> Imagine if the US could double its residencies instead of artificially limiting them!
I really wish we could place all the blame on the AMA, because I wish it was just a matter of mandating the doubling medical licenses and spots available at medical school/residency and be done with it: something probably thought to be impossible until all the strikes and union walk-outs as of late, particularly in the medical field.
But I've seen this first hand since I was a Bio undergrad: pre-med students were on adderall and ritalin since HS and the things these guys subject themselves to is altogether something else. We were all on 'something' to keep up with the school/work load (it was an impacted major with major cutbacks to the entire departmetn) but their's is even more cut throat and they looked like zombies to super hyper during a lecture--it was jarring as I wanted to just take notes after working a catering shift and coming down myself.
I won't go into hat much detail, because I have been talking about this for nearly a decade to those near and dear to me after some heavy situations with relationships with nurses, but the whole medical system rewards perverse incentives in the US (and later I found in Germany as well, especially after COVID). I went from being convinced med students were really after money and glory to compensate from some shortcomings to eventually feeling incredibly sorry of the incredibly dark form of debt servitude/bondage they subject themselves to for most of their careers. The substance abuse is something that I sincerly hope they speak to those considering go through the process at the HS level, because it has claimed so many lives and ruined so many families in the process.
The opioid crisis made the public aware that substance abuse by physicians was increasing because of how addictive they were, but the drug use/abuse was always there: cocaine, speed, and other SSRIs are common use in residency in order to keep up with the rigorous schedule and demands that come with it.
These people should be venerated for even considering taking the immense burden of dealing with matters of life and death, the fact that we have a system that punishes them for seeking help for mental health issues (revoking medical license) rather than have empathy and compassion should be a real eye opener.
Every medical professional I've known who has or is considering having children has always said they want their children to study art or philosophy instead... that should say it all.
I really felt the weight of this, and the subsequent sadness when I saw what my Orthopedic specialist (surgeon) has gone through before, during and after COVID: I'm genuinely glad her career has taken off, but the candid conversation I had with her back in 2019 when she was unknown makes so sad to see what it cost her.
It's not just doubling the medical licenses and slots in the system, it's about breaking the grip of "Doctor required to be present" behavior. Meaning more work in the hands of nurses, ultrasound technicians and other medical staff that aren't doctors but are working in the hospital.
That would require the dismantling or restructuring of malpractice law and litigation. The reason a doctor is required to be present is so that an individual can be held responsible to their Hippocratic oath when patients get litigious. Non-board certified staff, AFAIK, don't need to take a Hippocratic oath nor do they need to carry the burden of insurance the same way a doctor or nurse practitioner does.
Many doctors don't actually take the hippocratic oath (some make up their own, like wedding vows) and it wouldn't carry any actual legal force, either. It's like the american pledge of allegiance.
All of the intensity leading up to and through med school is also generated by the artificially competitive residency system. Pretty obvious.
Med students are not born leagues more competitive than people who go into other high-performing industries.
Edit: I said here “all” the intensity is due to this, which isn’t fair. It’s a lucrative job with lots of necessary education so it’ll be both difficult and competitive regardless. The “extraordinary” features of the medical track compared to any other lucrative field, starting from high school onward though, is generated by the residency bottleneck.
The residency system is going to have significant competition regardless of the amount of slight increase in artificial competition that you remove; high levels of natural competition will remain.
Sure, no one is complaining about “high levels of natural competition.”
They’re concerned about an extraordinary level of artificial competition that is causing kids and adults to kill themselves, extremely high care prices, and extremely low quality of care.
This is all correct, IMHO, and in addition: so many physicians have complained to me, in private/confidence, that they don't try to "help, above and beyond" anymore simply because they feel helpless, ineffective to implement actual useful changes to a profoundly corrupt system of pay-to-live healthcare.
When you're at a point that 45% of US healthcare (already the most-expensive, GDP%-wise) is already paid for by a US government entity... we might as well admit that a single-payer system MIGHT make a little more sense.?! Perhaps.?!
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myPOV: dropped out after intro ER med school rotation, 15+ years ago.
Americans keep telling me that their medical system is grossly unregulated so how can that be?
FYI the government here directly sets the number of spaces available for training doctors, dentists, and veterinarians and still complains that there is a shortage.
The medical system is not grossly unregulated. It is not centrally regulated in DC though there is a lot of regulation from there. It is states and localities that regulate it. For example, in some places, a medical professional can add an MRI without much more permission than safety concerns. But in most places, it needs to be negotiated with the various hospital systems, etc. This obviously drives costs up. Ambulance companies need to get permission from other ambulance companies to add an ambulance. These are just a couple of the examples I have come across, but I am sure there are many other examples.
Government in the US pays 60% of the medical costs in the US. State licensing applies to all levels of healthcare, not just doctors. Doing minor in home care requires some kind of nursing credential with a supervising doctor-type.
The common experience of patients is that they are interacting with private health systems and insurance companies. These systems are grotesquely obscure with prices and it feels like one is being fed to the wolves of capitalism unlike in almost any other market experience in the US. This makes it feel like it is unregulated. But, of course, this can only happen because the government has, by force of law and gun, created a medical cartel, limiting options, prices, and divergent practices.
> .. it cut into the 100-hour-plus weeks that were often the norm for surgical trainees.
Serious question: how are these surgeons still awake after one month without resorting to stimulants and other medications?
That would be 20h a day, with weekends, or 14h+ a day, every day with no break.
If you drive more than about 9h in one go, at least around here, you're considered a threat for others on the street and unfit to drive.
But US surgeons are considered high quality after working 14h?
As far as I am aware, it is time at the hospital. So they can sleep a bit, but it is not much.
These are smart people, they do not want it to change. Their income would decrease if more people were trained/brought in. Have a lot of physician friends, it's awful and they complain, but are worried about wages. They do not want to make less.
A big part is the expense of undergrad+med school+low residency wages+most grew up upper-middle class and have big expectations. They're very worried about losing ground wage-wise. which is fair in my opinion...they have a de facto union/guild (like most smart people who earn a wage try to do).
> These are smart people, they do not want it to change.
Somewhat undercut by the rampant suicide rate.
> A big part is the expense of undergrad+med school+low residency wages+most grew up upper-middle class and have big expectations.
Oh so when you say "they don't want things to change" what you mean is "they know the path to success and if they try to take care of themselves or demand decent working conditions there's a good chance they'll be fired and end up bankrupt and in a debt trap for life." Got it. That kind of explains the suicides.
Dang, I don't know if I want someone with life work balance skewed in the "sleeping odd hours, suicidal, needing the money" favor poking around in my body.
Well, ask two doctors and you'll get three opinions about work time. From my experience here in Germany:
- Doctors in training usually want to work as much as possible to finish their training as fast as possible, especially if they want to work in surgery. For instance, if you train for "general surgery", you need to do about 25 appendectomies, about 35 cholecystectomies, and so on. So in a perverse way, you need a bit of "luck" that you are working while these cases come in. More time in the hospital simply increases your luck.
- Young doctors without kids often want to work a lot to earn more money and accelerate their career.
- Older doctors with kids usually want to work less and more flexibility for choosing shifts.
I began US med school well over a decade ago, so my POV is dated (pre-ACA). I dropped out very early into my formal training.
However, I still keep up with three people whom completed grad school; two physicians, and one dentist (all practice medicine, now, except me).
Remembering their almost-simultaneous relief as each paid off their final $xxx,xxx student loan... the dentist still has to pay off his "Practice" financing (office), but all texted me upon the first deposits of their "first big-boy paychecks" — proud to finally be tackling this debt.
Two of the three have confided to me that "I am smarter than all three of them, having left medicine early [enough to pay off only $109k of student loans]."
I always thank medical staff, whatever the rank, for having to deal with the public. My dentist friend admits to never having-considered that his stubby fingers would have to work in tinier mouths (relative to normal hands).
> - Doctors in training usually want to work as much as possible to finish their training as fast as possible, especially if they want to work in surgery. For instance, if you train for "general surgery", you need to do about 25 appendectomies, about 35 cholecystectomies, and so on. So in a perverse way, you need a bit of "luck" that you are working while these cases come in. More time in the hospital simply increases your luck.
Sounds like a great way to incentivize tons of unnecessary surgeries as well.
Oh, you bet! Fortunately, it is not for the doctor in training to decide if these kind of surgeries are necessary. However, for smaller things in diagnostics, let's say a spinal tap or something like that, it is absolutely possible that on overeager doctor in training will do this unnecessarily, because I think they have a training quota for these as well. However, biggest risk for unnecessary surgery in Germany is still private health insurance...
These hours usually include stand-by time. If you work in a job like this, with time you usually learn to fall asleep very quickly, whenever, wherever. This will keep you at least functioning to some degree. You will miss a lot of slow-wave sleep compared to people with a normal routine, and that surely is one of the reasons people in these kind of jobs often struggle with mental health.
> with time you usually learn to fall asleep very quickly
Can that really be learned or is that a sign of a serious circadian rhythm dysfunction? A healthy human body doesn't just sleep at a moment's notice, that only works when the clock is broken.
This can definitely be learned in a methodical way, this is very common in the military, for instance. Of course, this will usually not work when you are wide awake and not sleepy at all, but in that case it is also not needed. So you are not wrong: this is for times when you simply cannot have a normal sleep schedule, for instance during a military operation or while doing a multi-day shift at the hospital, where you are practically always sleep-deprived. In the military, this is methodically trained specifically for these situations, in a civilian setting it will often simply develop naturally, out of necessity.
Drugs or power naps. Two quotes stood out for me. Years of experience teaching them how to deal with it.
“50 years ago … physicians had rates of narcotic addiction 30 to 100 times higher than the general population, and about 100 doctors a year in the US died by suicide.”
“They are taught, throughout a decade of grueling training, to dissociate themselves from their body’s natural cues, telling them that it is time to rest, eat or urinate.”
I’ve done a lot of long hours before in engineering work. I found that at 13 hours I am significantly impaired.
I’ve done 16-24hr days and caffeine stops working the same way around 16 hours. Ephedrine can get you some more time or the adrenaline of a stressful situation.
80-100 hour work weeks for years is crazy for residents. Work is their life. They may not even go home in between shifts. They can do some key drop power naps or navy seal power naps. My cousins are in the field and Maslow’s pyramid is a constant conversation topic.
I’m sure there are some military manuals or doctor support forums you could research further.
“This is going to hurt” is a good window into the field. Book/tv series.
It’s horrifying and also just accepted and pushed constantly by established doctors and administrators. It’s the same as teaching - only the most zealous will ever survive, because they’re the only one that will put up with the conditions.
My brother-in-law is an ER doctor who will get long shifts, especially overnight ones, where he's sleeping in the hospital bunker until he's needed. He said it's not a problem for him.
I had similar questions for him just last month. He pointed out that working so much keeps his critical skills really sharp which is what you want when you're doing surgery/emergency.
I suppose when you get woken up to intubate someone, you want it to be second nature rather than a faded skill you practice every couple months because you dropped down to saner hours. But he's also paid hundreds of thousands of dollars to do that.
Fun fact: he said one of the most preventable deaths he sees in the ER is people choking on food alone in their home. I think about that every time I almost choke to death on some gooey cheese. Make sure to chew well, folks.
I dropped out of US med school after my intro ER rotation, over a decade ago (pre-ACA). It is my opinion that you simply cannot pay a US-trained physician (I have no outside perspective) enough money for the inhuman sacrifices required, simply to take care of (y)our lazy asses... =D
My electrician career averaged less than 40 hours per week, and four-day workweeks were our norm. Life is nothing but sacrifices for an acceptable level of self-decided laziness/relaxation.
That's scary. I was recently struggling with some peanut butter (I often eat it directly) and had the thought 'could I wind up choking? Nah, no way'. Spooky.
> Fun fact: he said one of the most preventable deaths he sees in the ER is people choking on food alone in their home. I think about that every time I almost choke to death on some gooey cheese. Make sure to chew well, folks.
I normally advocate not living alone (slip-and-falls are also a concern; only god can help you if you have a stroke), but if you insist, take the Red Cross CPR class.
It's cheap/free, a few hours long, will teach you how to resuscitate anything, and most importantly...how to perform the Heimlich on yourself.
it's just measurement bias in any case. It's like asking a mechanic which car is the most reliable. They have no idea, they fix the ones that break down the most. Likewise, oncologists mostly see people dying of cancer.
> He pointed out that working so much keeps his critical skills really sharp
Has anyone tested this? When I teach for long hours (much less than a medical doctor), I make more mistakes. It's a mimus sign in a matrix in the blacboard that I'm solving using the Gauss method.
If none of the studens see the error, I'd notice when I verify the solution. It's not a big deal. My error can't kill anyone.
Airplane pilots and truck drivers have mandatory rests. Because when they make an error people may die. You don't want a super sharp pilot that has worked 100 hours last week.
I watched all of ER a few years back. There was only one episode where a doctor killed Simone by mistake because they were stuck there way longer than they should have been due to a staffing issue. However basically from the opening of the first episode, how exhausted all these doctors are is hammered home.
The career I just retired from was routinely 14-16 hour days, 7 days a week, for months or years on end with maybe a couple weeks off.
You get into a weird mental space where you are halfway auto pilot and halfway conscious, and your brain has a really hard time staying focused without being forced to. Hard to explain, but if you’ve been there it makes sense.
Note that this was working, among other places, on nuclear reactors and on flight decks in the US Navy. This is absolutely normal there, and those are fairly dangerous places to be.
> Physician health programs are designed to address the myth that illness automatically means impairment, says Chris Bundy, the executive medical director of the Washington Physicians Health Program and the immediate past president of the national federation that oversees the state programs. An addiction or mental illness may require a physician to take time off, but does not justify an automatic revoking of someone’s license.
Imagine if we took this same approach to airline pilots, another job that the performance of which decides whether people live or die.
It seems to me that even sleep disturbances should be disqualifying for medical practitioners (and pilots too).
We do pretty much take that approach with pilots (airline, corporate, and private).
Any new addiction (or an untreated old one) or sleep apnea is cause for revocation (or non-issuance) of the medical certificate. You need a medical and a pilot certificate to fly. You can lose the medical temporarily and regain it once the underlying issue is addressed.
Temporary illness or fatigue means you’re supposed to ground yourself voluntarily. That doesn’t happen as often as perhaps it should.
Is the system perfect? Not for physicians nor for pilots.
My point is that the system for doctors should be more like that for pilots: any substance abuse should render them unfit for practice until the situation changes.
It doesn't sound like that is the situation today.
I don't see the system for pilots as being praiseworthy. European airlines do not allow pilots to take prescribed antidepressants. It leads to outcomes like a severely psychotic pilot refusing to get appropriate help because they will lose their license and job. These policies are likely the root cause of the 150 deaths on https://en.wikipedia.org/wiki/Germanwings_Flight_9525.
That attitude is how you get a double digit percentage of pilots suffering from untreated mental illness while attempting to continue to fly passenger planes, yes.
> it cut into the 100-hour-plus weeks that were often the norm for surgical trainees.
The easy way out is to stop restricting the supply so much, but then the income won't be as stellar, so the top dogs won't be as eager to allow that to happen
What kind of salaries would justify this hell? If you're earning $400k working 100 hour weeks, its the same as earning $160k working 40 hour weeks. That's a totally standard albeit high US software engineer salary.
Not really. How many software devs do you know who work only 40 hours per week and book at least 160K? How many devs are actually able to hold down 2.5 engineering jobs all pulling in that salary?
It is a rational reaction. Those who are already in a field wouldn't react well to suggestions of having a lower wage or unemployment due to a massive expansion of supply or outsourcing. Who would be satisfied with that?
Supposedly it never used to be this nuts. It mainly came about because of one cokehead surgeon at John Hopkins who got in charge of the training program because of his "increased productivity" and basically started forcing these insane work weeks on everyone. See here:
The concluding line of this report[1] is absolutely amazing in that the authors still won't even recognise that he was abusive towards his trainees. After discussing his lifetime coke habit and how his "eager and enthusiastic students" would pick up his slack (e.g that he had conditioned to work ungodly hours for his approval) they write (emphasis mine):
*While we are not condemning Halsted*, we are suggesting that if one carefully analyzes and critiques the motivation for the structure of the Halsted surgical residency, his addiction was a major influencing factor.
Either way, any person who can pass the entrance exams should be allowed to train as a doctor or surgeon. The fact that we have artificial caps on the numbers, yet surgeons are routinely working 100 hour weeks is an absolute joke. Everyone's health suffers - both surgeon and the patient. The "wages will come down" argument is an absolute joke - at the end of the day, if there's one thing people will pay a high price for, it's "to stay alive". And if there's a second thing people will pay for, it's "to not be in pain".
> The "wages will come down" argument is an absolute joke - at the end of the day, if there's one thing people will pay a high price for, it's "to stay alive". And if there's a second thing people will pay for, it's "to not be in pain"
Demand for surgery is inelastic instantaneously. That does mean it’s also induced, i.e. more surgeons will generate more surgeries. Supply and demand will still apply.
Supply and demand will apply, but there's both a massive internal backlog (at least in the UK) as well as a massive backlog internationally. Globally, the population is still growing so the demand for essential medical treatment is only going to increase for the immediately foreseeable future. And that's just essential treatment. Rightly or wrongly, demand for non-essential treatment like cosmetic surgery and probably, as technology marches onwards, performance enhancing surgery is only increasing. For example, if we created enhanced ligaments that perform better than natural ones, it's not a stretch to imagine competitive athletes having surgery to replace them. I don't think wage protection is a valid reason not to be training surgeons who have the aptitude to do it.
If we could create (and safely implant) artificial ligaments that are even close to human ligaments that would be amazing for anyone with ligament injuries. Once you damage a ligament it never regrows, and current artificial ligaments don't last very long and can cause other health issues. At least for UCL rupture, the current state of the art surgery (Tommy John surgery) involves taking a ligament from some other part of the body and replacing the damaged ligament, which is obviously a major surgery and still doesn't work nearly as well as the original ligament.
This is not true, a lot (most?) surgery is elective and can be delayed or avoided altogether
Only emergency surgery is instantaneously inelastic
If more people can get the surgery they need, faster, then I see that as a positive
Also, not all doctors work as surgeons or need to perform surgery. Ideally we will also train a lot more of other specialties that can help people prevent surgery
> The "wages will come down" argument is an absolute joke - at the end of the day, if there's one thing people will pay a high price for, it's "to stay alive".
Good argument for universal public health care.
It’s absolutely dumb to have number of surgeons trained or number of patients undergoing surgery be a function of supply and demand. Enough surgeons should be trained to attend the population and it should be a normal career with normal working hours and a steady salary like any other.
Doesn't always work out well. I was just in Canada and the evening news was filled with stories that the wonderful "free medical" system was shipping patients down to the US for surgery. I hope they got a good rate on bulk deal.
If supply and demand don't set the number of surgeons, then who does?
Currently, the American Medical Association limits the number of new doctors being trained in medical school. The AMA judges this to be enough to attend to the population. The long working hours, high wages, and continuing shortage of doctors is direct evidence that their judgement is questionable.
The equilibrium found between supply and demand implies the existence of "excess demand." For some, myself included, the choice between excess demand and efficient markets leans heavily toward reducing excess demand, despite it being less effecient.
> If supply and demand don't set the number of surgeons, then who does?
Public policy. Have public education and graduate X number of doctors every year no matter what.
Free market doesn’t work well for essential services. Lobbying will artificially restrict supply to make more money at everyone else’s detriment. Demand for health is unbounded and any patient will value life over capital, so without forcing oversupply it will be exploitative.
There's no point in graduating more doctors per year if there are no residency program slots for them. We already have some students every year who graduate with an MD degree but are unable to practice because they can't obtain the necessary post-graduate training. We need to address that bottleneck first.
Surgeons have to complete the same amount of training regardless of how many hours they end up working per week after training. There is just no practical way to train three times as many surgeons: the teaching hospitals have nowhere near enough capacity.
In japan, they have large teaching hospitals where patients get treatment from several doctors, effectively free of charge, because you're paired with one senior doctor and several training doctors.
which is an artificial limitation. More positions can be generated easily, since there's a high demand for medical care and the costs currently are high to obtain medical care.
Until those residency programs have doctors sitting idle and twiddle their thumbs, the lack of position is just artificial in order to make it more competitive.
You appear to have a misunderstanding of the motivations and incentives here. The limit on residency program slots is not to make them more competitive but rather to hold down Federal government Medicare spending. If you want to help solve the problem then please ask your members of Congress to increase Medicare funding for residency programs.
There's a joke that grad school and med school are polar opposites - med school is hard to get into and easy to get out of, while a PhD is easy to start and hard to finish
Being a postdoc sucks, and you have to be pretty willing to do something radically different than what you did as a student - but it isn't the end of the world.
I can't see a situation where it makes health in the US worse overall to increase the number of students.
You can go ask the people on the bread lines what they think today. There are 34 million people living with food insecurity in the US alone. A triumph of efficient resource allocation!
The AMA has no power to limit the number of medical school slots. The actual limit is imposed by federal Medicare program funding for residency slots. The AMA has been actively lobbying Congress to increase those.
Sure, there is already some limited private funding for residency slots. If you have a few million dollars to spare you could probably endow a new slot at a teaching hospital. But in general the organizations that actually have a lot of money don't consider this a top priority.
It seems that this is a problem across nations, not only the US. For example, young Norwegian doctors are also protesting against too much work. Last week, the national broadcaster NRK wrote about a physician who committed suicide: https://www.nrk.no/innlandet/xl/lege-maiken-schultz-tok-sitt...
Any death by suicide is a tragedy, and whatever the rate is for surgeons it's too high. This is especially true because there are some protective factors for surgeons - high pay, stable employment, and close connections to health care.
But it's simply incorrect to say that surgeons, or doctors in general, have high rates of death by suicide.
Whenever anyone presents information about suicide it's important to ask what's being counted, how is it being counted, and who is doing the analysis.
And Male and female suicide rates per 100,000 civilian, noninstitutionalized working persons aged 16-64 years for major industry groups meeting reporting criteria: https://stacks.cdc.gov/view/cdc/84274
The rate for healthcare is 7.5 per 100,000 population, but that's driven by female nurses (who have a higher rate of death by suicide than doctors).
> Compared with rates in the total study population, suicide rates were significantly higher in five major industry groups: 1) Mining, Quarrying, and Oil and Gas Extraction (males); 2) Construction (males); 3) Other Services (e.g., automotive repair) (males); 4) Agriculture, Forestry, Fishing, and Hunting (males); and 5) Transportation and Warehousing (males and females). Rates were also significantly higher in six major occupational groups: 1) Construction and Extraction (males and females); 2) Installation, Maintenance, and Repair (males); 3) Arts, Design, Entertainment, Sports, and Media (males); 4) Transportation and Material Moving (males and females); 5) Protective Service (females); and 6) Healthcare Support (females).
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[ 2.7 ms ] story [ 363 ms ] threadImagine if the US could double its residencies instead of artificially limiting them!
I really wish we could place all the blame on the AMA, because I wish it was just a matter of mandating the doubling medical licenses and spots available at medical school/residency and be done with it: something probably thought to be impossible until all the strikes and union walk-outs as of late, particularly in the medical field.
But I've seen this first hand since I was a Bio undergrad: pre-med students were on adderall and ritalin since HS and the things these guys subject themselves to is altogether something else. We were all on 'something' to keep up with the school/work load (it was an impacted major with major cutbacks to the entire departmetn) but their's is even more cut throat and they looked like zombies to super hyper during a lecture--it was jarring as I wanted to just take notes after working a catering shift and coming down myself.
I won't go into hat much detail, because I have been talking about this for nearly a decade to those near and dear to me after some heavy situations with relationships with nurses, but the whole medical system rewards perverse incentives in the US (and later I found in Germany as well, especially after COVID). I went from being convinced med students were really after money and glory to compensate from some shortcomings to eventually feeling incredibly sorry of the incredibly dark form of debt servitude/bondage they subject themselves to for most of their careers. The substance abuse is something that I sincerly hope they speak to those considering go through the process at the HS level, because it has claimed so many lives and ruined so many families in the process.
The opioid crisis made the public aware that substance abuse by physicians was increasing because of how addictive they were, but the drug use/abuse was always there: cocaine, speed, and other SSRIs are common use in residency in order to keep up with the rigorous schedule and demands that come with it.
These people should be venerated for even considering taking the immense burden of dealing with matters of life and death, the fact that we have a system that punishes them for seeking help for mental health issues (revoking medical license) rather than have empathy and compassion should be a real eye opener.
Every medical professional I've known who has or is considering having children has always said they want their children to study art or philosophy instead... that should say it all.
I really felt the weight of this, and the subsequent sadness when I saw what my Orthopedic specialist (surgeon) has gone through before, during and after COVID: I'm genuinely glad her career has taken off, but the candid conversation I had with her back in 2019 when she was unknown makes so sad to see what it cost her.
Med students are not born leagues more competitive than people who go into other high-performing industries.
Edit: I said here “all” the intensity is due to this, which isn’t fair. It’s a lucrative job with lots of necessary education so it’ll be both difficult and competitive regardless. The “extraordinary” features of the medical track compared to any other lucrative field, starting from high school onward though, is generated by the residency bottleneck.
They’re concerned about an extraordinary level of artificial competition that is causing kids and adults to kill themselves, extremely high care prices, and extremely low quality of care.
When you're at a point that 45% of US healthcare (already the most-expensive, GDP%-wise) is already paid for by a US government entity... we might as well admit that a single-payer system MIGHT make a little more sense.?! Perhaps.?!
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myPOV: dropped out after intro ER med school rotation, 15+ years ago.
FYI the government here directly sets the number of spaces available for training doctors, dentists, and veterinarians and still complains that there is a shortage.
Government in the US pays 60% of the medical costs in the US. State licensing applies to all levels of healthcare, not just doctors. Doing minor in home care requires some kind of nursing credential with a supervising doctor-type.
The common experience of patients is that they are interacting with private health systems and insurance companies. These systems are grotesquely obscure with prices and it feels like one is being fed to the wolves of capitalism unlike in almost any other market experience in the US. This makes it feel like it is unregulated. But, of course, this can only happen because the government has, by force of law and gun, created a medical cartel, limiting options, prices, and divergent practices.
Serious question: how are these surgeons still awake after one month without resorting to stimulants and other medications? That would be 20h a day, with weekends, or 14h+ a day, every day with no break.
If you drive more than about 9h in one go, at least around here, you're considered a threat for others on the street and unfit to drive. But US surgeons are considered high quality after working 14h?
These are smart people, they do not want it to change. Their income would decrease if more people were trained/brought in. Have a lot of physician friends, it's awful and they complain, but are worried about wages. They do not want to make less.
A big part is the expense of undergrad+med school+low residency wages+most grew up upper-middle class and have big expectations. They're very worried about losing ground wage-wise. which is fair in my opinion...they have a de facto union/guild (like most smart people who earn a wage try to do).
Somewhat undercut by the rampant suicide rate.
> A big part is the expense of undergrad+med school+low residency wages+most grew up upper-middle class and have big expectations.
Oh so when you say "they don't want things to change" what you mean is "they know the path to success and if they try to take care of themselves or demand decent working conditions there's a good chance they'll be fired and end up bankrupt and in a debt trap for life." Got it. That kind of explains the suicides.
- Doctors in training usually want to work as much as possible to finish their training as fast as possible, especially if they want to work in surgery. For instance, if you train for "general surgery", you need to do about 25 appendectomies, about 35 cholecystectomies, and so on. So in a perverse way, you need a bit of "luck" that you are working while these cases come in. More time in the hospital simply increases your luck.
- Young doctors without kids often want to work a lot to earn more money and accelerate their career.
- Older doctors with kids usually want to work less and more flexibility for choosing shifts.
However, I still keep up with three people whom completed grad school; two physicians, and one dentist (all practice medicine, now, except me).
Remembering their almost-simultaneous relief as each paid off their final $xxx,xxx student loan... the dentist still has to pay off his "Practice" financing (office), but all texted me upon the first deposits of their "first big-boy paychecks" — proud to finally be tackling this debt.
Two of the three have confided to me that "I am smarter than all three of them, having left medicine early [enough to pay off only $109k of student loans]."
I always thank medical staff, whatever the rank, for having to deal with the public. My dentist friend admits to never having-considered that his stubby fingers would have to work in tinier mouths (relative to normal hands).
C'est la vi.
Sounds like a great way to incentivize tons of unnecessary surgeries as well.
Can that really be learned or is that a sign of a serious circadian rhythm dysfunction? A healthy human body doesn't just sleep at a moment's notice, that only works when the clock is broken.
“50 years ago … physicians had rates of narcotic addiction 30 to 100 times higher than the general population, and about 100 doctors a year in the US died by suicide.”
“They are taught, throughout a decade of grueling training, to dissociate themselves from their body’s natural cues, telling them that it is time to rest, eat or urinate.”
I’ve done a lot of long hours before in engineering work. I found that at 13 hours I am significantly impaired.
I’ve done 16-24hr days and caffeine stops working the same way around 16 hours. Ephedrine can get you some more time or the adrenaline of a stressful situation.
80-100 hour work weeks for years is crazy for residents. Work is their life. They may not even go home in between shifts. They can do some key drop power naps or navy seal power naps. My cousins are in the field and Maslow’s pyramid is a constant conversation topic.
I’m sure there are some military manuals or doctor support forums you could research further.
“This is going to hurt” is a good window into the field. Book/tv series.
I had similar questions for him just last month. He pointed out that working so much keeps his critical skills really sharp which is what you want when you're doing surgery/emergency.
I suppose when you get woken up to intubate someone, you want it to be second nature rather than a faded skill you practice every couple months because you dropped down to saner hours. But he's also paid hundreds of thousands of dollars to do that.
Fun fact: he said one of the most preventable deaths he sees in the ER is people choking on food alone in their home. I think about that every time I almost choke to death on some gooey cheese. Make sure to chew well, folks.
My electrician career averaged less than 40 hours per week, and four-day workweeks were our norm. Life is nothing but sacrifices for an acceptable level of self-decided laziness/relaxation.
I normally advocate not living alone (slip-and-falls are also a concern; only god can help you if you have a stroke), but if you insist, take the Red Cross CPR class.
It's cheap/free, a few hours long, will teach you how to resuscitate anything, and most importantly...how to perform the Heimlich on yourself.
Has anyone tested this? When I teach for long hours (much less than a medical doctor), I make more mistakes. It's a mimus sign in a matrix in the blacboard that I'm solving using the Gauss method.
If none of the studens see the error, I'd notice when I verify the solution. It's not a big deal. My error can't kill anyone.
Airplane pilots and truck drivers have mandatory rests. Because when they make an error people may die. You don't want a super sharp pilot that has worked 100 hours last week.
You get into a weird mental space where you are halfway auto pilot and halfway conscious, and your brain has a really hard time staying focused without being forced to. Hard to explain, but if you’ve been there it makes sense.
Note that this was working, among other places, on nuclear reactors and on flight decks in the US Navy. This is absolutely normal there, and those are fairly dangerous places to be.
Imagine if we took this same approach to airline pilots, another job that the performance of which decides whether people live or die.
It seems to me that even sleep disturbances should be disqualifying for medical practitioners (and pilots too).
Any new addiction (or an untreated old one) or sleep apnea is cause for revocation (or non-issuance) of the medical certificate. You need a medical and a pilot certificate to fly. You can lose the medical temporarily and regain it once the underlying issue is addressed.
Temporary illness or fatigue means you’re supposed to ground yourself voluntarily. That doesn’t happen as often as perhaps it should.
Is the system perfect? Not for physicians nor for pilots.
It doesn't sound like that is the situation today.
The easy way out is to stop restricting the supply so much, but then the income won't be as stellar, so the top dogs won't be as eager to allow that to happen
https://en.wikipedia.org/wiki/William_Stewart_Halsted
The concluding line of this report[1] is absolutely amazing in that the authors still won't even recognise that he was abusive towards his trainees. After discussing his lifetime coke habit and how his "eager and enthusiastic students" would pick up his slack (e.g that he had conditioned to work ungodly hours for his approval) they write (emphasis mine):
*While we are not condemning Halsted*, we are suggesting that if one carefully analyzes and critiques the motivation for the structure of the Halsted surgical residency, his addiction was a major influencing factor.
Either way, any person who can pass the entrance exams should be allowed to train as a doctor or surgeon. The fact that we have artificial caps on the numbers, yet surgeons are routinely working 100 hour weeks is an absolute joke. Everyone's health suffers - both surgeon and the patient. The "wages will come down" argument is an absolute joke - at the end of the day, if there's one thing people will pay a high price for, it's "to stay alive". And if there's a second thing people will pay for, it's "to not be in pain".
[1] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7828946/
Demand for surgery is inelastic instantaneously. That does mean it’s also induced, i.e. more surgeons will generate more surgeries. Supply and demand will still apply.
This is not true, a lot (most?) surgery is elective and can be delayed or avoided altogether
Only emergency surgery is instantaneously inelastic
If more people can get the surgery they need, faster, then I see that as a positive
Also, not all doctors work as surgeons or need to perform surgery. Ideally we will also train a lot more of other specialties that can help people prevent surgery
Good argument for universal public health care.
It’s absolutely dumb to have number of surgeons trained or number of patients undergoing surgery be a function of supply and demand. Enough surgeons should be trained to attend the population and it should be a normal career with normal working hours and a steady salary like any other.
Doesn't always work out well. I was just in Canada and the evening news was filled with stories that the wonderful "free medical" system was shipping patients down to the US for surgery. I hope they got a good rate on bulk deal.
the question is how much do we want to waste and how many should die?
Currently, the American Medical Association limits the number of new doctors being trained in medical school. The AMA judges this to be enough to attend to the population. The long working hours, high wages, and continuing shortage of doctors is direct evidence that their judgement is questionable.
Public policy. Have public education and graduate X number of doctors every year no matter what.
Free market doesn’t work well for essential services. Lobbying will artificially restrict supply to make more money at everyone else’s detriment. Demand for health is unbounded and any patient will value life over capital, so without forcing oversupply it will be exploitative.
Graduating X doctors per year seems like a much worse solution than allowing to graduate however many are willing to learn.
which is an artificial limitation. More positions can be generated easily, since there's a high demand for medical care and the costs currently are high to obtain medical care.
Until those residency programs have doctors sitting idle and twiddle their thumbs, the lack of position is just artificial in order to make it more competitive.
https://savegme.org/
Free market is like communism: when it doesn’t work we can complain it wasn’t the true thing.
There's a joke that grad school and med school are polar opposites - med school is hard to get into and easy to get out of, while a PhD is easy to start and hard to finish
Being a postdoc sucks, and you have to be pretty willing to do something radically different than what you did as a student - but it isn't the end of the world.
I can't see a situation where it makes health in the US worse overall to increase the number of students.
The USSR was very efficient at resource allocation. Those who "needed" the resources the most got it. Of the resources that existed, that is.
Socialists would love this system to return, as, in their narcissism, they consider it inevitable that they'll be chosen among those who "need" it.
https://savegme.org/
You should really take 5 minutes to do some basic fact checking before making false accusations.
Everything working, as intended.
45% US Healthcare is paid for by government, already; might as well universalize with the rest of the world's healthcare minimums.
But it's simply incorrect to say that surgeons, or doctors in general, have high rates of death by suicide.
Whenever anyone presents information about suicide it's important to ask what's being counted, how is it being counted, and who is doing the analysis.
Here's CDC suicide rates by industry: https://www.cdc.gov/mmwr/volumes/69/wr/mm6903a1.htm
And Male and female suicide rates per 100,000 civilian, noninstitutionalized working persons aged 16-64 years for major industry groups meeting reporting criteria: https://stacks.cdc.gov/view/cdc/84274
The rate for healthcare is 7.5 per 100,000 population, but that's driven by female nurses (who have a higher rate of death by suicide than doctors).
> Compared with rates in the total study population, suicide rates were significantly higher in five major industry groups: 1) Mining, Quarrying, and Oil and Gas Extraction (males); 2) Construction (males); 3) Other Services (e.g., automotive repair) (males); 4) Agriculture, Forestry, Fishing, and Hunting (males); and 5) Transportation and Warehousing (males and females). Rates were also significantly higher in six major occupational groups: 1) Construction and Extraction (males and females); 2) Installation, Maintenance, and Repair (males); 3) Arts, Design, Entertainment, Sports, and Media (males); 4) Transportation and Material Moving (males and females); 5) Protective Service (females); and 6) Healthcare Support (females).