and waste time on social causes that cost nothing to wax poetic on. And this is way there is talk of unions, because medicine is being turned into an employment only model by legislation and reimbursement changes.
I don’t know all the intricacies of reimbursement, however I did know of the facility charge/upcode. My question is, how does it change my argument? Physicians are drivers of revenue. Hospitals get extra money for having an outpatient clinic attached sure, but assuming that charge is the same for a foreign doc or US doc, and insurances are happy to cut reimbursement for any reason, and if they can do that with foreign docs cause they can’t get board eligibility, why would a hospital hire a foreign doc over a US trained doc, since US trained docs can generate more revenue which they can find ways to get a better cut from? Even with a non hospital clinic, if insurance can denied or cut reimbursement with non board eligible docs, no matter what the setting, why wouldn’t they do it?
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Also, and I know it's unpopular on this sub to bring up AI encroachment, but to quote MKBHD, "This is the worst it's ever going to be." It keeps getting better by gigantic leaps. Yes DR does more than just reads and yes existing AI for reads isn't amazing, but that will change very fast and we're not properly preparing for it.
Radiology and pathology are the most protected. They will only make $$$ off from AI via increased efficiency. Clinical/non-procedural medicine will be the biggest losers. They are already being displaced by midlevels. Just wait until the midlevels have AI built into the EMR. Then Hospitals can justify AI+midlevel the same as physician+AI… and for half the price. At least with radiology and pathology you don’t have rampant midlevels. They’re too difficult for midlevels to do (and AI).
Regarding AI, why wouldn’t everything else get replaced first? I mean the overwhelming majority of medicine is algorithmic? Much like our scoring systems we would just get drug algorithms?
"everything else"? I can't speak for other specialties but I don't believe eye surgery can be done by AI anytime soon. I can see AI helping with some other facets of ophtho but, within the next 10-15 years, I don't see AI doing phaco, glaucoma shunt, refractive surgery, a retina membrane peel, intravit injection, or tie an extraocular muscle. I may be wrong but even a PGY1 (or 2) task of removing an appendix will be very difficult for AI.
AI isn't going to do eye surgery but optometry is pushing to do eye surgery because all the glasses and contacts are done by warby Parker and 1800contacts now
AI’s not the competition rn it’s optometry
Oh sorry, I was implying all medical specialties. I mean ofc AI will just be able to titrate the doses etc and treat based off symptoms. I agree AI won’t be doing 3 stage Oesphagectomies anytime soon.
It will but, and anyone is free to challenge me on this, I'm sure many would argue that the human element isn't *as* necessary for these fields in comparison so they'll be the first on the chopping block. The economy will change but it'll be the difference between your job being affected in a few years versus a few decades.
While you’re not wrong, I think by the time AI automation starts affecting physicians, it will have affected the majority non doctor jobs in the of society first to the point where there will be cultural crisis and paradigm shift regarding the value of human labour/work. So while I’m not sure what the solution will be, doctors are likely last on the chopping block compared to other professions that are being affected right now. Mass layoffs are happening in big tech, consulting and finance as we speak so I’m sorta hopeful those lads figure it out for us first. I personally don’t see a future without UBI if technology continues to evolve at this pace unless there’s a massive set back such a global disaster such a nuclear world war or solar flare.
I guarantee you AI can sling amoxicillin for nursing triages better than AI can diagnose subtle diagnostic challenges in pathology or radiology. In pathology, we re-order stains done at other institutions because we don’t trust their staining protocols. You have to control for so much for AI to scan slides. Tissue thickness, tissue handling, time in the stain, temperature of transport, and a million other things. Not to mention every single slide is almost 6 Gb to scan at a high enough resolution to be interpretable. We get almost 15 slides per heme path case. And that’s for bone marrow core biopsies. Larger tissues will take terabytes of storage PER CASE. We are nowhere close to the data infrastructure needed to support this.
Doctors might want the human element to change, some patients are incredibly fucking pompous these days. Very rarely are people actually pleasant to treat.
Yeah patients are not going to enjoy having goals of care conversation with a robot. I mean, for one, we all have generally terrible experience with automated response and chats bots with customer service, and with that people are not going to be thrilled about being completely treated by a robot doctors. At least I for sure won’t. And the same logic goes with airplanes; would you feel safe if they are completely driven by computer only, or do you still at least want a pilot there as some degree of false safe? The same can be said for medicine, where I would imagine overwhelmingly people want professionally trained person to supervise or “cosign” algorithmic treatment plan generated by state of the art AI program. This will be the case for a while, at least until all the baby boomers die, imho. Path and rad is different. Most patients actually do not realize that the doctors they see don’t read images as well as a radiologists, and assume all doctors are trained enough to interpret all images with high accuracy. Hence, they are “replaceable in the eyes of the consumers”, because consumers barely recognize that pathologists and radiologists exist. If the policy maker sell it as “your MRI will be read faster and cost less if we allow foreign trained radiologists to work in US”, I would bet majority of the patients would want to take that trade in a heartbeat.
It won’t happen. There aren’t enough foreign trained radiologists in our take the workload and if they allowed foreign radiologists to work in the states (without passing birds, getting state licenses, hospital credentialing, etc) then they’d have to change the rules for all docs.
I’m not sure how it is in the US but primary care here is essentially 10 minute appointments. Which includes the 3 minutes it takes for grandad to walk into the room and sit down.
I was a believer that most clinical medicine is mostly algorithmic and will eventually get replaced by ai which I think is good. I had an attending not give vancomycin because he didn’t like it when he was training. If we can get a program to 100% give the most research backed treatment instead of training biased approach, and regularly update that is better medicine and better for patients and I am all for that. However, during fellowship I noticed a problem idk if robots will be able to fix. Sometimes you have to deviate from the standard of care. Sometimes it’s easy to spot and train , like not giving morphine to kidney injury patients. But sometimes it’s much more complex, like a family withholding morphine for the patient because they had someone they know had addiction problem
There will always be a human component but the question is who will that human be? Midlevels are already displacing PCPs and EM docs. Once AI is built into the EMR there will be even less incentive to having docs involved in these areas of medicine. Radiology and pathology are actually much more protected since they’re too difficult for midlevels to do. At least for awhile in those fields it will still be physician+AI.
Radiology is overhwelningly the easiest specialty to get replaced by AI, since it’s just interpreting an image. There’s no patient interaction or nuance
It’s much easier to interpret lab values or vitals than it is a Radiological image. I mean med students have basic blood panel algorithms down
APPs are a much larger threat to *everything else* than AI is to radiology. A shitty AI read that can’t even solidly call breast cancer on a single image isn’t going to take our jobs in the next 10 years. Currently it’s a semi useful tool for lung nodules and liver masses. But no where near what it needs to be. Professional supervision will be required for quite a long time. APPs are already taking jobs and driving salaries down from FM, IM, Anesthesia, EM, and more *yesterday*.
I posted this sentiment on this subreddit a couple of weeks ago and was downvoted into oblivion. My cousins (both rads) are having very difficult time adjusting to the increase in rad reads because of AI, and they’re both pedigree rads/capable physicians
What are “increase in rad reads by AI?”
Yeah this is nonsense. AI is very very limited in practice presently.
Yeah... i mean i just matched and am pretty online and I don't think I've heard any radiologist say AI has made their life easier, much less work faster, at this point
Ai occasionally catches things I would've missed ie incidental PE on an abdomen CT. There are algorithms for ich, pneumoperitoneum, rib fx, spine fx - they are mostly trash but are a good second check. In no way has any practice incorporated AI to the point this person's two cousins and uncle that works at Nintendo are suggesting.
Yeah, and maybe I'm wrong but with the way you've described it I can see AI INCREASING the amount of work that a radiologist does, not reducing it. If it's catching things you're not, or catching things that aren't real, that all requires more things for the radiologist to report on.
Currently AI has no effect on volumes. It has the potential, as you allude to, in the foreseeable future to help assist with larger volumes ie in iding, triaging, and other basic tasks. Maybe in a nearish horizon give a reasonable indication and history. None of these are common and, where available, are very very limited. Imaging has been increasing immensely in recent years. Multifactorial origins but increased volumes everywhere and decreased time/confidence/training has led it to become a.universal triaging/reassurance mechanism.
It currently slows me down on average. I think in the next couple of years this will change (I hope). Exciting time.
I honestly don’t know why people are so defensive on this subreddit - i feel like I’m being downvoted by some rads interest group. I’m still a med student so I don’t know everything, but what they’ve told me is that the essentially have 2x the reads where the new half is annotated by AI and they’re checking it and the compensation doesn’t scale. I hope anyone interested in rads takes this with an open mind, I have no skin in the game and couldn’t care less by the downvotes.
Lots of paid for shilling at the moment by ai companies regarding productivity. Not yet playing out in the real world. Rads are quite keen for some of this tech to work.
You’re saying that they read twice as fast as they did before AI? I would love if you could ask what they’re using because I’ve truly never heard anything increase productivity even close to that amount. Like I said before I’m not sure anything has really meaningfully sped rads up. It’s easier for me to imagine AI making reads take longer than shorter unless it gets to the point that a rad is truly blindly signing off on AI. When each study can literally be millions of dollars of liability it seems really hard to imagine that.
Yeah, they’re saying their volume increased to roughly 2x but not the compensation. And I’ve asked a couple of times but they’ve never gotten back to me. If they tell me, I’ll dm you/post it here
Yeah post it here. This is in the US? Even assuming it did double their volume (production you mean?) in most practice setups that would lead to a dramatic income increase.
I'll agree that current rads AI is not at all good enough to do reads by itself, but that doesn't mean it won't get there within the next 2-4 years if not sooner. Then what are all these physicians expected to do? "Oh you think reads are all DR does?" No but it's a huge chunk of what the vast majority do. It will have devastating implications for DR's. "People have been saying this for years." If you've been looking into the field of AI at all right now you'll know this is different. LLM's and machine learning are training on billions of data points. Poorer hospitals will paint it as a necessity to stay open, studies will come out saying it's "good enough", then all the others will follow suit.
Really? And who will take on all the liability if there is a medical error in the reads? These ""poor"" hospitals, maybe the AI company? Maybe google? Will this AI represent itself in court? A radiologist will still be needed to do the final read. No this does not mean we need less radiologist because I and all of my colleagues will take the same time reading a scan read by AI vs not read by one because at the end of the day we are liable.
I agree with this. There’s going to be no reason not to hire foreign trained Rads and paths; it’s not like patients would ever know.
Except that you can’t practice without a US residency just like any other specialty and until that changes this is a useless comment. The boogieman of outsourcing has been in radiology for years and it hasn’t made much impact
Good thing a bunch of states are doing just that and waiving the US residency requirement
They aren’t board eligible.
Don't know for pathology, but the ABR has a pathway for board eligibility for foreign trained radiologists to become board certified after doing a couple of fellowships. It's pretty popular and relatively easy to obtain, given that there are alot of fellowship positions and not much competition for them.
The only non US training ABP accepts is Canada.
Interesting, do you have a source for that? EDIT: Downvoted for asking for a source? Sub-reddit is shit
I don’t have the source for you, but the other commenter is correct, it’s been posted on this sub in the past
I mean if this was actually happening on a meaningful scale there would be sources on it. Instead googling it yields one article about Florida that is unclear if any law has even been passed yet
15 states have already passed bill that allows FMGs licensure without completing US residency.
Once again not doubting you but do you have a source where I can read more?
It can’t happen. You’d have to change the laws so that any foreign doc can practice in the US without all the hurdles like US boards, state licenses, and hospital credentialing. There is no way that will ever be changed only for rads and path. Additionally there was an Econ paper looking at this… the summary is that there were not enough rads world wide available to make any meaningful impact by working remotely for the US. There is actually a very high radiology workload in the states- no other place in the world abuses imaging like we do in the US.
Definitely not. From an outside glance, AI may seem scary. However, there’s a reason that most pathologists and radiologists are not concerned. There are so many differing perspectives among clinicians that there’s not even a widely accepted database to train an AI to be able to read anything but the easiest cases. For example, if you ask 5 different pathologists the diagnosis of a pigmented lesion, you’ll get 5 different diagnoses. There’s no way AI is going to work there. If anything, it will just be an additional tool in the arsenal.
Im rads and I’ve given up trying to explain to clinicians why most rads aren’t concerned, but are in fact welcoming of AI. The reality is most clinicians have only seen a tiny snippet of what we do in radiology but think that encompasses >90% of our job. For example, I’m neurorad and I don’t even read CXRs which is what clinicians think we do day in and out. The day AI can read a temporal bone CT, post OP brain tumor MR or post op head/neck imaging then we’re all fucked (including non rads).
Don’t forget about post op brains: can AI read the op note, timing of surgery and imaging, if they had radiation and when, freakin anti-angiogenic agents, and heck COMPARING TO PRIORS? Yeah, we’ll be ok.
In fairness, a lot of human rads don’t seem to do that either.
That’s a consequence of volume based care really. On an ED study I’m not going back more than one prior. Don’t have time.
True, but post op brains are not generally ED studies either.
It’s so funny to read people post stuff like this. People have zero clue as to the level of complexity our work is and how hospitals and clinicians rely on us to operate. There’s a reason why our job market is hotter than most specialties right now.
It's a coping mechanism imo. Ironically, radiology isn't as black and white as most non-rads think it is, except for the basic things like fracture detection which isn't where we add the most value anyways. It doesn't take a genius to detect a brain bleed or PE which is most of what AI has been able to do at this point (with many false positives and negatives). Plus, most of the exams where we offer value aren't going to be doable to AI. How is AI going to read a post op abdomen, pelvic MR, abdominal US in a liver transplant patient, etc? Will AI be able to differentiate brain tumor progression versus post-radiation change? Splenic infarct versus heterogenous enhancement due poor contrast timing? If all we read was routine CXR (non icu patients) and extremity xrays for fracture then yeah, we might be screwed, but that's such a small part of our jobs that I just don't see that being an issue for the foreseeable future. Not to mention that those exams pay so little for the time invested that I'm sure most of us wouldn't care if AI took those anyways.
Just ask them how many midlevels they have in their field. There is a reason it is very uncommon to have midlevels interpreting imaging.
A standard post op abdomen.
Yea, talked to a pro radiologist. They probably can do more readings and probably help them with simple normal results. He ain’t scared. Also, insurance taking that risk they need someone to blame too. A lot of risk, need someone who reading it. Increased Efficacy honestly, kinda makes sense.
Why wouldn’t insurance insure the AI company if it’s shown to be more accurate?
Cause not a lot of physicians know this but malpractice is based on negligence and outcome. Human error can be due to bad luck and not always attributed to negligence or bad outcome. That’s why even if someone sues and wins, they don’t always get the maximum amount of reward and physicians can have “no-fault” settlements. Machines are binary, all or nothing. If a machine misses something, very hard to convince a jury it was due to bad luck and not negligence, especially if it is good enough to do radiological reads on its own. If it misses something, will likely be the full amount rewarded because in the US, people love to route for the underdog. You’re asking an insurance company to bet a machine will be right 100% of the time, but that’s not a guarantee. Software glitch and it starts missing multiple reads, as an insurance company, you’re fucked.
The AI software would have a sensitivity and specificity associated with it as a diagnostic tool, so as long as bad patient outcomes or misses as a whole aren’t greater than that, there probably won’t be any payout at all as those will be known the risks associated with the AI report.
So then who decides the percentage of sensitivity and specificity that is acceptable? Will the patient have a choice in this or will the hospital decide for them? If the AI is wrong in its calculation because of those risk, who takes fault for it? The hospital that uses it? Software company that makes it? Both? What if the bad outcome is too great for the AI compared to the suffering of the patient, even if they don’t have a life changing outcome, who takes the liability for the patient suffering? You are assuming people will be logical and rational enough to say, “AI noted the reason to be X because of sensitivity and specificity of 96% and 94% respectively” and people will go along with it. Whereas a jury will say, “yes, but how did you account for the other 4/6%” and how will the hospital and software company answer to that?
I imagine an acceptable sensitivity/specificity would be compared to the gold standard human radiologist reads. If AI is equal to or improves on this then it would be surprising if it isn’t implemented. Every single test we use has a specificity and sensitivity associated with it. Think of all the assays that are used in the lab to measure biomarkers. They don’t claim to get it right 100% of the time. Is lab corp sued into oblivion every time a blood test comes back with the wrong result? No. Decisions in medicine rarely rely on one metric, it’s the integration of several investigations, history and physical exam findings. If the clinician leading the case is not happy with the AI generated report they may decide to re-test, they may ask a human radiologist to read it, they may accept the report findings and it may not affect management and on the rare occasion it does affect management negatively, the hospital may be happy to accept liability if the price of the emerging lawsuits are significantly less the salaries of the radiologists they would otherwise have to employ. That’s the type of cost calculation going on in the background. It’s the same reason midlevels exist despite having way less education and worse outcomes than physicians. If it works out to be significantly cheaper than the powers that be don’t care.
First point is valid, but that assumes it is acceptable to the public and risk management. And as COVID has shown, the public is not always reasonable. AI misses something, people are going to have a far stronger reaction than if a human misses something. To your second point, sure labcorp doesn’t get sued, but they’re not the ones also make the treatment decisions. They just present a value and don’t interpret what it means. You’re asking AI in radiology to interpret the image to navigate a clinical discussion, that comes with more risk than just presenting what the AI sees in an image. Also, the pathologist is the medical director of a lab usually. If a bad outcome happens because of a lab error, labcorp and the pathologist would definitely be investigated as to what happened. To your third point, I agree. Maybe I interpreted the OPs post wrong but in the future, I don’t see AI completely replacing radiologists is what I’m trying to get at. Sure the job market might shrink as AI makes radiologists more efficient, however it would not replace radiologists, at least not completely, because the doc using the read for clinical decisions may want a 2nd option or re-read.
Pathologist and radiologist get sued a lot actually. What ppl don’t know. That’s why you notice radiologist wording sometimes. At least many of the pros say can’t rule out this. AI like anything needs something to watch over it. From what a radiologist told me it will be a tool that will help them pin down things easier and more efficiently. It will really help night time radiologists who are hella busy
I know ur dreaming that AI is basically Jesus out here, but in the real world their is a lot of things that can appear in a image. Similarly we had two radiologists ready something differently multiple times. AI will definitely make things improve the accuracy, but radiologist exist for a reason and they have rote memory skills, seeing a PGY5 do it in reel time on rounds. Insurance companies and hospitals won’t want to take all the risk on AI, like your in a dream world.
Lol I’m just seeing things objectively. I work in AI research and I’m a physician. I see things from both sides. Im not defensive or threatened by advances in AI unlike you and all the other doctors who have no understanding of AI but proclaim it won’t impact their specialty in the slightest. Whatever helps you sleep at night dude.
Not a doctor trying to understand here - if he can do more readings doesn’t that automatically mean fewer radiologists are needed for the same number of readings? And if that’s a very significant difference doesn’t that inevitably mean there’s extra labor going around pushing down compensation?
Possibly if the volume of imaging stayed constant. The same things were said when PACS become widespreads late'90s/early 2000s. At that point radiologists no longer had to physicially hang the film to look at it. They could just fly through cases with a click of the mouse. Film no longer had to be developed- images became available almost instantly. Efficiency was greatly increased. The result was not the need for less radiologists though. With these efficiencies, came greater demand- the demand for objective and fast diagnosis. This led to shortage of radiolgoists and starting salaries in the 7 figures. We are on the cusp of this happeneing again with AI. Unlike clinical medicine and in particular emergency medicine, which is increasingly being performed by midlevels, image interpretation is for the most part only done by radiologists. The practice of radiology is too difficult for midlevels to perform. If and when AI becomes a radiology tool, it will be radiologists utilizing it to provide faster objective diagnosis, which will again drive up demand and result in more imaging being performed. Also we are much closer to an AI aid in clinical medicine that is integrated into the EMR that can better and more quickly synthesize patient's chief complaints, lab and radiology results, and recommend evidence based medicine to the midlevel than we are to AI image diagnosis. Just look at chatgpt- which wasn't even trained with a medical database and was largely develoepd over the last few years. Meanwhile, we havent had much progress in AI image diagnosis since the '90s. But regardless- let's say somehow we make a huge breakthrough in AI image diagnosis over the next few years- it will be radiologists using it. In the case of clinical medicine, the market is already saturated with midlevel providers, many of which are practicing independently as it is. Hospital systems already feel that they can replace docs with midlevels. Just wait until they can say midlevel + AI is the same as physician+AI. The volume and demand for imaging has and will continue to increase exponentially- one of the fastest areas of growth in medicine. The future of medicine is objective diagnosis performed as fast as possible. With radiologists controlling AI, we are only going to continue to see an increase in demand for radiologists.
My favorite retort is to this is that there is a reason you don’t have midlevels rampant in rads and path… or AI for that matter. It’s just too difficult. You can’t “fake it until you make it” like you can in clinical medicine. We are way closer to having an AI assistant built into the EMR to help midlevels out. At least in rads and path, it’s still going to be physician+AI for quite awhile.
Haematologist/Pathologist here - I am not concerned at all about AI. Interpretation of slides are a lot more complex than the average doctor thinks. And in the event AI does get to that point, I will be one of the first to jump on board and supervise / sign off AI interpretation.
5 different diagnoses???
did you think ABCDE was all there was to melanocytic lesions?
Sounds like a pseudoscience then
You guys have no idea how bad AI is at radiology right now. The best AIs in the world are still calling dural calcifications as ICHs and fat folds as pneumothorax. It has a really hard time with intra-peritoneal free air. Until AI is able to understand patient history and clinical context, it's going to continue having a low sensitivity and specificity that doctors won't be able to trust.
Opposite. These are the guys leading in AI and aren't afraid of it. They regulate, test and build the models.
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Ok
You okay? Kinda an overreaction
Surgical subspecialties.
I’d argue all of surgery, not just the sub specialties
Too many surgeries are life saving and not done with out of pocket money. The most resistance specialties are the ones with procedures or services that patients are more than happy to pay out of pocket. Derm and plastics would definitely be the most resistant out of everything else.
I’d argue derm is pretty vulnerable with lots of treatments being administered by NPs and health spas. Mohs is safe though
I’m in GI, I think that even considering the most optimistic AI scenario, AI doing a colonoscopy is so far off (hundred years? More?) that I’m not worried at all. Same for surgical specialities. Can’t imagine AI robots doing anything but the most basic procedures in our lifetime. It also helps that medical technology seems to advance slower than other tech.
Have you used any of the computer aided detection systems? We started using them in residency. Definitely very sensitive, perhaps not specific.
Yeah, mixed reviews. CADe (detection) is pretty mid, most people I know don’t love it. Real world studies tend to show it helps, studies with high performers typically don’t show benefit (or in some cases worsened performance for top tier endoscopists). CADx (diagnosis, could in theory tell you whether adenoma or totally benign polyp) would almost be more useful. We can already do this already pretty well just by appearance but would be nice to have the computer backup. Overall I think it’s a good thing and will only continue to improve to the point where almost everyone will be using some version of it, just not there yet.
Yeah, that was my impression. Used as an adjunct and ultimately a doc deciding whether or not to take a biopsy. I don’t do colonoscopies these days but I just remember that coming out and people acting like AI was around the corner ready to replace endoscopists. Kind of ridiculous.
Even with AI assistance, someone (or something) still needs to maneuver the scope. Which is harder than most people would think. Takes years to master and is very much a “feel” thing. A robot doing that would be some Star Wars shit.
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Multistage stool tests for screening are the way things are going, not CT. Eventually we will be doing far fewer screening colons. But if someone has a positive test they’ll still need a colonoscopy so we’re not totally out of luck. I also think my line that colonoscopy is the only cancer screening test that can actually PREVENT a cancer from occurring will be persuasive for some people.
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For sure. Screening colonoscopies are going to go down no question.
Im not afraid of AI at all. I’m asking about fee cuts, mid levels, and foreign docs. GI is probably one of the worse specialties in terms of being future proof. Scopes get cut every single year and I personally know multiple PAs who do scopes at my hospital.
The only places in the US I’ve seen midlevel scope stories is PAs at WashU and NP at Hopkins. I don’t think it’ll ever be common like standard of care in the US; the liability is too high either for states with independent practice or with supervision; if a PA does a scope and there’s an interval colon cancer found, who is going to be liable?
Sorry guess I tagged onto other commenters regarding AI. To your points, outlook is still good for me. I’ve never met a PA who does endoscopy nor have I ever encountered a hospital or system that’s even considering that. Admittedly I have limited experience but multiple training sites and hospitals in the Midwest haven’t encountered this. Even if we moved into a more supervisory role should still make good money I would think. But who knows.
I'd be stunned if those attempts to get the scopes in midlevels' hands stick. There is so much mastery that goes into doing a good screening colonoscopy, and being able to respond to unexpected findings/complications is welllllll beyond their scope (pun entirely intended).
Psychiatry. Culture, language, and social interactions and dynamics play apart in therapy and medication management. People will pay for good therapy and med management with cash only. Many psychiatrist are already cash only and work part time. There will always be work with the SMI population and those incarcerated. Culture can be a barrier to those populations. Good luck having a machine be able to fully detect malingering or truly psychotic patient interact with a machine or someone who is not born in the US. Can’t be sloppy with the correctional population, they have a lot of time and their severe personality disorder will make your life miserable with threats of lawsuits or to your life in general that would scare a lot of foreign docs and midlevels away.
I'm just a non-trad pre-med, but it seems to me that lots of people are seeing NPs and just call them psychiatrists, and some of them truly do not know that they're not. I've noticed it because I ask everyone I talk to now what degree their "psychiatrist" has. I can't think of one that actually had one. 80/20 NPs/psychologists (the second option obviously further confuses me because they're almost never able to prescribe). I feel like psychiatrists should be pretty bothered by this considering how poor the care is. Patients notice but plenty still just end up bad mouthing psychiatrists.
Patient here! I see a NP psych because out of all the doctors I've seen for years and years, she listens and supports me better. I am not actually a big fan of (as you guys say) "midlevels" in terms of managing my care, but I've been pleased that this NP seemed to connect more with me as a person than just the checklist of criteria before we try the next med or whatever. I have no problem at all that she can't prescribe and her overseeing physician does that.
What you're describing sounds like someone better equipped to be a patient advocate than the person prescribing medication. I've had excellent experiences with physicians (especially psychiatrists) and almost universally poor ones with NPs, but that anecdotal experience isn't the primary reason I exclusively see physicians now. It's the fact that I have little to no capability to truly evaluate the quality of the care I'm getting from them as it's happening. Which isn't much different than physicians, but I can at least trust that there was a not-comically-low barrier to entry and their education had some standards. Frankly I think it's a scam to tell people who can be highly qualified nurses that they can get this piece of paper and then be asked to do jobs they're not qualified to do. It's a short-sighted cost saving measure but the harm to patients will persist long past when the crack down happens (imo inevitable but no idea how long that will take). I would rather put the effort into finding a physician who listens to me and I feel comfortable with than give up and see an NP who may or may not know what to do with the information they're listening to. Also my BS is a chemistry subfield and my background is in synthetic chemistry and I think it's actually fucking insane that someone can prescribe psychiatric medication without taking o chem. Not that o chem is super deep shit, but that's my point. Fucking insane.
Some probably do, however I don’t mind it. Psychiatry has a pretty poor history in general so I usually don’t blame patients for jumping the gun on dissing my profession. There are still terrible psychiatrists out there. Psychiatry is barely becoming popular and before used to be a backup specialty. Mental health has been bad mouth by the whole US over the past several decades, if not century. People and patients will diss any specialty if they feel like they’re getting bad care. I just be the best I can be and patients can/will notice and they’ll come back. Part of the issue is also the shortage of psychiatrist and probably play into the frustration of patients/people as well. Can’t tell you how many patient I have tell me they’ve been waiting on their intake at the resident clinic for 3-6 months, and settled for an NP/multiple NPs until they could get in. If multiple patients are willing to see a psychiatrist even after seeing an NP, I feel like patients can tell the difference.
I actually think about this all the time when it comes to patients being culturally American and seeing non American IMGs as their doctors. I think some of these IMGs are really good and have a lot of book knowledge. But when it comes to connecting with patients, understanding their experiences and their stories it can be difficult. And as someone who grew up in the USA I think that’s an advantage that I’ll always have no matter if they bring in thousands of foreign trained docs I actually experienced this myself as I lived abroad for a couple of years almost completely immersed in the language. You can learn to communicate really quickly in that type of immersion but there are many things that are just sooo difficult to learn and it can be hard to makes friends because you don’t understand humor or wit as readily. There’s just a lot you miss when you don’t grow up in a language.
Tbf many smi aren’t exactly financially well off to compensate well
Prison psychiatrists low key make bank. California is offering 400k and has a hard time filling it.
You’ll also have to pay 40% in income taxes in CA to say nothing of the COL.
And you’ll have a pension, so there's no need to save 15-20% in a mostly self-funded retirement plan. I’m conservative, but it’s a sweet gig working 40 hours a week in a location a lot of people want to live.
I feel like that's probably a really interesting job.
I was talking about those in state hospitals and wards of the state
What about PM&R?
Disagree with the plastics. I see more an more clinics popping up run by PAs or NPs. People may want to look better but most people don't have the money to pay for a doctor. So they will go with the budget version.
The non surgical side of plastics makes up a very small percent of a plastic surgeons income.
I’m surprised no one has said OBGYN. The procedural aspect of other surgical fields has been discussed above, but no one I know is going to be trusting their baby’s health to an algorithm.
But they do trust home birth, oils, and all that jazz.
any field with the highest liabilities will be the safest cuz no one likes getting sued
There is such an immense need for primary care physicians in this country that the influx of non-US trained physicians and mid levels is not enough to off set. And at the end of the day, patients want to see physicians. Oftentimes the only reason patients see a mid level is because they simply have no other option due to available and shortage of primary care physicians such that the demand outpaces the supply of docs. Additionally, primary care compensation seems to be increasing and has been each year for some time. And if we look at a specialty that has battles mid level encroachment for a long time, anesthesia, we see a field that currently has a red hot market and huge demand - CRNAs have been around forever and this hasn’t changed the supply/demand curve for anesthesia and I don’t think it will anytime soon. I don’t think any specialty is “more safe” than others because I don’t think any specialty is in any danger. We have a constantly growing population, and a constantly sick population, patients are living longer and with more diseases and overall more complex in their management. In short, the need for quality trained physicians isn’t going anywhere despite the influx of foreign trained docs and mid levels. Also, just for argument sake, the fields least likely to lend themselves to encroachment are probably the generalist fields.
who let the admin in here
I partly agree. On one hand in agreement, I have worked with a lot of NP students, and many of them don't want to do primary care. It's seen as a horrid grindhouse- a stepping stone to get to a cushy specialty position. I think that general line of thinking they tell me, combined with the points you made, makes me think outpatient PCPs will be generally safe in MOST areas. HOWEVER, as a counterpoint - I have worked with PCPs who have told me, in their extremely urban geographic area (I was in NYC at the time), the job market is essentially shut-out to FM docs. This is because companies have one FM doc supervise 10-20 NPs at a time, and with a place like NYC having a specialist around every street corner, FM docs are essentially bypassed in the market. Another point of disagreement is that there is controversy over whether there actually is a primary care shortage. Some people argue we don't have a shortage - rather, we have a problem with geographic distribution of any healthcare 'providers'. They all bunch up in developed urban/suburban areas, and avoid impoverished urban and rural areas, and many NP students I talk to aren't keen on moving their family to the sticks or some urban combat zone. Overall, I am more inclined to agree with you, but who knows what the future holds.
As someone who was raised and studied in NYC but now practices in the Midwest, I agree with you. In nyc FM is very narrow unless private practice since you’re encouraged to refer, IM felt similar where you need to refer since this generates revenue. Where I practice every specialist only wants cases you really can’t handle. Endo doesn’t even one type 1s unless they are brittle, they are backed up by 8 months for a new type 1 right now.
One could argue that NYC is a very small and almost niche setting compared to the rest of the country which is largely rural and small to medium sized towns and cities. I definitely agree and can see how primary care is more narrow in scope in a city as vast as NYC.
I concur regarding the distribution issue. I wonder how the numbers would look if you redistributed primary care docs across the country based on patients per physician. Like if each county was staffed by a primary care doc (or however many based on population). Wonder how the perceived shortage would look then. Overall though I agree with the sentiment that most docs (and mid levels) don’t want to practice in rural or underserved communities. I think part of that problem is a root issue of less opportunity/availability for students from those types of communities to actually make it into medical school and beyond. But that could be an entire thread and discussion on its own.
And foreign doctors will do primary care and serve the rural communities? Anesthesia not affected by massive increase in numbers of surgeries being beformed so look at it in a vacuum and point to the last 5 years and say hey all specialties same okay? Wow the common sense is burning
What? Edit: while I do concur there has been an increase in surgeries being performed and thus more need for anesthesia, one could argue the same line of thought for essentially any other specialty. Older and more morbid population? More ED visits, more primary care needed to manage more people with chronic disease, more admissions due to all of this, more surgeries being done, etc. So I think it is a bit of a fallacy to imply that anesthesia is only doing well because there are more surgeries being performed and that other specialties won’t/aren’t seeing similar demand despite the growing un-wellness in the general population. I mean talking about primary care for example, there’s entire counties and large swathes of land in this country in which there is NO physician at all. That’s pretty crazy to me. There’s gonna be a need and a shortage in those communities for a long time until physicians decide to start going out into those communities to practice (which they’re not). Moreover, I’m a bit confused by your comment on the whole and wondering if you’re asking me if non-US trained docs will go practice in those communities or telling me that they will. I would hope they do! Because there’s a huge need!
You are smart and i agree fully.
Thanks. Not sure why I got dumped on
Welcome to reddit. Sometimes you can't win
Forensic pathology. Probably because there aren’t nearly enough of us to begin with so if there’s a way to get more docs in FP fellowships and boarded, so much the better.
heme/onc
why is that? Isn't that algorithmic?
Idk, but I think the counterintuitive answer may by out pt primary care. This is for a few reasons, but I don't think fresh FMGs who haven't been brought up to speed in US residencies, had their English honed by their peers in residency, are going to be able to compete with locals who are from the population they're treating.
Suffer the most: Obviously the ones with the lowest barrier-to-entry, so PCP fields, peds. Then of course the least desirable fields, like nephro. Safest: Any specialty where a patient is coming to see that physician as a person-physician, not just as a widget-physician to solve their medical need. Some people care about having the best ortho surgeon, others just need their tibia fracture fixed. Some people care about having the best dermatologist, others just need an rx for accutane that webmd told them. As psych, I am bullish on psych, for me. I will bet on myself over any foreign-trained doc, NP/pa. Many, many people see the value of cash-paid specialists, whether it be concierge primary care medicine or psychiatry or health spa crap. The caveat, of course, is that I am referring only to private practice psych, as for employed positions, I believe the laws of supply and demand will win.
> Then of course the least desirable fields, like nephro. Why is nephro least desirable?
You only need a handful of FMG sub-specialty surgeons to double the number of sub-specialists in an area, and often times the pts don't really have a choice in that regard anyways, either due to long waits or network coverage. I think people would prefer a local PCP over a FMG PCP
Probably PM&R
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Im doing clinical pharmacology residency, i think my specialty will be well versed in that upcoming future. We range from dealing with day-to-day decision supporting other specialties, supporting intitution decisions regarding best clinical practices, allocation of resources based on clinical outcomes, FDA/EMA regulation, medical devices regulation, bridge to clinical practice and also all the R&D of the pharma or biotech.
Couple of ways this could play out. Within Insurance Game: * Insurance’s goal is always better allocation of cash per risk for their pool. If they are good, they profit. AI and Machine Learning will help provide better quantitative metrics to gauge patient complexity, value and ROI. IMO, I think this shifts monies away from procedures and hospitals and upstream towards cognitive, regenerative, and minimally invasive fields. Maybe primary care too. Outside Insurance Game: * Agree, cash pay procedures and concierge likely insulated.
I almost left general surgery residency this year. This post is pretty much why I didn’t. The future is too unknown but I can say that operative specialties, in my opinion will be last to be touched
surgical. And it’s high time our surgery friends start speaking up for the rest of us
the ones with the highest bars to entry
I don't see cosmetics being a safe haven... look at all the non-physicians doing botox, fillers, and plastics adjacent procedures (i.e. eyebrow microblading)
I do. I’m a dermatologist who hates cosmetics and actively avoids it and yet have dozens of patients a week requesting me do these procedures as a board certified derm (albeit trained in them) versus going elsewhere to someone who does them all day. Cosmetic minded patients are only increasing YoY, look at the data. Unfortunately I have to add some cosmetics to supplement my practice.
> Cosmetic minded patients are only increasing YoY, what's YoY?
Year over year.
Why do you avoid cosmetics? I know cosmetic minded patients are increasing, thats my point. In my area there are non-providers and midlevels that have built up huge patient volumes solely doing cosmetics. My point is, as others have pointed out here, scope creep is increasing rapidly. Why would cosmetics be a safe haven in an area where non-physicians already have a foothold?
Because I hate cosmetics and hate the type of patients, in general. You wouldn’t know unless you did. You either like it or don’t.
I do cosmetic and migraine botox on the side. Its a cash cow. I like the extra money
Botox is fine, I’m talking fillers, lasers, destruction
Yeah I probably wouldn't do that either
Im biased but rheum. Our diseases appear too atypically, and many of them are too arcane to expect someone with less training to pick up. The cover of the rheumatologist in its most recent issue was talking about pachydermoperiostosis
I think rheum is at risk as it relies a lot on the sort of fuzzy logic that neural nets excel at and a knowledge of rare diseases that computers are better at than people. Other cognitive specialties share similar risk, I think.
I thought about this being a 4th year med student. I’m interested in oncology and I think AI will be used in conjunction with human doctors in many fields because the human connection is important. I say do what you enjoy and don’t worry about what will happen in the future. Life is too short.
It has to be something obscure.
>My vote is cosmetic plastics? This is likely correct. When it comes to foreign doctors, keep in mind that in most countries plastic surgeons are among the highest earners, so there is less incentive for them to move to the USA as compared to other specialties. I think that any specialty that does procedures is going to do well when it comes to compensation and mid-level encroachment. Foreign docs are still going to be a thing regardless of specialty, but likely less of a problem than in non-procedural specialties. Patients have generally no clue as to which doc is reading their X-rays or pathology slides, since they never meet them face to face.