Maybe just maybe new young doctors should be treated (like not be worked to death) and paid properly then there would be plenty of people willing to take up the profession and there would not be a shortaage
Agreed that working conditions are atrocious and have been for years. But getting new doctors domestically from scratch will take years, and the article argues that there’s just not enough time for that.
The problem with that line of thinking is how it creates systems like the H1-B and doesn't really solve the problem of "we aren't educating enough doctors". Instead of thinking both long-term and short-term, the solution that's chosen now to solve the problem becomes the permanent solution going forward, and the solution for now is attracting foreign doctors instead of fixing medical education locally.
> Maybe just maybe new young doctors should be treated (like not be worked to death) and paid properly
It seems to me, the tradition of working residents to the point of sleep exhaustion is a form of institutional hazing, perpetuated by people that endured it because "I did it, why shouldn't they?" I'm not sure how you crack that nut.
All that does is ensure no one gets fairly compensated for 12+ hours work, and shifts the complexity down the chain to accountants as people managers try to find other ways to compensate people for their extra effort. People don't stop being sick 12 hours in.
It also unfairly hamstrings smaller practices with fewer covered professionals. Work gets offloaded from the covered individual to uncovered people in order to maximize the amount of work the covered individual can get done in that time span, or people start getting really particular about what is practicing and what isn't.
Hate to sound like a broken record with other folks in the thread, but nothing is fundamentally changing the game with that regulation, just who pays the complexity tax at any one time does.
So ball bustingly frustrating how bloody interconnected everything is while remaining so broad it's nigh-impossible to model within the confines of your own head. I say this as someone whose occupation centers around being able to very quickly jump between distinct verticals and subsystems while maintaining the capability to project the consequences of a change in one vertical through subsequently connected verticals. Everything seems to come back to a form of dynamic equilibrium where as long as you don't stare too hard the thing behaves well, but the closer you look the chaotic it becomes.
> All that does is ensure no one gets fairly compensated for 12+ hours work, and shifts the complexity down the chain to accountants as people managers try to find other ways to compensate people for their extra effort. People don't stop being sick 12 hours in.
Sorry, but this stance seems like part of the problem.
Doctors shouldn't be working more than 12 hours at a time, for rather obvious safety reasons. People don't stop being sick, sure - that means you change the system so there are more doctors working fewer hours, rather than making doctors work insane hours that risk patients and are terrible for doctors' mental health and wellbeing.
I'm not advocating that doctors should work 12+ hour shifts. Merely that creating a regulation that caps doctoring to 12 hours max a day will tend to create an enhanced scrutiny and sensitivity to what is and is not doctoring; which will lead to unintuitive outcomes in terms of the actual effect of the regulation based on the difference between how the industry runs with it vs. How you actually think it's going to go.
I understood what you mean: doctors shouldn't have to work 12 hour shifts, but should be able to.
And I disagree with this, for 2 reasons:
1. It's unsafe to have doctors working for too long, even if they want to for some reason
2. It incentivizes management to make doctors work longer shifts (as the current situation is)
I also disagree that making this change would somehow cause confusion about who is a doctor or not - there are already regulations governing the medical profession, so no ambiguity.
I think the trick is actually getting such regulation passed into law. The medical industry has considerable political influence; attempts to reform it will doubtlessly run into road blocks unless you manage to convince doctors that reform is necessary. That's the tough nut.
They tried but everything medicine is hyper political in this country
> The antitrust class-action lawsuit Jung v. AAMC alleged collusion to prevent American trainee doctors from negotiating for better working conditions. The working conditions of medical residents often involved 80- to 100-hour workweeks. The suit had some early success, but failed when the U.S. Congress enacted a statute exempting matching programs from federal antitrust laws
The "bootcamp"/"student filter" culture is strong in the medical field. The bad conditions on residencies is only part of it (long shifts, low pay, attrition, etc)
We could make more doctors if medical school tuition was lower and new doctors were paid more than a garbage man. But The cabal that is the hospital and pharma lobby won’t allow it
Median residency salary for a doctor in the US is something like $65k (probably about twice what sanitation workers make, though I'm too lazy to look it up). That's somewhat low relative to other jobs requiring the same education, but not particularly out of range. Lawyers do better at that stage of their careers for sure, but we have plenty of post-docs making far less. I don't see that this is much of an argument in context.
If you're going to include long term assets then you need to include the rest of the career too. That's the way residents actually look at the problem, after all. "Doctors" do well. Residents struggle a bit in comparison, but not really that much relative to their other post-graduate-degree compatriots.
$200/300. Everyone uses income based repayment plans. It's literally impossible to make standard payment plan monthly payments on a residents salary (assuming a average debt).
Those payments don't even reach the principle though, so it's more just kicking the can down the road.
To be fair, most post-docs dont have an average debt of 200k. When I looked at STEM grad school they paid you if you were willing to do some teaching/grading. I dont believe post docs average 80+ hour weeks either.
It's got the lawyer problem. Bimodal income distribution. Some doctors make bank, some doctors work at a corner office in a mall.
Really if you wanted to revolutionize doctor-ing then i think creating a pathway from enrolled nurse all the way to consultant doctor would be the way to go. That should probably be a twenty year journey but it would open it up a lot.
Since residency spots have to be funded through Medicare, I was under the impression that they are very competitive essentially making them a zero sum game. If less get through on a visa, the spots will just be filled up by natives.
Or is it that there just aren't enough native applicants (like grad school) ?
There are not enough usa grads to fill all the training spots.
However, some usa grads do not match to a spot, around 1%, which makes lots of US educated doctors (rightfully) really mad. You get random foreign doctors going to state sponsored schools with openly nepotistic admissions sometimes getting spots over people who trained here.
Imo the solution is more us medical schools opening, which is slowly happening. It is however not so easy to do so due to the (rightfully imo) high requirements.
The application process is highly convoluted and not very well designed. Some people just fall through the cracks.
But yes, also a small number of people just don't have the intellectual ability to handle it, although schools do a lot of screening to minimize this. Graduation rates at schools are typically 100%, with maybe 1 person every other year failing out.
If one does not get matched and one is a citizen (or a green card holder), s/he really must have a lower than average USMLE score and/or GPA in med school. Or s/he made a mistake in shooting for too high of a program (e.g., trying to get into UPenn/JHU program when one's score isn't that good).
Foreign medical graduates who scores above 65-70th percentile have no problem getting into residency programs (I've made a comment above with more details as to how I know all this). For a green card holder, you just need to get ~60th percentile of the USMLE score (which translates to about 240+ in step 2 CK and step 3 USMLE scores).
All I wanted to say is that the bar isn't too high for a US citizen to get into a residency. That doesn't mean though that the path to get into residency is easy. It is extremely convoluted and requires a lot of persistence and planning. That's where (along the way) people fall through the cracks.
> There are not enough usa grads to fill all the training spots.
And there are more empty homes in the US then there are homeless people. Should be a no brainier to solve that to, right?
It's not as simple as the number of slots. In the SF Bay there are only a couple dozen family medicine slots every year and they all get filled but programs in the South and the Midwest leave spaces open on every scramble.
Brain drain is a huge problem for countries on the cusp -- countries where taxpayers foot the bill for most education. Forced labor isn't the answer, but taking away some of the incentives to leave will certainly help.
I usually agree that "brain drain" arguments are nonsense, but the United States really badly overpays for medical care because of our horribly dysfunctional system, so I'm a bit more sympathetic to them in this particular case.
It's not a clear cut because in many countries doctors are educated through public funding in hope to serve the society that funded their education.
Of corse it is not acceptable to hold human beings as resources and the same society should create the environment to keep their doctors that they gave so much to educate.
That said, brain drain is a real issue and when it happens at scale it turns in tragedy. Maybe at least, countries with public education should receive some kind of reimbursement for enabling these individuals.
This might kick off a small golden age for the countries the doctors are returning to, at great cost in american lives and permanent disability in this time of crisis. Who knew Trump's policies would be so magnanimous and self-sacrificing. Does he get a Nobel prize now?
While it may harm America short term, but there could be long term benefits from reversing the brain drain into America if it leads to more prosperity and stability in developing regions and eventually new trade partners.
Doctors don't really create economic growth unless they start medical tourism operations. Doctors are maintenance workers. Necessary but they don't push the needle.
It's almost as if the AMA shouldn't heavily limit residencies such that only a constrained amount of young people are able to enter the ranks and become doctors.
Most of the unmatched spots are in transitional year slots, which are meant to fulfill the first-year requirement of residencies that start in year 2 (e.g., some optho residencies), or just provide some time to circle the runway because you didn't successfully match. These aren't real residency spots.
There's no excess of residency training slots if you exclude the transition year slots.
Maybe open up more med schools and drop the excessive volunteering requirements. It only serves to filter out the talented with a poor economic background.
We already have an excess of medical schools. We have a shortage of residency training spots; we have med students every year that are stuck as non-practicing physicians because of this.
Residency training spots are, while not a snap of the fingers to increase, not difficult - if congress was willing to actually legislate the increase in funding, as it comes through CMS.
There's no real reason for the government to be funding residency slots. Residents are profitable for hospitals and the slots are objectively valuable things. Hahnemann Hospital shut down and auctioned off their residency slots for 1 million per slot. In other words, the right to hire a resident and collect their subsidy is worth 1 million dollars.
The government is a convenient scapegoat to protect a system that restricts the supply of doctors to maintain their wages.
To put it in tech terms, imagine if the FAANGs + 20 other big software companies had universities. Along comes the government and says that the only way for you to be a programmer is to work at one of these companies for 3-7 years. Oh yeah, and the FAANGs et.al. have an anti-trust exemption that allows them to collude on wages/benefits.
Pretty clear why that system gets abused. The result is that doctors have to pay 50k+ tuition for 4 years and then get paid (relatively) crap wages for 3-7. After that, they make bank because of how hard it is to become a doctor.
Existing doctors have been all to happy to pull the ladder up behind them. They continue to make it harder and harder to become a doctor by extending the training time. As a recent example, to work in a pediatric hospital now requires an addition two years time as a fellow. Of course, no current pediatrician is going to be required to do more training. Just anyone that wants to enter the field and compete now has to accept an additional two years of lower wages.
The linchpin holding this all together is the government license requirements for doctors. Take that away and it all crumbles.
Presumably most of the subsidy goes toward paying the resident, so most of the value to the hospital of the residency is the work done by the resident.
Can confirm this comment. Residents earn ~60-70K/year (usually close to 60K) and work ~60-65 hours/week (not 80 hours/week; there's a bit of exaggeration in that number). My wife is a current US medical resident and we have a lot of friends who are at various US residency programs.
Yes but how much is the subsidy and how much goes towards expenses the hospital only has due to the resident? For example the subsidy also covers the resident's malpractice insurance but the hospital isn't profiting from that. It also looks like there is the IME, a system where all Medicare payments are increased proportional to the number of residents intended to cover the extra work and expenses of training residents. So it's a rather thorny question and probably depends on the hospital (how many Medicare patients they have, etc). I imagine it's like NIH grants where the overhead is like 40% - substantial but I think the work done by the residents is likely to be a significant fraction of the value.
I believe residents need to have an attending sign off on everything they do, so while they could increase premiums indirectly, I don't know by how much. If anyone is named in a lawsuit, I think it would be the attending since the buck stops with them, and they should carry their own malpractice insurance in addition to the hospital's.
Based on what I've read, I suspect residents are very profitable for hospitals, even if they use a significant portion of the grant.
Little bit of both. The right to hire someone should be valued at 0 as it's an inherent right every company has. Going for one million per slot shows something is very wrong. Could be just the subsidy or it could be worth it to join the price fixing club.
100% this. If the hospitals are desperate to increase the supply of doctors in the states (US), they can easily fund the residency spots themselves. They pay ~60-70K USD/year for each resident for three years anyway. Those residents do most of the grunt work that more senior doctors (like attendings and hospitalists) in the hospital don't want to do. In comparison, generalist attendings and hospitalists (full-blown doctors) at hospitals earn salaries in the range of 210-250K USD/year easily.
To become a full-blown doctor in the US, one has to jump too many hoops and hurdles including --
1. maintaining 3.8+ GPA (out of 4.0 max) in undergrad while paying overpriced college tuition (which encourages students to take relatively easy course load other than the required ones like organic chemistry, biochem, a couple of basic math and physics classes, etc.);
2. pay yet another loads of money to attend med school, which is where you actually begin to learn something relatively useful;
3. volunteer unpaid at various research and/or healthcare institutions to beef up one's resume (which is only affordable/possible if you are well-connected and/or have money to volunteer);
4. pay exorbitant and unnecessary exams (each 8-9 hours long spanning sometimes 2 days for Step 3 USMLE: https://www.princetonreview.com/med-school-advice/usmle) that promotes rote learning (and you forget what you memorized ~2 months after the exam anyway);
5. pay a lot of money to apply for residency programs while footing the bill (hotels and air travels) yourself to go around the country for residency interviews;
6. spend 3 years (minimum) in residency while spending ~60+ hours per week in your first year doing the grunt work that no senior doctors want to do (e.g., night shifts/floats)
7. maybe spend another 2+ years in fellowships if you want to be a specialist
In contrast, one just need to do these in my home country to become a doctor (I know India has a very similar system to train their doctors):
1. get a high score in national standardized/matriculate exam (in my country, ~5% of top students have option to go to medical school) to get into public medical schools (there are four of them and three of them are definitely pretty good)
2. spend 5 years studying medicine (to be honest, they can cut out the first year if they want to, but it's still better than spending 4 years as undergrad in the US)
3. spend another 2 years as a rotational intern at major government hospitals (OBGYN, Surgery, Child, etc.) doing what the residents in the US system do [from what I've been told, those 2 years are certainly more demanding than the residency years in the US system]
4. take masters degree to specialize (takes ~3-4 years)
The quality of the doctors produced by these two aforementioned systems is not that different. How do I know this? My wife (foreign medical graduate) is a current medical resident at a US hospital and we have a lot of friends in the US residency programs, some of whom are foreign medical graduates. In order for them to get into these residencies as foreign graduates, they have to score on average better than their US counterparts (on top of having to work pretty hard to gain experience in the US because 99% of hospitals/medical institutions in the US don't allow volunteers/externs/interns unless one is trained from the US pipeline and is a citizen).
So the question is why is the path to becoming a doctor in the US needs to be paved with so much expenses and hurdles? Who established this path?
I'll close my long rant with what my wife recently told me after spending a year as a medical resident in the US, (I'm paraphrasing her a bit here) "I don't want to be a patient in the US hospital when I'm old. We need to go to somewhere like Singapore for treatment (she worked at a hospital in Singapore for a bit before...
Medical schools are biased towards wealthy students. Poor students don’t look at them as say, “huh, let’s make no money for a decade and get tons of debt”. Making the process longer and more expensive ensures that poor kids don’t have a chance, while also allowing universities and hospitals to milk the students for as much money as possible.
I have two college friends who are now full-blown specialist doctors (one orthopedic from UCSD and another psychiatrist graduated from JHU). Both of them came from well-off backgrounds (in fact, both of them have at least one parent who is a doctor). Their parents helped them connect with practicing doctors in famous hospitals (e.g., children hospital of Philly) when they were in college, and both of these friends already had a handful of internship/externship experiences at credible hospitals when they graduate from college.
The psychiatrist friend even took one year off to study for USMLE step 2 before she applied to med school. Who can afford this kind of luxury? It's simply because her parents are both doctors (one psychiatrist and one anesthesiologist) and make a total of easily 600K/year back in 2009.
In comparison, while she (my friend) was studying for USMLE step 2, I was frantically looking for a job in 2009 after graduating from college (the same class year as her).
If one does a bit of research on doctors, one may likely find a positive correlation with their parents being wealthy (and also being one of their parents being a doctor). To become a doctor, one has to be born in a truly middle-class family (like parents earning at least 200K/year total with nowadays dollar kind of middle class).
That highlights a fundamental difference between US vs other countries university education system. In most countries university is vocational training e.g. you learn very deeply what's needed for a relatively specialized job with few chance to retrain once enter the workplace. The US focuses on broad undergrad education system, thus students can/should be able to adapt in their long career, even retraining and switching career if necessary.
But let's say, for the sake of arguments, that US adopts the requirement of having highschoolers applying straight away to medical school. Then suddenly you need a very different selection criteria. High school grades are off. SAT is jokingly too easy, so you need a much more difficult national exam (and enforce that nationwide). Students either grind in high schools for high grade or they'd rather drop that early to go for "normal" universities. And finally, you need better schools across the board to provide students with such opportunity, because if left unchecked, you'll have 10-20 percent of students from California, and only a few spots from Tennessee, thus not ensuring rural area having enough doctors.
I assume you are asking about the ones in the US system (because in the system like India and my country, everyone who finishes the med school are assigned rotational spots without exception). From what little I observed (almost all of the people I know get into residency in the 3-5 years of trying), some decide to become physician assistants, some medical scribes or some chose pharmacy school. After studying medicine for 4 years or more, one has sufficient knowledge about medicine to branch into similar professions like those.
But speaking to the Australian experience:
Between 2000-2010 we went from producing 1500 new doctors to 3000.
We have a different training pathway to the US (and there are many criticisms of both) but you have to complete at least one, usually 2, generally 3-4 years of generalist or semi-generalist Training before entering your chosen speciality.
This results in a much older age of graduate. However it also results in people entering the speciality that they desire.
On the other upside, we exit with little Med school debt (most Americans I met left with 250-300k in debt)
The persistent bottleneck is with medical education and training.
You can not, in the course of a handful of years, massively increase the number of trainees for speciality isotopes without adequately upskilling sown the line and making sure people have jobs to go into and that the existing power structures are there to facilitate integration and adequate skill set/not be overly disenfranchised by their own hold on things that they don’t let go.
Capability is evenly distributed, opportunity is not. We must all work to improve on this
As the other poster mentioned, med schools aren't actually the barrier to increasing the physician workforce. In order to be a practicing physician you need to go through residency training. However the number of residency spots has stayed fixed for the last 3 decades and is controlled by government funding.
If you want more doctors, lobby your government to increase residency training funding.
Such a requirement doesn't exist. 77% of residency slots are funded by the federal government. But there are slots that aren't funded by the federal government. And this makes sense because residents make residency programs money.
The number of residencies is set by a board which the AMA controls a majority of the seats on. They blame the lack of Medicare funding for additional residency spots, but that is such a preposterous excuse. American medicine is one of the most lucrative industries in the world, and American doctors some of the highest paid people in the world. They don't need the public to subsidize their training.
The AMA is a guild and the doctor shortage is their fault.
Yes. One time I was (politely) arguing this with a MD acquaintance and I let him convince me it was an unfortunate, unintentional outcome rather than a successful hustle.
A few weeks later I read an article about a new cuneiform tablet that had just been translated. The oldest translated writing in the world, at the time. Evidently the brick-making guild hadn't been training enough young apprentices and the price of construction was becoming excessive. They wanted the king to step in. It was the same trick! This was literally the oldest trick in all of recorded history!
I am still somewhat adjacent to the biomedical scene and I've heard that the AMA has reversed course recently -- but I don't know the degree to which the new words correspond to actual actions. In any case, the sentiment is correct: if they don't become part of the solution, they will be seen as part of the problem when the eye of Sauron turns in their direction, and the terms imposed on them will be much worse than the terms that could otherwise have been arranged.
I’m less optimistic. It’s just too easy for the AMA to say “hey we are saving lives and we need to make sure we have the best of the best!”. I think a parallel system needs to happen which won’t be controlled by AMA. It will happen eventually but it will probably take a long time.
I think it's happening right now. There's a reason CVS and Walgreens are both trying to position themselves less as drugstores and more as walk-in clinics.
There's a huge opportunity in the market for providing low cost care that has fewer regulations and restrictions.
Honestly, I don't know if it will work or not, but I think it's interesting they're trying to take advantage of the (frankly ridiculous) medical situation in the US right now.
Or to lower the requirements. Doctors with no experience but a medical school are still much better than no doctors. I don't need a doctor with a fancy license, I need a doctor who has a scientifically adequate (and up-to-date) idea of how does a human body work and what has a good chance to be a reasonable way to cure my sickness.
I agree with this comment. US medicine has setup a long and tortuous road, which might result in extremely well qualified people (or might not), but other developed countries seem to do just fine without the hazing ritual the US required doctors to go through.
Why would you ever choose to be a doctor over an employee at a FAANG? It would be worse for your mental and physical health, and now the pay isn’t even much higher for doctors.
I would guess the average pay is not higher at all. Even if you don't account for opportunity cost and the time value of money, I think it may be that top tech cos pay better for someone with similar levels of experience. Certainly I don't think many of my doctor friends my age are making as much as I do, and I was also earning for almost a decade before most of them were able to become attending physicians. And many of them went into family practice or other solidly middle class specialties, which certainly pay a good deal less. This is not even accounting for the fact I work like 36h a week with zero on call time (at least on the current project), and few doctors can swing that.
I left FANG for medicine. I think this is not a good argument for 2 main reasons.
1) People tend to compare FANG to family medicine. It wouldn't be more apt to compare the average tech worker making 100-200k to family medicine, or compare to some of the more competitive specialties.
2) Salaries are underestimated by many people. The best source is the MGMA is is often used to negotiate salaries by the hiring side. Unfortunately the data is expensive to access so few have it - there's an older screenshot someone took [1]. Further, these are biased lower since academic medicine and part time researchers tend to make less. You can also tailor you're career with more flexibility. Want to make $1M? Go for it. Want to work 2 weeks a year and still bring in 2-300k? Go for it.
Now if you want to live in NY or SF tech will pay more as medicine pays more as you get more rural.
It was always on the radar for me so I just worked for a few years and applied.
I do know people who were engineers for a decade plus, and they had to do a year of coursework (special medicine program) before applying to med school.
If it's something you personally are interested in, happy to talk more.
Yeah, I'm interested in chatting with you on this because I'm curious about the process. I looked in your profile but couldn't find an email. Would you mind sending me a message at renewiltord@protonmail.com
I think the last 40 years were golden years for doctors in the US. They made great money, but now the jig is up and there are 2 options for the next generation:
1) if US goes with taxpayer funded healthcare, expect pay to go down similar to other developed countries with taxpayer funded healthcare. Because there will be no negotiating power.
2) with the ACA framework, it’s a race for insurers, hospitals, and physicians groups to get as big as they can do they can gain as much negotiating power as they can. I can see it with all the M&A in the hospital and provider space, and the rule of thumb is “the closer you are to the money, the more you make”. In this case, insurers will hold the money, so it will be at their mercy that they approve or deny payments for certain procedures.
The American people themselves don’t have enough money to continue paying for this gravy train, and the government was picking up the slack, but I think that’s going to be over soon.
The CVS/Aetna vertical integration model is interesting too, as they are talking about adding doctors to their stores to make it a one stop shop. Insurance, provider, medicine all in one, similar to Kaiser.
And then there’s doctor groups who are able to pump out more work from one doctor by using physician assistances and nurse practitioners to actually see patients “supervised” by one doctor, but the doctor never actually sees the patient.
Pay may go down a bit. I don't have a source off hand but a huge portion of medical expense are due to administrator bloat, doc pay is much smaller. Ideally the regulations and billing gets simpler cutting that bloat. Regardless many docs advocate for better healthcare despite lower pay. I don't have data to say most, but my experience has been that in a conservative part of the US.
The NP/PA practice is also a growing concern amongst doctors. Those groups are advocating for independent practice despite reduced training.
I'll admit, I'm a fairly stereotypical introvert tech guy and tend to judge people more than I should. Talking to patients has a way of shifting your views. I used (and I suppose still do a bit) to judge alcoholics, drug users, and other preventable conditions. But you realize how they really are a result of social or medical circumstance and I think for that reason many doctors are willing to sacrifice some pay. Hell I went into medicine for the security and money (mostly, plus more academic stimulation than software), as taboo as that is, and I'd be ok with it.
That said I think specialty medicine pay is fairly safe. Fact is supply is limited, right thing or not.
I doubt there are many doctors that bring in 200-300k in two weeks a year of work. :) And are these numbers net of expenses or gross? E.g. is it net of malpractice insurance costs?
But yes it appears the median doctor gets paid somewhat more than I thought. Although only a few of the surgical specialties outstrip my personal compensation, I would guess I'm a good deal above the median for software engineers and the median engineer is probably only in the same neighborhood as the median doctor, not above.
I think what'll happen eventually is that the doctor situation will be sidestepped and the role doing stuff like looking at patients coming in to check on a generic cough or headache will go to physician assistants and nurse practitioners. To some extent I'm already seeing it happen.
They're already kind of doing that with Nurse Practitioners. I used to have asthma, and for years I always saw a doctor. Towards the end, I rarely saw a doctor but saw a nurse practitioner instead. I strongly doubt the difference in pay was reflected in my bill.
Depends on the specialty, I would think. Pediatricians, general practice, etc. can probably have lower standards than other specialties since they are where people typically enter the medical system for treatment. If they haven't seen a malady before, they refer the patient.
However, for cardiologists, anesthesiologists, neurosurgeons, etc. you probably want a higher education standard.
The way Medicare funds residencies is also odd. What they do is add a pay bump to all reimbursement for a teaching hospital.
For example, for an appendectomy, a non-teaching hospital might be reimbursed $4,500. If you’re a teaching hospital you get an extra 1.3% (too lazy to look up exact number, but it’s quite small), so $4,559. And that’s for every procedure at the hospital, whether the resident was involved or not.
Seems like a more direct, “here is $80,000 for each residency spot” would make things a bit more transparent?
Employers are complaining about a "labor shortage"?
Just raise wages. That will send the proper signal to labor to train for the job.
This is the same for any other product or service in the economy.
0€. Med school is "free" as no debt for students in France. It's tough but it's "free". But some politicians are trying very hard to adopt the American model.
Say you owe 300K in med school loan. On average, a doctor in the US makes ~230-250K (even if the doctor does not have a speciality). If one lives in Los Angeles, CA with 250K/year income (in CA metropolitan areas, generalist doctors usually make more than 250K/year; it's more like 280K/year minimum), the take home pay would be ~160K. How long do you think it would take for someone to pay back the 300K loan? If one is financially responsible, it would take at most 5 years to pay it back.
So by the time one becomes a full-blown doctor at age 32 (usually in the US, it only takes ~12 years to become a generalist doctor, who specializes in Internal Medicine, from the time s/he graduates from high school), s/he is making 250K. I wish I could make something like that as a programmer, but we know that that kind of salary is reserved for people who work for FAANG and/or are at the top of their game in the software field. For doctors, that is just the starting salary.
This is all to say that I disagree that the medical debt is much of a concern for US doctors once they become one. It is the unnecessarily convoluted path, which they have to take to become a doctor, that is more of the problem.
I think you should also include in undergrad debt.
Are you factoring in opportunity cost during the years of not getting paid as much?
And not all doctors get paid that much; instead of average, a median would be better for comparison since some speciality get paid a lot, and some barely.
Also, at age 32, you already have 10 years of experience as a SWE and have been getting paid a lot, with chance to invest (same assumptions of financially responsible person for a doctor as you mentioned)
Most people who went to undergrad (at least the ones in the US) have college loans, so the undergrad debt is unfortunately unavoidable for most (unless they have well-off parents who decided to foot their college bills) regardless of whether you are a med student or not. Actually, it's because of the undergrad loans that only relatively well-off students can afford to go to med school in the US (I wrote another comment related to that in this thread).
For the opportunity cost part, I have to agree with you to an extent. But let me present my rough calculation. I can probably make ~70-120K/year for 10 years before I reach the age of 32 (assuming I don't get laid off in the meantime and assuming I'm not lucky enough to be employed by FAANG). To make it simple, let's assume make an average of 95K/year (average of 70K+120K) for 10 years starting from when I graduate from college. So my take home pay in Los Angeles would be 65K/year. Suppose I can live relatively frugal in LA and save ~30K/year for those 10 years, my investments would have probably grown to about 415K in 10 years (assuming there is no recession and the returns for my investment averages 7%/year; https://www.investor.gov/financial-tools-calculators/calcula...). That is NOT a lot of head-start for those who chose to do programming (or cannot afford to go to med school).
Remember that programmers are actually one of the better-paid professionals among those who graduate from college every year. Also you have to keep in mind that a lot professions have issues keeping their jobs when they get older (e.g., old programmers tend to have a difficult time finding programming jobs while maintaining their senior salaries unless they are really good at what they do; employers will prefer find young, fresh programmers who are willing to be paid less and can spend a lot more time at work than older programmers, but that's for another discussion). Doctors don't have that problem (at least for now because the supply of doctors is artificially limited in the US).
Also, if you are really hard-working (and greedy) as a doctor, you can take two jobs (as a hospitalist or attending) at once. I know two doctors (from my country), who live in CA suburb and make ~500K+ by working at two hospitals (of course, they have to work 6 days a week, alternating 3 days at each hospital). Alternatively, you can run your own practice (either as primary income or just a side hustle on weekends). My wife used to volunteer at several private clinics in NY metro area. Most of the generalist doctors (i.e. Internal Medicine) she volunteered for see ~30-40 patients a day (actually one doctor sees 70-80 patients a day!). They make ~$80 net (that is assuming the patients uses medicaid/medicare, which is actually at the lower end of the pay per visit) from each patient (because my wife enters the code and helps with miscellaneous things around the clinic for them). These clinicians are making each year ~$8030 patients20 days per month * 12 months a year = $576K/year. All of these doctors she volunteered are above 60+ years old. I am not exaggerating about that. Of course, this is in NY-like metro area where population is diverse and dense. Some rural area doctors wouldn't have such opportunity to make that much money, but what I'm saying is that generalist doctors sure have opportunity to make significantly more than 250K/yr average.
All in all, I'm not buying that the opportunity cost of becoming a doctor is a sacrifice one mad. It is (in my opinion) part of the trade-off one have to make to get a steady and pretty good income for the remaining 30 years of your working life (assuming one retires at 62, but if you are a generalist doctor--i.e. not related to ICU or surgery--you can work until 65+ just like the anesthesiologist from my host ...
It’s a really long post but in the first paragraph you’re already making a mistake of not adding any undergraduate fees because in the US other undergraduate degrees would also have those; however we are making a comparison with France, not other degrees in the US.
This seems to be the stock answer to everything: "Raise wages", this would raise your healthcare costs many x more. This is as insane a policy as Open Borders and Free Trade. There are no solutions, only trade-offs.
As someone who makes the "raise wages" argument here on HN pretty often, I'm going to go ahead and partially agree with you. "Raise wages" shouldn't be a conversation ender. But I do think "raise wages" is a very reasonable conversation starter, and often holds up under scrutiny.
Another factor is that here on HN, aa lot of people are programmers who work in a field without an AMA or ABA controlling the number of people who are allowed to work in a field (under penalty of fines or imprisonment), nor does our field have a governing body that has greatly limited foreign competition (in fact, the US government has generally created immigration visas to increase the supply of programmers, even if not to the levels demanded by high tech employers).
On top of that, we constantly hear about companies being "unable to hire", with no mention of the salary. Like, not even a peep. Or open offices, or obnoxious white board exams on inverting binary trees, or open distain for anyone who has family obligations, or...
I remember, back during some of the earlier debates in the early 2000s about the H1B, a tech CEO testified in congress about a critical worker they were trying to hire. They wanted someone with a PhD in a genetics-related field, specialized programming ability, and unix sysadmin skills.
Feinstein asked "what are you offering?". The answer: "90k a year, "generous" options - and a lease on a new BMW!".
Feinstein answered "what was the name of your company again?" and everyone laughed (right, ultra wealthy Feinstein would consider 90k a year livable in Palo Alto). What she didn't say is: "uh, why do you think you can hire someone with a difficult doctoral degree that takes 7 years to complete with a 50% attrition rate, specialized programming skills that take years to develop, and unix sysadmin skills that would make someone highly employable without all that other stuff, for 75% of the salary you'd offer to 2 year MBA or 3 year law degree from programs with a 99% completion rate".
Raise wages. Or, even better, let the market work. Allow immigrants to come here without letting tech companies tell them what they have to study, where they have to live, or what jobs they're allowed to work. Allow all people, immigrant or born here, to choose their profession in response to their own interests and external market signals.
You know, "raise wages", compete, put up or shut up. No, it doesn't end discussion, but it's usually a very compelling argument.
That's a well reasoned argument, I am especially thrilled to hear one that didn't appeal to the extremes,
although I don't agree that there is a direct causal relationship between supposedly low salaries and h1b.
Here's a quick experiment, click clearancejobs.com [1], as of this writing it lists 50K+ well paying jobs (high 6-figs) fully reserved for US Citizens, especially those whose antecedents can be traced. And this usually means people with surnames like Smith, Green, Johnson et al. And, this is just one website, over say a job cycle time of a few weeks. Now one can extrapolate that there are hundreds of thousands of such jobs.
Now H1b is 65K Visas a year, Let's say that 80% of H1b are fraudulent - which it is NOT, but just for the sake of argument, let's say 80% are outright fakes - this is more than offset by very high paying US citizen only jobs in on a single website, over just a few weeks!
Now salaries might not be going up as as much as some wish for, but in an economy there are many more variables than just supply & demand, that determine wages. I would also remind you tech worker salaries are already among the highest, if not the highest, salaries in any professional class. Only very specialized doctors like Neurosurgeons, plastic surgeons etc make more.
To somehow say that H1b is the root of all evil can only come from a very spoilt entitled class - dare-I-say White American Males - that has all the bountiful benefit of an economy with FULL employment, Actually FULL++ employment. And yet, they are just so fragile, entitled and selfish....
H1b is, at most, a _minor_ inconvenience to a set of very spoilt brats, used to having it their way, or throwing a tantrum otherwise. 65K jobs is not even a droplet in the ocean that's the US economy, and yet the fact that this issue gets some much coverage is a testament to the power of this very privileged group.
Sure, but does it make sense to speak of a “shortage” of Ph.d holders when shorter degrees with vastly lower attrition rates pay much more?
The Rand institute, a historically very pro-immigration organization, published a paper concluding that the aversion to STEM phds among people with choice is rational and market driven.
I’m all for immigration, but I Am deeply against allowing corporations to coerce immigrants into a narrow set of career choices as a condition of living and working in the US.
I don't think it has ever made financial sense to do a PhD, except in "pure science" fields with thin job markets for those with only undergraduate degrees.
Then why is congress discussing “stapling a green card” to PhD degrees recipients a way we wouldn’t for other immigrants? I’m not saying we should shut these People out, I’m asking why we force them to get these degrees as a condition of living and working in the US?
This is all based on industry claims of a shortage, when all evidence points to long completion times, high attrition rates, poor pay, and dim career prospects as driving the low interest in these degrees.
I think the low pay and long hours during the PhD program are also a large contributor to that aversion. There's a ton of opportunity cost associated with it too.
The problem is that "raise wages" alone isn't a panacea. Higher prices are a signal to stimulate higher supply. If the supply is artificially constrained that signal is useless. So I agree with the rest of your post - raise wages, but also increase supply without restrictions on employees or the types of jobs they can take.
The problem is that H1-B exists. Instead of that, expand green cards to people who want to immigrate and have desirable skills.
H1-B is mostly used to offshore jobs anyway. It allows offshoring companies to bring in captive workers to learn the skills/jobs to be offshored, and then to send them back. That is not a benefit to the US, and taxpayers should not be footing the bill for it.
It's become a horrible profession in US. Radiologists used to have bit of cachet now are required to review 300+ MRIs/x-rays a Day. No wonder they need insurance to cover the error rate.
One would have to be crazy to want to become a radiologist in the US.
In addition to what you mentioned, remote radiology has been here for quite a while. Jobs are being outsourced to to "scabs" in low wage countries. A definite race to the bottom.
True. On top of all that Watson / etc are supposedly more accurate for several cancers already. Given IBM, probably still have a few decades before they can effectively get to market. ;)
This is an artificially created shortage. The number of doctors entering the system every year is limited by the number of residency spots.
Because resident salaries are paid for by the CMS Medicaid fund, the number of residency spots are therefore limited by how many spots the American Medical Association is able to negotiate with Congress.
Congress needs to increase funding to residencies so they can do a better job of keeping up with demand for doctors.
Thankfully, this is being worked on:
"The number of residency positions has increased only 1% a year, far lower than the 52% growth in medical school spots since 2002, the AAMC said. Federally supported residency training slots have been capped by Congress for more than 20 years, limiting the spots for medical school graduates to undergo additional training in a residency program before they can practice medicine.
To increase the supply of doctors in the U.S., the AAMC supports a multipronged approach, including passage of legislation by Congress that would provide a modest but critical increase in the number of federally supported graduate medical education positions.
A bill, the Resident Physician Shortage Reduction Act of 2019, is awaiting action in both the Senate and the House of Representatives. It would gradually provide 15,000 Medicare-supported residency positions over a five-year period starting in 2021."
Boo effing hoo, my brother is ~300K in debt and making 60K a year at 31, and now is considering leaving medicine. I don't see why I'm supposed to feel sorry for hospitals here.
You look at how much McKinsey will pay you and look at how much money corporate pays, and it becomes a tough deal to stay in medicine if you're even a bit financially motivated. Schools like NYUs new free med school and adaptations like nurse practitioners for primary care are the only way this field will survive.
Way more debt + years of residency to let that debt pile on makes earning more in the end irrelevant. And you can only really be financially free in a few specialties that pay you enough. If you become a primary care doctor, you're only making 160k a year. You can make more in areas where doctors are in short supply. That's not enough to pay off 300k in debt compounding at 7-8% a year for years before you can start paying into it, especially when you also have to pay 7500+ a year in malpractice insurance costs. You've also spent so long getting tot hat point that you're probably around 31 years old, meaning you might be starting a young family around then and cant fit everyone in a cheap studio apartment anymore.
> If you become a primary care doctor, you're only making 160k a year.
There are many more lucrative choices than PCP that don't require specialization. A friend of mine was making $250-350K/yr as a hospitalist - no specialization needed. Just the usual 3 years of residency.
The real issue is that doctors don't want to live where the work is lucrative (rural areas in Midwest, etc).
Doctors (especially disgruntled ones) have it in their minds that they'd all be at Google or a hedge fund or white shoe consultancy making bank if they hadn't become a doctor. They consider themselves underpaid because they compare themselves to the best paid jobs out there. Of course most of them probably wouldn't make it to those levels but that inconvenient truth is ignored.
60K a year is more like a salary for a resident. My friend made approx 60k a year for 4years of residency and one year of fellow ship and then his first job paid him 250k a year. He even had an offer for approx 400K a year from an unethical private clinic which was abusing insurance so he didn't take that job. So yes, doctors in US make a ton of money compared to here in Canada.
There's quite a bit of anti-work-visa sentiment in HN, primarily because they assume it increases supply and reduces pay.
So, It's implicitly assumed that the visa ban is not the cause behind the doctor shortage - its expensive medical school, low resident pay and a limit on residency spots (blamed on AMA lobbying).
The hypothesis here (I don't necessarily fully agree with this) is if the path to becoming a doctor is expanded with removing limits on residency slots, more pay and less debt, more natives will choose to become doctors.
I am a medical resident. I'd be very surprised if the ban affected a significant number of foreign educated residents, as most programs require their incoming residents to be there for orientation before July 1. Our orientation was mid June. I doubt you'd move last minute, as it does take a few days to settle down.
Also, if your program doesn't understand and help you get to this county after matching you to their program, it's now a problem that encompasses the program as well as the politics of the visa ban.
Ninja edit: I will however note some personal anecdotes of some resident friends impacted by the h4 dependent visa, that are having trouble renewing due to the virus, and have to put their training on hold for the time being.
I mean, I still think that the immigration guidelines were pretty poorly implemented and caused a lot of unnecessary stress/confusion. I just don't think a ton of residents are actually in a precarious position right now.
Part of the problem is the unnecessarily long path to becoming a doctor in the US. It takes 4 years longer in the US, compared to UK, to become a doctor.
In the US medical school is a graduate program, which means students must obtain a bachelor’s degree before going on to medical school. The subjects US students study vary: earning a “pre-med” degree is not necessarily required to qualify for medical school. In fact, medical students can and do major in everything from mathematics to physics, even music!
Becoming a doctor in the US takes a minimum of 11 years: 4 years to obtain an undergraduate degree, followed by 4 years to complete medical school then 3 years of residency.
Compare that to UK: There the study of medicine starts at the undergraduate level. After spending between 5 years in medical school, students earn their bachelor’s degree and enter the workforce as junior doctors. They then spend 2 years in the “foundation programme,” which is intended to reinforce what they have learned at the university in a professional environment. That's a total of 7 years to become a doctor in the UK.
The difference is the 4 years US students spend obtaining an undergraduate degree before starting medical school. This seems wasteful. Eliminating this requirement will reduce the amount of debt medical students accumulate, and encourage more people to become doctors.
Theoretically medical schools only require two years of undergraduate before entry. But the high competition for a medical school seat means complete graduates are highly preferred to "prove" they can handle medical school.
While there is gate-keeping in medicine (MCAT scoring preferring English-native applicants, limited residency spots, financial costs of medical school) I would argue the residency system as it is prefers American-educated applicants versus foreign-born grads.
You can see this when looking at prestigious residency programs where the rosters are primarily filled with AMGs. In fact, highly sought after specialties such as dermatology, orthopaedics or neurosurgery tend to accept only AMGs because the number of qualified applicants usually outstrips the available residency spots. Though International Medical Graduates (IMGs) are usually academically outstanding (in my experience as an MD working alongside them) they are more likely to fill residency spots (rural, less prestigious) that AMGs don't want. Not to say that there are not IMGs in highly-sought after residency programs, it's just that their qualifications usually outstrip comparable AMG or they have other connections.
I assume you meant “prefers American-educated vs foreign-educated”? If so, I think that’s true, but having trained in the UK and the US, I thing the US system is much fairer (= less unfair) than the UK. At least once you match to a residency program, it’s almost inevitable that you will complete residency and be able to get licensed and board-certified. In the UK, it was pretty easy for foreign grads to get stuck in some dead-end medical job with no way to advance - though my experience is at least 10 years out of date, so things may have changed since then. From my colleagues who have spent time working in France, France is apparently even worse than England in this regard.
The question is why are local grads preferred? I suspect because even with good USMLE scores, US program directors have no good way to judge the quality of applicants, compared to US-educated grads who have formal standardized letters of recommendation from other program directors where the applicant spent time during medical school (med students often do ‘sub-internships’ at outside medical schools during their studies in order to introduce themselves to those programs and improve their chances of matching there). I suspect that if a foreign-educated medical student arranged subinternships in the US in their chose specialty while in medical school, their success rate would be much higher, because it reduces the risk for the program. Unfortunately, most foreign grads (including myself) have already finished medical school by the time they think about coming to the US, and while I believe it’s relatively easy for foreign medical students to get sub-internships, it’s almost impossible for foreign doctors to do the same.
Yes. And it makes it very appealing for hospitals to just import practicing doctors from abroad on H1-B visas. It also makes those doctors very dependent on their employers due to their visa restrictions, which allows to suppress their wages and makes them even more appealing.
In Canada at least, foreign-trained doctors need to complete a medical degree equivalency exam and to re-do their residency. Due to the complete lack of residency spots available to them a low number of foreign trained doctors ever end up practicing medicine again after moving to Canada. It's pretty nutty.
Curious how it works in the US but I suspect it's not wildly different.
If you have a medical degree from a foreign country you take the USMLE test followed by 3 years of residency in order to get a license to practice in the US.
> 4 years US students spend obtaining an undergraduate degree before starting medical school. This seems wasteful.
While it's not required, the majority of students DO follow a pre-med program that allows them to take Biology, Organic chem, Chemistry, Physics, Psychology, etc...
These aren't wasted years, for the majority of medical students.
I think the solution is more about having more medical schools and reinforcing STEM for younger students so that the supply can keep up with demand.
One of the reasons so many foreign students go into medicine is because they come from countries with very strong culture of STEM education at a young age - something that's not done in the majority of US school districts.
> These aren't wasted years, for the majority of medical students.
They aren't wasted but they're not necessary either, and I think that was the point. Let's say I wanted to become a general contractor, but for some reason that's a graduate program. I spend 4 years taking civil engineering. Did I waste my time learning about concrete... no, probably not, but it is necessary to do my job? Also no.
It's also hard to equate your "stronger early focus on STEM" with a pre-med program. If all it takes is teaching biology and math a little earlier, is that 4 years really the best use of time?
I place enormous value on my undergrad training in chemistry before going on to med school. Impossible to prove but I do think the deeper your foundation in life sciences the better your ability to adapt to new medicines, procedures, & other advances in medicine. Speaking as a urologist.
Edit: the pre med prereqs are a good start. But I value the skills & concepts from the senior level bio/chem classes that I wouldn’t have gotten with a 6 yr track. Something also to be said for the emotional maturity that comes with 4 yrs prior to med school.
"Impossible to prove..." sure, but that's tautology outside some very constrained problem domains like mathematics.
The salient question is cost/benefit. What is the cost in terms of lives and resources of those extra years? Do sufficient benefits obtain?
The US is globally known as a great place to get treated for cancers, especially. 5 year survival rates are relatively high - but of course only a fraction of Americans actually have access to the kind of diagnostics and treatments that deliver these outcomes, and only a smaller fraction of those with said access actually pass on significant assets to their heirs. For most, the medical- and death-industrial complex fulfills its primary extractive purpose.
I find it deeply ironic that your literally academic perspective ("Something also to be said for the emotional maturity that comes with 4 yrs prior to med school") is so utterly subjective - i.e. about your feelings, NOT data around outcomes. In the OECD, people live longer, on average, in places where less time and money is spent educating physicians. Yes, there are confounding factors - but this is true even controlling for the big ones like obesity
Presumably, at a whole society level that would then mean the UK adapts poorer to new procedures than the US. Have you observed things that make you believe that is the case?
Not looking for proof of what you say (you say “impossible to prove” after all, and that’s fair) but surely something makes you believe this.
I don't understand your example. A strong knowledge of concrete is necessary to do a good job as a general contractor. I'm pretty sure the licensing exam has some questions about concrete.
All accredited US allopathic schools do require the same set of prerequisite classes to be taken by applicants (the ones you mentioned). The required courses typically take 1-2 years to complete depending on an individual’s course load and pain tolerance.
In the US if someone says medical student or medical school they either mean a DO or MD. If someone says allopathic, the mean the MD school subsection of medical students.
As of last year, MD and DO students go on to the same residencies, the difference lies only in name and the addition of osteopathy (a combination of valid physical therapy and some voodoo techniques) which the majority of DO students don't believe in, and the few that do keep perpetuating the BS forward unfortunately
Thanks for the perspective, my country (Canada) doesn't have DO so it's not something I understand too well. Here, "allopath" seems mostly used as a derogatory term by naturopaths, homeopaths, etc.
Also remember that many third world type countries see these types of careers as a way to leave their country to go to the western world. People in the western world figure out they can make more than doctors by being jackasses on YouTube.
These are good students, so they enter college with AP Chemistry and AP Biology credit. Start off college with Organic Chemistry 1, then Organic Chemistry 2, then Biochemistry. That's just 1 year to take the classes actually needed to enter medical school in the USA.
Some students might even take those classes via dual enrollment (a.k.a. dual credit, early college, etc.) while still in high school.
That is 0 to 1 years needed after high school. The medical schools demand a 3-year degree (actual time) at minimum, which in the USA means a 4-year degree. Subtract as you please, and you'll get an unjustified excess of 2 to 4 years.
My honors chem class was in 10th grade. It barely touched on electronegativity, nor acid/base chemistry in a through way.
To expect a student to pull that experience forward two years later and integrate it with calculus to pull off organic chemistry seems non-ideal for many students.
And you really need the through physics/calculus component unless you want to wave biochem students past thermodynamics, which seems crazy to this former biochem student.
Cut the one quarter quantum mechanics class, perhaps.
Most UK doctors will be doing further training after the foundation programme, pretty similarly to the US residency scheme. For example, it takes 3 more years training in the GP scheme to become a GP (family doctor) [0]. Other specialities can take longer.
The British doctors will have spent a year longer hanging around hospitals by the time they are qualified to hang up their own shingle, but the overall timeline is pretty close.
Edit: also, you get paid, both as a trainee doctor in the UK and as a resident in the US.
But for those 3 years, the UK doctor (in training) is seeing patients and being paid (stipend or smaller wages)? From the MD’s perspective, the timeline may be similar, but for society, those doctors in training are available to supplant fully qualified MDs (vs the US, where they’re sitting in a classroom).
Curious... did you have a bad experience with a PA (or NP)?
I haven't seen an MD for family medicine stuff (physicals, flu, travel inoculations, etc) in at least a decade. The PAs are easier to schedule and for those tasks, seem more than competent.
With specialists, it's been 50-50. Check-ups have been with PAs (or NPs), with intervention by the MD when required.
A UK medical student starts earning a salary after 5 years of medical school [0]. An American medical student starts earning a salary after 8 years (4 years undergrad + 4 years of med school). Not to mention huge difference in tuition.
To add on, they also limit the number of seats in med school. Doctors are only scarce, and thus well paid, because of the extra 4 years and the artificial seat limit.
This is in part cultural. In UK, much of Asia, and continental Europe, students specialize earlier. On average, most degree programs (and especially professional degrees like MD) take longer in the US system. Not saying this is necessarily how it should be, but it is how things are.
There are a few combined UG-med programs in the US, but not as many as one might think. So perhaps there just isn't demand for them. Or they're too selective.
So that’s only one year longer than the UK system, and if you wanted to get a BSc and and MD (MBBS) degree in England, it would take you 6 years there too.
And think about the cost difference on any given year, despite the length increase. Doctors tend to graduate with 170k in debt. On average, they're paid $60-70k per year for 3 years of residency in which they're the most productive they will probably ever be in their lives. As usual in the US, the middlemen (hospitals in this situation) have figured out how to perfectly extract all the monetary gains.
It's astounding that the HN readership has become completely captured by labour economics concerns, even to the exclusion of considering a critical shortage of critical workers DURING A PANDEMIC.
The point is that the Trump admin political posturing on immigration is causing a shortage of doctors, and people will die because of that.
We have people people with 3.7 gpas and 31 on their MCAT that can't get into medschool. I don't think it's an issue of not having enough people trying to be doctors.
I knew US citizens that went to foreign medical schools (think Spain) 50 years ago because it was so hard to get into US schools.
The beauty then (don't know if it's true now) is it was simple to get US residency on return. Just go work for a trauma center in a run-down area in Brooklyn. Shootings galore on a daily basis. You never run out of new patients.
This year our greedy hospital administrators hired 2,685 non-US citizen graduates of foreign medical schools. During this time, there were 1,218 US MD seniors, 826 US MD graduates, 613 DO seniors, 326 DO graduates and 2013 US citizen graduates of foreign medical schools who applied for these training positions but weren’t hired. The government should clarify that they won’t be relaxing visa rules. Hospitals should interview and hire Americans from the above pool. I’m sure the people complaining in the news article are decent doctors: they should busy themselves treating coronavirus patients in their own countries rather than pushing a false narrative in the US media that Americans are dying because a few foreign doctors weren’t allowed into the country.
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[ 2.8 ms ] story [ 225 ms ] threadThis will always be excuse "we have to act now, because X is terrible if we dont"
It seems to me, the tradition of working residents to the point of sleep exhaustion is a form of institutional hazing, perpetuated by people that endured it because "I did it, why shouldn't they?" I'm not sure how you crack that nut.
With regulation - for example, there could be a law that prevents doctors working more than 12 hours in a 24 hour period.
Come to think of it, surely something like this exists already?
It also unfairly hamstrings smaller practices with fewer covered professionals. Work gets offloaded from the covered individual to uncovered people in order to maximize the amount of work the covered individual can get done in that time span, or people start getting really particular about what is practicing and what isn't.
Hate to sound like a broken record with other folks in the thread, but nothing is fundamentally changing the game with that regulation, just who pays the complexity tax at any one time does.
So ball bustingly frustrating how bloody interconnected everything is while remaining so broad it's nigh-impossible to model within the confines of your own head. I say this as someone whose occupation centers around being able to very quickly jump between distinct verticals and subsystems while maintaining the capability to project the consequences of a change in one vertical through subsequently connected verticals. Everything seems to come back to a form of dynamic equilibrium where as long as you don't stare too hard the thing behaves well, but the closer you look the chaotic it becomes.
Sorry, but this stance seems like part of the problem.
Doctors shouldn't be working more than 12 hours at a time, for rather obvious safety reasons. People don't stop being sick, sure - that means you change the system so there are more doctors working fewer hours, rather than making doctors work insane hours that risk patients and are terrible for doctors' mental health and wellbeing.
I'm not advocating that doctors should work 12+ hour shifts. Merely that creating a regulation that caps doctoring to 12 hours max a day will tend to create an enhanced scrutiny and sensitivity to what is and is not doctoring; which will lead to unintuitive outcomes in terms of the actual effect of the regulation based on the difference between how the industry runs with it vs. How you actually think it's going to go.
And I disagree with this, for 2 reasons:
1. It's unsafe to have doctors working for too long, even if they want to for some reason
2. It incentivizes management to make doctors work longer shifts (as the current situation is)
I also disagree that making this change would somehow cause confusion about who is a doctor or not - there are already regulations governing the medical profession, so no ambiguity.
> The antitrust class-action lawsuit Jung v. AAMC alleged collusion to prevent American trainee doctors from negotiating for better working conditions. The working conditions of medical residents often involved 80- to 100-hour workweeks. The suit had some early success, but failed when the U.S. Congress enacted a statute exempting matching programs from federal antitrust laws
https://en.m.wikipedia.org/wiki/Jung_v._Association_of_Ameri...
Those payments don't even reach the principle though, so it's more just kicking the can down the road.
Really if you wanted to revolutionize doctor-ing then i think creating a pathway from enrolled nurse all the way to consultant doctor would be the way to go. That should probably be a twenty year journey but it would open it up a lot.
Or is it that there just aren't enough native applicants (like grad school) ?
However, some usa grads do not match to a spot, around 1%, which makes lots of US educated doctors (rightfully) really mad. You get random foreign doctors going to state sponsored schools with openly nepotistic admissions sometimes getting spots over people who trained here.
Imo the solution is more us medical schools opening, which is slowly happening. It is however not so easy to do so due to the (rightfully imo) high requirements.
But yes, also a small number of people just don't have the intellectual ability to handle it, although schools do a lot of screening to minimize this. Graduation rates at schools are typically 100%, with maybe 1 person every other year failing out.
Foreign medical graduates who scores above 65-70th percentile have no problem getting into residency programs (I've made a comment above with more details as to how I know all this). For a green card holder, you just need to get ~60th percentile of the USMLE score (which translates to about 240+ in step 2 CK and step 3 USMLE scores).
All I wanted to say is that the bar isn't too high for a US citizen to get into a residency. That doesn't mean though that the path to get into residency is easy. It is extremely convoluted and requires a lot of persistence and planning. That's where (along the way) people fall through the cracks.
And there are more empty homes in the US then there are homeless people. Should be a no brainier to solve that to, right?
It's not as simple as the number of slots. In the SF Bay there are only a couple dozen family medicine slots every year and they all get filled but programs in the South and the Midwest leave spaces open on every scramble.
And those doctors don't get a say in where they want to live?
Of corse it is not acceptable to hold human beings as resources and the same society should create the environment to keep their doctors that they gave so much to educate.
That said, brain drain is a real issue and when it happens at scale it turns in tragedy. Maybe at least, countries with public education should receive some kind of reimbursement for enabling these individuals.
There are more residency slots than there are American med school grads.
Most of the unmatched spots are in transitional year slots, which are meant to fulfill the first-year requirement of residencies that start in year 2 (e.g., some optho residencies), or just provide some time to circle the runway because you didn't successfully match. These aren't real residency spots.
There's no excess of residency training slots if you exclude the transition year slots.
Residency training spots are, while not a snap of the fingers to increase, not difficult - if congress was willing to actually legislate the increase in funding, as it comes through CMS.
The government is a convenient scapegoat to protect a system that restricts the supply of doctors to maintain their wages.
Pretty clear why that system gets abused. The result is that doctors have to pay 50k+ tuition for 4 years and then get paid (relatively) crap wages for 3-7. After that, they make bank because of how hard it is to become a doctor.
Existing doctors have been all to happy to pull the ladder up behind them. They continue to make it harder and harder to become a doctor by extending the training time. As a recent example, to work in a pediatric hospital now requires an addition two years time as a fellow. Of course, no current pediatrician is going to be required to do more training. Just anyone that wants to enter the field and compete now has to accept an additional two years of lower wages.
The linchpin holding this all together is the government license requirements for doctors. Take that away and it all crumbles.
https://www.reddit.com/r/Residency/comments/hdx3gw/no_laughi...
Based on what I've read, I suspect residents are very profitable for hospitals, even if they use a significant portion of the grant.
To become a full-blown doctor in the US, one has to jump too many hoops and hurdles including -- 1. maintaining 3.8+ GPA (out of 4.0 max) in undergrad while paying overpriced college tuition (which encourages students to take relatively easy course load other than the required ones like organic chemistry, biochem, a couple of basic math and physics classes, etc.); 2. pay yet another loads of money to attend med school, which is where you actually begin to learn something relatively useful; 3. volunteer unpaid at various research and/or healthcare institutions to beef up one's resume (which is only affordable/possible if you are well-connected and/or have money to volunteer); 4. pay exorbitant and unnecessary exams (each 8-9 hours long spanning sometimes 2 days for Step 3 USMLE: https://www.princetonreview.com/med-school-advice/usmle) that promotes rote learning (and you forget what you memorized ~2 months after the exam anyway); 5. pay a lot of money to apply for residency programs while footing the bill (hotels and air travels) yourself to go around the country for residency interviews; 6. spend 3 years (minimum) in residency while spending ~60+ hours per week in your first year doing the grunt work that no senior doctors want to do (e.g., night shifts/floats) 7. maybe spend another 2+ years in fellowships if you want to be a specialist
In contrast, one just need to do these in my home country to become a doctor (I know India has a very similar system to train their doctors): 1. get a high score in national standardized/matriculate exam (in my country, ~5% of top students have option to go to medical school) to get into public medical schools (there are four of them and three of them are definitely pretty good) 2. spend 5 years studying medicine (to be honest, they can cut out the first year if they want to, but it's still better than spending 4 years as undergrad in the US) 3. spend another 2 years as a rotational intern at major government hospitals (OBGYN, Surgery, Child, etc.) doing what the residents in the US system do [from what I've been told, those 2 years are certainly more demanding than the residency years in the US system] 4. take masters degree to specialize (takes ~3-4 years)
The quality of the doctors produced by these two aforementioned systems is not that different. How do I know this? My wife (foreign medical graduate) is a current medical resident at a US hospital and we have a lot of friends in the US residency programs, some of whom are foreign medical graduates. In order for them to get into these residencies as foreign graduates, they have to score on average better than their US counterparts (on top of having to work pretty hard to gain experience in the US because 99% of hospitals/medical institutions in the US don't allow volunteers/externs/interns unless one is trained from the US pipeline and is a citizen).
So the question is why is the path to becoming a doctor in the US needs to be paved with so much expenses and hurdles? Who established this path?
I'll close my long rant with what my wife recently told me after spending a year as a medical resident in the US, (I'm paraphrasing her a bit here) "I don't want to be a patient in the US hospital when I'm old. We need to go to somewhere like Singapore for treatment (she worked at a hospital in Singapore for a bit before...
I have two college friends who are now full-blown specialist doctors (one orthopedic from UCSD and another psychiatrist graduated from JHU). Both of them came from well-off backgrounds (in fact, both of them have at least one parent who is a doctor). Their parents helped them connect with practicing doctors in famous hospitals (e.g., children hospital of Philly) when they were in college, and both of these friends already had a handful of internship/externship experiences at credible hospitals when they graduate from college.
The psychiatrist friend even took one year off to study for USMLE step 2 before she applied to med school. Who can afford this kind of luxury? It's simply because her parents are both doctors (one psychiatrist and one anesthesiologist) and make a total of easily 600K/year back in 2009.
In comparison, while she (my friend) was studying for USMLE step 2, I was frantically looking for a job in 2009 after graduating from college (the same class year as her).
If one does a bit of research on doctors, one may likely find a positive correlation with their parents being wealthy (and also being one of their parents being a doctor). To become a doctor, one has to be born in a truly middle-class family (like parents earning at least 200K/year total with nowadays dollar kind of middle class).
But let's say, for the sake of arguments, that US adopts the requirement of having highschoolers applying straight away to medical school. Then suddenly you need a very different selection criteria. High school grades are off. SAT is jokingly too easy, so you need a much more difficult national exam (and enforce that nationwide). Students either grind in high schools for high grade or they'd rather drop that early to go for "normal" universities. And finally, you need better schools across the board to provide students with such opportunity, because if left unchecked, you'll have 10-20 percent of students from California, and only a few spots from Tennessee, thus not ensuring rural area having enough doctors.
But speaking to the Australian experience: Between 2000-2010 we went from producing 1500 new doctors to 3000.
We have a different training pathway to the US (and there are many criticisms of both) but you have to complete at least one, usually 2, generally 3-4 years of generalist or semi-generalist Training before entering your chosen speciality. This results in a much older age of graduate. However it also results in people entering the speciality that they desire. On the other upside, we exit with little Med school debt (most Americans I met left with 250-300k in debt)
The persistent bottleneck is with medical education and training.
You can not, in the course of a handful of years, massively increase the number of trainees for speciality isotopes without adequately upskilling sown the line and making sure people have jobs to go into and that the existing power structures are there to facilitate integration and adequate skill set/not be overly disenfranchised by their own hold on things that they don’t let go.
Capability is evenly distributed, opportunity is not. We must all work to improve on this
If you want more doctors, lobby your government to increase residency training funding.
Maybe drop the requirement that "only" governments fund residency slots?
They could say this is the quick fix but the long term solution is different.
The AMA is a guild and the doctor shortage is their fault.
They are a labor organization that's intentionally limiting supply.
A few weeks later I read an article about a new cuneiform tablet that had just been translated. The oldest translated writing in the world, at the time. Evidently the brick-making guild hadn't been training enough young apprentices and the price of construction was becoming excessive. They wanted the king to step in. It was the same trick! This was literally the oldest trick in all of recorded history!
I am still somewhat adjacent to the biomedical scene and I've heard that the AMA has reversed course recently -- but I don't know the degree to which the new words correspond to actual actions. In any case, the sentiment is correct: if they don't become part of the solution, they will be seen as part of the problem when the eye of Sauron turns in their direction, and the terms imposed on them will be much worse than the terms that could otherwise have been arranged.
There's a huge opportunity in the market for providing low cost care that has fewer regulations and restrictions.
Honestly, I don't know if it will work or not, but I think it's interesting they're trying to take advantage of the (frankly ridiculous) medical situation in the US right now.
Why would you ever choose to be a doctor over an employee at a FAANG? It would be worse for your mental and physical health, and now the pay isn’t even much higher for doctors.
1) People tend to compare FANG to family medicine. It wouldn't be more apt to compare the average tech worker making 100-200k to family medicine, or compare to some of the more competitive specialties.
2) Salaries are underestimated by many people. The best source is the MGMA is is often used to negotiate salaries by the hiring side. Unfortunately the data is expensive to access so few have it - there's an older screenshot someone took [1]. Further, these are biased lower since academic medicine and part time researchers tend to make less. You can also tailor you're career with more flexibility. Want to make $1M? Go for it. Want to work 2 weeks a year and still bring in 2-300k? Go for it.
Now if you want to live in NY or SF tech will pay more as medicine pays more as you get more rural.
[1] : https://imgur.com/gallery/ZQo6aKo
I do know people who were engineers for a decade plus, and they had to do a year of coursework (special medicine program) before applying to med school.
If it's something you personally are interested in, happy to talk more.
1) if US goes with taxpayer funded healthcare, expect pay to go down similar to other developed countries with taxpayer funded healthcare. Because there will be no negotiating power.
2) with the ACA framework, it’s a race for insurers, hospitals, and physicians groups to get as big as they can do they can gain as much negotiating power as they can. I can see it with all the M&A in the hospital and provider space, and the rule of thumb is “the closer you are to the money, the more you make”. In this case, insurers will hold the money, so it will be at their mercy that they approve or deny payments for certain procedures.
The American people themselves don’t have enough money to continue paying for this gravy train, and the government was picking up the slack, but I think that’s going to be over soon.
The CVS/Aetna vertical integration model is interesting too, as they are talking about adding doctors to their stores to make it a one stop shop. Insurance, provider, medicine all in one, similar to Kaiser.
And then there’s doctor groups who are able to pump out more work from one doctor by using physician assistances and nurse practitioners to actually see patients “supervised” by one doctor, but the doctor never actually sees the patient.
The NP/PA practice is also a growing concern amongst doctors. Those groups are advocating for independent practice despite reduced training.
I'll admit, I'm a fairly stereotypical introvert tech guy and tend to judge people more than I should. Talking to patients has a way of shifting your views. I used (and I suppose still do a bit) to judge alcoholics, drug users, and other preventable conditions. But you realize how they really are a result of social or medical circumstance and I think for that reason many doctors are willing to sacrifice some pay. Hell I went into medicine for the security and money (mostly, plus more academic stimulation than software), as taboo as that is, and I'd be ok with it.
That said I think specialty medicine pay is fairly safe. Fact is supply is limited, right thing or not.
But yes it appears the median doctor gets paid somewhat more than I thought. Although only a few of the surgical specialties outstrip my personal compensation, I would guess I'm a good deal above the median for software engineers and the median engineer is probably only in the same neighborhood as the median doctor, not above.
People also bring up malpractice but a good employment contract will include that with tail coverage.
However, for cardiologists, anesthesiologists, neurosurgeons, etc. you probably want a higher education standard.
For example, for an appendectomy, a non-teaching hospital might be reimbursed $4,500. If you’re a teaching hospital you get an extra 1.3% (too lazy to look up exact number, but it’s quite small), so $4,559. And that’s for every procedure at the hospital, whether the resident was involved or not.
Seems like a more direct, “here is $80,000 for each residency spot” would make things a bit more transparent?
Why are people only discussing the long term changes necessary and not the fact that we need more people to treat the coronavirus now?
https://www.medscape.com/slideshow/2019-international-compen...
So by the time one becomes a full-blown doctor at age 32 (usually in the US, it only takes ~12 years to become a generalist doctor, who specializes in Internal Medicine, from the time s/he graduates from high school), s/he is making 250K. I wish I could make something like that as a programmer, but we know that that kind of salary is reserved for people who work for FAANG and/or are at the top of their game in the software field. For doctors, that is just the starting salary.
This is all to say that I disagree that the medical debt is much of a concern for US doctors once they become one. It is the unnecessarily convoluted path, which they have to take to become a doctor, that is more of the problem.
Are you factoring in opportunity cost during the years of not getting paid as much?
And not all doctors get paid that much; instead of average, a median would be better for comparison since some speciality get paid a lot, and some barely.
Also, at age 32, you already have 10 years of experience as a SWE and have been getting paid a lot, with chance to invest (same assumptions of financially responsible person for a doctor as you mentioned)
For the opportunity cost part, I have to agree with you to an extent. But let me present my rough calculation. I can probably make ~70-120K/year for 10 years before I reach the age of 32 (assuming I don't get laid off in the meantime and assuming I'm not lucky enough to be employed by FAANG). To make it simple, let's assume make an average of 95K/year (average of 70K+120K) for 10 years starting from when I graduate from college. So my take home pay in Los Angeles would be 65K/year. Suppose I can live relatively frugal in LA and save ~30K/year for those 10 years, my investments would have probably grown to about 415K in 10 years (assuming there is no recession and the returns for my investment averages 7%/year; https://www.investor.gov/financial-tools-calculators/calcula...). That is NOT a lot of head-start for those who chose to do programming (or cannot afford to go to med school).
Remember that programmers are actually one of the better-paid professionals among those who graduate from college every year. Also you have to keep in mind that a lot professions have issues keeping their jobs when they get older (e.g., old programmers tend to have a difficult time finding programming jobs while maintaining their senior salaries unless they are really good at what they do; employers will prefer find young, fresh programmers who are willing to be paid less and can spend a lot more time at work than older programmers, but that's for another discussion). Doctors don't have that problem (at least for now because the supply of doctors is artificially limited in the US).
Also, if you are really hard-working (and greedy) as a doctor, you can take two jobs (as a hospitalist or attending) at once. I know two doctors (from my country), who live in CA suburb and make ~500K+ by working at two hospitals (of course, they have to work 6 days a week, alternating 3 days at each hospital). Alternatively, you can run your own practice (either as primary income or just a side hustle on weekends). My wife used to volunteer at several private clinics in NY metro area. Most of the generalist doctors (i.e. Internal Medicine) she volunteered for see ~30-40 patients a day (actually one doctor sees 70-80 patients a day!). They make ~$80 net (that is assuming the patients uses medicaid/medicare, which is actually at the lower end of the pay per visit) from each patient (because my wife enters the code and helps with miscellaneous things around the clinic for them). These clinicians are making each year ~$8030 patients20 days per month * 12 months a year = $576K/year. All of these doctors she volunteered are above 60+ years old. I am not exaggerating about that. Of course, this is in NY-like metro area where population is diverse and dense. Some rural area doctors wouldn't have such opportunity to make that much money, but what I'm saying is that generalist doctors sure have opportunity to make significantly more than 250K/yr average.
All in all, I'm not buying that the opportunity cost of becoming a doctor is a sacrifice one mad. It is (in my opinion) part of the trade-off one have to make to get a steady and pretty good income for the remaining 30 years of your working life (assuming one retires at 62, but if you are a generalist doctor--i.e. not related to ICU or surgery--you can work until 65+ just like the anesthesiologist from my host ...
How much do programmers get paid in the usa compared to france? Lawyers? Genetic engineers? Police?
Literally all of them get paid a lot more. Our gdp/capita is like 45% higher.
Another factor is that here on HN, aa lot of people are programmers who work in a field without an AMA or ABA controlling the number of people who are allowed to work in a field (under penalty of fines or imprisonment), nor does our field have a governing body that has greatly limited foreign competition (in fact, the US government has generally created immigration visas to increase the supply of programmers, even if not to the levels demanded by high tech employers).
On top of that, we constantly hear about companies being "unable to hire", with no mention of the salary. Like, not even a peep. Or open offices, or obnoxious white board exams on inverting binary trees, or open distain for anyone who has family obligations, or...
I remember, back during some of the earlier debates in the early 2000s about the H1B, a tech CEO testified in congress about a critical worker they were trying to hire. They wanted someone with a PhD in a genetics-related field, specialized programming ability, and unix sysadmin skills.
Feinstein asked "what are you offering?". The answer: "90k a year, "generous" options - and a lease on a new BMW!".
Feinstein answered "what was the name of your company again?" and everyone laughed (right, ultra wealthy Feinstein would consider 90k a year livable in Palo Alto). What she didn't say is: "uh, why do you think you can hire someone with a difficult doctoral degree that takes 7 years to complete with a 50% attrition rate, specialized programming skills that take years to develop, and unix sysadmin skills that would make someone highly employable without all that other stuff, for 75% of the salary you'd offer to 2 year MBA or 3 year law degree from programs with a 99% completion rate".
Raise wages. Or, even better, let the market work. Allow immigrants to come here without letting tech companies tell them what they have to study, where they have to live, or what jobs they're allowed to work. Allow all people, immigrant or born here, to choose their profession in response to their own interests and external market signals.
You know, "raise wages", compete, put up or shut up. No, it doesn't end discussion, but it's usually a very compelling argument.
Here's a quick experiment, click clearancejobs.com [1], as of this writing it lists 50K+ well paying jobs (high 6-figs) fully reserved for US Citizens, especially those whose antecedents can be traced. And this usually means people with surnames like Smith, Green, Johnson et al. And, this is just one website, over say a job cycle time of a few weeks. Now one can extrapolate that there are hundreds of thousands of such jobs.
Now H1b is 65K Visas a year, Let's say that 80% of H1b are fraudulent - which it is NOT, but just for the sake of argument, let's say 80% are outright fakes - this is more than offset by very high paying US citizen only jobs in on a single website, over just a few weeks!
Now salaries might not be going up as as much as some wish for, but in an economy there are many more variables than just supply & demand, that determine wages. I would also remind you tech worker salaries are already among the highest, if not the highest, salaries in any professional class. Only very specialized doctors like Neurosurgeons, plastic surgeons etc make more.
To somehow say that H1b is the root of all evil can only come from a very spoilt entitled class - dare-I-say White American Males - that has all the bountiful benefit of an economy with FULL employment, Actually FULL++ employment. And yet, they are just so fragile, entitled and selfish....
H1b is, at most, a _minor_ inconvenience to a set of very spoilt brats, used to having it their way, or throwing a tantrum otherwise. 65K jobs is not even a droplet in the ocean that's the US economy, and yet the fact that this issue gets some much coverage is a testament to the power of this very privileged group.
[1] www.clearancejobs.com
The Rand institute, a historically very pro-immigration organization, published a paper concluding that the aversion to STEM phds among people with choice is rational and market driven.
I’m all for immigration, but I Am deeply against allowing corporations to coerce immigrants into a narrow set of career choices as a condition of living and working in the US.
This is all based on industry claims of a shortage, when all evidence points to long completion times, high attrition rates, poor pay, and dim career prospects as driving the low interest in these degrees.
H1-B is mostly used to offshore jobs anyway. It allows offshoring companies to bring in captive workers to learn the skills/jobs to be offshored, and then to send them back. That is not a benefit to the US, and taxpayers should not be footing the bill for it.
In addition to what you mentioned, remote radiology has been here for quite a while. Jobs are being outsourced to to "scabs" in low wage countries. A definite race to the bottom.
Because resident salaries are paid for by the CMS Medicaid fund, the number of residency spots are therefore limited by how many spots the American Medical Association is able to negotiate with Congress.
Congress needs to increase funding to residencies so they can do a better job of keeping up with demand for doctors.
Thankfully, this is being worked on:
"The number of residency positions has increased only 1% a year, far lower than the 52% growth in medical school spots since 2002, the AAMC said. Federally supported residency training slots have been capped by Congress for more than 20 years, limiting the spots for medical school graduates to undergo additional training in a residency program before they can practice medicine.
To increase the supply of doctors in the U.S., the AAMC supports a multipronged approach, including passage of legislation by Congress that would provide a modest but critical increase in the number of federally supported graduate medical education positions.
A bill, the Resident Physician Shortage Reduction Act of 2019, is awaiting action in both the Senate and the House of Representatives. It would gradually provide 15,000 Medicare-supported residency positions over a five-year period starting in 2021."
There are many more lucrative choices than PCP that don't require specialization. A friend of mine was making $250-350K/yr as a hospitalist - no specialization needed. Just the usual 3 years of residency.
The real issue is that doctors don't want to live where the work is lucrative (rural areas in Midwest, etc).
So, It's implicitly assumed that the visa ban is not the cause behind the doctor shortage - its expensive medical school, low resident pay and a limit on residency spots (blamed on AMA lobbying).
The hypothesis here (I don't necessarily fully agree with this) is if the path to becoming a doctor is expanded with removing limits on residency slots, more pay and less debt, more natives will choose to become doctors.
https://thesheriffofsodium.com/2019/03/02/the-etiology-of-ap...
Also, if your program doesn't understand and help you get to this county after matching you to their program, it's now a problem that encompasses the program as well as the politics of the visa ban.
Ninja edit: I will however note some personal anecdotes of some resident friends impacted by the h4 dependent visa, that are having trouble renewing due to the virus, and have to put their training on hold for the time being.
Is free market residency a better long term solution for that market, rather than expanding imported skilled labor?
Letting the market self correct in 10-20-80 years works for making chewing gum or PCs or toilet paper, but not for human lives.
In the US medical school is a graduate program, which means students must obtain a bachelor’s degree before going on to medical school. The subjects US students study vary: earning a “pre-med” degree is not necessarily required to qualify for medical school. In fact, medical students can and do major in everything from mathematics to physics, even music!
Becoming a doctor in the US takes a minimum of 11 years: 4 years to obtain an undergraduate degree, followed by 4 years to complete medical school then 3 years of residency.
Compare that to UK: There the study of medicine starts at the undergraduate level. After spending between 5 years in medical school, students earn their bachelor’s degree and enter the workforce as junior doctors. They then spend 2 years in the “foundation programme,” which is intended to reinforce what they have learned at the university in a professional environment. That's a total of 7 years to become a doctor in the UK.
The difference is the 4 years US students spend obtaining an undergraduate degree before starting medical school. This seems wasteful. Eliminating this requirement will reduce the amount of debt medical students accumulate, and encourage more people to become doctors.
You can see this when looking at prestigious residency programs where the rosters are primarily filled with AMGs. In fact, highly sought after specialties such as dermatology, orthopaedics or neurosurgery tend to accept only AMGs because the number of qualified applicants usually outstrips the available residency spots. Though International Medical Graduates (IMGs) are usually academically outstanding (in my experience as an MD working alongside them) they are more likely to fill residency spots (rural, less prestigious) that AMGs don't want. Not to say that there are not IMGs in highly-sought after residency programs, it's just that their qualifications usually outstrip comparable AMG or they have other connections.
The question is why are local grads preferred? I suspect because even with good USMLE scores, US program directors have no good way to judge the quality of applicants, compared to US-educated grads who have formal standardized letters of recommendation from other program directors where the applicant spent time during medical school (med students often do ‘sub-internships’ at outside medical schools during their studies in order to introduce themselves to those programs and improve their chances of matching there). I suspect that if a foreign-educated medical student arranged subinternships in the US in their chose specialty while in medical school, their success rate would be much higher, because it reduces the risk for the program. Unfortunately, most foreign grads (including myself) have already finished medical school by the time they think about coming to the US, and while I believe it’s relatively easy for foreign medical students to get sub-internships, it’s almost impossible for foreign doctors to do the same.
Curious how it works in the US but I suspect it's not wildly different.
See https://www.usmle-courses.eu/united-states-medical-licensure...
While it's not required, the majority of students DO follow a pre-med program that allows them to take Biology, Organic chem, Chemistry, Physics, Psychology, etc...
These aren't wasted years, for the majority of medical students.
I think the solution is more about having more medical schools and reinforcing STEM for younger students so that the supply can keep up with demand.
One of the reasons so many foreign students go into medicine is because they come from countries with very strong culture of STEM education at a young age - something that's not done in the majority of US school districts.
They aren't wasted but they're not necessary either, and I think that was the point. Let's say I wanted to become a general contractor, but for some reason that's a graduate program. I spend 4 years taking civil engineering. Did I waste my time learning about concrete... no, probably not, but it is necessary to do my job? Also no.
It's also hard to equate your "stronger early focus on STEM" with a pre-med program. If all it takes is teaching biology and math a little earlier, is that 4 years really the best use of time?
Edit: the pre med prereqs are a good start. But I value the skills & concepts from the senior level bio/chem classes that I wouldn’t have gotten with a 6 yr track. Something also to be said for the emotional maturity that comes with 4 yrs prior to med school.
The salient question is cost/benefit. What is the cost in terms of lives and resources of those extra years? Do sufficient benefits obtain?
The US is globally known as a great place to get treated for cancers, especially. 5 year survival rates are relatively high - but of course only a fraction of Americans actually have access to the kind of diagnostics and treatments that deliver these outcomes, and only a smaller fraction of those with said access actually pass on significant assets to their heirs. For most, the medical- and death-industrial complex fulfills its primary extractive purpose.
I find it deeply ironic that your literally academic perspective ("Something also to be said for the emotional maturity that comes with 4 yrs prior to med school") is so utterly subjective - i.e. about your feelings, NOT data around outcomes. In the OECD, people live longer, on average, in places where less time and money is spent educating physicians. Yes, there are confounding factors - but this is true even controlling for the big ones like obesity
Not looking for proof of what you say (you say “impossible to prove” after all, and that’s fair) but surely something makes you believe this.
These are good students, so they enter college with AP Chemistry and AP Biology credit. Start off college with Organic Chemistry 1, then Organic Chemistry 2, then Biochemistry. That's just 1 year to take the classes actually needed to enter medical school in the USA.
Some students might even take those classes via dual enrollment (a.k.a. dual credit, early college, etc.) while still in high school.
That is 0 to 1 years needed after high school. The medical schools demand a 3-year degree (actual time) at minimum, which in the USA means a 4-year degree. Subtract as you please, and you'll get an unjustified excess of 2 to 4 years.
My honors chem class was in 10th grade. It barely touched on electronegativity, nor acid/base chemistry in a through way.
To expect a student to pull that experience forward two years later and integrate it with calculus to pull off organic chemistry seems non-ideal for many students.
And you really need the through physics/calculus component unless you want to wave biochem students past thermodynamics, which seems crazy to this former biochem student.
Cut the one quarter quantum mechanics class, perhaps.
There is a competing college credit test system, International Baccalaureate, that actually includes lab work as part of the test.
Physics and calculus are available too. The right ones would be AP Calculus BC, AP Physics C Mechanics, and AP Physics C E+M.
Most UK doctors will be doing further training after the foundation programme, pretty similarly to the US residency scheme. For example, it takes 3 more years training in the GP scheme to become a GP (family doctor) [0]. Other specialities can take longer.
The British doctors will have spent a year longer hanging around hospitals by the time they are qualified to hang up their own shingle, but the overall timeline is pretty close.
Edit: also, you get paid, both as a trainee doctor in the UK and as a resident in the US.
[0] https://www.ucas.com/ucas/after-gcses/find-career-ideas/expl...
Hell, I generally prefer an MD to a PA...
I haven't seen an MD for family medicine stuff (physicals, flu, travel inoculations, etc) in at least a decade. The PAs are easier to schedule and for those tasks, seem more than competent.
With specialists, it's been 50-50. Check-ups have been with PAs (or NPs), with intervention by the MD when required.
Same for my wife.
[0] https://www.prospects.ac.uk/job-profiles/general-practice-do...
There are a few combined UG-med programs in the US, but not as many as one might think. So perhaps there just isn't demand for them. Or they're too selective.
So that’s only one year longer than the UK system, and if you wanted to get a BSc and and MD (MBBS) degree in England, it would take you 6 years there too.
The 3rd world needs them if they are ever to develop.
The developed world should figure out how to create more doctors from their own countries
Experienced a lot of this sentiment in questions on the subreddit.
The point is that the Trump admin political posturing on immigration is causing a shortage of doctors, and people will die because of that.
it's more complicated than just getting Trump out. The 'orange man bad' narrative is getting out of control.
I knew US citizens that went to foreign medical schools (think Spain) 50 years ago because it was so hard to get into US schools.
The beauty then (don't know if it's true now) is it was simple to get US residency on return. Just go work for a trauma center in a run-down area in Brooklyn. Shootings galore on a daily basis. You never run out of new patients.