Kevin, M.D. - Medical Weblog

No surprises here. Most of the would-be should-be neurosurgeons no doubt are managing hedge funds or taking their brains to Silicon Valley instead. The ones who already trained find it much more lucrative and easier to sleep at night doing backs and forgetting the cranies.
 

What level of profitability must we guarantee liability insurers so this isn't the case?

And really, why not just go to universal healthcare if it's necessary to guarantee insurance companies a certain level of profitability to keep neurosurgeons, since as the article implies, we're entitled to them.
 

Why are they only graduating 100 per year? Can anyone say supply side restriction...
 

This sub-specialist shortage isn't isolated to Neurosurgery. Shortages are not limited to small town America either.

I am an Orthopedist in a large Level I trauma center. Many of the smaller institutions "up the line" no longer have Orthopedists on-call to the ER. This has had a profound effect on the number of patients we see in the ER. This has also changed the level of complexity of the injuries we see through the ER. We have patients who spend 4 hours in an ambulance, to reach our ER to see their ankle sprain, wrist fracture or shoulder dislocation.

Blame the malpractice environment in NY, blame the shortage of specialist docs or the declining level of reimbursement. Perhaps it's a combination thereof.

Trauma centers do not handle "small", routine, straight forward injuries in a cost efficient or profitable manner. Forget the fact that most who are transferred to us are uninsured. Shifting the cost burden to your "local" Level I trauma center goes straight to its bottom line and threatens the existence of Trauma centers in this country.

As this problem worsens, our ability to treat the medivac true emergency will be affected as our staff and infrastructure is stretched to its limit treating lesser injuries.
 

Perhaps we can blame it on the fact that not enough are being trained to start with. We have the capability to train thousands per year but we do not. Instead we let the few that are trained exert undue influence on the market secondary to the lack of competition.
 

the only "undue influence" on the market is the ability to stop practicing, since fees are set by medicare, and unalterable /non-negociable by ANYONE.
 

Please - supply side restriction? Try exorbitant malpractice premiums, high risk of lawsuits and lousy lifestyle.
 

"haps we can blame it on the fact that not enough are being trained to start with. We have the capability to train thousands per year but we do not."

What 'we' is this poster talking about? Is he a neurosurgeon in a teaching hospital? He proposes a 10 fold increase in neurosurgeon training, yet seems to have little understanding of the training process itself. If somehow the training capacity were expanded, where would the qualified physicians interested in neurosurgery come from? My med school class (mizzou '91) had only 2 interested, and both landed a residency. Only one completed his 7 years (plus lab years) of training, the other happily in a specialty taking much less than the decade total it takes from med school till practice.

The idea that you can merely open the spigot and instantly have more qualifed surgeons is pure bunk. I'll let you have one of these docs, I'll take one made the slow way.
 

"Please - supply side restriction? Try exorbitant malpractice premiums, high risk of lawsuits and lousy lifestyle."

Average salary of $250K a year, AFTER expenses, is a lousy lifestyle? Do you have any idea what a sheltered world you live in?
 

That suggestion was made by the same so-called "economist" (most qualified economists usually aren't so mouthy) who . . .

-- thinks that there is a un-tapped supply of adequately teachable premedical students who will leap to take spots at new medical schools, if we would just open them already (figure that these are students who haven't been able to find themselves a spot already in one of the tens of thousands of medical school seats open each year already--the normal admitting class--or in the already functioning offshore "for-profit" alternatives), and . . .

--who thinks that "for-profit" "Tijuana Tech" style institutions are the way we ought to teach medicine (so if it is such a good idea, why haven't the private for-profit University of Phoenix schools jumped on that already, or maybe medical schools don't seem so profitable after all), and . . .

--who thinks that real market forces, like opportunity costs of long education and residency and real costs of tuition, living expenses, loan interest, Medicare and private carrier price fixing have nothing to do with attractiveness of medicine and physician supply, but . . .

--tinfoil-hat-grade nutcase conspiracy theories that the AMA, held in the Svengali-like thrall of century-old Flexner-report recommendations are the real reason there aren't enough of whatever particular stripe of doctor seems in short supply (so take that, you Trilateral Commission theorists), and . . .

--the fact that neurosurgery, requiring one of the longest residencies, seven to nine years, depending on how much research time is being packed in, just naturally isn't one of the most attractive fields. This is particularly true since the back end ain't so pretty: long attending hours, high malpractice liability, lots of uncompensated trauma care and just not a whole lot of fun unless you want to be a workaholic burnout.

So all together now:

C-R-I (cry if he bores you to tears)
M-I-N (don't mind him too much)
A-L-L-O-PATH
 

"Why are they only graduating 100 per year? Can anyone say supply side restriction...

# posted by Anonymous : 11:59 PM"

This and other posts talk about training more neurosurgeons and their 'restricted supply'. The problem is that there are only so many cases to adequately train any specialist. A board certified neurosurgeon is expected to have performed a certain number of craniotomies for tumor, spinal reconstructions, peripheral nerve repairs, etc. etc. to sit for and receive certification.

All procedural specialties have this limit of teaching substrate, more acute when the condition treated is less and less common in the populace. One extreme example is Pediatric surgery and congenital anomolies. When Tracheal esophogeal fistula has a rate of approx. 1:5000 incident occurence a year, there are limited numbers to give adequate training and have excellent results - ergo they are concentrated at large centers and specialty pediatric hospitals.

I would want my Ped surgeon for my son to have actually done TEFs if he had that certification, and my Neurosurgeon to actually have done several trans-sphenoidal hypophesectomies before doing my pituitary tumor.

Given what all the other comments have said, we are lucky to have enough of any of the specialites still practicing in many locals.
 

"Average salary of $250K a year, AFTER expenses, is a lousy lifestyle? Do you have any idea what a sheltered world you live in?"

I hardly live in a sheltered environment. I suspect you hardly have a clue what life as a neurosurgeon is like. Though they may make the salary you suggest they do, they don't have much of a life. They're too busy with "long attending hours, high malpractice liability, lots of uncompensated trauma care and just not a whole lot of fun". Since when did salary level absolutely equate with joy in life? Maybe YOU need to get out of the shelter.
 

The neurosurgeons don't always quit of course. They rearrange their lives in such a way as to avoid the trauma work.

In my area, they leave the trauma center and work at a nearby small hospital, non-trauma, and they do spine work or even elective cranial work.

The neurosurgeon is still in town, but not available if there is head trauma.
 

Then do something different. With great reward comes great responsibility.
 

"With great reward comes great responsibility."

Yeah, tell that to the malpractice lawyer who just won the jackpot.
 

The only neurosurgeon around here whose income I actually know makes more than 4 times what I make practicing a "cognitive" specialty--and I don't envy him one little bit. Well, maybe I envy the money a little, but not the job. He can have it.
 

"Yeah, tell that to the malpractice lawyer who just won the jackpot."

Which one? What was your patient's name?
 

Ditto. One former MD I know who left one of the most desirable medical specialities for another nonmedical career made over $4 million last year, with better hours and less stress than any neurosurgeon. And, oh yes, much less "responsibility". And no malpractice or call concerns. Can you blame him?

A former neurosurgeon I know went back to school, got a JD, and now works as a lawyer. I guess he did not have enough "responsibility" in his former career if it is at all related to his larger income as a lawyer.

I am no neurosurgeon. I consider myself too intelligent and unwilling to take the equivalent vows of a monk relative to what it would entail.
 

"Average salary of $250K a year, AFTER expenses, is a lousy lifestyle? Do you have any idea what a sheltered world you live in?"

You must be writing in from Cuba or Venezuela. In the US this IS very lousy compensation relative to what the job duties entail. Not to mention the alimony the average neurosurgeon pays when the first and second wife leave you after discovering the truth about your career.
 

Then stop whining and do something else. Although you guys should think hard before relying too much on what you heard this or that guy did or how much easier their jobs are. Surgeons in general make an average 250% more than lawyers, who after regular physicians are the next highest paid profession.

But whatever you do, stop crying about it. Good luck in the true free market!
 

ya... the "true" free market.

So are you saying I can be a lawyer by studying on my own and taking the bar exam?

okay whatever....
 

Clearly, you're struggling with this concept. You should probably stay in medicine, where the govt. pays your bill.
 

Uh......the neurosurgeons aren't crying about it. They're doing something else. Either not doing neurosurgery at all, or doing just spine work, moving to non-trauma hospitals if they do any intracranial work at all.

I think the patients are the ones crying about it, when they can't find someone to care for their head injury.

That's sorta the point of the article.
 

In the "true free market" you would cough up 10k or more cash-or-die per procedure. Free market compensation would be in the millions of dollars annually. Please set us free!
 

CJD:
The simple fact is there is not adeqaute neurosurgery coverage in large swaths of this country. This is a medical opinion, not a legal or business opinion and the vast majority of other docs would agree with me on this. The day me or my loved one has an operative SDH I would like to have it addressed in a timely basis. Try not to be professional devil's advocate for one minute. Wouldn't you want the same?
 

This has nothing to do with being the devil's advocate. This is the question that will define your profession for the rest of your lifetime. If you and your loved one have a right to have a neurosurgeon within X miles of your home, then let's go to universal healthcare.

If you don't have that right, then you need to assess that risk in terms of where you want to live. Some people factor schools, some people factor access to airports, some factor in pollution. You factor in access to neurosurgeons if you want.

Telling me it's your "medical opinion" doesn't mean a whole lot with respect to this issue.
 

This has nothing to do with being the devil's advocate. This is the question that will define your profession for the rest of your lifetime. If you and your loved one have a right to have a neurosurgeon within X miles of your home, then let's go to universal healthcare.

If you don't have that right, then you need to assess that risk in terms of where you want to live. Some people factor schools, some people factor access to airports, some factor in pollution. You factor in access to neurosurgeons if you want.

Telling me it's your "medical opinion" doesn't mean a whole lot with respect to this issue.
 

"If you and your loved one have a right to have a neurosurgeon within X miles of your home, then let's go to universal healthcare. "


Non sequitur.

You assume that "universal coverage" means that there will automatically be enough surgical specialists to cover presently underserved areas. That isn't necessarily the case. "Universal' does not mean "adequate" or "competitive", as anyone presently taking or who has taken Medicare and Medicaid payment can verify. Making those presently uninsured the recipients of low-paying government insurance (or private contractor HMO proxy) isn't a guarantee of access at all. All it really means is that more of the population is locked into a price-fixing scheme. So no, lets not go to "universal healthcare."

Entitled to specialty care? When have we ever been entitled? Accustomed, perhaps, even to the point of having little regard for its value or cost, but even public utilities aren't entitlements.
 

You're right it's a non-sequitur. The whole "shortage of this or that specialist" cry is a non-sequitur.
 

"You're right it's a non-sequitur. The whole "shortage of this or that specialist" cry is a non-sequitur."

Since you don't know what the hell you are talking about, your opinion is meaningless.
 

What don't I know? There aren't specialists in the sticks. Did you just learn this? There won't ever be specialists in the sticks.
 

ya... the "true" free market.

So are you saying I can be a lawyer by studying on my own and taking the bar exam?

okay whatever....
# posted by Anonymous Anonymous : 11:29 AM

Its a free-market; not a freebie-market. If you want to be a lawyer, you can study hard, get into a good undergrad pre-law program, study hard, and get As and get perfect LSAT score and get into a good law school, take out loans to pay for said law school, study hard, get A's, be captain of the debate team or president of the newspaper club, get into a competitive internship, graduate, pass the bar, enter a masters of law program, become a specialist, be hired by a large firm, and become a fat-well-paid lawyer.