Dying Specialties by Steven Mussey MD


Those of us in primary care like to drone on about the death of our specialty.  Yet, another group of specialists is also growing scarce. These are the doctors who provide thoughtful assessments, yet lack the advantage of expensive procedures. Specifically, I include Endocrinology, Rheumatology, Neurology, and Infectious Disease specialists in this vanishing category. Existing large groups with large patient bases and older experienced hardworking physicians in these fields are surviving. Yet, newer groups and younger physicians in these fields are either not appearing or must leave town within a few years.

The scenario plays out like this:

  • A new “cognitive field” specialist arrives. The doctor expects a substantial salary because… well… a specialist warrants such a salary. If there is any doubt, the specialist references the inflated salary guarantees listed by the recruiting firm.
  • Hospitals and groups desperate to recruit realize they have little choice but to offer the high salary.
  • The specialist is hired and the medical community rejoices.
  • Soon, a problem develops..
  • Successful and experienced primary care doctors know a key survival fact: They have to see a certain number of people per day in order to survive. 
  • Spending 30, 60, or 90 minutes of time with a complex patient would be great but it does not pay the bills..
  • Remember, the specialist reimbursement differential vanished a few years ago for Medicare and most insurances. The “cognitive specialists” are in the same boat as primary care doctors.
  • Unfortunately, specialists often get patients because the patients are really… well… complicated. Plus, the patients are on a lot of expensive drugs which require all sorts of prior authorizations.
  • The doctor cannot keep up with the minimal amount of patient flow to survive. The employing group or hospital keeps running the numbers and finds the practice is losing their shirts on this thoughtful new doctor.
  • Eventually, there is the difficult conversation: “You make too much money. Either you see more patients or we cut your salary.”
  • The indignant specialist rightly responds: “I CANNOT CUT QUALITY! You are asking that I put lives in jeopardy! All you care about is money and your own ridiculous hospital administrator pay!”

Of course, you know it is all downhill from there.

  • Soon the embattled, but thoughtful specialist is talking to recruiters again, all of whom promise a fabulous salary at another location. Sure, the salary offer at the new location is absurd, but try to explain that to the knowledgeable specialist.
  • The town loses its specialist and the physician employer has second thoughts about repeating the whole terrible money-losing process again.
  • Referring doctors and patients complain about the lack of such specialists in their town. 
  • The hospital and big doctor groups shrug their shoulders. What can they do?
  • On the other hand, we can always hire another invasive Cardiologist, Orthopedic Surgeon, or Vascular specialist or anyone doing lots of expensive procedures.

So, you think silly ACO’s, practice networks, and other such nonsense will fix this?

Keep drinking the Kool Aid and it will be okay…

59930cookie-checkDying Specialties by Steven Mussey MD