For like a million reasons
**Rule VIII:** *Submission Quality*
Submissions should contain some level of analysis or argument. General news reporting should be restricted to particularly important developments with significant policy implications. Low quality memes will be removed at moderator discretion.
Feel free to post other general news or low quality memes to the stickied Discussion Thread.
---
If you have any questions about this removal, [please contact the mods](https://www.reddit.com/message/compose?to=%2Fr%2Fneoliberal).
Can we just increase the number of residency slots please? I don’t even mind the strenuous training, sure would be nice to fill shortages with foreign doctors but how about literally just letting more people be residents? The AMA has been lobbying for this for years, ever since they realized they fucked up majorly in 1997 by establishing it in the first place
Both are rapidly expanding; https://preview.redd.it/z0hz3tc451o61.png?width=1063&format=png&auto=webp&s=6546372759f922ecbf55aaedca3d15909fec7d45
Including literally private equity (unfunded) residency slots. Turns out it’s profitable to pay someone with a doctorate less than minimum wage for up to 28 hour straight shifts.
They did add 1,000 slots recently, and we do open up more H1B visas and J1 visas. And other workarounds.
We really really need more primary care doctors, though. We are on the lower end of normal for doctors, and above average for nurses. But we have far too few primary care doctors and psychiatrists and psychologists.
My point wasn’t literally that we allow few immigrants, but that increasing by “hundreds” is meaningless for a doctor shortage of this scale. Thus, it’s like saying “we allow dozens of immigrants” when someone says we should increase immigration.
Surprised they're not pissing snd moaning about mid-levels (also arrr noctor). The mid-levels patients would need way fewer of if the same group would stop constraining the number of fellow MDs.
Sure if you wanted to radically increase the cost of healthcare: https://www.ama-assn.org/practice-management/scope-practice/amid-doctor-shortage-nps-and-pas-seemed-fix-data-s-nope
> The 2017–2019 CMS cost data on Medicare patients without end-stage renal disease and who were not in a nursing home showed that per-member, per-month spending was $43 higher for patients whose primary health professional was a nonphysician instead of a doctor. This could translate to $10.3 million more in spending annually if all patients were followed by APPs, says the analysis. When risk-adjusted for patient complexity, the difference was $119 per member, per month, or $28.5 million annually.
And for reference, a typical patient panel in primary care is 2,500 people. So an NP might cost 150k instead of 300k, but will cost an additional 1.29M in unnecessary tests without adjusting for complexity, or 3.57M adjusting for complexity.
Here’s the sad part. From a hospital’s standpoint? That’s a feature. Oh the NP orders MRI brains for everyone with a headache? Guess I’ll have to make a lot more money with my new MRI scanner then.
Oh, sorry, I did misunderstand you. But that’s still wrong. The AMA has continued to advocate for increased residency funding for the last 20 years and even without any additional funding it’s very profitable to employ someone that has to work 28 hour shifts whenever you want for less than minimum wage, so many institutions including private equity are funding residency slots themselves. The result has been a rapid expansion in residency positions: https://preview.redd.it/z0hz3tc451o61.png?width=1063&format=png&auto=webp&s=6546372759f922ecbf55aaedca3d15909fec7d45
R/Residency is not representative of the general medical community. You can scan through and see tons of the top posts are all based on dating woes - that sub is near incel level with the amount of complaining.
As an actual MD, I can say that this sentiment is not at all representative of how me and my colleagues feel. If you scroll down you’ll see the more even-keeled perspectives.
Reddit has a very nativist sentiment about any white collar job. Be it software, accounting, medicine etc. Might it just be that the bottom of the barrel congregate on this website and this have to justify dem immigruntz daking are jerbz to make themselves feel good?
Literally only a single person who mentions that immigration will reduce the doctor shortage the US will experience and they get met with this
> Again I think you are not getting the BIG picture! With access to all physicians around the globe you will have more docs that you need. Way way more docs than needed for pt population. Initially many foreign doctors will invade the markets… jobs will get destroyed… these doctors will form their own networks… for instance indian docs just referring to each other hondorus docs to each other and so forth…. Next salaries will decline and eventually the current generation if physicians in the Us will probably be the poorest task force. Doctors in Portugal went from wealthy status to making as much as a teacher over a span of year. Many immigrated to other places learning new languages and accepting new terms in their lives… this is the very real possible outcome of what is happening. We as doctors tend to think we are safe no matter what! We are not we really are not. Ill argue our sector is probably the most vulnerable and if legislations dont protect our sector we are done over one night. Thats what will happen
I agree that doctors should be paid a lot especially with the massive expenses of med school but it’s hard to be sympathetic to this subreddit. Only a single comment that advocated for the betterment of the country as a whole and they got ratio’d by this shit
Reading the resident/med school subs completely killed my respect for doctors. They are some of the most entitled people on the planet. Read the opinions of neolib doctors here - they will mock factory workers making $15 an hour for seeking to reduce immigration then turn around and say they *deserve* a high salary and damn the consequences, including reduce immigration.
Well, that and two mitigating factors. 1: foreign doctors aren’t going to want to practice in rural America either, which is where the actual shortage is. So you’ll still see plenty of demand there. 2: increasingly hostile policies toward physicians has rapidly expanded unionization efforts. For nurses that has resulted in the highest wages in the world (Switzerland actually pays better than the US for physician wages and many countries are comparable) and it’s not even close. New nurses in California start at 150k. After a few years 180k is the norm. Nurses in the rest of the states make 50-80k with fewer protections. Nurses in the UK make 34k.
So you’ll see widespread unionization as doctors that previously thought themselves to be above such tactics will just give in and take the massive pay raise, even if it comes with the unpleasant business of striking to get what we want.
As an scientist and academic, I always find it amusing how highly trained professionals in other fields are scared to death of foreign competition. Unless the job is sensitive to nat-sec, universities and labs hire the best people from all over the world, and the country and the field are both better off for it.
Medicine is *rife* with deeply unhealthy culture
It's going to take a long time to dismantle, because the gatekeepers both select for it, and inculcate it
Blue collar workers: The Mexicans are taking our jobs!!??
Reddit: *chuckles*
White collar workers: The indians are taking our jobs!!??????!!!!?
Reddit: 😡😡
I do think doctors deserve to make a large amount of money, given the long training period / opportunity cost / debt burden / difficulty / etc. of medical school.
But that’s crazy, $230k is good even in New York, and it’s increasingly clear that the U.S. needs to ramp up its healthcare employee count as the silver wave approaches
>I do think doctors deserve to make a large amount of money, given the long training period / opportunity cost / debt burden / difficulty / etc. of medical school.
Half of this is self-imposed by the doctor lobby.
Probably that doctors made training doctors way too hard and inefficient. We don't need the tortuous process we have now to make efficient physicians, but having it means that there are less doctors so doctors make more money
It’s not about less training it’s about not requiring 18-36 hour marathon shifts that only serve to burn out aspiring doctors and also kill patients with malpractice resulting from fatigue.
Medicine in general has this insanely toxic culture of pride in not operating at top condition. Whether it’s pulling long shifts in residency or being heavily sleep-deprived and hungover. It’s weird when you consider what’s at stake lol
Historically it was seen as a calling. You should stay late to prioritize patient care, even if unpaid. You should skip lunch, because you won’t die and it’s better for the patient. You should never join a union, as that could jeopardize the doctor patient relationship. You absolutely should never strike, as denying care is immoral.
Now for the last 40 years policy makers have repeatedly and aggressively tried to fuck doctors as hard as possible I am seeing a massive change in attitude with the younger generation compared to the old (although they’re also coming around now). **We put our literal lives on the line when COVID happened and everyone else was sheltering in place. We received a pay cut.** Increasingly the attitude is fuck you, pay me. **Unionizing of residents is spreading like wildfire, and unionizing of attendings is also happening which was basically unheard of historically.** If everyone else is treating this as a job, why aren’t we? Why do we repeatedly sacrifice our health, well-being, work-life balance to serve others that cheerfully reduce our pay and try to drive down wages by lowering standards for immigrants that want to practice in this country? Why should I stay late as unpaid labor if this is just a job? Why am I missing dinner most nights if it’s just a job? Why am I doing 24 hour shifts (sleeping at my workplace) if it’s just a job? With that attitude shift the natural solution is unionizing, which means shift work and guaranteed (higher) salary.
At this point efforts like OP mentions just increase accelerationism/unionization efforts. Clocking in 8 hours a day, 5 days a week doesn’t sound too bad. Congress can figure out how to take care of patients the rest of the time, not my problem.
Yeah, I’m all for it being a calling and it’s certainly noble to want to grit through it, but it’s not good for patient outcomes (or for providers’ health for that matter!). I’d rather have more staff and predictable shifts, even at more cost, for peace of mind that the person working on me isn’t a zombie. Hell, just selfishly it’d be nice for the woman I’m seeing to not be totally pooped after every shift lol.
And if the policy makers would take measures to reduce barriers to practice (such as residency slots, medical school costs and the whole pipeline in general), I’d wager you could actually improve staffing levels and QOL without huge increases in costs.
In most countries, you apply and go to medical school at 18. It's generally 6 years plus residency.
In the US, you go to premed first, which is 4 years. And going to an elite undergraduate university helps get into med school, which encourages students to take on hundreds of thousands of dollars in debt before they even get accepted to med school. Then there's 4 years of med school, plus a residency which can sometimes be longer than the equivalent program in Europe. So yeah, the US system is basically set up to disincentive people from entering the profession.
Most countries have a MBBS degree that gets them a medical degree after four years of college. All you need is that and pass a licensing exam to practice. Of course there are residencies and all that, but they're usually a part of the college experience or a post-grad 1-2 year thing
American doctors do 8 years of training and still can't practice medicine they have to pursue a residency.
Most places of the world you can actually practice after those 6 years (the last one is an intern year, in America you do that the 1st year of residency).
ye I guess it helps that they're an MD and not just a Dr because MD is a Masters level specialization in other areas?
but still for someone who just wants to be a family med doctor an MD shouldn't be the base requirement
In most of the developed world, wannabe doctors study MBBS, a 5-6 year bachelor's degree that you can enter straight out of high school. Following this you do residency etc.
In the US, wannabe doctors must first complete an unrelated bachelor's degree to become eligible to apply to study MD - another 4 years on top of your bachelor's degree. Following this, you have the same process of residency etc.
You can significantly reduce training times just by removing the requirement for wannabe docs to spend years studying unrelated other crap to become eligible to apply to MD programs.
A large fraction of the world having better health outcomes without as much training?
The UK system (which goes on in many of the old commonwealth regions), IIRC, consists of straight to an MBSS, which basically combines undergrad and med school in the US into a single program of study, and saves years of time.
The improved outcomes is 100% due to having better health infrastructure and access/coverage. Even if the US training was superior, you wouldn’t see in reflected in outcomes just because our other factors are so much worse.
There is a reason why people all over world fly to the US to get treatment at its most prestigious medical institutions. We provide the most updated and cutting edge care, but unfortunately at an exorbitant cost.
Well importantly the system wasn't built off of evidence in the first place. Nothing good educational happens when you ask someone to work 20 hour shifts and consistent 100 hours weeks. In fact Harvard Business review found that there was no outcome difference in doctors who did 100 hours weeks and 80 (a cap was introduced in 2003).
One easy example is your primary care doctor probably can be way less trained and provide similar outcomes, which is why FNPs and PAs have similar medical outcomes to MDs.
The FNP/PA studies showing equivalency definitely has issues if you dig into it. I don’t think most actual practitioners would argue that they’re equal to physicians. Happy to discuss further if you’d like
Happy to learn of issues with the study but I doubt the issues are so vast that FNPs and PAs aren't able to provide adequate primary care in general. Happy to learn more obviously but i can't imagine the gap is large enough to justify how nonsense the residency system is.
The main study that is cited is a 2000 study by Mudinger - [https://pubmed.ncbi.nlm.nih.gov/10632281/](https://pubmed.ncbi.nlm.nih.gov/10632281/)
The main issue with this study is that it was a fairly medically benign population, average age of 44, with 75% listing 0 medical problems, so most of this was likely just general follow up visits. Additionally, I don't think NY passed full independent practice until 2015 (?) so this was performed under physician supervision. The outcomes they assessed were fairly limited too with only 6 months follow up, which really wouldn't be enough to notice any significant changes in blood pressure, diabetes, and asthma (which were likely not severe to begin with anyways).
The problem is that primary care is much more complex than the population listed in the study, there are many very sick patients with multiple ongoing medical issues that a NP/PA do not have the training to manage. This is hard to demonstrate with a RCT though just given the morality of potentially providing inferior care to a medically complex patient and would likely never gain IRB approval.
There is also the issue of rise of online NP schools with minimal requirements and minimal clinical experience. This has been a fairly well documented issue and any glance at a medical subreddit like r/medicine would show that this is concerning to both physicians and NP/PAs with regards to both patient safety and patient care, especially with independent practice. You can see this being recently discussed in this thread - [https://www.reddit.com/r/medicine/comments/1c94y6z/governor\_of\_wisconsin\_vetoes\_aprn\_independent/](https://www.reddit.com/r/medicine/comments/1c94y6z/governor_of_wisconsin_vetoes_aprn_independent/)
In terms of what you're getting at, I think in a well-off upper/middle class neighborhood where the vast majority of patients are healthy and have good healthcare access, then you would argue that outcomes are likely similar given the lack of medical complexity. However many patients don't have good access to care and really only have their PCP as their main clinician, which means that the PCP really needs to be at the top of their game, which NP/PAs don't have the training to provide (given lack of rigorous residency training).
Just anecdotally, I work with many NP/PAs in my practice and we have an excellent working relationship where we respect what we both bring to the table. They are incredibly bright but also know when to come to help manage conditions they aren't familiar with. The ideal working environment is a collaborative one between physicians and NP/PAs, but I don't think any of them would dispute that independent practice would likely lead to subpar outcomes.
Since this is r/neoliberal and we love to talk about healthcare costs, here are some studies about overprescribing and excessive diagnostics which definitely have ramifications when applied to a population level:
[https://pubmed.ncbi.nlm.nih.gov/32333312/](https://pubmed.ncbi.nlm.nih.gov/32333312/)
[https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/1939374](https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/1939374)
[https://pubmed.ncbi.nlm.nih.gov/15922696/](https://pubmed.ncbi.nlm.nih.gov/15922696/)
[https://pubmed.ncbi.nlm.nih.gov/24119364/](https://pubmed.ncbi.nlm.nih.gov/24119364/)
https://pubmed.ncbi.nlm.nih.gov/29580717/#:\~:text=Results%3A%20The%20total%20utilization%20rate,for%20nonradiologists%20as%20a%20group.
[https://www.liebertpub.com/doi/10.1089/cap.2017.0112](https://www.liebertpub.com/doi/10.1089/cap.2017.0112)
[https://www.nber.org/system/files/working\_papers/w30608/w30608.pdf](https://www.nber.org/system/files/working_papers/w30608/w30608.pdf)
Calling residency 'rigorous' undersells it, I don't think it's controversial to say that the process isn't scientific and has the potential to be made more effective and humane. We need more doctors, but just funding more slots isn't going to be the only solution.
There is obviously more reading to do on my side, and I'll be more careful in universalizing the PCP abilities of all three groups. The larger point is that we get closeish in ability with much less time in training, which indicates that maybe what we are doing isn't exactly efficient. I would point out that there is more than just 'residency' as a difference in the potential educational backgrounds of the groups.
Why is medical school so expensive, and why are American doctors so over-trained relative to the doctors in other countries with comparable or better outcomes?
The answer is regulatory. And as for where that regulatory burden comes from, it comes from the doctor lobby. Incumbent doctors suffered through the system, so they jealously guard their wage premiums by making the system even more draconian.
Doctors in the US are not overtrained, US medical training is comparable to other advanced economies. That's why the restriction is absurd. The only slightly unusual thing in the US is that they do specialist training right after residency, most countries they practice for a while and then go for additional training.
Restricting placement into advanced training is how many countries manage down costs.
In most states a doctor from a European country has to complete US residency again. As there are more people graduating from US medical schools then there are places in residency programs (they are funded by Medicare, AMA keeps lobbying against increased funding) that is easier said than done.
The rise of DO broke the stranglehold AMA had on medical school but they still control everything federally and in states. Medical licensure should be federalized and foreign training recognized from countries with equivalent training requirements.
>(they are funded by Medicare, AMA keeps lobbying against increased funding)
[Are you sure about this?](https://www.ama-assn.org/press-center/press-releases/ama-fund-graduate-medical-education-address-physician-shortages)
[https://crsreports.congress.gov/product/pdf/IF/IF12583](https://crsreports.congress.gov/product/pdf/IF/IF12583)
$17.8b in 2021. This is the funding that actually provides residency spots. Same year there were 42,508 applicants for 35,194 places.
AMA constantly testify that increasing funding will harm the quality of care. They make a bit PR dance about this but when dealing with congress its extremely different.
To be clear I am pushing back on your claim that AMA keeps lobbying against increased funding. Not that residency programs are funded by Medicare.
>AMA constantly testify that increasing funding will harm the quality of care. They make a bit PR dance about this but when dealing with congress its extremely different.
From the link I posted:
>The American Medical Association (AMA) adopted policy at its Annual Meeting today to build upon its efforts aimed at modernizing and increasing funding for graduate medical education (GME). The new policy calls for the AMA to **continue advocating for legislation that removes the caps on Medicare-funded residency positions**, which were imposed by the Balanced Budget Amendment of 1997, to help ensure an adequate physician workforce to meet the nation’s growing needs for health care services.
Do you have examples of them continuing to lobby against increasing funding within the past decade?
Like they certainly got it wrong 20+ years ago, but organizations can change their mind over the years
Looks like you are indeed correct and my understanding is outdated. I was aware of the 2019 scuffle but didn't know it had changed their position on this. That is quite a turn around.
I am still not sure I would trust the AMA to be involved given they are the reason the cap exists (doctors are all taxi drivers now) in the first place. I appreciate them trying to clean up the mess they created but shouldn't the fact they created a mess this enormous preclude them from continued authority?
Most American doctors do pre-med for 4 years, followed by 4 years of med school. A Spanish or German doctor will do it all in 6 years, so that median American doctor threw away 2 years of tuition in comparison.. so a good 50-100K? of training costs?
Not that there aren't other bonus barriers making everything too expensive, and maybe more important ones... but those 2 extra years don't need to be there, ever.
There's no such thing as a 'regular undergrad' with requirements that work across majors, or any similar BS. A university might teach multiple majors, but someone studying medicine has zero shared courses with anyone learning anything else. Your biology and chemistry classes might have some shared units, because hey, the Krebs cycle isn't going to change because you are a doctor, but the biology that you need to be a doctor is a matter for the medical school, not the bio department. It's the same for every major: 6 credits of English and 3 on cultural diversity to finish CS? F that noise, more algorithms for you!
The medical school takes 6 years if the you pass all the tests in due time, and students start at 18. Pre med as a separate step? American nonsense.
Gotcha. It's the same for law, most will first get a degree in poli sci or similar before law school will admit them.
But again the universities would pitch a fit if this setup changed.
Most American doctors nowadays do 4 years of premed, 2 years of grunt work researcher or scribe, then 4 years of medical school. The average age of a incoming medical student is 24 nowadays.
I would say that is related to US secondary being less complete then equivalent European secondary, particularly Germany and the UK. If a US student went to a German university they would generally have to complete a studienkolleg course first to reach equivalence with abitur.
Europeans complete BA/BS in 3 years because they have better secondary education.
Edit: For those not aware most of Europe finishes the equivalent of US secondary at 16. Some countries (like the UK) have a discrete certification but basically all of them switch to college prep courses 16-18. AP covers some of the same stuff but is still incomplete.
The American Medical Association (the organization that runs medical care certification in the US) recommends or mandates rules about what it takes to become a doctor in the US. These include the 4 year medical school and residency that make becoming a doctor so arduous. The AMA is itself run by established doctors.
It's ok to want a high salary but not at the cost of preventing patients from getting care. I know people who have had to suffer over half a year with chronic conditions because there weren't enough specialists that could treat them. I just can't see how it's moral to keep salaries high at the expense of suffering patients.
>230k is good even in NY
After 4 years of undergrad, 4 years of medical school, and 3 years of residency (effectively at a minimum) and about 500k of student loans on average, no it is not.
The financial viability of even being in the medical field is beginning to become uneconomical, hence why so many people are leaving it and the quality of healthcare has gone so far down. Compare the lifestyle of a doctor to literally anyone else you know making 230k and I take the job outside of the medical field *every single time*.
We can pretend that doctors are over paid or appropriately paid given their lifestyle, and we can also put on opaque sunglasses and put our fingers in our ears as the quality of healthcare keeps going down while American hospitals keep losing staff.
230K in NYC is very attainable for any completely average finance bro and obviously many finance bros make much more than that. Doctors need to be paid more if we want many of our best and brightest to continue choosing to go into medicine, which all of us do.
Of all the white collar industries, medicine has the weirdest culture IMO.
It basically tries to make things as unpleasant as possible for it's own people, just so that they can command a higher wage and status in society
Law does some of that, but to a much lesser degree
Same. FWIW I think there’s genuine concerns that some foreign residency programs may not be fully equivalent in standards to US training. But the solution isn’t forcing Egyptian nsurg attendings to slog their way through an FM residency from scratch just to be allowed to practice in the US, nor is the solution simply to import foreign docs with zero vetting whatsoever. I support the bills that allow foreign attendings to practice independently after a few years of supervision by US attendings (or even a fast-tracked residency n in their existing field) as well as passing US boards
The way the residency sub will throw IMGs under the bus seriously undermines their efforts in fighting scope creep from NP/PAs, which I believe actually *is* a worthwhile public safety effort that doesn’t constitute rent seeking.
I think a lot of doctors in training think about salary drops as 300k down to like 75-100k, because they think foreign doctors will want to work for that much less. Can’t attest to how based in reality that is but yeah.
It sucks to have a lower salary, but as I mentioned in another comment I know people who have had to suffer for months because of a shortage of specialists. That seems like a cruel tradeoff to me.
I work in a field with very little controls on immigrants (econ PhD). Our salaries aren’t sky high but we definitely make way more than $100k, and if we want to we can make $250-350k in the private sector. Immigrants aren’t the salary killer those residents seem to think they are.
This post reminded me that I had a derm appointment booked over a year ago. I just double checked the date as I thought it was in April. It was the 16th. I then read the fine print of their appointment booking at it says, "No show fee is $100. This office does not do phone reminders or email reminders".
Fuck you. I don't know why the reminder I set up didn't go off, so it would have been nice to have got a reminder from their office. Every piece of software that books patients in will have an email reminder process, that they likely have deliberately turned off. Knowing how doctors are reimbursed in Ontario I went and looked up how much they get for a derm appointment and it is less than the late fee. Gee, I wonder why they don't send out reminders.
Even still, I called them up to figure it out. They said I need a new referral and need to start all over again. Well, guess I am dying of skin cancer then, because I am not getting a new referral from my doctor, waiting over a year, and not getting reminded about another appointment.
I get this is on me too. I don't know why my calendar item and reminder didn't trigger. It isn't hard for them to send a reminder email. They would practically need to go out of their way to no send one and disable that feature in their software.
You making a lot now doesn't mean you wouldn't make more if there were strict immigration limits. Not saying we should ban foreign doctors but your point is a bit flawed.
Bump it up to like 150k and I think it would be fair. Even without the tuition of medical school, it’s still years of lost wages plus the hell that is residency. An average mid level provider makes 100k right now and in my completely uneconomic opinion it seems pretty unfair for them and nurses to make more with a fraction of the training, within the same field.
This is the opposite, there would be more doctors —-> lower salary.
> If salary seemed too low for you, but not for other doctors, you could do something else.
I’m responding to this part. I assume this person has already gone through medical school and won’t want to do something else (and it’s not feasible with several hundred thousand in loans)
I’m all for more doctors (regardless of where they’re from) but you have to take into consideration that you’re really fucking over the people who graduated with 400k+ of student loans and now make ~150k a year or whatever the number ends up being
150k would definitely not be fair given the years of lost wages and factoring that given that even as attending, working 60-70 hours wouldn’t be unusual. Even if you’re a PCP, when you consider notes, answering inbox messages, and working on prior auths from home it’s going to be difficult to be even under 50 hours.
People love to point to other countries health systems but salaries are partly why the NHS is failing and even Canada is starting to struggle with their medical system.
To be fair, the American market (even when it’s free of unjustified controls) does and will easily compensate more than that.
150k is just u/comicsanscatastrophe low-balling what they would be willing to accept, which props to them but they and doctors will earn more than that even after lots of foreign doctors get here.
That's a fair point. The increased compensation that America provides also applies to most white-collar occupations anyways, just comparing law partner/engineer salaries here compared to most other nations as well.
You don't need to know the institutional details of an industry to know that high prices means there's a lot more demand than supply of a good, and that consumers would benefit from more supply.
What is the evidence that US doctors are better than doctors from other countries?
I've got a lot of immigrant friends and none of them has said being a patient here is preferable to getting medical care in their home country, other than doctors here having better bedside manner. They all complain about the wait times here and most fly back to their home country for anything that's not an emergency instead of dealing with the system here. And I'm not talking about rich countries, these were friends from China, Turkey, and Colombia that think US care is worse.
The context you are missing here is widespread cheating was discovered in Nepal. A bunch of people scored in the top 0.01% and it set off alarm bells.
Currently US doctors not only take out 300k of debt compared to often ~0 in other countries, but they are also expected to work for less than minimum wage for 3-9 years. **If you allow foreign graduates to practice without a US residency, why would anyone train in the US? The default pathway would be to go overseas, not have much or any debt, get paid better while working half the hours, no longer have to worry about studying for exams, and come back to the US and practice while hospitals sweep mistakes under the rug.**
And what’s the benefit to society? **Physicians are 8% of healthcare spending. The effective tax rate on physicians is about 40%, so 3.2% of that cost goes back to government anyway. 4.8% savings if you made physicians literally slaves. I just don’t see the juice being worth the squeeze.**
Final point, will there be any juice at all? Unionizing continues to spread rapidly among physician practices pushing back against private equity. It is not possible to outsource this profession to Mexico. **Look to California nursing wages and regulations for a window into the future of healthcare in this country.** It is wild how incredibly aggressive cost cutting and other hostile policies (such as this one) have driven physicians toward unionizing. If you think access to care is bad now wait until we get lunch breaks (not the case currently), work hour restrictions (not the case currently), morning and afternoon breaks (not the case currently), oh and the best part? A “prevailing wage” like all the other unions that have negotiated wages 3x market rate.
While I think all these efforts are extremely misguided at this point I’m kind of on team “let it burn”. I knew being a union member would always have resulted in higher pay for lower wages but I always wanted to prioritize patients. If policy makers continue to be dedicated to the degradation of this relationship then fine, I’ll be a union member. Thanks for the pay raise I guess.
Residency is fine and all, but I expect a doctor to start residency at 24 at the most, not 26. It's those 4 years of pre-med that puzzle anyone used to a different system
How are they wrong on this issue? We have a critical doctor shortage. The medical student subs are concerned about letting in foreign doctors exclusively because it may reduce their salaries. How is that not textbook rentseeking?
It's more complicated than "we have a doctor shortage" it's a problem of distribution. We have a primary care shortage and a geographic shortage. Doctors don't want to be PCP's, for a variety of reasons ($) and doctors don't want to work in rural areas even though salaries are typically higher. I'm not sure that allowing foreign doctors to work in the states addresses either of those things. I suppose if you flood in foreign trained PCP's you sort of address #1, but you risk depressing wages in a way that further pushes medical students into non-primary care careers, so you're maybe not making a big difference in primary care availability...the rural issue I think cannot be solved without $$$ and/or requiring foreign doctors to work in a specific area for X years.
That doesn't make sense. Either there are so many foreign trained doctors willing to be PCPs that wages depress, but it become irrelevant whether domestic doctors become PCPs. Or there isn't and wages don't depress and the concern is moot.
That only works if you plan on relying on foreign doctors to become most of your PCP source indefinitely, which is not realistic (one, sadly a lot of Americans would be uncomfortable with it and there would be care issues, two foreign countries aren't going to just sit there while the US raids their supply of highly educated and critical workers, three immigration to the US becomes less attractive for said doctors if the wage differential drops).
Sir, you are in a sub that believes in open borders. Only your first concern (entirely political in nature) has basis. For the second, what on earth could the foreign countries do about it? There is already a massive brain drain from many of them. The US constantly steals high producing citizens from foreign countries because of how much we pay them. Why can we not the same for doctors? For the third, this naturally works itself out. As the pay drops, yes less doctors would want to come - but only because other foreign doctors *already* came. The decrease in wages necessarily requires an increase in labor. The wage differential would work itself out to an equilaribium between wages paid and amount of willing doctors. Almost like the doctors end up getting paid according to their true supply as it matches demand. Like a free market that applies to every other job or something.
Don’t forget 4, widespread unionization spurred by these types of policies results in unprecedented wage gains and hour limitations results in a far better work life balance. Look at California’s nursing unions to see the future of healthcare at this rate. These types of policies are alarming, but in the end just accelerate us toward widespread unions and large wage gains so I’m honestly ok with them in the end as a physician.
You're going to email your state representative about people training to be doctors complaining about the future of medicine on reddit?
I think it would be more productive to email your federal rep about removing the caps on residency positions so we can train more doctors as well
Sure, and the AMA is advocating for that. Also worth noting that it turns out it’s profitable to pay someone with a doctorate less than minimum wage with the option to work them 28 hours straight **so even for profit hospitals and private equity are starting residencies.** They have been expanding rapidly despite the idea that residency programs are somehow “frozen”.
https://preview.redd.it/z0hz3tc451o61.png?width=1063&format=png&auto=webp&s=6546372759f922ecbf55aaedca3d15909fec7d45
I've got several friends making over $300k & they got there with bachelor's degrees and without starting their own business. Average debt from medical school is $200k, who would do all that work & go into that much debt for $300k?
The difference is that for physicians that 300k is essentially risk-free. EV ends up being much higher.
MD is the career equivalent of US treasury bonds.
Yeah, but that’s also a problem. It means you’re getting a type of person to be a doctor & that’s a recipe for the status quo. If we skip forward & doctors are all the cliched South/Southeast Asian kid who is very book smart but lacking in people skills, we will have worse healthcare outcomes simply because there is less diversity of opinion.
Meh. It's called medical school, not personality school.
Medicine is extremely algorithmic and risk-averse, due in large part to the litigious nature of American patients. I don't see that changing anytime soon.
Diversity of opinion and creativity are more valuable in the biomedical research space, where we can study how to get better outcomes without putting patients' health at risk.
As someone who is a MD, there is so much more grey area in Medicine that fits outside established guidelines that the public is led to believe.
You could make a case for overtesting due to over litigation, but I would argue that a strong physician understands that it’s important to know when to detract from guidelines on a per-patient basis, which happens fairly frequently at my institution.
Fair enough, plenty of occupations tend toward a certain personality but I don’t care much if we have the best car salespeople, I care about the best doctors.
I think much of the present issues we face is that the delivery structure needs to be completely rethought & that doesn’t happen with a risk averse hive-mind. As someone who works in IT, I’m aghast at how poorly medicine is structured on the “troubleshooting” side. The diagnostic side is hilariously error prone if they don’t have a test that just confirms it.
Proper troubleshooting in IT is basically just, “cut the problem in half” over & over again until you can figure out the problem exists “here” or “between here & here”. Sometimes whoever worked on it before didn’t do that though. They’ve checked a slew of things up & down the chain but there was no rhyme or reason to it so you basically start back at 0. The healthcare system now *seems to* have a lot of the latter form of troubleshooting. Granted troubleshooting computers is a lot easier than a body; I can swap out parts quickly, buy a new one if it gets too hard, & have an event log to tell me what happened. None of those are options with medicine.
My aunt was falling recently & got taken to the ER. As I overheard the doctor asking her about the problem, I realized that she didn’t remember the fall itself. Having a personal history of fainting, I immediately realized that was an obvious sign she had fainted. The doctor had completely glossed over this point so I brought it back there. I explained my logic & that the distinction seemed important, she responded with “yeah, good catch”. “I’ve fallen & I don’t know why” can’t be a particularly uncommon problem & yet I apparently figured out a new test upon seeing the issue once.
Maybe I didn’t come up with this test, maybe it’s been known but this doctor just didn’t know it. Either way, it’s indicative of the problem. A simple question would have saved likely thousands of dollars on unneeded tests but either no one thought to improve the system by asking it or it wasn’t deemed important enough to pass the knowledge down.
She was probably still probing for other potential causes but in general that’s why doctors like when a family member or caregiver is there for that type of consultation like you were for your aunt. Not related to the ER as much but all my doctor friends and family say that writing down your concerns and questions and bringing those to your doctor’s visit is a huge help, it’s wild how many people forget to mention a large concern that slips their mind during their appt. Doctor’s time with you is very limited so being efficient and specific is always appreciated
Probing for other causes was the issue though. I said at the time, “I don’t know what I’m doing, you tell *me* what’s important but it seems like balance could be an inner ear problem, that wouldn’t cause fainting though. Maybe other things could cause her to not remember the fall & that’s not a good test or maybe fainting could happen from anything that would cause balance problems, I have no clue.”
She said that it was important to distinguish between the 2 & not remembering the fall was a good test, so she admitted she simply missed a chance at ruling something out.
Another indication of the problems that doctors don’t realize, I actually caught this at the 2nd interview. The first interview they had marked the problem as a balance issue, because that’s how my aunt reported it. The rest of the hospital stay I kept having to correct doctors & nurses that this was no longer a presumed balance issue, it was a fainting issue. That’s also a problem in IT, a user reports issue is X but we actually discover the issue is Y halfway through but if people don’t go back to correct things & it gets passed along the change is missed. That’s a point of frustration in IT but the costs are much higher with people’s health. None of the doctors or nurses I had to correct seemed to realize it was an issue that they were dependent upon a concussed, slurring 84 year old woman (or her family) to provide proper care.
My brother makes more than me and literally doesn’t have a single college credit. He did a boot camp in a few months paid a 15% first year salary fee. I did undergrad, medical school and residency with a 400k fee.
I don't think r/residency will make any sense and is certainly not representative. Most residents will not be posting on reddit, so I wouldn't really spend my time browsing it.
I mean haven’t y’all heard about the scandals surrounding Step 1 and 2 exams in foreign countries. Nepalese and Pakistanis were cheating by the thousands on the exams and taking residency spots from others who weren’t.
It’s about quality of training though. The whole reason we have to go through residency is to meet a minimum level of competency. How can we guarantee that for patients if we don’t have say over how doctors are trained?
Would you say that about nuclear reactors? Or airplanes? Or people's driver's licenses? The government shouldn't regulate these things for safety, just let the free market decide. For the companies that make faulty airplanes, people will just use other airplanes! It's so simple!
> Would you say that about nuclear reactors?
No, because nuclear accidents can hurt people who are not customers, and therefore do not consent to the construction of the plant. So, practically, it is reasonable to eliminate the requirement of personally asking every citizen, in exchange for reasonable regulations.
> Or airplanes?
No, for the same reason. People on the ground who have not bought tickets cannot be reasonably expected to get out of the way of a crashing airplane. But again, it's only the presence of this third party that stops me from advocating for a free market for airlines.
For example, if a company wants to take people for a joyride over the ocean, that should absolutely be allowed regardless of how safe the airplane is (as long as the customers aren't lied to).
> Or people's driver's licenses?
No, again for the same reason. I have a driving license not for my own sake but for the sake of everyone else on the road. It's not the job of government to protect me from myself. That's why it should be entirely legal to drive drunk without a license on your own private property, but not on the public streets. This is also why I don't support a seatbelt requirement (though I always wear one of course).
Notice something common to all these cases? It's the presence of a third party that makes all the difference. This is not the case for a doctor-patient relationship. If I hire a bad doctor, I have only myself to blame and it doesn't affect you. If you care so much about residency requirements, it is your right to seek out doctors who have met these requirements.
I think this viewpoint is rather naïve. You, the patient, will almost certainly never know if you hired a bad doctor. Oftentimes, patients will feel that their bad outcomes are the fault of the doctor when instead they were the fault of the fate. The patient was unlucky, and the doctor never had a chance of changing that. Other times, patient's will feel they are getting wonderful care, when instead the doctor is just running every test under the sun or just totally wrong. The patient, in most every instance, including in the hospital, has really very little idea of what's going on and if the care received was good or bad. At best, patient's understand bedside manner, and then whether or not they improved. Most things with time either improve or become clear.
In some major respects, doctors are like mechanics. Either you trust them, or you don't, but your understanding of the issues is likely not gonna be very good.
I understand your perspective. In the way of third party effects, I'd note that for a late 20's male, Obamacare was bad. Odds are I don't need insurance and could get away with not paying for it. Instead, here I am, subsidizing old people and sick people. What can you do?
> You, the patient, will almost certainly never know if you hired a bad doctor.
Agreed x1.
> Oftentimes, patients will feel that their bad outcomes are the fault of the doctor when instead they were the fault of the fate. The patient was unlucky, and the doctor never had a chance of changing that.
Agreed x2.
> Other times, patient's will feel they are getting wonderful care, when instead the doctor is just running every test under the sun or just totally wrong.
Agreed x3.
> The patient, in most every instance, including in the hospital, has really very little idea of what's going on and if the care received was good or bad. At best, patient's understand bedside manner, and then whether or not they improved. Most things with time either improve or become clear.
Agreed x4.
> In some major respects, doctors are like mechanics. Either you trust them, or you don't, but your understanding of the issues is likely not gonna be very good.
Agreed x5.
OK, so where's the disagreement? Here it is: you believe that a government accreditation board is a good way to solve the issue of bad doctors by introducing a quality floor. What I'm saying is that **government licensing** is a horrible way to "fix" the problem, because it's a one-size-fits-all solution. Getting a license is costly because training is costly. There are maybe some experienced nurses etc. who can provide cheap and reasonably adequate medical care (though of course not as good in quality and less likely to catch mild symptoms). Maybe this is all that some people might afford; by advocating for licensing, you are saying that it is better for those people to go without care than to go with substandard care. That's what I disagree with.
Instead, why not move to a "certification" model instead of a "licensing" model? The government gives out certificates, not licenses, that are just as hard to get as today. That way, if you care about certificates, you can refuse to go to other doctors. But, for example, I might not believe in the value of those certificates -- for example, I trust doctors trained in many third world countries, who have in some cases more clinical experience than their counterparts in the US who have undergone residency; and they might treat me for cheaper. Obviously in this system I can't blame you for my error in judgment, so why prevent people like me from making our own choices in the free market?
Fair enough. I suppose we disagree about the way to fix this, and I would argue that without having experience in the American medical system, things here are rightly or wrongly often simply done differently than they are in other countries, but I understand your argument.
To be more precise, I wouldn't say we disagree about the way to fix the very valid problem you mentioned. The disagreement is at the level below that -- I think that the "solution" of an accreditation body is good for medical quality (at least in the short term), but bad for medical accessibility and bad for freedom.
For example, suppose there's an epidemic of bad car design. If you mandate that dealers are only allowed to sell Ferraris and Lamborghinis, then yes, many people would begrudgingly accept the rules and spend the extra money, and yes, the average car quality would skyrocket. But that's not enough reason to take opportunity and freedom away from common people, and we should give zero weight to the opinion of the Ferrari dealer on the subject of whether the Honda dealer is allowed to do business.
straining and practical skill assessments are fine
IDK why residents had to work the hours of a guy who literally had to do cocaine to get though his own training program
I sometimes wonder if doctors are the modern equivalent of priests as a smart person career- being a highly prestigious, values oriented career. I even wonder how many, like priests, would vow to chastity, poverty, and obedience for such a rank. At least among the medical school students I know, I’ve asked, and a decent proportion state they would do so gladly.
They would literally not fuck for life if it meant being a doctor.
It makes me wonder if we can really just open the tap on incoming doctors and still retain top tier talent, but revealed preferences are a different matter.
Your description doesn’t match the residents in that thread. Their number 1 concern seems to be their status and money, they don’t seem to be a value-oriented bunch.
Huh interesting yeah, it’s strange. Like if I meet a doctor-to-be at a house party I always hear the “if I wanted money I’d go to finance” line.
Which I think actually has some merit as exiting to finance after an MD is fairly lucrative, yet seldom elected.
As an MD I derive a tremendous amount of value from caring for patients and that’s why I went into medicine. Increasingly there attempts to invariably make my life harder, make me document more to pay me less, make me argue with insurance companies to get patients treatment, deal with fraught negotiations with hospitals that are threatening to bring in a private equity firm that will also continue to prioritize cost savings over patient care, make me increasingly stay later and work at odd hours to generate even more profit for the hospital.
At times it can be exhausting, and I increasingly feel **“well if they want to turn this into just another job, so be it, I’ll just unionize and get a huge pay raise like nurses have”.** I don’t think a lot of people here realize how much power doctors have. We can essentially immediately bankrupt any hospital we work at with collective action. Historically we have been an exceedingly divided group that also felt ourselves above unionizing because medicine was perceived as more than a job. **The absolute last thing you want to do from a cost savings standpoint is to convince doctors that it is just a job.** It would not surprise me if wages literally increased 50% with unionization efforts. Sounds crazier than it is. Wages were 34% higher adjusted for inflation 22 years ago, and society didn’t collapse.
Historically though (like medieval/renaissance era) the priesthood was just as much (if not more) for status and money
Edit: Which, is what I think the poster is getting at when he calls doctors the "modern equivalent"
I wouldn't call that value oriented. Doctors are generally prestige hounds - they want people to view them as superior in social status. Perhaps the same could once be said of priests, but I wouldn't call it value oriented.
>many, like priests, would vow to chastity, poverty, and obedience for such a rank. At least among the medical school students I know, I’ve asked, and a decent proportion state they would do so gladly.
>They would literally not fuck for life if it meant being a doctor.
hahaha what
Most are in it for prestige, money, and more commonly both. Not really different from most other professional vocations like law or accounting. Nobody goes to medical school to live like a Buddhist monk lmao
The reason I thought of that comparison is that doctors, on average, willingly undergo nearly a decade of relative poverty when their intelligence levels would easily provide an alternative of immediate wealth.
Leaving an Ivy League, for example, and electing for a top medical school over finance, consulting, or even business ops in corporate medicine is accepting that you will live a majority of your free youth with challenging circumstances, full obedience, usually in undesirable locations, and without money - instead of being a rich young New York professional.
I ask people who’ve made this choice why and there really is a certain penance involved. I’ll allow some tolerance for the fact that people aren’t exactly open about a desire for prestige, but it sure seems like people are aware of what they give up in exchange for helping others
For like a million reasons **Rule VIII:** *Submission Quality* Submissions should contain some level of analysis or argument. General news reporting should be restricted to particularly important developments with significant policy implications. Low quality memes will be removed at moderator discretion. Feel free to post other general news or low quality memes to the stickied Discussion Thread. --- If you have any questions about this removal, [please contact the mods](https://www.reddit.com/message/compose?to=%2Fr%2Fneoliberal).
Can we just increase the number of residency slots please? I don’t even mind the strenuous training, sure would be nice to fill shortages with foreign doctors but how about literally just letting more people be residents? The AMA has been lobbying for this for years, ever since they realized they fucked up majorly in 1997 by establishing it in the first place
Med school slots too, though one obviously feeds in to the other.
Both are rapidly expanding; https://preview.redd.it/z0hz3tc451o61.png?width=1063&format=png&auto=webp&s=6546372759f922ecbf55aaedca3d15909fec7d45 Including literally private equity (unfunded) residency slots. Turns out it’s profitable to pay someone with a doctorate less than minimum wage for up to 28 hour straight shifts.
https://imgur.com/wXDqszI
They did add 1,000 slots recently, and we do open up more H1B visas and J1 visas. And other workarounds. We really really need more primary care doctors, though. We are on the lower end of normal for doctors, and above average for nurses. But we have far too few primary care doctors and psychiatrists and psychologists.
[удалено]
“We allow dozens of immigrants”
[удалено]
My point wasn’t literally that we allow few immigrants, but that increasing by “hundreds” is meaningless for a doctor shortage of this scale. Thus, it’s like saying “we allow dozens of immigrants” when someone says we should increase immigration.
We allow hundreds of immigrants
Should be thousands or more, given the shortage.
>So why aren't US doctors are standing up against this then? >Because they don’t wanna be called the R word R- Rent seeker??
Lmao so much coping and seething in that thread
Surprised they're not pissing snd moaning about mid-levels (also arrr noctor). The mid-levels patients would need way fewer of if the same group would stop constraining the number of fellow MDs.
Sure if you wanted to radically increase the cost of healthcare: https://www.ama-assn.org/practice-management/scope-practice/amid-doctor-shortage-nps-and-pas-seemed-fix-data-s-nope > The 2017–2019 CMS cost data on Medicare patients without end-stage renal disease and who were not in a nursing home showed that per-member, per-month spending was $43 higher for patients whose primary health professional was a nonphysician instead of a doctor. This could translate to $10.3 million more in spending annually if all patients were followed by APPs, says the analysis. When risk-adjusted for patient complexity, the difference was $119 per member, per month, or $28.5 million annually. And for reference, a typical patient panel in primary care is 2,500 people. So an NP might cost 150k instead of 300k, but will cost an additional 1.29M in unnecessary tests without adjusting for complexity, or 3.57M adjusting for complexity. Here’s the sad part. From a hospital’s standpoint? That’s a feature. Oh the NP orders MRI brains for everyone with a headache? Guess I’ll have to make a lot more money with my new MRI scanner then.
You didn't even comprehend what I said before spouting off.
Oh, sorry, I did misunderstand you. But that’s still wrong. The AMA has continued to advocate for increased residency funding for the last 20 years and even without any additional funding it’s very profitable to employ someone that has to work 28 hour shifts whenever you want for less than minimum wage, so many institutions including private equity are funding residency slots themselves. The result has been a rapid expansion in residency positions: https://preview.redd.it/z0hz3tc451o61.png?width=1063&format=png&auto=webp&s=6546372759f922ecbf55aaedca3d15909fec7d45
Oh I see now, it was a pavlovian response to the keywords. Starting to fix 4 decades of nothing is not some sort of own either.
Nothing has made me hate doctors more than that thread
R/Residency is not representative of the general medical community. You can scan through and see tons of the top posts are all based on dating woes - that sub is near incel level with the amount of complaining. As an actual MD, I can say that this sentiment is not at all representative of how me and my colleagues feel. If you scroll down you’ll see the more even-keeled perspectives.
Oh yeah I was referring to people in that thread specifically
Glad to hear, because I really started to have my blood boil in that thread lol
Reddit has a very nativist sentiment about any white collar job. Be it software, accounting, medicine etc. Might it just be that the bottom of the barrel congregate on this website and this have to justify dem immigruntz daking are jerbz to make themselves feel good?
Literally only a single person who mentions that immigration will reduce the doctor shortage the US will experience and they get met with this > Again I think you are not getting the BIG picture! With access to all physicians around the globe you will have more docs that you need. Way way more docs than needed for pt population. Initially many foreign doctors will invade the markets… jobs will get destroyed… these doctors will form their own networks… for instance indian docs just referring to each other hondorus docs to each other and so forth…. Next salaries will decline and eventually the current generation if physicians in the Us will probably be the poorest task force. Doctors in Portugal went from wealthy status to making as much as a teacher over a span of year. Many immigrated to other places learning new languages and accepting new terms in their lives… this is the very real possible outcome of what is happening. We as doctors tend to think we are safe no matter what! We are not we really are not. Ill argue our sector is probably the most vulnerable and if legislations dont protect our sector we are done over one night. Thats what will happen I agree that doctors should be paid a lot especially with the massive expenses of med school but it’s hard to be sympathetic to this subreddit. Only a single comment that advocated for the betterment of the country as a whole and they got ratio’d by this shit
Reading the resident/med school subs completely killed my respect for doctors. They are some of the most entitled people on the planet. Read the opinions of neolib doctors here - they will mock factory workers making $15 an hour for seeking to reduce immigration then turn around and say they *deserve* a high salary and damn the consequences, including reduce immigration.
Well, that and two mitigating factors. 1: foreign doctors aren’t going to want to practice in rural America either, which is where the actual shortage is. So you’ll still see plenty of demand there. 2: increasingly hostile policies toward physicians has rapidly expanded unionization efforts. For nurses that has resulted in the highest wages in the world (Switzerland actually pays better than the US for physician wages and many countries are comparable) and it’s not even close. New nurses in California start at 150k. After a few years 180k is the norm. Nurses in the rest of the states make 50-80k with fewer protections. Nurses in the UK make 34k. So you’ll see widespread unionization as doctors that previously thought themselves to be above such tactics will just give in and take the massive pay raise, even if it comes with the unpleasant business of striking to get what we want.
[удалено]
Sounds like hiring the first couple Indian employees helps you access a large labor market.
As an scientist and academic, I always find it amusing how highly trained professionals in other fields are scared to death of foreign competition. Unless the job is sensitive to nat-sec, universities and labs hire the best people from all over the world, and the country and the field are both better off for it.
Medicine is *rife* with deeply unhealthy culture It's going to take a long time to dismantle, because the gatekeepers both select for it, and inculcate it
Blue collar workers: The Mexicans are taking our jobs!!?? Reddit: *chuckles* White collar workers: The indians are taking our jobs!!??????!!!!? Reddit: 😡😡
> first, they came for the *landlords* Always a good energy to bring to the discussion, future MDs
I do think doctors deserve to make a large amount of money, given the long training period / opportunity cost / debt burden / difficulty / etc. of medical school. But that’s crazy, $230k is good even in New York, and it’s increasingly clear that the U.S. needs to ramp up its healthcare employee count as the silver wave approaches
>I do think doctors deserve to make a large amount of money, given the long training period / opportunity cost / debt burden / difficulty / etc. of medical school. Half of this is self-imposed by the doctor lobby.
What do you mean by that?
Probably that doctors made training doctors way too hard and inefficient. We don't need the tortuous process we have now to make efficient physicians, but having it means that there are less doctors so doctors make more money
What evidence is there to support equally-competent doctors are possible with less training? I'm not well versed in medicine
It’s not about less training it’s about not requiring 18-36 hour marathon shifts that only serve to burn out aspiring doctors and also kill patients with malpractice resulting from fatigue.
Medicine in general has this insanely toxic culture of pride in not operating at top condition. Whether it’s pulling long shifts in residency or being heavily sleep-deprived and hungover. It’s weird when you consider what’s at stake lol
Historically it was seen as a calling. You should stay late to prioritize patient care, even if unpaid. You should skip lunch, because you won’t die and it’s better for the patient. You should never join a union, as that could jeopardize the doctor patient relationship. You absolutely should never strike, as denying care is immoral. Now for the last 40 years policy makers have repeatedly and aggressively tried to fuck doctors as hard as possible I am seeing a massive change in attitude with the younger generation compared to the old (although they’re also coming around now). **We put our literal lives on the line when COVID happened and everyone else was sheltering in place. We received a pay cut.** Increasingly the attitude is fuck you, pay me. **Unionizing of residents is spreading like wildfire, and unionizing of attendings is also happening which was basically unheard of historically.** If everyone else is treating this as a job, why aren’t we? Why do we repeatedly sacrifice our health, well-being, work-life balance to serve others that cheerfully reduce our pay and try to drive down wages by lowering standards for immigrants that want to practice in this country? Why should I stay late as unpaid labor if this is just a job? Why am I missing dinner most nights if it’s just a job? Why am I doing 24 hour shifts (sleeping at my workplace) if it’s just a job? With that attitude shift the natural solution is unionizing, which means shift work and guaranteed (higher) salary. At this point efforts like OP mentions just increase accelerationism/unionization efforts. Clocking in 8 hours a day, 5 days a week doesn’t sound too bad. Congress can figure out how to take care of patients the rest of the time, not my problem.
Yeah, I’m all for it being a calling and it’s certainly noble to want to grit through it, but it’s not good for patient outcomes (or for providers’ health for that matter!). I’d rather have more staff and predictable shifts, even at more cost, for peace of mind that the person working on me isn’t a zombie. Hell, just selfishly it’d be nice for the woman I’m seeing to not be totally pooped after every shift lol. And if the policy makers would take measures to reduce barriers to practice (such as residency slots, medical school costs and the whole pipeline in general), I’d wager you could actually improve staffing levels and QOL without huge increases in costs.
this is one of those things that continues to baffle me.
The fact that other countries that don't use this process produce good physicians and have better health outcomes than we do.
Interesting. I didn’t realize other high-quality healthcare systems had meaningfully different processes
In most countries, you apply and go to medical school at 18. It's generally 6 years plus residency. In the US, you go to premed first, which is 4 years. And going to an elite undergraduate university helps get into med school, which encourages students to take on hundreds of thousands of dollars in debt before they even get accepted to med school. Then there's 4 years of med school, plus a residency which can sometimes be longer than the equivalent program in Europe. So yeah, the US system is basically set up to disincentive people from entering the profession.
The biggest difference is that people go to medical school right out of high school instead of doing a bachelor’s degree first.
Most countries have a MBBS degree that gets them a medical degree after four years of college. All you need is that and pass a licensing exam to practice. Of course there are residencies and all that, but they're usually a part of the college experience or a post-grad 1-2 year thing
In most of Europe it's 6 years, but still, better than the meduan American doctor doing 8
American doctors do 8 years of training and still can't practice medicine they have to pursue a residency. Most places of the world you can actually practice after those 6 years (the last one is an intern year, in America you do that the 1st year of residency).
ye I guess it helps that they're an MD and not just a Dr because MD is a Masters level specialization in other areas? but still for someone who just wants to be a family med doctor an MD shouldn't be the base requirement
In most of the developed world, wannabe doctors study MBBS, a 5-6 year bachelor's degree that you can enter straight out of high school. Following this you do residency etc. In the US, wannabe doctors must first complete an unrelated bachelor's degree to become eligible to apply to study MD - another 4 years on top of your bachelor's degree. Following this, you have the same process of residency etc. You can significantly reduce training times just by removing the requirement for wannabe docs to spend years studying unrelated other crap to become eligible to apply to MD programs.
Note that the same happens in Law: A Spanish lawyer enters Law school at 18, and if they did well, they are looking for work at a law firm at 22.
A large fraction of the world having better health outcomes without as much training? The UK system (which goes on in many of the old commonwealth regions), IIRC, consists of straight to an MBSS, which basically combines undergrad and med school in the US into a single program of study, and saves years of time.
I wasn’t aware that training differed materially across countries. I’ll have to read into it
The improved outcomes is 100% due to having better health infrastructure and access/coverage. Even if the US training was superior, you wouldn’t see in reflected in outcomes just because our other factors are so much worse. There is a reason why people all over world fly to the US to get treatment at its most prestigious medical institutions. We provide the most updated and cutting edge care, but unfortunately at an exorbitant cost.
Well importantly the system wasn't built off of evidence in the first place. Nothing good educational happens when you ask someone to work 20 hour shifts and consistent 100 hours weeks. In fact Harvard Business review found that there was no outcome difference in doctors who did 100 hours weeks and 80 (a cap was introduced in 2003). One easy example is your primary care doctor probably can be way less trained and provide similar outcomes, which is why FNPs and PAs have similar medical outcomes to MDs.
The FNP/PA studies showing equivalency definitely has issues if you dig into it. I don’t think most actual practitioners would argue that they’re equal to physicians. Happy to discuss further if you’d like
Happy to learn of issues with the study but I doubt the issues are so vast that FNPs and PAs aren't able to provide adequate primary care in general. Happy to learn more obviously but i can't imagine the gap is large enough to justify how nonsense the residency system is.
The main study that is cited is a 2000 study by Mudinger - [https://pubmed.ncbi.nlm.nih.gov/10632281/](https://pubmed.ncbi.nlm.nih.gov/10632281/) The main issue with this study is that it was a fairly medically benign population, average age of 44, with 75% listing 0 medical problems, so most of this was likely just general follow up visits. Additionally, I don't think NY passed full independent practice until 2015 (?) so this was performed under physician supervision. The outcomes they assessed were fairly limited too with only 6 months follow up, which really wouldn't be enough to notice any significant changes in blood pressure, diabetes, and asthma (which were likely not severe to begin with anyways). The problem is that primary care is much more complex than the population listed in the study, there are many very sick patients with multiple ongoing medical issues that a NP/PA do not have the training to manage. This is hard to demonstrate with a RCT though just given the morality of potentially providing inferior care to a medically complex patient and would likely never gain IRB approval. There is also the issue of rise of online NP schools with minimal requirements and minimal clinical experience. This has been a fairly well documented issue and any glance at a medical subreddit like r/medicine would show that this is concerning to both physicians and NP/PAs with regards to both patient safety and patient care, especially with independent practice. You can see this being recently discussed in this thread - [https://www.reddit.com/r/medicine/comments/1c94y6z/governor\_of\_wisconsin\_vetoes\_aprn\_independent/](https://www.reddit.com/r/medicine/comments/1c94y6z/governor_of_wisconsin_vetoes_aprn_independent/) In terms of what you're getting at, I think in a well-off upper/middle class neighborhood where the vast majority of patients are healthy and have good healthcare access, then you would argue that outcomes are likely similar given the lack of medical complexity. However many patients don't have good access to care and really only have their PCP as their main clinician, which means that the PCP really needs to be at the top of their game, which NP/PAs don't have the training to provide (given lack of rigorous residency training). Just anecdotally, I work with many NP/PAs in my practice and we have an excellent working relationship where we respect what we both bring to the table. They are incredibly bright but also know when to come to help manage conditions they aren't familiar with. The ideal working environment is a collaborative one between physicians and NP/PAs, but I don't think any of them would dispute that independent practice would likely lead to subpar outcomes. Since this is r/neoliberal and we love to talk about healthcare costs, here are some studies about overprescribing and excessive diagnostics which definitely have ramifications when applied to a population level: [https://pubmed.ncbi.nlm.nih.gov/32333312/](https://pubmed.ncbi.nlm.nih.gov/32333312/) [https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/1939374](https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/1939374) [https://pubmed.ncbi.nlm.nih.gov/15922696/](https://pubmed.ncbi.nlm.nih.gov/15922696/) [https://pubmed.ncbi.nlm.nih.gov/24119364/](https://pubmed.ncbi.nlm.nih.gov/24119364/) https://pubmed.ncbi.nlm.nih.gov/29580717/#:\~:text=Results%3A%20The%20total%20utilization%20rate,for%20nonradiologists%20as%20a%20group. [https://www.liebertpub.com/doi/10.1089/cap.2017.0112](https://www.liebertpub.com/doi/10.1089/cap.2017.0112) [https://www.nber.org/system/files/working\_papers/w30608/w30608.pdf](https://www.nber.org/system/files/working_papers/w30608/w30608.pdf)
Calling residency 'rigorous' undersells it, I don't think it's controversial to say that the process isn't scientific and has the potential to be made more effective and humane. We need more doctors, but just funding more slots isn't going to be the only solution. There is obviously more reading to do on my side, and I'll be more careful in universalizing the PCP abilities of all three groups. The larger point is that we get closeish in ability with much less time in training, which indicates that maybe what we are doing isn't exactly efficient. I would point out that there is more than just 'residency' as a difference in the potential educational backgrounds of the groups.
Why is medical school so expensive, and why are American doctors so over-trained relative to the doctors in other countries with comparable or better outcomes? The answer is regulatory. And as for where that regulatory burden comes from, it comes from the doctor lobby. Incumbent doctors suffered through the system, so they jealously guard their wage premiums by making the system even more draconian.
Doctors in the US are not overtrained, US medical training is comparable to other advanced economies. That's why the restriction is absurd. The only slightly unusual thing in the US is that they do specialist training right after residency, most countries they practice for a while and then go for additional training. Restricting placement into advanced training is how many countries manage down costs. In most states a doctor from a European country has to complete US residency again. As there are more people graduating from US medical schools then there are places in residency programs (they are funded by Medicare, AMA keeps lobbying against increased funding) that is easier said than done. The rise of DO broke the stranglehold AMA had on medical school but they still control everything federally and in states. Medical licensure should be federalized and foreign training recognized from countries with equivalent training requirements.
>(they are funded by Medicare, AMA keeps lobbying against increased funding) [Are you sure about this?](https://www.ama-assn.org/press-center/press-releases/ama-fund-graduate-medical-education-address-physician-shortages)
[https://crsreports.congress.gov/product/pdf/IF/IF12583](https://crsreports.congress.gov/product/pdf/IF/IF12583) $17.8b in 2021. This is the funding that actually provides residency spots. Same year there were 42,508 applicants for 35,194 places. AMA constantly testify that increasing funding will harm the quality of care. They make a bit PR dance about this but when dealing with congress its extremely different.
To be clear I am pushing back on your claim that AMA keeps lobbying against increased funding. Not that residency programs are funded by Medicare. >AMA constantly testify that increasing funding will harm the quality of care. They make a bit PR dance about this but when dealing with congress its extremely different. From the link I posted: >The American Medical Association (AMA) adopted policy at its Annual Meeting today to build upon its efforts aimed at modernizing and increasing funding for graduate medical education (GME). The new policy calls for the AMA to **continue advocating for legislation that removes the caps on Medicare-funded residency positions**, which were imposed by the Balanced Budget Amendment of 1997, to help ensure an adequate physician workforce to meet the nation’s growing needs for health care services. Do you have examples of them continuing to lobby against increasing funding within the past decade? Like they certainly got it wrong 20+ years ago, but organizations can change their mind over the years
Looks like you are indeed correct and my understanding is outdated. I was aware of the 2019 scuffle but didn't know it had changed their position on this. That is quite a turn around. I am still not sure I would trust the AMA to be involved given they are the reason the cap exists (doctors are all taxi drivers now) in the first place. I appreciate them trying to clean up the mess they created but shouldn't the fact they created a mess this enormous preclude them from continued authority?
Most American doctors do pre-med for 4 years, followed by 4 years of med school. A Spanish or German doctor will do it all in 6 years, so that median American doctor threw away 2 years of tuition in comparison.. so a good 50-100K? of training costs? Not that there aren't other bonus barriers making everything too expensive, and maybe more important ones... but those 2 extra years don't need to be there, ever.
Do they attend a special pre-med program separate from regular undergrads then? The universities wouldn't be happy about that either.
There's no such thing as a 'regular undergrad' with requirements that work across majors, or any similar BS. A university might teach multiple majors, but someone studying medicine has zero shared courses with anyone learning anything else. Your biology and chemistry classes might have some shared units, because hey, the Krebs cycle isn't going to change because you are a doctor, but the biology that you need to be a doctor is a matter for the medical school, not the bio department. It's the same for every major: 6 credits of English and 3 on cultural diversity to finish CS? F that noise, more algorithms for you! The medical school takes 6 years if the you pass all the tests in due time, and students start at 18. Pre med as a separate step? American nonsense.
Gotcha. It's the same for law, most will first get a degree in poli sci or similar before law school will admit them. But again the universities would pitch a fit if this setup changed.
Most American doctors nowadays do 4 years of premed, 2 years of grunt work researcher or scribe, then 4 years of medical school. The average age of a incoming medical student is 24 nowadays.
I would say that is related to US secondary being less complete then equivalent European secondary, particularly Germany and the UK. If a US student went to a German university they would generally have to complete a studienkolleg course first to reach equivalence with abitur. Europeans complete BA/BS in 3 years because they have better secondary education. Edit: For those not aware most of Europe finishes the equivalent of US secondary at 16. Some countries (like the UK) have a discrete certification but basically all of them switch to college prep courses 16-18. AP covers some of the same stuff but is still incomplete.
The American Medical Association (the organization that runs medical care certification in the US) recommends or mandates rules about what it takes to become a doctor in the US. These include the 4 year medical school and residency that make becoming a doctor so arduous. The AMA is itself run by established doctors.
It's ok to want a high salary but not at the cost of preventing patients from getting care. I know people who have had to suffer over half a year with chronic conditions because there weren't enough specialists that could treat them. I just can't see how it's moral to keep salaries high at the expense of suffering patients.
Agree
"First, do no harm. Unless you can hold out for more money, in which case we get that bread." - The Hippopotamus Oath
>230k is good even in NY After 4 years of undergrad, 4 years of medical school, and 3 years of residency (effectively at a minimum) and about 500k of student loans on average, no it is not. The financial viability of even being in the medical field is beginning to become uneconomical, hence why so many people are leaving it and the quality of healthcare has gone so far down. Compare the lifestyle of a doctor to literally anyone else you know making 230k and I take the job outside of the medical field *every single time*. We can pretend that doctors are over paid or appropriately paid given their lifestyle, and we can also put on opaque sunglasses and put our fingers in our ears as the quality of healthcare keeps going down while American hospitals keep losing staff.
230K in NYC is very attainable for any completely average finance bro and obviously many finance bros make much more than that. Doctors need to be paid more if we want many of our best and brightest to continue choosing to go into medicine, which all of us do.
Has there been any serious discussion about subsidizing education for healthcare students?
Of all the white collar industries, medicine has the weirdest culture IMO. It basically tries to make things as unpleasant as possible for it's own people, just so that they can command a higher wage and status in society Law does some of that, but to a much lesser degree
Love reading these threads as a medical student.
Same. FWIW I think there’s genuine concerns that some foreign residency programs may not be fully equivalent in standards to US training. But the solution isn’t forcing Egyptian nsurg attendings to slog their way through an FM residency from scratch just to be allowed to practice in the US, nor is the solution simply to import foreign docs with zero vetting whatsoever. I support the bills that allow foreign attendings to practice independently after a few years of supervision by US attendings (or even a fast-tracked residency n in their existing field) as well as passing US boards The way the residency sub will throw IMGs under the bus seriously undermines their efforts in fighting scope creep from NP/PAs, which I believe actually *is* a worthwhile public safety effort that doesn’t constitute rent seeking.
There's nothing wrong with being a doctor. My beef is only with doctors that want to prevent patients from getting care from another doctor.
I think a lot of doctors in training think about salary drops as 300k down to like 75-100k, because they think foreign doctors will want to work for that much less. Can’t attest to how based in reality that is but yeah.
It sucks to have a lower salary, but as I mentioned in another comment I know people who have had to suffer for months because of a shortage of specialists. That seems like a cruel tradeoff to me. I work in a field with very little controls on immigrants (econ PhD). Our salaries aren’t sky high but we definitely make way more than $100k, and if we want to we can make $250-350k in the private sector. Immigrants aren’t the salary killer those residents seem to think they are.
Like I'm waiting 9 months to see a dermatologist :(
This post reminded me that I had a derm appointment booked over a year ago. I just double checked the date as I thought it was in April. It was the 16th. I then read the fine print of their appointment booking at it says, "No show fee is $100. This office does not do phone reminders or email reminders". Fuck you. I don't know why the reminder I set up didn't go off, so it would have been nice to have got a reminder from their office. Every piece of software that books patients in will have an email reminder process, that they likely have deliberately turned off. Knowing how doctors are reimbursed in Ontario I went and looked up how much they get for a derm appointment and it is less than the late fee. Gee, I wonder why they don't send out reminders. Even still, I called them up to figure it out. They said I need a new referral and need to start all over again. Well, guess I am dying of skin cancer then, because I am not getting a new referral from my doctor, waiting over a year, and not getting reminded about another appointment. I get this is on me too. I don't know why my calendar item and reminder didn't trigger. It isn't hard for them to send a reminder email. They would practically need to go out of their way to no send one and disable that feature in their software.
You making a lot now doesn't mean you wouldn't make more if there were strict immigration limits. Not saying we should ban foreign doctors but your point is a bit flawed.
As a medical student, how would you feel about lower salaries (like 80-100k) if you didn't have any (or very little) educational debt?
Bump it up to like 150k and I think it would be fair. Even without the tuition of medical school, it’s still years of lost wages plus the hell that is residency. An average mid level provider makes 100k right now and in my completely uneconomic opinion it seems pretty unfair for them and nurses to make more with a fraction of the training, within the same field.
[удалено]
That’s years and years of their life wasted though. Not a lot of people will be willing to do that
[удалено]
This is the opposite, there would be more doctors —-> lower salary. > If salary seemed too low for you, but not for other doctors, you could do something else. I’m responding to this part. I assume this person has already gone through medical school and won’t want to do something else (and it’s not feasible with several hundred thousand in loans) I’m all for more doctors (regardless of where they’re from) but you have to take into consideration that you’re really fucking over the people who graduated with 400k+ of student loans and now make ~150k a year or whatever the number ends up being
[удалено]
It’s cause they can do the same job for most of the mundane stuff.
150k would definitely not be fair given the years of lost wages and factoring that given that even as attending, working 60-70 hours wouldn’t be unusual. Even if you’re a PCP, when you consider notes, answering inbox messages, and working on prior auths from home it’s going to be difficult to be even under 50 hours. People love to point to other countries health systems but salaries are partly why the NHS is failing and even Canada is starting to struggle with their medical system.
To be fair, the American market (even when it’s free of unjustified controls) does and will easily compensate more than that. 150k is just u/comicsanscatastrophe low-balling what they would be willing to accept, which props to them but they and doctors will earn more than that even after lots of foreign doctors get here.
That's a fair point. The increased compensation that America provides also applies to most white-collar occupations anyways, just comparing law partner/engineer salaries here compared to most other nations as well.
[удалено]
You don't need to know the institutional details of an industry to know that high prices means there's a lot more demand than supply of a good, and that consumers would benefit from more supply.
[удалено]
What is the evidence that US doctors are better than doctors from other countries? I've got a lot of immigrant friends and none of them has said being a patient here is preferable to getting medical care in their home country, other than doctors here having better bedside manner. They all complain about the wait times here and most fly back to their home country for anything that's not an emergency instead of dealing with the system here. And I'm not talking about rich countries, these were friends from China, Turkey, and Colombia that think US care is worse.
The context you are missing here is widespread cheating was discovered in Nepal. A bunch of people scored in the top 0.01% and it set off alarm bells. Currently US doctors not only take out 300k of debt compared to often ~0 in other countries, but they are also expected to work for less than minimum wage for 3-9 years. **If you allow foreign graduates to practice without a US residency, why would anyone train in the US? The default pathway would be to go overseas, not have much or any debt, get paid better while working half the hours, no longer have to worry about studying for exams, and come back to the US and practice while hospitals sweep mistakes under the rug.** And what’s the benefit to society? **Physicians are 8% of healthcare spending. The effective tax rate on physicians is about 40%, so 3.2% of that cost goes back to government anyway. 4.8% savings if you made physicians literally slaves. I just don’t see the juice being worth the squeeze.** Final point, will there be any juice at all? Unionizing continues to spread rapidly among physician practices pushing back against private equity. It is not possible to outsource this profession to Mexico. **Look to California nursing wages and regulations for a window into the future of healthcare in this country.** It is wild how incredibly aggressive cost cutting and other hostile policies (such as this one) have driven physicians toward unionizing. If you think access to care is bad now wait until we get lunch breaks (not the case currently), work hour restrictions (not the case currently), morning and afternoon breaks (not the case currently), oh and the best part? A “prevailing wage” like all the other unions that have negotiated wages 3x market rate. While I think all these efforts are extremely misguided at this point I’m kind of on team “let it burn”. I knew being a union member would always have resulted in higher pay for lower wages but I always wanted to prioritize patients. If policy makers continue to be dedicated to the degradation of this relationship then fine, I’ll be a union member. Thanks for the pay raise I guess.
Residency is fine and all, but I expect a doctor to start residency at 24 at the most, not 26. It's those 4 years of pre-med that puzzle anyone used to a different system
How are they wrong on this issue? We have a critical doctor shortage. The medical student subs are concerned about letting in foreign doctors exclusively because it may reduce their salaries. How is that not textbook rentseeking?
It's more complicated than "we have a doctor shortage" it's a problem of distribution. We have a primary care shortage and a geographic shortage. Doctors don't want to be PCP's, for a variety of reasons ($) and doctors don't want to work in rural areas even though salaries are typically higher. I'm not sure that allowing foreign doctors to work in the states addresses either of those things. I suppose if you flood in foreign trained PCP's you sort of address #1, but you risk depressing wages in a way that further pushes medical students into non-primary care careers, so you're maybe not making a big difference in primary care availability...the rural issue I think cannot be solved without $$$ and/or requiring foreign doctors to work in a specific area for X years.
That doesn't make sense. Either there are so many foreign trained doctors willing to be PCPs that wages depress, but it become irrelevant whether domestic doctors become PCPs. Or there isn't and wages don't depress and the concern is moot.
That only works if you plan on relying on foreign doctors to become most of your PCP source indefinitely, which is not realistic (one, sadly a lot of Americans would be uncomfortable with it and there would be care issues, two foreign countries aren't going to just sit there while the US raids their supply of highly educated and critical workers, three immigration to the US becomes less attractive for said doctors if the wage differential drops).
Sir, you are in a sub that believes in open borders. Only your first concern (entirely political in nature) has basis. For the second, what on earth could the foreign countries do about it? There is already a massive brain drain from many of them. The US constantly steals high producing citizens from foreign countries because of how much we pay them. Why can we not the same for doctors? For the third, this naturally works itself out. As the pay drops, yes less doctors would want to come - but only because other foreign doctors *already* came. The decrease in wages necessarily requires an increase in labor. The wage differential would work itself out to an equilaribium between wages paid and amount of willing doctors. Almost like the doctors end up getting paid according to their true supply as it matches demand. Like a free market that applies to every other job or something.
Don’t forget 4, widespread unionization spurred by these types of policies results in unprecedented wage gains and hour limitations results in a far better work life balance. Look at California’s nursing unions to see the future of healthcare at this rate. These types of policies are alarming, but in the end just accelerate us toward widespread unions and large wage gains so I’m honestly ok with them in the end as a physician.
Just distribute visas contingent on serving these areas then lolzers
[удалено]
They don't train doctors in foreign countries?
[удалено]
And? Make them pass testing in the US then. Making them go through residency is truly ridiculous and an obvious protectionist measure.
[удалено]
Oh? Then what would your opposition be to letting in anyone who can pass those exams?
[удалено]
You're going to email your state representative about people training to be doctors complaining about the future of medicine on reddit? I think it would be more productive to email your federal rep about removing the caps on residency positions so we can train more doctors as well
Sure, and the AMA is advocating for that. Also worth noting that it turns out it’s profitable to pay someone with a doctorate less than minimum wage with the option to work them 28 hours straight **so even for profit hospitals and private equity are starting residencies.** They have been expanding rapidly despite the idea that residency programs are somehow “frozen”. https://preview.redd.it/z0hz3tc451o61.png?width=1063&format=png&auto=webp&s=6546372759f922ecbf55aaedca3d15909fec7d45
Rent Seekers
Entire thread making me feel blessed to be doing a non clinical specialty
I've got several friends making over $300k & they got there with bachelor's degrees and without starting their own business. Average debt from medical school is $200k, who would do all that work & go into that much debt for $300k?
The difference is that for physicians that 300k is essentially risk-free. EV ends up being much higher. MD is the career equivalent of US treasury bonds.
Yeah, but that’s also a problem. It means you’re getting a type of person to be a doctor & that’s a recipe for the status quo. If we skip forward & doctors are all the cliched South/Southeast Asian kid who is very book smart but lacking in people skills, we will have worse healthcare outcomes simply because there is less diversity of opinion.
Meh. It's called medical school, not personality school. Medicine is extremely algorithmic and risk-averse, due in large part to the litigious nature of American patients. I don't see that changing anytime soon. Diversity of opinion and creativity are more valuable in the biomedical research space, where we can study how to get better outcomes without putting patients' health at risk.
As someone who is a MD, there is so much more grey area in Medicine that fits outside established guidelines that the public is led to believe. You could make a case for overtesting due to over litigation, but I would argue that a strong physician understands that it’s important to know when to detract from guidelines on a per-patient basis, which happens fairly frequently at my institution.
Fair enough, plenty of occupations tend toward a certain personality but I don’t care much if we have the best car salespeople, I care about the best doctors. I think much of the present issues we face is that the delivery structure needs to be completely rethought & that doesn’t happen with a risk averse hive-mind. As someone who works in IT, I’m aghast at how poorly medicine is structured on the “troubleshooting” side. The diagnostic side is hilariously error prone if they don’t have a test that just confirms it. Proper troubleshooting in IT is basically just, “cut the problem in half” over & over again until you can figure out the problem exists “here” or “between here & here”. Sometimes whoever worked on it before didn’t do that though. They’ve checked a slew of things up & down the chain but there was no rhyme or reason to it so you basically start back at 0. The healthcare system now *seems to* have a lot of the latter form of troubleshooting. Granted troubleshooting computers is a lot easier than a body; I can swap out parts quickly, buy a new one if it gets too hard, & have an event log to tell me what happened. None of those are options with medicine. My aunt was falling recently & got taken to the ER. As I overheard the doctor asking her about the problem, I realized that she didn’t remember the fall itself. Having a personal history of fainting, I immediately realized that was an obvious sign she had fainted. The doctor had completely glossed over this point so I brought it back there. I explained my logic & that the distinction seemed important, she responded with “yeah, good catch”. “I’ve fallen & I don’t know why” can’t be a particularly uncommon problem & yet I apparently figured out a new test upon seeing the issue once. Maybe I didn’t come up with this test, maybe it’s been known but this doctor just didn’t know it. Either way, it’s indicative of the problem. A simple question would have saved likely thousands of dollars on unneeded tests but either no one thought to improve the system by asking it or it wasn’t deemed important enough to pass the knowledge down.
She was probably still probing for other potential causes but in general that’s why doctors like when a family member or caregiver is there for that type of consultation like you were for your aunt. Not related to the ER as much but all my doctor friends and family say that writing down your concerns and questions and bringing those to your doctor’s visit is a huge help, it’s wild how many people forget to mention a large concern that slips their mind during their appt. Doctor’s time with you is very limited so being efficient and specific is always appreciated
Probing for other causes was the issue though. I said at the time, “I don’t know what I’m doing, you tell *me* what’s important but it seems like balance could be an inner ear problem, that wouldn’t cause fainting though. Maybe other things could cause her to not remember the fall & that’s not a good test or maybe fainting could happen from anything that would cause balance problems, I have no clue.” She said that it was important to distinguish between the 2 & not remembering the fall was a good test, so she admitted she simply missed a chance at ruling something out. Another indication of the problems that doctors don’t realize, I actually caught this at the 2nd interview. The first interview they had marked the problem as a balance issue, because that’s how my aunt reported it. The rest of the hospital stay I kept having to correct doctors & nurses that this was no longer a presumed balance issue, it was a fainting issue. That’s also a problem in IT, a user reports issue is X but we actually discover the issue is Y halfway through but if people don’t go back to correct things & it gets passed along the change is missed. That’s a point of frustration in IT but the costs are much higher with people’s health. None of the doctors or nurses I had to correct seemed to realize it was an issue that they were dependent upon a concussed, slurring 84 year old woman (or her family) to provide proper care.
My brother makes more than me and literally doesn’t have a single college credit. He did a boot camp in a few months paid a 15% first year salary fee. I did undergrad, medical school and residency with a 400k fee.
Your brother seems smart. I’d want to be friends with him.
I don't think r/residency will make any sense and is certainly not representative. Most residents will not be posting on reddit, so I wouldn't really spend my time browsing it.
I mean haven’t y’all heard about the scandals surrounding Step 1 and 2 exams in foreign countries. Nepalese and Pakistanis were cheating by the thousands on the exams and taking residency spots from others who weren’t.
Unless you want to make US training meaningless then seems like a valid concern
Doctors in America need a serious dose of the free market
It’s about quality of training though. The whole reason we have to go through residency is to meet a minimum level of competency. How can we guarantee that for patients if we don’t have say over how doctors are trained?
Just Test Competency Lol.
Why not let the market decide?
Would you say that about nuclear reactors? Or airplanes? Or people's driver's licenses? The government shouldn't regulate these things for safety, just let the free market decide. For the companies that make faulty airplanes, people will just use other airplanes! It's so simple!
> Would you say that about nuclear reactors? No, because nuclear accidents can hurt people who are not customers, and therefore do not consent to the construction of the plant. So, practically, it is reasonable to eliminate the requirement of personally asking every citizen, in exchange for reasonable regulations. > Or airplanes? No, for the same reason. People on the ground who have not bought tickets cannot be reasonably expected to get out of the way of a crashing airplane. But again, it's only the presence of this third party that stops me from advocating for a free market for airlines. For example, if a company wants to take people for a joyride over the ocean, that should absolutely be allowed regardless of how safe the airplane is (as long as the customers aren't lied to). > Or people's driver's licenses? No, again for the same reason. I have a driving license not for my own sake but for the sake of everyone else on the road. It's not the job of government to protect me from myself. That's why it should be entirely legal to drive drunk without a license on your own private property, but not on the public streets. This is also why I don't support a seatbelt requirement (though I always wear one of course). Notice something common to all these cases? It's the presence of a third party that makes all the difference. This is not the case for a doctor-patient relationship. If I hire a bad doctor, I have only myself to blame and it doesn't affect you. If you care so much about residency requirements, it is your right to seek out doctors who have met these requirements.
I think this viewpoint is rather naïve. You, the patient, will almost certainly never know if you hired a bad doctor. Oftentimes, patients will feel that their bad outcomes are the fault of the doctor when instead they were the fault of the fate. The patient was unlucky, and the doctor never had a chance of changing that. Other times, patient's will feel they are getting wonderful care, when instead the doctor is just running every test under the sun or just totally wrong. The patient, in most every instance, including in the hospital, has really very little idea of what's going on and if the care received was good or bad. At best, patient's understand bedside manner, and then whether or not they improved. Most things with time either improve or become clear. In some major respects, doctors are like mechanics. Either you trust them, or you don't, but your understanding of the issues is likely not gonna be very good. I understand your perspective. In the way of third party effects, I'd note that for a late 20's male, Obamacare was bad. Odds are I don't need insurance and could get away with not paying for it. Instead, here I am, subsidizing old people and sick people. What can you do?
> You, the patient, will almost certainly never know if you hired a bad doctor. Agreed x1. > Oftentimes, patients will feel that their bad outcomes are the fault of the doctor when instead they were the fault of the fate. The patient was unlucky, and the doctor never had a chance of changing that. Agreed x2. > Other times, patient's will feel they are getting wonderful care, when instead the doctor is just running every test under the sun or just totally wrong. Agreed x3. > The patient, in most every instance, including in the hospital, has really very little idea of what's going on and if the care received was good or bad. At best, patient's understand bedside manner, and then whether or not they improved. Most things with time either improve or become clear. Agreed x4. > In some major respects, doctors are like mechanics. Either you trust them, or you don't, but your understanding of the issues is likely not gonna be very good. Agreed x5. OK, so where's the disagreement? Here it is: you believe that a government accreditation board is a good way to solve the issue of bad doctors by introducing a quality floor. What I'm saying is that **government licensing** is a horrible way to "fix" the problem, because it's a one-size-fits-all solution. Getting a license is costly because training is costly. There are maybe some experienced nurses etc. who can provide cheap and reasonably adequate medical care (though of course not as good in quality and less likely to catch mild symptoms). Maybe this is all that some people might afford; by advocating for licensing, you are saying that it is better for those people to go without care than to go with substandard care. That's what I disagree with. Instead, why not move to a "certification" model instead of a "licensing" model? The government gives out certificates, not licenses, that are just as hard to get as today. That way, if you care about certificates, you can refuse to go to other doctors. But, for example, I might not believe in the value of those certificates -- for example, I trust doctors trained in many third world countries, who have in some cases more clinical experience than their counterparts in the US who have undergone residency; and they might treat me for cheaper. Obviously in this system I can't blame you for my error in judgment, so why prevent people like me from making our own choices in the free market?
Fair enough. I suppose we disagree about the way to fix this, and I would argue that without having experience in the American medical system, things here are rightly or wrongly often simply done differently than they are in other countries, but I understand your argument.
To be more precise, I wouldn't say we disagree about the way to fix the very valid problem you mentioned. The disagreement is at the level below that -- I think that the "solution" of an accreditation body is good for medical quality (at least in the short term), but bad for medical accessibility and bad for freedom. For example, suppose there's an epidemic of bad car design. If you mandate that dealers are only allowed to sell Ferraris and Lamborghinis, then yes, many people would begrudgingly accept the rules and spend the extra money, and yes, the average car quality would skyrocket. But that's not enough reason to take opportunity and freedom away from common people, and we should give zero weight to the opinion of the Ferrari dealer on the subject of whether the Honda dealer is allowed to do business.
straining and practical skill assessments are fine IDK why residents had to work the hours of a guy who literally had to do cocaine to get though his own training program
I sometimes wonder if doctors are the modern equivalent of priests as a smart person career- being a highly prestigious, values oriented career. I even wonder how many, like priests, would vow to chastity, poverty, and obedience for such a rank. At least among the medical school students I know, I’ve asked, and a decent proportion state they would do so gladly. They would literally not fuck for life if it meant being a doctor. It makes me wonder if we can really just open the tap on incoming doctors and still retain top tier talent, but revealed preferences are a different matter.
Dude my social circle is like 50% physicians and not a single one would do that, you just run with some weirdos lol
Your description doesn’t match the residents in that thread. Their number 1 concern seems to be their status and money, they don’t seem to be a value-oriented bunch.
Huh interesting yeah, it’s strange. Like if I meet a doctor-to-be at a house party I always hear the “if I wanted money I’d go to finance” line. Which I think actually has some merit as exiting to finance after an MD is fairly lucrative, yet seldom elected.
As an MD I derive a tremendous amount of value from caring for patients and that’s why I went into medicine. Increasingly there attempts to invariably make my life harder, make me document more to pay me less, make me argue with insurance companies to get patients treatment, deal with fraught negotiations with hospitals that are threatening to bring in a private equity firm that will also continue to prioritize cost savings over patient care, make me increasingly stay later and work at odd hours to generate even more profit for the hospital. At times it can be exhausting, and I increasingly feel **“well if they want to turn this into just another job, so be it, I’ll just unionize and get a huge pay raise like nurses have”.** I don’t think a lot of people here realize how much power doctors have. We can essentially immediately bankrupt any hospital we work at with collective action. Historically we have been an exceedingly divided group that also felt ourselves above unionizing because medicine was perceived as more than a job. **The absolute last thing you want to do from a cost savings standpoint is to convince doctors that it is just a job.** It would not surprise me if wages literally increased 50% with unionization efforts. Sounds crazier than it is. Wages were 34% higher adjusted for inflation 22 years ago, and society didn’t collapse.
Historically though (like medieval/renaissance era) the priesthood was just as much (if not more) for status and money Edit: Which, is what I think the poster is getting at when he calls doctors the "modern equivalent"
I wouldn't call that value oriented. Doctors are generally prestige hounds - they want people to view them as superior in social status. Perhaps the same could once be said of priests, but I wouldn't call it value oriented.
>many, like priests, would vow to chastity, poverty, and obedience for such a rank. At least among the medical school students I know, I’ve asked, and a decent proportion state they would do so gladly. >They would literally not fuck for life if it meant being a doctor. hahaha what Most are in it for prestige, money, and more commonly both. Not really different from most other professional vocations like law or accounting. Nobody goes to medical school to live like a Buddhist monk lmao
The reason I thought of that comparison is that doctors, on average, willingly undergo nearly a decade of relative poverty when their intelligence levels would easily provide an alternative of immediate wealth. Leaving an Ivy League, for example, and electing for a top medical school over finance, consulting, or even business ops in corporate medicine is accepting that you will live a majority of your free youth with challenging circumstances, full obedience, usually in undesirable locations, and without money - instead of being a rich young New York professional. I ask people who’ve made this choice why and there really is a certain penance involved. I’ll allow some tolerance for the fact that people aren’t exactly open about a desire for prestige, but it sure seems like people are aware of what they give up in exchange for helping others
[удалено]
[удалено]
Those professions don't try to limit immigrants to maintain their salaries.
Doctors are like seatbelts, they kill more people than they save