By that logic all food production and distribution should not be privatized because is should be for the public good rather then the profit of the few.
There are are arguments to be made about private or public but that logic makes no sense.
Some system that have many private aspects outperform other public systems and the other way around. And even in a public system many people will profit as many of the companies that are your suppliers are still for profit.
By that logic all food production and distribution should not be privatized because is should be for the public good rather then the profit of the few.
Sounds like good logic to me, at least for essentials!
If you want to make the argument that anything that is essential should be publicly owned you can make that argument. But I would suggest if you want to make that argument 'nobody should make profit' shouldn't be the relevant argument. The argument should be 'this is how we can solve X problem efficiently'.
Universal healthcare solves the problem. The US is #1 in science and tech, but spends the most with worse outcomes in general healthcare than other peer countries by far.
But it doesn't solve the problem. Does it sound like the nationalized healthcare in Australia is going well? How about Canada? The NHS in Great Britain?
Those countries DO have better healthcare outcomes than the US. You are so ignorant.
The US is #1 in developed countries for infant and maternal mortality.
Americans die from preventable and treatable causes at much higher rates than residents of peer countries, alongside a life expectancy of 79, or two to four years lower than the average for OECD countries.
We spend 18% of our GDP on healthcare, NEARLY DOUBLE the average of other peer countries.
The number one cause of bankruptcy is medical debt.
When will the American people wake up and realize their private healthcare model only benefits the rich that are able to afford the care.
The US is #1 in developed countries for infant mortality.
This is only because the United States is unique in its huge amount of preterm babies, which some other developed countries do not even count within their infant mortality statistics. If we had the same average infant gestation length as Sweden, we would be tied for fourth best with France and Portugal, which considering how obese we are is pretty impressive. If we had that and adopted more restrictive reporting categories like Poland or the Netherlands, we could very well be reporting as the lowest.
I mean the US gives enormous subsidies to farmers for food production, and Walmart receives somewhere around $27 billion a year in SNAP from customers. So in that sense, both of these are essentially public to some degree
Food is, in general, very accessible, cheap, and elastic (People's food decisions are easily changed depending on the price).
Healthcare in America is not accessible, extremely expensive, and inelastic.
We have not had a famine in the developed world in quite a long time, but the healthcare crises continues.
The fact remains clear: The number one cause of bankruptcy is medical debt.
Healthcare is the only service that is life and death, where the money paid by the patient is completely inelastic.
I'm not saying doctors shouldn't be paid well. But what is really clear is that while the rich pay for premium concierge VIP treatment, the poor are regularly turned away for treatment they can't afford. You health insurance here is tied to your job. Lose your job? Pay $2000/month for COBRA or you don't deserve to have healthcare.
Don't act like public healthcare, expanding access to primary care physicians, and reducing medical administrative bloat is some economic degeneration headed for the sickle and hammer. I'm tired of pretending Ayn Rand style libertarianism capitalism is the perfect solution that has worked for everything including healthcare.
The government already subsidizes private overproduction on US farmland.
USAID was, at its heart, a farm subsidy.
And it should be said that most 'small' farmers in the US are millionaire scions and shouldn't need subsidies to make a profit in most parts of the US (we have abundant natural resources).
More than half of all calories produced in the US are not even for human consumption. And globally enough calories to feed every human on earth are lost to inefficiency each year.
We can all benefit from a better system of distribution and production without getting lost in the magical thinking of a public/private false dichotomy.
You might ask, why can’t you work less? It’s not as easy as that. If I decide to work less, who is going to cover the hospital? If the hospital aren’t employing other doctors, we can’t allow patients to go uncovered. I accept the fact that I have a duty of care to be on call.
Yes, you can allow patients to go uncovered. This hero mentality is what leads the bosses to not properly staff and the politicians to not properly fund in the first place.
It is not an individual’s responsibility to correct a societal failure by hurting themselves.
We saw this during the COVID crisis: declare nurses and doctors "heroes" and then it's ok that they burn out, get PTSD or die due to lack of PPE because "that's just what heroes do"
I remember some friends working in intensive care during the pandemic, I'll never forget their facial expressions after these 24hr shifts... I really wish someone would come up with a better way to do this
And that's the main reason why lock downs extended so far later than they should have. Our hospitals run at 120% during normal times; during abnormal times they're stretched to the breaking point. Our small local hospital had two nurse suicides during the pandemic. Not early in the pandemic, but well after vaccines were available.
Our societies should have expanded their healthcare capacity afterwards and maintained it to a high standard, but unfortunately it sounds like the political classes continue to treat healthcare as a cost centre that they can starve or pull money from for other projects.
I had worked in a hospital network that covered 4 campuses and drove 500kms a week when covering these sites. I had worked in a hospital where I didn’t get home for days at a time, sleeping overnight in hospital quarters, outpatient clinic benches and in my car.
As a patient, I'd like the person performing surgery on me to be well-rested!
It gets worse:
I used to be able to arrange the operating list because I know that some operations take longer than others. But now, the bookings office determine that that all my tonsillectomies take 14 minutes because that’s the average time recorded on the computer. The moment I scrub in, the timer starts. The moment I unscrub timer stops. Click. Click. Click. Because the theatre bookings does not take into account the interpreter time, pre-med period or transfer to ICU, the list is running late. The nurse in charge is breathing down my neck to finish on time.
And yet somehow that 14 minute tonsillectomy gets billed at ~$10,000.
This seems to me like a system that has been hyperoptimized in a way that grinds down the participants.
Really? This funny limbo seems pretty specific to American healthcare, which is a fairly unique and admittedly fascinating study in the intersection of politics and capitalism.
You don't perceive that system to be different from grocery stores, auto manufacturing, Nvidia, or lemonade stands? They're all very different in my mind, I'm surprised you see them as identical.
I assumed the linked article was written by a non American, given the use of kilometers and anecdote of a Brisbane doctor committing suicide.
Although the whole website has 1 post and there’s a prominent advertising link to some doctor book that then links to herbal stuff, so not sure if the whole thing is fake to advertise books.
sooner or later whole world(west) is going to hire more doc at lower(not as high as it is right now) salary from East(asia). they might lower the barrier to entry. same would happen in medicine the causes are inflation, economic conditions and poor health system.
I think the system will burn down before AMA would allow any US States to import a massive amount of doctors from anywhere in the world. Which maybe is better for the rest of the world - they get to keep their doctors.
I hear people say "we need more doctors" all the time. It would seem to me, the people deciding how many new doctors we train per year, are doctors. Their pay is proportionate to their scarcity, if we had 5x as many doctors, existing doctors would make far less.
Imagine if existing software engineers got to decide how many juniors entered our profession each year. I think things would look very, very different.
We have created a society in which the tail wags the dog. We have deferred so much control to institutions like the AMA that we have forgotten how to govern. Our politicians wring their hands and wax lyrical about the intractability of issues while they hold all the power to affect change.
I think it's time we stop allowing institutions to rule. We elect our leaders to lead. They need to start fucking leading, or people are going to start voting for some radical alternatives.
The AMA has no control over this. While they do advocate for training more doctors they don't have authority over medical school admissions or residency program funding or anything like that.
One area where we can perhaps legitimately criticize the AMA is for their lobbying state governments to limit the scope of practice for lower licensed PA/NP clinicians. While some of their concerns about care quality and patient safety might be legitimate, the reality is that we're not going to have enough primary care doctors to ensure adequate patient access. Some of that work has to be delegated down.
In the SF Bay Area there's a town called Milpitas. There's a gigantic island next to it made of garbage. A government funded study has been running for over 10 years now trying to determine why Milpitas smells. They have not yet been successful. You see, succeeding means getting funding withdrawn from the study.
I'm not sure about the salaries. Vocation-motivated people are already doing it. The rest needs a good reason to put their entire life, quite literally, into one single purpose. It's one of those professions that requires a complete dedication of free time, youth, health, mind, etc.
If you look across countries, you realize that a lot of the sacrifices are part of the pipeline, but not necessarily key to good outcomes. Just like the grueling hours at certain residencies.
It's like claiming that one needs to cram hours upon hours of leetcode practice to be a quality software developer. It might be necessary for some companies to hire you, but that's to meet a filter that is less and less predictive over time, not an actual performance requirement.
Education system was set up in XIX century. It's not clear how much of it is necessary in XXI century.
Back in the day religious books were copied by scribes educated in a monastic tradition. Now printers can print them in a completely godless manner but the result isn't any worse.
Would you say that people also need to be more responsible to be healthy themselves? Reducing pressure on the system and freeing capacity. E.g. healthy lifestyle to reduce diabetes.
Of course people need to take some responsibility, but reality is most people live in a society and do as the society does. You can minimally change people with some financial intensives but the effect of that is pretty limited and its hard to implement.
You have to create a healthy system, that takes social engineering and government cooperating on a general plan. And in the US such a thing is basically not possible, even if they wanted to do it.
Ideally your transportation, agricultural, educational policies should all work together to produce healthy population. But this simply isn't the case.
But it will not 'reduce pressure' in a practical way, because such changes purely private or public take decades to work themselves threw the population.
Well let’s start with insurance actually acknowledging preventative care as a worthwhile investment. We have a system that incentivizes waiting until emergency care is necessary and that comes with massive cons.
I can’t even get basic foot stuff covered, they won’t care until my feet and knees land me under “disability,” so people like me - but unlike me they can’t afford to spend hundreds more a year on special inserts and shoes - just keep doing what they’re doing until they’re hurt.
People go to the grocery store and marketing teams are trying to sell them “vitamin water” which is neither of those things, so they have to do tons of research and pay constant attention to literally every food they buy. Then when they get hurt they can’t afford to go to a doctor and the insurance that is sucking up huge amount amounts of their annual pay doesn’t pay for it either.
Meanwhile we have a US administration that is telling everybody, a population that is incredibly predisposed to heart disease already, to go eat more red meat. Also, they have spent a decade telling people that vaccines are shady and maybe they shouldn’t get them. How much damage have we done to preventative care with that one?
I could go on and on, I’m barely covering the breadth and depth of this problem. We can’t just call it “personal responsibility” or whatever
Are you sure you can find that many more doctors? That they'll be any good?
Speaking from Romania: here medicine is prestigious. So many parents push their kids towards medicine. There's a glut of newly minted doctors every year, but rumour has it that the quality drops every year. Sure, they pass the exams and residency and what not, but... They're just not into medicine as much.
Do you want to get treated by such a person?
This year I had to go to a neurologist. I went to one locally, they dismissed me in 5 minutes, told me to take some vitamins basically. Went to another one in a much bigger city, they talked to me for an hour, ordered a ton of tests.
Would it help if we get a lot more of the first kind of doctors?
We do have qualified people to do the work of doctors, and they're called nurses. But arbitrary lines are drawn between what they can do and what doctors can do, just to maintain the existing salary structure.
If nurses are to do more of the work of physicians, nursing education needs to drastically change. Nurses are mostly taught the how of nursing and not the why of medicine. If you look at the curricula of DNP programs, which are often touted as a way to get nurses practicing with lots of autonomy in places where they are short on physicians, they're heavy on nonsense nursing theory and light on things that actually matter like pathophysiology and pharmacology.
We actually do have a better model in the form of physician assistants. They're taught the same kinds of things physicians are taught, just in less depth.
That is the kind of thing makes me wonder how much of "things that actually matter like pathophysiology and pharmacology" can be factored out into the automation land now.
AI isn't perfect, but even loosely scaffolded generalist systems show promise in the field of medicine now. And the alternative isn't some hypothetical "perfect healthcare" - the status quo is often closer to "nurses running near the limits of their competence" or "physicians stretched thin almost to the breaking point".
The fundamental problem of healthcare is that it struggles to scale. The need for well educated, well paid professionals is inescapable. Or, was inescapable? We might be at the point where this can start changing.
Yep. I haven’t seen an actual MD in quite some time. Instead my general care provider is a Nurse Practitioner and he’s been handling all my routine healthcare needs.
Hate to be cynical, but going by the stories a doctor in my personal circles tells me, "talked to me for an hour, ordered a ton of tests" could be more about billing the national healthcare fund for many tests, that may not be most useful, but carry best margins for the facility.
In my country, there's a big feud between cardiologists and radiologists right now, big enough to be a regular topic in national media. Inside sources tell me it has nothing to do with quality of care, and is entirely about the march of technology allowing radiologists to perform some diagnostics that previously required cardiological procedures, and those procedures happened to be the major funding source for the cardiology departments.
Which is why we need more doctors trained more cheaply who are earning less money. They have far too much labor power currently for a role that increasingly can be fulfilled by a pure “technician” style expertise.
I'd like not to have to wait for three months to see a doctor to prescribe me the routine treatment for my routine illness, so yes, more mediocre doctors would be good for me. It would also unburden the doctors who are "really into medicine" so that they could spend their time on more difficult cases.
Earlier you just need to find a doctor and they were probably good. Now you have to take your luck with many till you find a good one (if you are still alive by then)..
I don't know why people think that they can mass produce competence..
I have the impression that some people imagine that you can produce now 10x more doctors at the same cost that you were producing one doctor 10 years ago. Mostly because some tasks (even programming) got many times "more efficient" I feel people transfer to easy to other topics.
Ah yes and when doctors give everyone expensive tests because the patients are a bunch of drama queens who think they know better because they have a doctorate in Google the costs go up.
I'll give you some N=1 sample on older doctors since I'm also from Romania: a lot of these older doctors haven't opened a book in a very long time and are still using older practices instead of providing their patients with the latest and most effective treatments available because they're too lazy and/or prestigious to go and learn new things. Would you say that they "into medicine"?
Would it help if we get a lot more of the first kind of doctors?
It would certainly help hypochondriacs a lot. Ordering "a ton of tests" needs to have some basis behind it, and doing it just to make the patient "feel seen" is not a great way to do your profession. People being dismissed quickly also happens in the US quite a lot, sometimes with disastrous results though it's not incredibly common, it's typically labeled under "diagnostic error" https://qualitysafety.bmj.com/content/23/9/727.long
You get the same problems in the US with the attitudes of doctors.
In the US, medical school is extremely expensive (like $400,000 expensive). There are many people who are excellent doctors who are just priced out of the profession. If we could make medical school less expensive (by subsidizing it and by reducing the amount of instruction), we would probably get many more excellent doctors.
Half a million in debt is scary. Especially if you have any doubts that you can match and make it through residency at the end. It's even scarier if you come from a family making $50k/yr.
Don't they have to back these gigantic loans? That might deter people from going to medical school out of fear they're not gonna have what it takes and drop out halfway with huge debt.
"Are you sure you can find that many more doctors? That they'll be any good?
Speaking from Romania: ..."
The prior post was specifically talking about the US. (I assure you, arrogant dismissive doctors are also a thing in the US)
In the US, there are a number of things that artificially increase the barriers to becoming a doctor.
1) You typically need a four year college degree to apply to medical school
2) Medical schools are accredited by the AMA, which is controlled by doctors. The AMA makes it very difficult to start a new MD-granting medical school.
3) Medical school in the US is very competitive to get in. They are likely turning away a lot of people who could complete the degree.
4) Since 1997, the federal government has a fixed number of Medicare (Medicare is a federal health insurance program for people over 65) supported residency positions. That number was basically flat for 25 years. We lost about 20% per capita of doctors being trained with support from this program. The caveat to this is that the total number of residents per capita has increased over time, particularly the past 15 years or so. My understanding is that they are less likely to be fully funded, so they spend more money getting trained, and then have higher students loans (on average graduating with debt above 200k going back to the late 2000s) that they need to pay off, so they charge more.
And you can add to this that it can be very difficult to be a doctor in another country and come to the US to practice here.
I totally dont by the "no medicare funds for training". A doctor will see you for 10min (perhaps another 10min prep) and bill $1000. If you doubt this, just check your EOB statements from the insurance company or check your deductible history.
The entire salary for the resident can be earned back in 3-4 days. You still have 360 days left to pay back admin overhead, facility overhead, supplies, etc. That is earned back in the next several weeks. After that, the next ~300 days of the year are profit.
In states with balance billing, the doctor can set any price and bill you for the remaining figure with a balance bill. In NY and NJ these can be thousands or tens of thousands. If you dont pay, it goes to collection and the provider still gets 10 to 15 cents on the dollar. So no...the $75k annual salary of a resident is not a barrier to training more doctors according to any math i'm seeing. What am I missing?
What seems more likely is that supply is artificially constrained to increase scarcity and prices.
First, private practice docs see patients with very good employer provided insurance, but residents are largely seeing patients that private practices wont see - patients who are far too medically complex to fit into a 10 minute slot and who also have particularly stingy insurance.
So as opposed to a private practice doc who is seeing 30 patients per day and billing an a average of $250 to $300 per patient (certainly not $1000 - that is unrealistic in my experience), a resident is seeing more like 10 to 15 patients per day (30 minute slots) and billing less than $100 per patient.
Second, residents have to be supervised. You have not included the salary of the physicians supervising them in your calculation.
Third, and I have mentioned this many times before on HN, training is limited by chiefly by the number of training sites that can offer quality training. For example, most hospitals will not see a single case of Guillan-Barre in a single year. Would you want to be treated by a nuerologist who trained at such a hospital? This is why neurology training is generally limited to places with a high volume of neurologic cases that would be considered rare at the average hospital, and these hospitals can only accommodate so many residents. Even for general medicine, you probably do not want to be treated by a doctor who trained at a hospital where any case that passed a certain complexity was transferred out to a bigger center.
On top of these, a few things with the training process also jump out to me from a "can we attract smart and motivated people to this work" point of view: the sheer cost of medical school that creates an imperative for high pay down the line, coupled with a real chance that you can wind up without a residency match but still owe all that money for school, and in particular the grueling nature of the residency system, currently capped at only 80 hours/week since 2003, because people were working >100 and making mistakes.
There are arguments that these are factors that filter out the people who are not sufficiently motivated, but it's hard for me to imagine there aren't a lot of bright young people who might be interested in medicine, but see one of the various paths that exist today to making doctor-level money with only an undergraduate degree and in an environment that doesn't require a working schedule that actively harms your health.
Would it help if we get a lot more of the first kind of doctors?
Depends? Did the tests actually find anything, or did they just make you feel better?
I had a talk with my GP about this at some point, and he more or less told me that he can just say "Go home, rest, come back in two weeks if it doesn't get better.", and 95% of the time that'll be exactly what is necessary. The hard part of his job is figuring out which of the visits are those 5%.
Their salaries need to be lower, training needs to be cheaper and faster, and we need a lot more of them.
We need to reduce the requirements to be a doctor. I think general ability is way way way more important than the specialisation. I don't think the speciality that doctors spend money and time on add that much value..
I think general ability is way way way more important than the specialisation. I don't think the speciality that doctors spend money and time on add that much value..
And why do you think that? I'm a doctor and I disagree completely - the medicine nowadays is so advanced, that it's impossible to keep up with advances without specialising yourself in narrow area.
Please read what I said again - it’s impossible to keep up unless you specialize. It’s really bad tactic to cut something out of context where context is literally in the same sentence.
I say this as a tech person married to a physician. Hacker News is a very bad place to discuss medicine because most of the readers and writers are tech people who just don't have exposure to medicine in depth.
It would be the same as someone from Hacker News going to read a medical forum where people are discussing AI, and the takes would feel similarly juvenile and uninformed, simply due to lack of exposure.
You are right, of course… but unfortunately I don't think it's worth arguing too much here.
I don't think Dr salaries are even that high a percent of healthcare spending. Although, maybe better work life balance, lower salary escalation and less debt would help everyone.
Agree - one sensible start would be to at least hybridize the European model where students are a whole lot closer to getting there medical degree as an undergraduate.
In most countries that do this training is longer which that total training time is only 1-2 years shorter.
So you’re doing a few things.
1. Moving more training from cheaper colleges to more expensive medical schools.
2. Moving the filter from undergrad to medical school
3. There is no national curriculum in US high schools, so essentially the first 2 years is getting everyone on the same footing. Removing this without changing high school, puts students at poor high schools at an even greater disadvantage.
While you're at it why not no crime so there's no police. Nothing dangerous so no firemen. Nobody throws anything away, so no need for factories. Peace on earth, so no soldiers.
I think you’re not sufficiently taking into account the demographic trajectory of age distribution [0], and the lag induced by the length of the human lifespan on health improvements. For the next few decades, more doctors will be needed.
That is a good analogy. Let us consider that there is a growing number of fire events in the recent years. Instead of finding out what is causing it, and fixing it we are asking for more firemen....
I think building a better prevention layer is more important.
Don't get me wrong, I agree that we need more doctors (and nurses, and physios, and dietetists, and ...), but it is much easier to scale a good prevention system than the number of workers in healthcare.
I think one issue is that the admissions for medicine are getting harder and harder. In many places you practically need a 4.0.GPA, volunteer work, great mcat scores, research experience, sometimes a post grad degree like an MSc and PhD etc. This selects for highly competitive and intense personalities that are not always suited for every medicine specialty. Most of them don't want to go into family medicine and pediatrics because it's more work, less money, less prestige etc. The friends I had who wanted to go into family medicine couldn't because of the admission requirements. Their only alternative was to have family money to pay for medical school in places like Ireland.
Edit: I should have mentioned that pediatrics and family medicine represent a large proportion of available residency spots each year and are rarely full.
General practitioners make something like 150k on average in the US. Specialists tend to make a lot more (upwards of double) and also tend to skew perceptions of doctors’ pay.
You could argue specialists should make less but considering how long it takes to become a doctor, how much work it takes to get there, how long you’re putting off real earning potential, school debt, etc., I do not consider 150k overpaid.
From a more practical angle, I don’t know how you could possibly find more doctors by lowering their earning potential.
Other countries have double, even triple the number of physicians per capita. They also pay them a lot less. Are they all less competent? Are US filtering requirements actually all that predictive of future performance? Can we, say, see that MCAT scores really line up well with clinical performance? Because it's easy to be selective, but not so easy for the selectivity to be predictive of actual quality, especially when you are being selective before training starts.
The author:
"Doctors are caught in a web of business, no longer a noble vocation. The altruism of young doctors have been replaced by the shackles of efficiency, productivity and key performance indicators."
The answer: here's some key performance indicator we can improve.
Speculating, but it could be a spiral where the shortage places more responsibilities on existing doctors, making the field less appealing to potential doctors. For too many people no amount of income compensates for a difficult lifestyle (we see this with air traffic control). If this were the case it would be productive to redesign medical systems to unburden doctors, but the current for-profit, scarcity-oriented system (in the US anyway) seems calibrated to squeeze everyone.
Most countries get good results with shorter training and much lower salaries. And, just like most other US university degrees, the majority of the filtering is done on entrance, not on training. So it's not that we are evaluating the best doctor, but the best diligent people that get great scores in the MCAT. Whether that actually lines up well with being a good doctor is not all that clear.
Here’s an excerpt from a study of more than 1m physicians:
“Better examination performance was linked to improved adherence to mammography screening recommendations, appropriate prescribing practices, improved care of patients with diabetes, lower patient morbidity and mortality, fewer complaints to regulatory bodies, and lower malpractice payments. The association was observed across examination formats and medical specialties.”
It's low because there's no competition. MDs are like medieval guild: once you're in, you're set for life. Restrictive regulations are lobbied by MD associations, which limit competition.
Then you end up with students from places like Nepal and Pakistan, where cheating is so rampant that you can't really evaluate the quality of your medical student or applicant. Even standardized exams like the USMLE/STEP series have been gamed. You also end up with significant cultural mismatch. I don't believe this is a good solution.
anecdote alert: had a family member treated by a foreign doctor last year, and received advice from that doc that was both 1) highly dangerous, 2) bare minimum 20 years out of date.
Inconceivable that a domestically-trained doc would have made the same mistake.
Probably better solution is to upskill nurses + AI to do handle all the simpler tasks like prescribing standard treatments, etc. There's already a concept of mid-level practitioner which can be expanded.
This is so hilariously false and completely inverted that it shocks me that people not in medicine can believe it.
Out of respect for you as a fellow intelligent HN commenter — you are deeply misinformed, and I would urge you to reconsider your perspectives on this.
Every study shows that utilization of APPs and nurse practitioners Leads to decreased quality of care and a significant increase in utilization of other healthcare resources, like the emergency department and imaging, that better-trained physicians don't need.
Less-trained providers misdiagnose cancers, refer patients to the wrong specialists, overprescribe antibiotics, and generally cost the system significantly more in overall health load than if we had better-paid general practitioners.
There is an argument that not enough physicians go into general practice, which is true, but it's because subspecialties are in such high demand that they're generally better paid. The unfortunate fix is that we need to find a way to better compensate primary care, even though Medicare physician reimbursement rates continually decline and our health insurance system is not well structured to support this kind of primary care model.
I've left a few links below if you'd like to read them:
It’s called physicians assistants and nurse practitioners. They are essentially exactly what’s you’re talking about. They make less and they have less training.
For a lot of specialties, we just don't have enough caseload to train doctors well enough. There is this meme that there's a cap on residency positions, which is the main limiter, but caseload is a significant limiter as well, especially for anything procedural or less knowledge-based.
(speaking from US): The reality is we need more doctors. A lot more.
[Doctors only spend around 18% of their time with patients in the U.S.](https://pubmed.ncbi.nlm.nih.gov/40500897/) The rest is spent on administration. I respectfully contend that the bigger issue is not the number of doctors per patient (though I admit that it could be a contributing factors), but rather that successive bureaucracy and compliance and laws and insurance requirements and policies have resulted in a system which forces doctors away from patients and towards ass covering. Remove the bureaucracy and you instantly have 5x as many doctors, effectively. Add more doctors to the machine and the machine will only find more creative ways to waste their time and talents.
Re-engineer the entire US system or train more doctors…
Remove the bureaucracy and you instantly have 5x as many doctors, effectively. Add more doctors to the machine and the machine will only find more creative ways to waste their time and talents.
That’s a huge leap and not at all evidenced by your comment.
I’m all for simplifying all these administrative stuff. But no, that will not solve the fact that we have way more people who are way sicker and fewer doctors for them.
Yes, that's true to an extent. Some administrative tasks can really only be done by the attending physician. Ultimately they're the ones taking legal accountability. But other tasks can be automated or shifted to cheaper employees or not done at all. The problem is that many health system managers and administrators treat physician time as an unlimited free resource and impose all sorts of extra burdens on them. This is one of the factors driving physicians to burn out and leave the profession, further exacerbating the shortage.
True, but the other side of that is a lot of primary care will be taken over by lower licensed PA/NP. We can't possibly train enough new physicians to meet the demand imposed by an aging population. It doesn't take a real doctor to deal with routine scrapes and sniffles.
Not enough doctors in the pipeline. The government gave doctor associations control over the pipeline and basically even encouraged reduction, because it increases wages. They don't want to many doctors. Lawyers do the same potentially even better.
I'm sure burnouts happen but the fundamental problem is the pipeline.
"I have lost control of my days. I had worked in a hospital where I was oncall 24/7, 12 days out of 14. I had fortnightly weekends off."
Medicine is ran by a bunch of creepy boards. "ACGME Review Committee for Dermatology." For example gets together and votes on how many Dermatologist we get, fun fact it doesn't go up much.
$They were so kind to add 400 more Dermatologist$ in the past decade to the student pipeline.$ What could the rea$son be?
What I would do if you are a doctor and don't hate humans - ask these boards to let more people in (hopefully Americans, but Americans have an uphill climb getting accepted with the flood of fraud applications from around the world).
How the US does scheduling is kind of insane. Doctors like pilots (and truck drivers in Europe) should have clear rules about how long they work with rest periods and so on. Giving people 24h shifts is nonsensical and insane.
And the interesting part is that health care is mostly privatized, while education is mostly public. So the private/public conversation may make very little sense.
I'm not suicidal and have never been suicidal or thought about suicide. I'm happy and in a good mood every day. If someone is thinking about suicide please reach out to me: rviragh@gmail.com I'll listen to your issues and concerns and we will find a better solution for you.
Don't reach out to random strangers on the Internet. Instead, reach out to the official support hotlines in your own country and talk to someone with training:
Are these problems consistent all over the world, or are they particularly severe in certain countries? I assume there are many studies of this already so it would be good to understand whether this is a problem that has a solution.
I see a lot of comments that we need more doctors to be able to pay doctors less. There are of course exceptions but I really don't think 300k a year is unreasonable when coming out with nearly 600k in debt in a field with such high burn out and liability risk.
Unlike salary position that 300k, at least in my field, is all via private equity and we are all independent contractors--meaning does not include any vacation, any paid time off, any sick days, any retirement or medical care or insurance of any kind.
I have not seen a raise since I started which was prior to covid. I'm not saying I need a raise I am well paid but again to be 500k in debt with zero benefits and I see on Reddit buckees managers or UPS /fed ex drivers making 150 to 200k with benefits and the ability to call out sick and the ability to not lose everything because of a single case where you follow standard practices or guidelines followed around the country but something bad still happens.
I go to work everyday with the understanding that the majority of my colleagues have been sued and even if not career ending the stress is enormous. At work I wear a tracker so that every fart and cough and patent interaction can be tracked. A VIP club of patients that donates to the hospital can ruin me with some bad reviews. A stray comment about poor care by an ems crew can end my career (as they bring the hospitals patients).
I don't believe doctors are overpaid and we need more to bring their pay down. A patient will get billed 2000 dollars if they ask for a burrito out front in triage, walk in, are told by me that Taco Bell is across the street, and they promptly walk out without a single test done.
On the other hand I may see sixty people in a busy night which require procedures such as being intubated and put on a ventilator, fractures being reduced , etc.
A major problem is private equity in medicine. Everyone should be focused on removing these groups which skim money off everyone both doctors and patients included. Even if the argument that somehow their efficiency increases result in extra money to the system they can feed on there is no reason why hospitals can't group up and also be efficient and cut them out and pass down savings to the customer or not overwork us docs or treat us like expendable McDonald's employees. The lack of working directly for the hospital there is no metric for skill or seniority or anything like that you are an expendible piece of meat/fall guy that they load down with as many mid level providers as they can get away with
I wonder if "Dcotor" ought not be a short career—one where you transition out after, say, two decades. Perhaps they establish a role of mentor within hospitals where "aged-out" doctors can be a part of new surgeons surgeries.
we need more doctors to be able to pay doctors less
I don't think this is really the point being raised. We need to relax the artificial constraints on the number of doctors. This would lead to more doctors. There's likely to be a side effect which is that doctors get paid less.
While the net effect is doctors getting paid less, it's not the reason.
I see a lot of comments that we need more doctors to be able to pay doctors less. There are of course exceptions but I really don't think 300k a year is unreasonable when coming out with nearly 600k in debt in a field with such high burn out and liability risk.
Why would a doctor start their career with a 600k debt, though? THAT is the problem.
In Belgium you can start your career as a doctor with zero debt and around 75k salary, working 35 hours per week. It's comfortable and lets you live a normal life.
We still have a shortage of doctors though like everywhere else, regardless of how well or how bad doctors are paid.
I understand the point is not getting more doctors to pay doctors less.
However when people mention how getting more doctors will reduce physician pay naturally the argument they are putting forth is that somehow physician pay in America is higher than it should be.
That consumers are being gouged on scarcity. That physician pay is currently a "problem" that could be remedied if there was sufficient workforce and physician pay is responsible for your astronomical bills.
I do not think the salary has as much room to go down as people think given the 500k plus debt , years of schooling and residency , pressures of working the job , enormous liability , the fact the pay includes zero sick days /vacations , paid days of any kind , benefits, retirement, insurance etc.
My argument as a physician is this is the least of the problems in healthcare financing and your bill.
The two thousand dollar charge for waking into the hospital then promptly walking out was a real world example --not an exaggeration. The amount charged for that one patient would pay my wage for the night and it was 1 in 60 and took approximately 5 minutes. You can only imagine what the other 59 patients getting critical life saving procedures , CPR , etc are getting billed.
If anything reading this story made me think maybe physicians should be taken care of better and have vacations , time off , etc instead of everything being designed to grind them down.
A few years back a great doctor working at a local children’s hospital took his own life. News said he’d become despondent over children dying when he couldn’t save them. The whole thing is heartbreaking.
I thought the point of this article is that unsuitable technology and the associated loss of personal agency is seriously affecting the mental health of doctors, yet none of the comments here seem to reflect that.
While I agree partially (there is so much shit IT out there and healthcare seems to particularly abundant with it, Oracle got publically famous in Sweden recently for an expensive failed rollout, luckily clinicians were able to halt the full rollout since it was worse than the system it replaced).
The root cause that is also mentioned fleetingly in the article, is the "effectivization" of at least some western societies, in previously "socialist" Sweden were many things like the post and schools have been sold out to the market there's been an immense amount of enshittification in societal functions, some people still say that "private companies are more efficient" but most people over 40 also remember that stuff actually used to work and has only gotten worse over the years (even if many can't peg it on the actual reasons and listen to anti-immigrant rethorics).
But even publicly owned services have been affected (a few years back there was articles about NPM in medicine, yet not much seems to be changing and it's just getting more entrenched).
Politicians might try to rally people over public waste, but in reality "waste" (too many employees, people having free time at work,etc) is a cushion so that when shit does hit the fan the society has extra capacity to handle things.
Doctors, nurses, rail workers, postal workers,etc shouldn't need to be heroes for keeping up with increasing demands of efficiency that eventually causes chaos when taken too far, they should be able to have "boring" jobs where shit doesn't hit the fan unless an airliner crashes or a war happens.
You might ask, why can’t you work less? It’s not as easy as that. If I decide to work less, who is going to cover the hospital? If the hospital aren’t employing other doctors, we can’t allow patients to go uncovered. I accept the fact that I have a duty of care to be on call.
Ultimately, this is a situation in which doctors doing this is worse in the long run.
Burning yourself out to cover for understaffing means both worse life balance for you BUT ALSO worse patient care.
No one quantifies how many people die, or how many diagnoses are missed, or how many patients feel unheard and become disillusioned with going to doctors, because doctors are dead tired and mentally burnt out, because they're trying to do right by patients.
You have to force hospital admin and owners do THEIR JOB, which is (in part) to provide needed staff to run properly, by not letting them exploit or impart a hero complex onto a job.
Yes, it's one of those cases where compassion works against people - because it's a dirty, costly local fix that enables the structural problem to fester.
You don't want a system that requires "heroic effort" as a baseline. You want a system where "heroic effort" is reserved for heroic circumstances.
If doctors are running ragged and putting in unreasonable hours and burning out during a natural disaster or a worldwide pandemic, it's understandable. If doctors are running ragged and putting in unreasonable hours and burning out during "business as usual"? Something's rotten.
Run long enough like this, and you'll simply deplete the people who dared to care - and leave ones who never did, or learned not to.
The challenge in the US is that the best and brightest increasingly have no interest in entering the medical profession. The debt, crazy years of minimum income, all to let an insurance company admin dictate your every move and while more and more physicians become a labor pool for PE healthcare tracked with metrics fit for warehouse workers (edit: and that’s not OK in a warehouse either). All to earn a decent income but no longer the top of the market. A decent mid-level developer or tech executive makes more than nearly all physicians. No sane top performing talent would dive head first into that mess.
There are exceptions of course but when my brother was considering medical school he visited about 10 different top physicians to seek input and advice and nearly all said if given a Time Machine they wouldn’t do it all over again. That was a real wake up call.
If you go into medicine as a business entrepreneur and build a successful medical business then there’s opportunities for one to still taste some of the glory of the medical profession that once was. Outside that it’s basically a reasonably well paid life of indentured servitude. Yes you’re “helping people” but that only carries you so far which is why so many just burn out and leave.
Massive reform is needed but the powers that be between the AMA and insurance companies seem unlikely to let that change happen unless it’s forced on them by Congress, and that too seems unlikely for now. Something more alike to an apprenticeship model where one grows up from EMT, to nurse, to physician fits the current business model much better than trying to preserve the old world “Officer vs enlisted” model where folks enter the profession directly as officers (physicians).
Yes, poorly worded on my part. Wasn’t intending to suggest it was ok to do that to a warehouse workers either, just that this is how physicians are being treated today (but neither is OK).
"decent mid-level developer or tech executive makes more than nearly all physicians"
That's no where near true for a mid level developer or most tech execs or most senior developers. If you exclude faangs a top developer doesn't make as much as a doctor.
You need to consider the economic cost of delayed earnings, which is massive for the physician, and the higher pay later typically doesn’t make up for the massive debt and low pay early on. It’s not just about a point in time salary sizing contest. Earning little to nothing early in one’s career creates a massive net worth void to fill.
Physician lifetime earnings counting for delay, and debt… normal investment, etc: 8.5-10m. Software engineer median is much lower. About 6.5m. Specialist and high end varies greatly. Median doctor is earning 2x a SWE (130k vs 250k).
People on HN vastly overestimate SWE pay as an industry, biased by FAANG as we are :).
Lifetime earnings of 6.5M is more than lifetime earnings of 8.5M if the 6.5M is front-end loaded and the 8.5M is back-end loaded and starts with a 0.5M hole.
It's the difference between compound interest working for you vs compound interest working against you.
I accounted for that when I modeled it. I explicitly added investment start and compounding. A thing to remember: a physician is delayed yes but their higher income lets them much more heavily invest as their income often exceeds life expenses by a lot more than median swe.
and the higher pay later typically doesn’t make up for the massive debt and low pay early on.
It does, actually.
Physicians have high early career earnings. It’s not like grinding your way up the ladder until you get paid a lot.
Developers only make more if you only look at the very top end. Like a Stanford grad who goes straight to FAANG earning $200K the day after they graduate.
I agree, but it’s amazing how many times I’ve heard variations of this repeated as truth.
Developer compensation talk always gets biased toward top companies and high cost areas. The median developer or even top 10% developer isn’t living in the Bay Area working at FAANG, but that’s what gets talked about.
I think the problem is that physicians are self-selected to be highly intelligent and driven individuals. Med school is not at all a walk in the park, and is very competitive.
You cannot compare the median physician who endured the years of grueling med school and residency to an average developer. FAANG is probably a more apt comparison.
It is unfortunately true. Sr/Staff making a tech salary outearns all but the most specialized doctors. Even if you exclude FAANG that's true (other companies have to offer FAANG salaries to get FAANG talent).
You have to be living in a VHCOL to get that, but if you make >$300k TC you are outearning most doctors.
"nearly all said if given a Time Machine they wouldn’t do it all over again. That was a real wake up call."
And do they have experience working any other job as a comparables? The question you ask is the equivalent of saying do you think there are better jobs out there? Being a doctor is about the lowest risk job you can get if you are smart and capable. You get high status in society, excellent paycheck and on net are helping people.
Also, people are not aware of their skill sets. A lot of doctors I know think, just because they were "smart" in school, that if they had gone into, for example, tech or finance, they would have become a CEO. But you can tell they don't have the skill set for business. I mean, they can't even run a medical office with 8 employees well, and they think they could run a business with 100K people. The office is a mess, the records are sloppy, the appointments are 2 hrs. behind, they don't pay the staff well, the receptionist is rude, the photocopied forms are barely readable. Yet they think they would be inovating like Jeff Bezos.
Something like 17 out of the best 20 jobs by median pay in the U.S. are physicians, just various subspecialties. I guarantee you that people in medicine are incredibly driven and bright. You're just not exposed to them and the training they go through.
I'm not here to defend the AMA but they have very little power over the lives of working physicians. While they do define the CPT code system used on most insurance claims they don't control which procedures are authorized or how much anyone gets paid. The real abrasion has come from health system administrators imposing additional rules and paperwork that waste physician time without doing anything to improve care quality.
A decent mid-level developer or tech executive makes more than nearly all physicians.
I’ve had access to various compensation data products and I’ve done hiring at distributed companies across dozens of US states. This is not true unless you’re defining “decent mid-level” as working for FAANG. Conversations about developer comp always get skewed toward the top end for top 5-10% devs, with the median numbers being a lot lower.
If you go into medicine as a business entrepreneur and build a successful medical business then there’s opportunities for one to still taste some of the glory of the medical profession that once was.
I don’t know what you mean by “glory of the medical profession” if your definition of achieving it is… not being a medical professional?
Are you just talking about the money and social prestige that comes from being wealthy? The medical professionals I know didn’t go into the career because they wanted to maximize salaries. The days of becoming a physician primarily to seek money and social status are dwindling because there are better ways to make a lot of money where you get to sit at a desk and write emails, and honestly that may not be a bad thing. Let those people go be lawyers and finance bros or mediocre product managers.
Yes anyone who thinks engineers (HW or SW) are all paid amazingly needs to start taking in the wages of contractors too when calculating averages. Even many engineers working at FAANG HQs are lowly paid, abused contractors, making $50k-$80k.
I know personally of one big famous tech firm that has QA devs making literal minimum wage, because they are contracted from an outsourced firm. But 100% of those people's work is directed by and exclusively for the big tech firm so like all contracting it is an obvious paperwork scam to just mistreat their workers.
If this was true competition for med school spots would be a lot lower. On the contrary it's getting harder: you now basically need a 4.0 to get in.
Some of the best and brightest definitely are getting discouraged, I too have similar personal anecdotes from my daughter's peers. But anecdote does not necessarily correspond to data. Competition for spots is the data.
burn out and leave.
Here the data definitely supports your argument. Doctors are leaving the industry at far younger ages than they did in the past.
I mean, this is not what the article is about though.
What the author of article is describing is just bureaucracy ever expanding (anyone who’s worked at the same place for a decade knows that bureaucracy rarely gets better), mostly decided by mediocre admin people who have never heard of Goodheart’s law. Bureaucrats loves KPIs, shitty average metrics (because distributions are hard to understand for bureaucrats for some reason), and generally does not have to field the consequences of their actions (notably because they don’t measure them!).
Interestingly, the above physical and emotional stressors are reasonably manageable to me. I’m understanding my own physical and emotional limits. These stressors induce exhaustion, but the excitement of the work and the intellectual challenge of the job bring a lot of personal satisfaction.
This is the poisonous pill. In any job.
This AI is set to fail and if it was a real person i'd be concerned.
This is Episode 1 of a Trilogy.
>Episode 2: The Dark Side Awakens
>Episode 3: Restoring Hope and Humanity to Health Care. Here I write about the 3 corresponding antidotes to the 3 issues above.
>Episode 2 will be published next Thursday
>Would you agree or disagree with my thoughts? What other “Dark Side of Doctoring” issues can you think of?
Doctors are caught in a web of business, no longer a noble vocation. The altruism of young doctors have been replaced by the shackles of efficiency, productivity and key performance indicators.
And later
To some hospitals and their business, I’m not a Surgeon. I’m just an employee. Overworked, burned out, replaceable. The noble call to Medicine has been suffocated by the bureaucratic force exerting itself as the medical industry.
How much of the world has gone this way? Feels like there is something sick deep down in society that is manifesting itself as “you are not a human, you’re a set of metrics”.
Seems like this aspect could have been written by an Academic, a designer, certainly a software developer. The debasement of human dignity.
I think previously it was at least as bad. For hundreds of years slavery was fine. Killing people for believing into one thing or another (witchcraft, different religions, etc). Making people kill each other because the ruler says so. And many others.
Sure, we are not an ideal society and over relying on metrics is bad, but it is HARD to decide how we best use the resources to improve the world, and everybody has an opinion.
I still cannot understand why a profession like medical doctor does not have better working conditions + a guild or union to enforce that, like actuaries have. Doctor is a profession that few can do, few want to do, it's very hard, many barriers to entry etc. so all that would seem like it should result in doctors getting great pay and benefits like good working hours, even moreso because no one wants a surgeon who is severely sleep deprived and possibly suicidally depressed!
I just don't get it. Do doctors collectively do something wrong here that allows hospital admins to mistreat them so much, including the mistreatment of interns/residents during med school? And this is international too, I have heard these awful working conditions from doctors in Australia, USA, and the Netherlands. In the Netherlands example the resident intern I spoke to was even in a Dutch union but apparently the union was pretty worthless because he got paid extremely little and had the same 20-30 hour shifts that doctors in the USA have.
Everyday, there’s a new form, a new guideline, a new protocol, a new health software, a new policy all dictating, restricting and modifying clinician activities.
I felt this one... Takes all the running you can do, to keep in the same place.
The entire loss of support section is way too real. I'd almost forgotten what that sort of institutional chaos felt like. So glad I don't work in a hospital anymore. It kills you inside.
Loss of meaning was different for me. The author seems to long for patient contact... Just as easy to lose meaning there, I'm afraid. It's just as tiresome but in a different way. The repetitiveness can easily lead to a sort of depersonalization.
What I am realising is that today in modern medicine, a doctor is just one of the many commodities in this complex industry.
This could be a fourth chapter all of its own: loss of autonomy.
Friends in medicine often mention the constant emotional drain from dealing with suffering and death. Takes a serious toll.
Healthcare is the last industry that should be privatized. It should be for the public good rather than for the profit of few.
By that logic all food production and distribution should not be privatized because is should be for the public good rather then the profit of the few.
There are are arguments to be made about private or public but that logic makes no sense.
Some system that have many private aspects outperform other public systems and the other way around. And even in a public system many people will profit as many of the companies that are your suppliers are still for profit.
Sounds like good logic to me, at least for essentials!
If you want to make the argument that anything that is essential should be publicly owned you can make that argument. But I would suggest if you want to make that argument 'nobody should make profit' shouldn't be the relevant argument. The argument should be 'this is how we can solve X problem efficiently'.
Universal healthcare solves the problem. The US is #1 in science and tech, but spends the most with worse outcomes in general healthcare than other peer countries by far.
But it doesn't solve the problem. Does it sound like the nationalized healthcare in Australia is going well? How about Canada? The NHS in Great Britain?
Why would it be any different here?
I don't know anything about those countries healthcare problems.
Hospital bills causing bankruptcy.
Deciding between meds or food.
Donation jars at gas station checkouts begging for money to pay for a child's cancer treatment.
Putting off preventative care because of endless co-pays.
Out-of-network providers being a thing I have to worry.
Those problems I do know.
Those countries DO have better healthcare outcomes than the US. You are so ignorant.
The US is #1 in developed countries for infant and maternal mortality.
Americans die from preventable and treatable causes at much higher rates than residents of peer countries, alongside a life expectancy of 79, or two to four years lower than the average for OECD countries.
We spend 18% of our GDP on healthcare, NEARLY DOUBLE the average of other peer countries.
The number one cause of bankruptcy is medical debt.
When will the American people wake up and realize their private healthcare model only benefits the rich that are able to afford the care.
This is only because the United States is unique in its huge amount of preterm babies, which some other developed countries do not even count within their infant mortality statistics. If we had the same average infant gestation length as Sweden, we would be tied for fourth best with France and Portugal, which considering how obese we are is pretty impressive. If we had that and adopted more restrictive reporting categories like Poland or the Netherlands, we could very well be reporting as the lowest.
I mean the US gives enormous subsidies to farmers for food production, and Walmart receives somewhere around $27 billion a year in SNAP from customers. So in that sense, both of these are essentially public to some degree
This is terrible reasoning.
Food is, in general, very accessible, cheap, and elastic (People's food decisions are easily changed depending on the price).
Healthcare in America is not accessible, extremely expensive, and inelastic.
We have not had a famine in the developed world in quite a long time, but the healthcare crises continues.
The fact remains clear: The number one cause of bankruptcy is medical debt.
Healthcare is the only service that is life and death, where the money paid by the patient is completely inelastic.
I'm not saying doctors shouldn't be paid well. But what is really clear is that while the rich pay for premium concierge VIP treatment, the poor are regularly turned away for treatment they can't afford. You health insurance here is tied to your job. Lose your job? Pay $2000/month for COBRA or you don't deserve to have healthcare.
Don't act like public healthcare, expanding access to primary care physicians, and reducing medical administrative bloat is some economic degeneration headed for the sickle and hammer. I'm tired of pretending Ayn Rand style libertarianism capitalism is the perfect solution that has worked for everything including healthcare.
The government already subsidizes private overproduction on US farmland. USAID was, at its heart, a farm subsidy.
And it should be said that most 'small' farmers in the US are millionaire scions and shouldn't need subsidies to make a profit in most parts of the US (we have abundant natural resources).
More than half of all calories produced in the US are not even for human consumption. And globally enough calories to feed every human on earth are lost to inefficiency each year.
We can all benefit from a better system of distribution and production without getting lost in the magical thinking of a public/private false dichotomy.
The doctor who killed himself was an Australian man living and working in Australia. Australia has public, universal healthcare.
You realise this is an Australian doctor writing?
Yes, you can allow patients to go uncovered. This hero mentality is what leads the bosses to not properly staff and the politicians to not properly fund in the first place.
It is not an individual’s responsibility to correct a societal failure by hurting themselves.
We saw this during the COVID crisis: declare nurses and doctors "heroes" and then it's ok that they burn out, get PTSD or die due to lack of PPE because "that's just what heroes do"
I remember some friends working in intensive care during the pandemic, I'll never forget their facial expressions after these 24hr shifts... I really wish someone would come up with a better way to do this
There is no better way to do this. Perhaps all doctors should be on suicide watch and under psychiatric supervision.
And that's the main reason why lock downs extended so far later than they should have. Our hospitals run at 120% during normal times; during abnormal times they're stretched to the breaking point. Our small local hospital had two nurse suicides during the pandemic. Not early in the pandemic, but well after vaccines were available.
I'm sorry to hear that... this thing really took away a lot of good people...
Covid kills people even today! We should have a lockdows every winter!
Those nurses saved many people! It was worth it!
Our societies should have expanded their healthcare capacity afterwards and maintained it to a high standard, but unfortunately it sounds like the political classes continue to treat healthcare as a cost centre that they can starve or pull money from for other projects.
Wow.
As a patient, I'd like the person performing surgery on me to be well-rested!
It gets worse:
And yet somehow that 14 minute tonsillectomy gets billed at ~$10,000.
This seems to me like a system that has been hyperoptimized in a way that grinds down the participants.
Sounds like just about every other system in modern capitalism.
Really? This funny limbo seems pretty specific to American healthcare, which is a fairly unique and admittedly fascinating study in the intersection of politics and capitalism.
You don't perceive that system to be different from grocery stores, auto manufacturing, Nvidia, or lemonade stands? They're all very different in my mind, I'm surprised you see them as identical.
I assumed the linked article was written by a non American, given the use of kilometers and anecdote of a Brisbane doctor committing suicide.
Although the whole website has 1 post and there’s a prominent advertising link to some doctor book that then links to herbal stuff, so not sure if the whole thing is fake to advertise books.
Huh, you're right! This is by an Australian doctor:
https://ericlevi.com/ - "Paediatric & Adult Specialist Otolaryngologist, Ear Nose & Throat, Head & Neck Surgeon" in Melbourne.
The doctor who wrote the article is Australian, not American.
(speaking from US): The reality is we need more doctors. A lot more.
There's no solution other than training a lot, lot, lot, lot more doctors.
Their salaries need to be lower, training needs to be cheaper and faster, and we need a lot more of them.
The American Medical Association would sooner let the whole thing burn than allow that to happen
sooner or later whole world(west) is going to hire more doc at lower(not as high as it is right now) salary from East(asia). they might lower the barrier to entry. same would happen in medicine the causes are inflation, economic conditions and poor health system.
I think the system will burn down before AMA would allow any US States to import a massive amount of doctors from anywhere in the world. Which maybe is better for the rest of the world - they get to keep their doctors.
This is the bottleneck, right?
I hear people say "we need more doctors" all the time. It would seem to me, the people deciding how many new doctors we train per year, are doctors. Their pay is proportionate to their scarcity, if we had 5x as many doctors, existing doctors would make far less.
Imagine if existing software engineers got to decide how many juniors entered our profession each year. I think things would look very, very different.
Now that senior engineers can utilize an LLM as his junior, the job market its deciding that don't need too many juniors.
We have created a society in which the tail wags the dog. We have deferred so much control to institutions like the AMA that we have forgotten how to govern. Our politicians wring their hands and wax lyrical about the intractability of issues while they hold all the power to affect change.
I think it's time we stop allowing institutions to rule. We elect our leaders to lead. They need to start fucking leading, or people are going to start voting for some radical alternatives.
The AMA has no control over this. While they do advocate for training more doctors they don't have authority over medical school admissions or residency program funding or anything like that.
https://savegme.org/
One area where we can perhaps legitimately criticize the AMA is for their lobbying state governments to limit the scope of practice for lower licensed PA/NP clinicians. While some of their concerns about care quality and patient safety might be legitimate, the reality is that we're not going to have enough primary care doctors to ensure adequate patient access. Some of that work has to be delegated down.
No, the AMA has been lobbying for more residency slots for decades.
Congress decides how many slots get funded and they have been way too slow to fund them.
The bottleneck is funding for residents and the AMA has been lobbying for more resident slots for nearly 30 years.
In the SF Bay Area there's a town called Milpitas. There's a gigantic island next to it made of garbage. A government funded study has been running for over 10 years now trying to determine why Milpitas smells. They have not yet been successful. You see, succeeding means getting funding withdrawn from the study.
Irrelevant
I'm not sure about the salaries. Vocation-motivated people are already doing it. The rest needs a good reason to put their entire life, quite literally, into one single purpose. It's one of those professions that requires a complete dedication of free time, youth, health, mind, etc.
If there are more doctors, it would require less of each one's time though.
Yes it would, but the sacrifices start at the university already, that part is incompressible I'm afraid
And there's certain constraints related to patient's safety which have an impact (i.e. less handovers, longer shifts)
If you look across countries, you realize that a lot of the sacrifices are part of the pipeline, but not necessarily key to good outcomes. Just like the grueling hours at certain residencies.
It's like claiming that one needs to cram hours upon hours of leetcode practice to be a quality software developer. It might be necessary for some companies to hire you, but that's to meet a filter that is less and less predictive over time, not an actual performance requirement.
Education system was set up in XIX century. It's not clear how much of it is necessary in XXI century.
Back in the day religious books were copied by scribes educated in a monastic tradition. Now printers can print them in a completely godless manner but the result isn't any worse.
It does not require more than your standard 8-17. Know tons of doctors that work the same hours as I do and spend their free time the way I do.
so... you didn't read the article?
Would you say that people also need to be more responsible to be healthy themselves? Reducing pressure on the system and freeing capacity. E.g. healthy lifestyle to reduce diabetes.
Of course people need to take some responsibility, but reality is most people live in a society and do as the society does. You can minimally change people with some financial intensives but the effect of that is pretty limited and its hard to implement.
You have to create a healthy system, that takes social engineering and government cooperating on a general plan. And in the US such a thing is basically not possible, even if they wanted to do it.
Ideally your transportation, agricultural, educational policies should all work together to produce healthy population. But this simply isn't the case.
But it will not 'reduce pressure' in a practical way, because such changes purely private or public take decades to work themselves threw the population.
Well let’s start with insurance actually acknowledging preventative care as a worthwhile investment. We have a system that incentivizes waiting until emergency care is necessary and that comes with massive cons.
I can’t even get basic foot stuff covered, they won’t care until my feet and knees land me under “disability,” so people like me - but unlike me they can’t afford to spend hundreds more a year on special inserts and shoes - just keep doing what they’re doing until they’re hurt.
People go to the grocery store and marketing teams are trying to sell them “vitamin water” which is neither of those things, so they have to do tons of research and pay constant attention to literally every food they buy. Then when they get hurt they can’t afford to go to a doctor and the insurance that is sucking up huge amount amounts of their annual pay doesn’t pay for it either.
Meanwhile we have a US administration that is telling everybody, a population that is incredibly predisposed to heart disease already, to go eat more red meat. Also, they have spent a decade telling people that vaccines are shady and maybe they shouldn’t get them. How much damage have we done to preventative care with that one?
I could go on and on, I’m barely covering the breadth and depth of this problem. We can’t just call it “personal responsibility” or whatever
Are you sure you can find that many more doctors? That they'll be any good?
Speaking from Romania: here medicine is prestigious. So many parents push their kids towards medicine. There's a glut of newly minted doctors every year, but rumour has it that the quality drops every year. Sure, they pass the exams and residency and what not, but... They're just not into medicine as much.
Do you want to get treated by such a person?
This year I had to go to a neurologist. I went to one locally, they dismissed me in 5 minutes, told me to take some vitamins basically. Went to another one in a much bigger city, they talked to me for an hour, ordered a ton of tests.
Would it help if we get a lot more of the first kind of doctors?
We do have qualified people to do the work of doctors, and they're called nurses. But arbitrary lines are drawn between what they can do and what doctors can do, just to maintain the existing salary structure.
The medical training involved for nurses and physicians is absolutely not equivalent
There are APPS as well that have more training than nurses.
lol
lmao even
If nurses are to do more of the work of physicians, nursing education needs to drastically change. Nurses are mostly taught the how of nursing and not the why of medicine. If you look at the curricula of DNP programs, which are often touted as a way to get nurses practicing with lots of autonomy in places where they are short on physicians, they're heavy on nonsense nursing theory and light on things that actually matter like pathophysiology and pharmacology.
We actually do have a better model in the form of physician assistants. They're taught the same kinds of things physicians are taught, just in less depth.
That is the kind of thing makes me wonder how much of "things that actually matter like pathophysiology and pharmacology" can be factored out into the automation land now.
AI isn't perfect, but even loosely scaffolded generalist systems show promise in the field of medicine now. And the alternative isn't some hypothetical "perfect healthcare" - the status quo is often closer to "nurses running near the limits of their competence" or "physicians stretched thin almost to the breaking point".
The fundamental problem of healthcare is that it struggles to scale. The need for well educated, well paid professionals is inescapable. Or, was inescapable? We might be at the point where this can start changing.
Yep. I haven’t seen an actual MD in quite some time. Instead my general care provider is a Nurse Practitioner and he’s been handling all my routine healthcare needs.
Hate to be cynical, but going by the stories a doctor in my personal circles tells me, "talked to me for an hour, ordered a ton of tests" could be more about billing the national healthcare fund for many tests, that may not be most useful, but carry best margins for the facility.
In my country, there's a big feud between cardiologists and radiologists right now, big enough to be a regular topic in national media. Inside sources tell me it has nothing to do with quality of care, and is entirely about the march of technology allowing radiologists to perform some diagnostics that previously required cardiological procedures, and those procedures happened to be the major funding source for the cardiology departments.
Which is why we need more doctors trained more cheaply who are earning less money. They have far too much labor power currently for a role that increasingly can be fulfilled by a pure “technician” style expertise.
Radiology and imaging gets that treatment everywhere. They are treated as a photography service for doctors and only doctors can diagnose.
I'd like not to have to wait for three months to see a doctor to prescribe me the routine treatment for my routine illness, so yes, more mediocre doctors would be good for me. It would also unburden the doctors who are "really into medicine" so that they could spend their time on more difficult cases.
Yea, that is what is going to happen.
Earlier you just need to find a doctor and they were probably good. Now you have to take your luck with many till you find a good one (if you are still alive by then)..
I don't know why people think that they can mass produce competence..
You can mass produce anything, but it has a cost.
I have the impression that some people imagine that you can produce now 10x more doctors at the same cost that you were producing one doctor 10 years ago. Mostly because some tasks (even programming) got many times "more efficient" I feel people transfer to easy to other topics.
Even worse, education expenditure is decreasing for many countries! (see some examples: https://ourworldindata.org/grapher/education-spending?tab=li...)
Ah yes and when doctors give everyone expensive tests because the patients are a bunch of drama queens who think they know better because they have a doctorate in Google the costs go up.
This is another one of those "kids these days" thing based on nothing but vibes. https://www.science.org/doi/10.1126/sciadv.aav5916
I'll give you some N=1 sample on older doctors since I'm also from Romania: a lot of these older doctors haven't opened a book in a very long time and are still using older practices instead of providing their patients with the latest and most effective treatments available because they're too lazy and/or prestigious to go and learn new things. Would you say that they "into medicine"?
It would certainly help hypochondriacs a lot. Ordering "a ton of tests" needs to have some basis behind it, and doing it just to make the patient "feel seen" is not a great way to do your profession. People being dismissed quickly also happens in the US quite a lot, sometimes with disastrous results though it's not incredibly common, it's typically labeled under "diagnostic error" https://qualitysafety.bmj.com/content/23/9/727.long
Hard to tell when you don't let us know which of those doctors ended up solving the issues that made you seek a doctor.
Dismissive doctors are bad but so are those that waste your time and risk complications from unnecessary invasive tests.
You get the same problems in the US with the attitudes of doctors.
In the US, medical school is extremely expensive (like $400,000 expensive). There are many people who are excellent doctors who are just priced out of the profession. If we could make medical school less expensive (by subsidizing it and by reducing the amount of instruction), we would probably get many more excellent doctors.
Essentially no one pays for medical school outright. They take out loans. Those loans aren’t credit based. People aren’t priced out of being doctors.
They are priced out earlier - when they can't get the academic credentials to pass the medical school gatekeeping.
Half a million in debt is scary. Especially if you have any doubts that you can match and make it through residency at the end. It's even scarier if you come from a family making $50k/yr.
Don't they have to back these gigantic loans? That might deter people from going to medical school out of fear they're not gonna have what it takes and drop out halfway with huge debt.
I'd love to vote for loan forgiveness for anyone who successfully qualifies and practices as a doctor
We have the Public Service Loan Forgiveness program where qualifying public servants pay 10 years of their loans and the rest is forgiven tax free.
Removing financial stress from doctors seems like a public good most people could get behind
Maybe I would rather be treated by such a doctor with time on their hands than a burned out brilliant doctor?
"Are you sure you can find that many more doctors? That they'll be any good? Speaking from Romania: ..."
The prior post was specifically talking about the US. (I assure you, arrogant dismissive doctors are also a thing in the US)
In the US, there are a number of things that artificially increase the barriers to becoming a doctor.
1) You typically need a four year college degree to apply to medical school
2) Medical schools are accredited by the AMA, which is controlled by doctors. The AMA makes it very difficult to start a new MD-granting medical school.
3) Medical school in the US is very competitive to get in. They are likely turning away a lot of people who could complete the degree.
4) Since 1997, the federal government has a fixed number of Medicare (Medicare is a federal health insurance program for people over 65) supported residency positions. That number was basically flat for 25 years. We lost about 20% per capita of doctors being trained with support from this program. The caveat to this is that the total number of residents per capita has increased over time, particularly the past 15 years or so. My understanding is that they are less likely to be fully funded, so they spend more money getting trained, and then have higher students loans (on average graduating with debt above 200k going back to the late 2000s) that they need to pay off, so they charge more.
And you can add to this that it can be very difficult to be a doctor in another country and come to the US to practice here.
I totally dont by the "no medicare funds for training". A doctor will see you for 10min (perhaps another 10min prep) and bill $1000. If you doubt this, just check your EOB statements from the insurance company or check your deductible history.
The entire salary for the resident can be earned back in 3-4 days. You still have 360 days left to pay back admin overhead, facility overhead, supplies, etc. That is earned back in the next several weeks. After that, the next ~300 days of the year are profit.
In states with balance billing, the doctor can set any price and bill you for the remaining figure with a balance bill. In NY and NJ these can be thousands or tens of thousands. If you dont pay, it goes to collection and the provider still gets 10 to 15 cents on the dollar. So no...the $75k annual salary of a resident is not a barrier to training more doctors according to any math i'm seeing. What am I missing?
What seems more likely is that supply is artificially constrained to increase scarcity and prices.
It is not in the interest of the members of a cartel to add new members. What's so hard to understand?
Anyone here should be familiar with the ""sAfEtY"" argument at this point.
Several things.
First, private practice docs see patients with very good employer provided insurance, but residents are largely seeing patients that private practices wont see - patients who are far too medically complex to fit into a 10 minute slot and who also have particularly stingy insurance.
So as opposed to a private practice doc who is seeing 30 patients per day and billing an a average of $250 to $300 per patient (certainly not $1000 - that is unrealistic in my experience), a resident is seeing more like 10 to 15 patients per day (30 minute slots) and billing less than $100 per patient.
Second, residents have to be supervised. You have not included the salary of the physicians supervising them in your calculation.
Third, and I have mentioned this many times before on HN, training is limited by chiefly by the number of training sites that can offer quality training. For example, most hospitals will not see a single case of Guillan-Barre in a single year. Would you want to be treated by a nuerologist who trained at such a hospital? This is why neurology training is generally limited to places with a high volume of neurologic cases that would be considered rare at the average hospital, and these hospitals can only accommodate so many residents. Even for general medicine, you probably do not want to be treated by a doctor who trained at a hospital where any case that passed a certain complexity was transferred out to a bigger center.
On top of these, a few things with the training process also jump out to me from a "can we attract smart and motivated people to this work" point of view: the sheer cost of medical school that creates an imperative for high pay down the line, coupled with a real chance that you can wind up without a residency match but still owe all that money for school, and in particular the grueling nature of the residency system, currently capped at only 80 hours/week since 2003, because people were working >100 and making mistakes.
There are arguments that these are factors that filter out the people who are not sufficiently motivated, but it's hard for me to imagine there aren't a lot of bright young people who might be interested in medicine, but see one of the various paths that exist today to making doctor-level money with only an undergraduate degree and in an environment that doesn't require a working schedule that actively harms your health.
Depends? Did the tests actually find anything, or did they just make you feel better?
I had a talk with my GP about this at some point, and he more or less told me that he can just say "Go home, rest, come back in two weeks if it doesn't get better.", and 95% of the time that'll be exactly what is necessary. The hard part of his job is figuring out which of the visits are those 5%.
We need to reduce the requirements to be a doctor. I think general ability is way way way more important than the specialisation. I don't think the speciality that doctors spend money and time on add that much value..
And why do you think that? I'm a doctor and I disagree completely - the medicine nowadays is so advanced, that it's impossible to keep up with advances without specialising yourself in narrow area.
That's interesting because it is exactly for the reason you give "impossible to keep up" that I think general ability is crucial.
Please read what I said again - it’s impossible to keep up unless you specialize. It’s really bad tactic to cut something out of context where context is literally in the same sentence.
I say this as a tech person married to a physician. Hacker News is a very bad place to discuss medicine because most of the readers and writers are tech people who just don't have exposure to medicine in depth.
It would be the same as someone from Hacker News going to read a medical forum where people are discussing AI, and the takes would feel similarly juvenile and uninformed, simply due to lack of exposure.
You are right, of course… but unfortunately I don't think it's worth arguing too much here.
I don't think Dr salaries are even that high a percent of healthcare spending. Although, maybe better work life balance, lower salary escalation and less debt would help everyone.
It’s 8%.
Agree - one sensible start would be to at least hybridize the European model where students are a whole lot closer to getting there medical degree as an undergraduate.
In most countries that do this training is longer which that total training time is only 1-2 years shorter.
So you’re doing a few things.
1. Moving more training from cheaper colleges to more expensive medical schools.
2. Moving the filter from undergrad to medical school
3. There is no national curriculum in US high schools, so essentially the first 2 years is getting everyone on the same footing. Removing this without changing high school, puts students at poor high schools at an even greater disadvantage.
In brazil, we imported doctors from Cuba
No, the reality is we should be more healthy, so we need less doctors.
While you're at it why not no crime so there's no police. Nothing dangerous so no firemen. Nobody throws anything away, so no need for factories. Peace on earth, so no soldiers.
I think you’re not sufficiently taking into account the demographic trajectory of age distribution [0], and the lag induced by the length of the human lifespan on health improvements. For the next few decades, more doctors will be needed.
[0] https://www.calculatedriskblog.com/2013/08/us-population-dis...
We don't need firemen. Just don't start fires.
That is a good analogy. Let us consider that there is a growing number of fire events in the recent years. Instead of finding out what is causing it, and fixing it we are asking for more firemen....
I think building a better prevention layer is more important.
Don't get me wrong, I agree that we need more doctors (and nurses, and physios, and dietetists, and ...), but it is much easier to scale a good prevention system than the number of workers in healthcare.
I think one issue is that the admissions for medicine are getting harder and harder. In many places you practically need a 4.0.GPA, volunteer work, great mcat scores, research experience, sometimes a post grad degree like an MSc and PhD etc. This selects for highly competitive and intense personalities that are not always suited for every medicine specialty. Most of them don't want to go into family medicine and pediatrics because it's more work, less money, less prestige etc. The friends I had who wanted to go into family medicine couldn't because of the admission requirements. Their only alternative was to have family money to pay for medical school in places like Ireland.
Edit: I should have mentioned that pediatrics and family medicine represent a large proportion of available residency spots each year and are rarely full.
General practitioners make something like 150k on average in the US. Specialists tend to make a lot more (upwards of double) and also tend to skew perceptions of doctors’ pay.
You could argue specialists should make less but considering how long it takes to become a doctor, how much work it takes to get there, how long you’re putting off real earning potential, school debt, etc., I do not consider 150k overpaid.
From a more practical angle, I don’t know how you could possibly find more doctors by lowering their earning potential.
You certainly could if you were willing to accept people who are terrible at being a physician.
The notion that you can just throw more warm bodies at the problem is ludicrous
Other countries have double, even triple the number of physicians per capita. They also pay them a lot less. Are they all less competent? Are US filtering requirements actually all that predictive of future performance? Can we, say, see that MCAT scores really line up well with clinical performance? Because it's easy to be selective, but not so easy for the selectivity to be predictive of actual quality, especially when you are being selective before training starts.
But those countries also pay less in a lot of other fields as well. Developers make less in those countries than they make in the US.
I would be surprised if wages in most of those countries were not lower overall, not just for doctors.
General practitioners make more like 250k on average. 150k for general practitioners working in academics, but not overall.
there is another solution that will be (and is) actually happening: diffusion of doctor responsibilities to other less regulated/trained workers
sucks but that's incentives for ya
The author: "Doctors are caught in a web of business, no longer a noble vocation. The altruism of young doctors have been replaced by the shackles of efficiency, productivity and key performance indicators."
The answer: here's some key performance indicator we can improve.
Sigh.
If you want more doctors you need to find out what’s holding people back to become doctors.
I have no idea what this might be.
Speculating, but it could be a spiral where the shortage places more responsibilities on existing doctors, making the field less appealing to potential doctors. For too many people no amount of income compensates for a difficult lifestyle (we see this with air traffic control). If this were the case it would be productive to redesign medical systems to unburden doctors, but the current for-profit, scarcity-oriented system (in the US anyway) seems calibrated to squeeze everyone.
The quality of the average physician is already so low I am not sure what you are hoping to accomplish with lower salaries and faster training.
Doctoring isn't a matter of more warm bodies
Most countries get good results with shorter training and much lower salaries. And, just like most other US university degrees, the majority of the filtering is done on entrance, not on training. So it's not that we are evaluating the best doctor, but the best diligent people that get great scores in the MCAT. Whether that actually lines up well with being a good doctor is not all that clear.
Here’s an excerpt from a study of more than 1m physicians:
https://academic.oup.com/academicmedicine/article-abstract/1...
Unfortunately, it’s very clear.
It's low because there's no competition. MDs are like medieval guild: once you're in, you're set for life. Restrictive regulations are lobbied by MD associations, which limit competition.
It's an old joke:
Q: What do you call the worst student to be admitted to medical school?
A: Doctor.
Seems like having doctors emigrate from other countries would work as well.
It might not work for the other countries.
Then you end up with students from places like Nepal and Pakistan, where cheating is so rampant that you can't really evaluate the quality of your medical student or applicant. Even standardized exams like the USMLE/STEP series have been gamed. You also end up with significant cultural mismatch. I don't believe this is a good solution.
anecdote alert: had a family member treated by a foreign doctor last year, and received advice from that doc that was both 1) highly dangerous, 2) bare minimum 20 years out of date.
Inconceivable that a domestically-trained doc would have made the same mistake.
Probably better solution is to upskill nurses + AI to do handle all the simpler tasks like prescribing standard treatments, etc. There's already a concept of mid-level practitioner which can be expanded.
There's basically no need for GP to be a doctor.
This is so hilariously false and completely inverted that it shocks me that people not in medicine can believe it.
Out of respect for you as a fellow intelligent HN commenter — you are deeply misinformed, and I would urge you to reconsider your perspectives on this.
Every study shows that utilization of APPs and nurse practitioners Leads to decreased quality of care and a significant increase in utilization of other healthcare resources, like the emergency department and imaging, that better-trained physicians don't need.
Less-trained providers misdiagnose cancers, refer patients to the wrong specialists, overprescribe antibiotics, and generally cost the system significantly more in overall health load than if we had better-paid general practitioners.
There is an argument that not enough physicians go into general practice, which is true, but it's because subspecialties are in such high demand that they're generally better paid. The unfortunate fix is that we need to find a way to better compensate primary care, even though Medicare physician reimbursement rates continually decline and our health insurance system is not well structured to support this kind of primary care model.
I've left a few links below if you'd like to read them:
General burden of NPs higher than physicians even with lower appointment cost: https://static1.squarespace.com/static/615326dd2c363f1e2a5c8...
Skin cancer misdiagnosis: https://www.ovid.com/journals/jaderm/abstract/10.1001/jamade...
Antibiotics overprescribed: https://pmc.ncbi.nlm.nih.gov/articles/PMC5047413/
"There's no solution other than training"
Not true.. according to most around here, it will be AI and robots all the way.
The reality is we need a lot more than just more doctors.The entire system needs to be revamped.
We already have a system for cheaper doctors.
It’s called physicians assistants and nurse practitioners. They are essentially exactly what’s you’re talking about. They make less and they have less training.
Exactly! I suspect the parent commenter does not interact much with the US healthcare system.
Nah you just need to unfuck your insurance system. It’s fine in other places without watering down the quality of medical professionals.
For a lot of specialties, we just don't have enough caseload to train doctors well enough. There is this meme that there's a cap on residency positions, which is the main limiter, but caseload is a significant limiter as well, especially for anything procedural or less knowledge-based.
[Doctors only spend around 18% of their time with patients in the U.S.](https://pubmed.ncbi.nlm.nih.gov/40500897/) The rest is spent on administration. I respectfully contend that the bigger issue is not the number of doctors per patient (though I admit that it could be a contributing factors), but rather that successive bureaucracy and compliance and laws and insurance requirements and policies have resulted in a system which forces doctors away from patients and towards ass covering. Remove the bureaucracy and you instantly have 5x as many doctors, effectively. Add more doctors to the machine and the machine will only find more creative ways to waste their time and talents.
Re-engineer the entire US system or train more doctors…
That’s a huge leap and not at all evidenced by your comment.
I’m all for simplifying all these administrative stuff. But no, that will not solve the fact that we have way more people who are way sicker and fewer doctors for them.
Yes, that's true to an extent. Some administrative tasks can really only be done by the attending physician. Ultimately they're the ones taking legal accountability. But other tasks can be automated or shifted to cheaper employees or not done at all. The problem is that many health system managers and administrators treat physician time as an unlimited free resource and impose all sorts of extra burdens on them. This is one of the factors driving physicians to burn out and leave the profession, further exacerbating the shortage.
True, but the other side of that is a lot of primary care will be taken over by lower licensed PA/NP. We can't possibly train enough new physicians to meet the demand imposed by an aging population. It doesn't take a real doctor to deal with routine scrapes and sniffles.
Why do you think you're going to get more doctors by paying less?
In the same vein: there’s the fantastic book
This is Going to Hurt: Secret Diaries of a Junior Doctor by Adam Kay
Adapted into a TV series with Ben Whishaw and Ambika Mod:
https://en.wikipedia.org/wiki/This_Is_Going_to_Hurt_(TV_seri...
It seems there needs to be more doctors to help reduce the insane workload. Must be lots burn out suffered ? by Drs?
Not enough doctors in the pipeline. The government gave doctor associations control over the pipeline and basically even encouraged reduction, because it increases wages. They don't want to many doctors. Lawyers do the same potentially even better.
I'm sure burnouts happen but the fundamental problem is the pipeline.
Makes you wonder if they face similar on-call burnout but with actual life-or-death stakes. Way more intense than a buggy deploy.
"I have lost control of my days. I had worked in a hospital where I was oncall 24/7, 12 days out of 14. I had fortnightly weekends off."
Medicine is ran by a bunch of creepy boards. "ACGME Review Committee for Dermatology." For example gets together and votes on how many Dermatologist we get, fun fact it doesn't go up much.
$They were so kind to add 400 more Dermatologist$ in the past decade to the student pipeline.$ What could the rea$son be?
What I would do if you are a doctor and don't hate humans - ask these boards to let more people in (hopefully Americans, but Americans have an uphill climb getting accepted with the flood of fraud applications from around the world).
Why? Do you think Americans make better doctors?
It's ridiculous. We need more doctors.
How the US does scheduling is kind of insane. Doctors like pilots (and truck drivers in Europe) should have clear rules about how long they work with rest periods and so on. Giving people 24h shifts is nonsensical and insane.
While I don’t disagree, this is an article written by an Australian doctor.
This very much points to the administrative side causing the damage. The overall toolset is broken and nobody is fixing.
I had a patient who tried and failed to use the legal system to extort me. Extremely frivolous.
I'm in the process of leaving the profession.
I don't feel guilty for the patients who will be left behind, they voted for this.
I would guess “us vs them” mentalities are not good for productive societies
Which votes exactly led to that?
Friends in residency describe it as a grind that breaks people, not just physically but emotionally too. The toll is immense.
Feels like a hundred years later we're still cursed by the cocaine addiction of Dr. William Stewart Halsted
I feel like a very similar article could be written by a teacher.
And the interesting part is that health care is mostly privatized, while education is mostly public. So the private/public conversation may make very little sense.
The article appears to be written by an Australian in Australia, FWIW.
I'm not suicidal and have never been suicidal or thought about suicide. I'm happy and in a good mood every day. If someone is thinking about suicide please reach out to me: rviragh@gmail.com I'll listen to your issues and concerns and we will find a better solution for you.
That is beautiful to offer but they should also call a crisis line, emergency number or talk to mental health professional.
Don't reach out to random strangers on the Internet. Instead, reach out to the official support hotlines in your own country and talk to someone with training:
https://en.wikipedia.org/wiki/List_of_suicide_crisis_lines
Same corporate-greedy shit as everywhere but harder, because it's dealing with suffering and death.
Are these problems consistent all over the world, or are they particularly severe in certain countries? I assume there are many studies of this already so it would be good to understand whether this is a problem that has a solution.
I see a lot of comments that we need more doctors to be able to pay doctors less. There are of course exceptions but I really don't think 300k a year is unreasonable when coming out with nearly 600k in debt in a field with such high burn out and liability risk.
Unlike salary position that 300k, at least in my field, is all via private equity and we are all independent contractors--meaning does not include any vacation, any paid time off, any sick days, any retirement or medical care or insurance of any kind.
I have not seen a raise since I started which was prior to covid. I'm not saying I need a raise I am well paid but again to be 500k in debt with zero benefits and I see on Reddit buckees managers or UPS /fed ex drivers making 150 to 200k with benefits and the ability to call out sick and the ability to not lose everything because of a single case where you follow standard practices or guidelines followed around the country but something bad still happens.
I go to work everyday with the understanding that the majority of my colleagues have been sued and even if not career ending the stress is enormous. At work I wear a tracker so that every fart and cough and patent interaction can be tracked. A VIP club of patients that donates to the hospital can ruin me with some bad reviews. A stray comment about poor care by an ems crew can end my career (as they bring the hospitals patients).
I don't believe doctors are overpaid and we need more to bring their pay down. A patient will get billed 2000 dollars if they ask for a burrito out front in triage, walk in, are told by me that Taco Bell is across the street, and they promptly walk out without a single test done.
On the other hand I may see sixty people in a busy night which require procedures such as being intubated and put on a ventilator, fractures being reduced , etc.
A major problem is private equity in medicine. Everyone should be focused on removing these groups which skim money off everyone both doctors and patients included. Even if the argument that somehow their efficiency increases result in extra money to the system they can feed on there is no reason why hospitals can't group up and also be efficient and cut them out and pass down savings to the customer or not overwork us docs or treat us like expendable McDonald's employees. The lack of working directly for the hospital there is no metric for skill or seniority or anything like that you are an expendible piece of meat/fall guy that they load down with as many mid level providers as they can get away with
I wonder if "Dcotor" ought not be a short career—one where you transition out after, say, two decades. Perhaps they establish a role of mentor within hospitals where "aged-out" doctors can be a part of new surgeons surgeries.
I know, never gonna happen.
Same with politicians.
In the US if a doctor is remotely competent with money then this is very achievable.
Everyone gets paid what they can demand and everyone pays as little as they can get away with, it's nothing specific to doctors or private equity.
I don't think this is really the point being raised. We need to relax the artificial constraints on the number of doctors. This would lead to more doctors. There's likely to be a side effect which is that doctors get paid less.
While the net effect is doctors getting paid less, it's not the reason.
The article is written by an Australian doctor, living in Australia, speaking about the death of a doctor who committed suicide in Brisbane.
Their work and living conditions are probably quite different from those of American doctors.
Why would a doctor start their career with a 600k debt, though? THAT is the problem.
In Belgium you can start your career as a doctor with zero debt and around 75k salary, working 35 hours per week. It's comfortable and lets you live a normal life.
We still have a shortage of doctors though like everywhere else, regardless of how well or how bad doctors are paid.
To clarify I misspoke.
I understand the point is not getting more doctors to pay doctors less.
However when people mention how getting more doctors will reduce physician pay naturally the argument they are putting forth is that somehow physician pay in America is higher than it should be.
That consumers are being gouged on scarcity. That physician pay is currently a "problem" that could be remedied if there was sufficient workforce and physician pay is responsible for your astronomical bills.
I do not think the salary has as much room to go down as people think given the 500k plus debt , years of schooling and residency , pressures of working the job , enormous liability , the fact the pay includes zero sick days /vacations , paid days of any kind , benefits, retirement, insurance etc.
My argument as a physician is this is the least of the problems in healthcare financing and your bill.
The two thousand dollar charge for waking into the hospital then promptly walking out was a real world example --not an exaggeration. The amount charged for that one patient would pay my wage for the night and it was 1 in 60 and took approximately 5 minutes. You can only imagine what the other 59 patients getting critical life saving procedures , CPR , etc are getting billed.
If anything reading this story made me think maybe physicians should be taken care of better and have vacations , time off , etc instead of everything being designed to grind them down.
Important context that's not obvious from the article - this is about the Australian healthcare system. I'd assumed it was the USA.
To be fair the driving distance was in km, not freedom units!
Er, do you mean miles? Like they use in Great Britain?
A few years back a great doctor working at a local children’s hospital took his own life. News said he’d become despondent over children dying when he couldn’t save them. The whole thing is heartbreaking.
I thought the point of this article is that unsuitable technology and the associated loss of personal agency is seriously affecting the mental health of doctors, yet none of the comments here seem to reflect that.
This is HackerNews, its like Silicon Valley central
While I agree partially (there is so much shit IT out there and healthcare seems to particularly abundant with it, Oracle got publically famous in Sweden recently for an expensive failed rollout, luckily clinicians were able to halt the full rollout since it was worse than the system it replaced).
The root cause that is also mentioned fleetingly in the article, is the "effectivization" of at least some western societies, in previously "socialist" Sweden were many things like the post and schools have been sold out to the market there's been an immense amount of enshittification in societal functions, some people still say that "private companies are more efficient" but most people over 40 also remember that stuff actually used to work and has only gotten worse over the years (even if many can't peg it on the actual reasons and listen to anti-immigrant rethorics).
But even publicly owned services have been affected (a few years back there was articles about NPM in medicine, yet not much seems to be changing and it's just getting more entrenched).
Politicians might try to rally people over public waste, but in reality "waste" (too many employees, people having free time at work,etc) is a cushion so that when shit does hit the fan the society has extra capacity to handle things.
Doctors, nurses, rail workers, postal workers,etc shouldn't need to be heroes for keeping up with increasing demands of efficiency that eventually causes chaos when taken too far, they should be able to have "boring" jobs where shit doesn't hit the fan unless an airliner crashes or a war happens.
Ultimately, this is a situation in which doctors doing this is worse in the long run.
Burning yourself out to cover for understaffing means both worse life balance for you BUT ALSO worse patient care.
No one quantifies how many people die, or how many diagnoses are missed, or how many patients feel unheard and become disillusioned with going to doctors, because doctors are dead tired and mentally burnt out, because they're trying to do right by patients.
You have to force hospital admin and owners do THEIR JOB, which is (in part) to provide needed staff to run properly, by not letting them exploit or impart a hero complex onto a job.
Yes, it's one of those cases where compassion works against people - because it's a dirty, costly local fix that enables the structural problem to fester.
You don't want a system that requires "heroic effort" as a baseline. You want a system where "heroic effort" is reserved for heroic circumstances.
If doctors are running ragged and putting in unreasonable hours and burning out during a natural disaster or a worldwide pandemic, it's understandable. If doctors are running ragged and putting in unreasonable hours and burning out during "business as usual"? Something's rotten.
Run long enough like this, and you'll simply deplete the people who dared to care - and leave ones who never did, or learned not to.
The challenge in the US is that the best and brightest increasingly have no interest in entering the medical profession. The debt, crazy years of minimum income, all to let an insurance company admin dictate your every move and while more and more physicians become a labor pool for PE healthcare tracked with metrics fit for warehouse workers (edit: and that’s not OK in a warehouse either). All to earn a decent income but no longer the top of the market. A decent mid-level developer or tech executive makes more than nearly all physicians. No sane top performing talent would dive head first into that mess.
There are exceptions of course but when my brother was considering medical school he visited about 10 different top physicians to seek input and advice and nearly all said if given a Time Machine they wouldn’t do it all over again. That was a real wake up call.
If you go into medicine as a business entrepreneur and build a successful medical business then there’s opportunities for one to still taste some of the glory of the medical profession that once was. Outside that it’s basically a reasonably well paid life of indentured servitude. Yes you’re “helping people” but that only carries you so far which is why so many just burn out and leave.
Massive reform is needed but the powers that be between the AMA and insurance companies seem unlikely to let that change happen unless it’s forced on them by Congress, and that too seems unlikely for now. Something more alike to an apprenticeship model where one grows up from EMT, to nurse, to physician fits the current business model much better than trying to preserve the old world “Officer vs enlisted” model where folks enter the profession directly as officers (physicians).
Maybe no one should be tortured by those metrics
Thank you.
Yes, poorly worded on my part. Wasn’t intending to suggest it was ok to do that to a warehouse workers either, just that this is how physicians are being treated today (but neither is OK).
Yes, but: that's an even narrower elite group than doctors.
"decent mid-level developer or tech executive makes more than nearly all physicians"
That's no where near true for a mid level developer or most tech execs or most senior developers. If you exclude faangs a top developer doesn't make as much as a doctor.
You need to consider the economic cost of delayed earnings, which is massive for the physician, and the higher pay later typically doesn’t make up for the massive debt and low pay early on. It’s not just about a point in time salary sizing contest. Earning little to nothing early in one’s career creates a massive net worth void to fill.
Physician lifetime earnings counting for delay, and debt… normal investment, etc: 8.5-10m. Software engineer median is much lower. About 6.5m. Specialist and high end varies greatly. Median doctor is earning 2x a SWE (130k vs 250k).
People on HN vastly overestimate SWE pay as an industry, biased by FAANG as we are :).
The median physician definitely earns more than $250K as well.
Lifetime earnings of 6.5M is more than lifetime earnings of 8.5M if the 6.5M is front-end loaded and the 8.5M is back-end loaded and starts with a 0.5M hole.
It's the difference between compound interest working for you vs compound interest working against you.
I accounted for that when I modeled it. I explicitly added investment start and compounding. A thing to remember: a physician is delayed yes but their higher income lets them much more heavily invest as their income often exceeds life expenses by a lot more than median swe.
It does, actually.
Physicians have high early career earnings. It’s not like grinding your way up the ladder until you get paid a lot.
Developers only make more if you only look at the very top end. Like a Stanford grad who goes straight to FAANG earning $200K the day after they graduate.
I agree, but it’s amazing how many times I’ve heard variations of this repeated as truth.
Developer compensation talk always gets biased toward top companies and high cost areas. The median developer or even top 10% developer isn’t living in the Bay Area working at FAANG, but that’s what gets talked about.
I think the problem is that physicians are self-selected to be highly intelligent and driven individuals. Med school is not at all a walk in the park, and is very competitive.
You cannot compare the median physician who endured the years of grueling med school and residency to an average developer. FAANG is probably a more apt comparison.
It is unfortunately true. Sr/Staff making a tech salary outearns all but the most specialized doctors. Even if you exclude FAANG that's true (other companies have to offer FAANG salaries to get FAANG talent).
You have to be living in a VHCOL to get that, but if you make >$300k TC you are outearning most doctors.
"nearly all said if given a Time Machine they wouldn’t do it all over again. That was a real wake up call."
And do they have experience working any other job as a comparables? The question you ask is the equivalent of saying do you think there are better jobs out there? Being a doctor is about the lowest risk job you can get if you are smart and capable. You get high status in society, excellent paycheck and on net are helping people.
The unemployment rate for licensed physicians is ~0.
Also, people are not aware of their skill sets. A lot of doctors I know think, just because they were "smart" in school, that if they had gone into, for example, tech or finance, they would have become a CEO. But you can tell they don't have the skill set for business. I mean, they can't even run a medical office with 8 employees well, and they think they could run a business with 100K people. The office is a mess, the records are sloppy, the appointments are 2 hrs. behind, they don't pay the staff well, the receptionist is rude, the photocopied forms are barely readable. Yet they think they would be inovating like Jeff Bezos.
Something like 17 out of the best 20 jobs by median pay in the U.S. are physicians, just various subspecialties. I guarantee you that people in medicine are incredibly driven and bright. You're just not exposed to them and the training they go through.
https://www.bls.gov/ooh/highest-paying.htm
I'm not here to defend the AMA but they have very little power over the lives of working physicians. While they do define the CPT code system used on most insurance claims they don't control which procedures are authorized or how much anyone gets paid. The real abrasion has come from health system administrators imposing additional rules and paperwork that waste physician time without doing anything to improve care quality.
I’ve had access to various compensation data products and I’ve done hiring at distributed companies across dozens of US states. This is not true unless you’re defining “decent mid-level” as working for FAANG. Conversations about developer comp always get skewed toward the top end for top 5-10% devs, with the median numbers being a lot lower.
I don’t know what you mean by “glory of the medical profession” if your definition of achieving it is… not being a medical professional?
Are you just talking about the money and social prestige that comes from being wealthy? The medical professionals I know didn’t go into the career because they wanted to maximize salaries. The days of becoming a physician primarily to seek money and social status are dwindling because there are better ways to make a lot of money where you get to sit at a desk and write emails, and honestly that may not be a bad thing. Let those people go be lawyers and finance bros or mediocre product managers.
Yes anyone who thinks engineers (HW or SW) are all paid amazingly needs to start taking in the wages of contractors too when calculating averages. Even many engineers working at FAANG HQs are lowly paid, abused contractors, making $50k-$80k.
I know personally of one big famous tech firm that has QA devs making literal minimum wage, because they are contracted from an outsourced firm. But 100% of those people's work is directed by and exclusively for the big tech firm so like all contracting it is an obvious paperwork scam to just mistreat their workers.
If this was true competition for med school spots would be a lot lower. On the contrary it's getting harder: you now basically need a 4.0 to get in.
Some of the best and brightest definitely are getting discouraged, I too have similar personal anecdotes from my daughter's peers. But anecdote does not necessarily correspond to data. Competition for spots is the data.
Here the data definitely supports your argument. Doctors are leaving the industry at far younger ages than they did in the past.
It's even worse than that.
I used to enjoy this blog:
https://web.archive.org/web/20101218031844/http://www.medsch...
This dude hated US medical school and it shows. I can't blame him, either.
AMA is working to keep salaries high. That's the only reason why this profession is still attractive. Probably unwise to change that.
I mean, this is not what the article is about though.
What the author of article is describing is just bureaucracy ever expanding (anyone who’s worked at the same place for a decade knows that bureaucracy rarely gets better), mostly decided by mediocre admin people who have never heard of Goodheart’s law. Bureaucrats loves KPIs, shitty average metrics (because distributions are hard to understand for bureaucrats for some reason), and generally does not have to field the consequences of their actions (notably because they don’t measure them!).
This is the poisonous pill. In any job.
This AI is set to fail and if it was a real person i'd be concerned.
https://deemagclinic.com/2017/08/27/dark-side/
And later
How much of the world has gone this way? Feels like there is something sick deep down in society that is manifesting itself as “you are not a human, you’re a set of metrics”.
Seems like this aspect could have been written by an Academic, a designer, certainly a software developer. The debasement of human dignity.
I think previously it was at least as bad. For hundreds of years slavery was fine. Killing people for believing into one thing or another (witchcraft, different religions, etc). Making people kill each other because the ruler says so. And many others.
Sure, we are not an ideal society and over relying on metrics is bad, but it is HARD to decide how we best use the resources to improve the world, and everybody has an opinion.
Hands you a copy of Volume 1 of Karl Marx's "Capital"
If only someone had written an explanation of this effect 170 years ago...
Yeah, the burnout is insane. Knew a resident who basically lived at the hospital for years, completely lost their social life.
Not defending the practices, but at least they will have a very comfortable retirement.
I still cannot understand why a profession like medical doctor does not have better working conditions + a guild or union to enforce that, like actuaries have. Doctor is a profession that few can do, few want to do, it's very hard, many barriers to entry etc. so all that would seem like it should result in doctors getting great pay and benefits like good working hours, even moreso because no one wants a surgeon who is severely sleep deprived and possibly suicidally depressed!
I just don't get it. Do doctors collectively do something wrong here that allows hospital admins to mistreat them so much, including the mistreatment of interns/residents during med school? And this is international too, I have heard these awful working conditions from doctors in Australia, USA, and the Netherlands. In the Netherlands example the resident intern I spoke to was even in a Dutch union but apparently the union was pretty worthless because he got paid extremely little and had the same 20-30 hour shifts that doctors in the USA have.
What country is this Doctor in?
Here in the UK, it seems that every time there is a problem they just add more managers.
I felt this one... Takes all the running you can do, to keep in the same place.
The entire loss of support section is way too real. I'd almost forgotten what that sort of institutional chaos felt like. So glad I don't work in a hospital anymore. It kills you inside.
Loss of meaning was different for me. The author seems to long for patient contact... Just as easy to lose meaning there, I'm afraid. It's just as tiresome but in a different way. The repetitiveness can easily lead to a sort of depersonalization.
This could be a fourth chapter all of its own: loss of autonomy.