As a practicing surgeon that has one foot in the world of teaching and the other in corporate health care delivery, I enjoy speaking to students and residents about the future. We often discuss topics like the shift from volume to value, consolidation, insurance models, and specialization.
Often this information is new to them, and overwhelmingly they ask some form of the question: “How will this affect my career?” The following are some key considerations that I share with my own trainees.
1. Choose a specialty that is unlikely to be replaced by a less expensive provider or technology. Physicians are expensive. As we necessarily drive costs down, if a physician can be replaced by a lower-cost alternative, there will be strong incentives in that direction. The reality is that there is little evidence to show any difference in outcomes when advance practice providers perform the same tasks as physicians. Artificial intelligence and machine learning are making inroads in many fields, including radiology, pathology, and cardiology. This will undoubtedly impact the physician workforce in the future. It is also important to consider the rise of telemedicine. Can a local provider be replaced by the remote clinician? This is already happening in radiology, primary care, and critical care. Understanding these trends in a given specialty is key. In some cases, the role of the physician may shift more towards supervisor rather than provider.
2. Choose a specialty that has high demand and low supply. As we drive down costs and shift from volume to value, physicians will no longer be rewarded (i.e., compensated) for doing more. In fact, physicians with higher rates of intervention will decrease significantly in value to the system. If compensation is no longer tied to productivity, it will become more a function of supply and demand. The number of physicians trained in any given specialty or sub-specialty relative to the demand will strongly influence compensation. For instance, there are very few pediatric surgery fellowships, and thus supply is low, which drives compensation higher.
3. Choose a specialty that is not dependent on a relatively small number of procedures or diseases. Medicine is changing at a faster pace than ever before. New genetic, pharmaceutical, and immunotherapy interventions will revolutionize the way we practice. Any given problem we treat could be solved in the relatively near-term. At the same time, more specialization is the trend. Narrowing your scope of practice to just a few treatments or diseases may be risky. If a less expensive or more permanent solution arises, practice opportunities may be limited. For instance, what will happen to bariatric surgeons if someone is able to cure obesity with CRISPR?
4. Choose your place, people and practice model very carefully: Your happiness depends on it. Geography is a key variable relative to your career. The physician workforce is generally local (see telemedicine above). Certain specialties may be saturated in one market, absent in another. Urban and rural, for example, are completely different. If you have geographic requirements such as needing to be near family, it’s key to understand what the demand is for the specialties you are considering in that market. In general, the more specialized you become, the more likely it is that you will have to be flexible in terms of geography, and the more likely you will need to be in a large city.
Spend time talking to providers and understand how satisfied they are with their careers. I always tell trainees: “If other people are unhappy, you will likely be unhappy. You probably won’t be the exception.” Still, the practice that is working well now might not be equipped for the future. Is a private practice likely to be acquired? Is the system or group likely to merge?
Looking at trends in any given field or market can help discern this. As you look at positions, understanding your interaction with patients and colleagues is vital. But asking questions about the economic engine of any job you are considering is also key. Major changes in the delivery model will affect your practice, and subsequently, your satisfaction with it.
5. Choose a specialty where you love the bread and butter. Students and residents often get seduced by interesting or exciting cases. But the most common patient interactions are far more important to both feeling fulfilled and the bottom line. I always tell residents: “If you want to be a trauma surgeon, you better like taking out gallbladders!” While gunshot wounds are exciting, most time spent in the operating room is doing routine general surgery. And that’s what pays the bills.
Choosing a specialty is an emotional decision — you have to do what you love and follow your passion. But it’s important to listen to your head as well as your heart. Make sure you’ve considered the practical and financial aspects of your career in a rapidly changing health care landscape.
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