By that logic all food production and distribution should not be privatized because is should be for the public good rather then the profit of the few.
There are are arguments to be made about private or public but that logic makes no sense.
Some system that have many private aspects outperform other public systems and the other way around. And even in a public system many people will profit as many of the companies that are your suppliers are still for profit.
> By that logic all food production and distribution should not be privatized because is should be for the public good rather then the profit of the few.
Sounds like good logic to me, at least for essentials!
You don’t have to read very far into each of these to see that the historical conditions in each are very different to any first-world country right now.
You don't seem to understand the cause and effect here. Adopting collectivist economic central planning would be an effective way to turn prosperous first-world countries into third-world shitholes.
None of the countries you’ve cited were prosperous first-world countries before the events described. And I didn’t necessarily advocate for central planning in the same way that Stalin or Mao directed it. I don’t pretend to be an expert in such things, but fundamentally I think we can do a lot better than how we organise things now, and that profit for natural monopolies is stupid. If you think that naturally entails famine, I think you have a sad lack of hope and imagination.
True. The problem is inefficiency, corruption, and incompetence. There is a flow of information, and when it's slow to flow, or false, gaps are created within the system that have to be filled by a person's judgement (some systems require highly specialized judgement, like surgery). Or the whole system simply collapses.
You can see a lot of the issues above from Mao's commune attempt (communes to manage food production, a system that also requires careful judgement). Studying the commune failures helps to shed light on gaps of the system and the issues of information flow.
The Doctor's post is arguing against an 'over-adminstrated' system that has become so efficient, it grinds the emotions of anyone who cares because they're left with no time for themselves.
As technologists: when we are burnt out we can step away (I'm oversimplifying, I know we have mouths to feed). When doctors burn out, people suffer: doctors or patients.
It may never be possible to fully patch the healthcare system because we simply cannot flow the patient diagnostic information into the doctors hear with 100% efficiency.
So we're left with looking at the problem as supply and demand....
I mean the US gives enormous subsidies to farmers for food production, and Walmart receives somewhere around $27 billion a year in SNAP from customers. So in that sense, both of these are essentially public to some degree
The subsidies are not 'enormous' vs the total value of all food consumption or production.
There is a huge difference also between subsidizing demand with private supply and providing supply. Exactly the debate that is relevant in healthcare as well. A system can do both, or neither or a combination of the two.
Food is, in general, very accessible, cheap, and elastic (People's food decisions are easily changed depending on the price).
Healthcare in America is not accessible, extremely expensive, and inelastic.
We have not had a famine in the developed world in quite a long time, but the healthcare crises continues.
The fact remains clear: The number one cause of bankruptcy is medical debt.
Healthcare is the only service that is life and death, where the money paid by the patient is completely inelastic.
I'm not saying doctors shouldn't be paid well. But what is really clear is that while the rich pay for premium concierge VIP treatment, the poor are regularly turned away for treatment they can't afford. You health insurance here is tied to your job. Lose your job? Pay $2000/month for COBRA or you don't deserve to have healthcare.
Don't act like public healthcare, expanding access to primary care physicians, and reducing medical administrative bloat is some economic degeneration headed for the sickle and hammer. I'm tired of pretending Ayn Rand style libertarianism capitalism is the perfect solution that has worked for everything including healthcare.
> Healthcare in America is not accessible, extremely expensive, and inelastic.
Did I somehow make the argument that the US has a good health care system? I must have missed that.
> Healthcare is the only service that is life and death, where the money paid by the patient is completely inelastic.
Most healthcare spending isn't actually 'life and death' either. And even if it in the medium term is 'life and death' only a very small amount of health care is an emergency where you can not potentially consider different options.
Just as most time when you are going to the store its not 'life and death'. But still if don't do anything eventually you will starve.
> The fact remains clear: The number one cause of bankruptcy is medical debt.
My goal would be to achieve the best overall healthcare outcomes at reasonable cost. That's at least the first stab at a definition, I'm sure we could come up with a better criteria.
If you increase payroll taxes as much as a fully public system would required, you would just have more people default on their houses and cars instead. Because there is no world, no matter how many billionaires you disown, that you can implement a universal system without massive increases of income taxes.
Again I'm not even arguing that a universal system is bad or wrong thing to aim for. The argument that I actually made was that 'some people make profit' isn't actually a good argument against any system.
> Don't act like public healthcare, expanding access to primary care physicians, and reducing medical administrative bloat is some economic degeneration headed for the sickle and hammer. I'm tired of pretending Ayn Rand style libertarianism capitalism is the perfect solution that has worked for everything including healthcare.
You are literally just ranting about shit I have never argued. I guess I must have trigger something.
The government already subsidizes private overproduction on US farmland.
USAID was, at its heart, a farm subsidy.
And it should be said that most 'small' farmers in the US are millionaire scions and shouldn't need subsidies to make a profit in most parts of the US (we have abundant natural resources).
More than half of all calories produced in the US are not even for human consumption. And globally enough calories to feed every human on earth are lost to inefficiency each year.
We can all benefit from a better system of distribution and production without getting lost in the magical thinking of a public/private false dichotomy.
Subsidies account for a very small % of either production or consumption of food.
Not sure why you are making an argument about food subsidizes to me, I have not argued in favor of them.
> More than half of all calories produced in the US are not even for human consumption.
Most of those go threw animals and are then consumed by humans. There is a lost factor there but saying its not for human consumption misses the point I would say. For Chicken, Pork and fish the lost factor is pretty small.
Not exactly. The Australian system is mixed public/private and many physicians work at for-profit organizations. While Australia does have some level of universal coverage it's a two-tier system where people who can afford it pay for private insurance to obtain better care.
>You might ask, why can’t you work less? It’s not as easy as that. If I decide to work less, who is going to cover the hospital? If the hospital aren’t employing other doctors, we can’t allow patients to go uncovered. I accept the fact that I have a duty of care to be on call.
Yes, you can allow patients to go uncovered. This hero mentality is what leads the bosses to not properly staff and the politicians to not properly fund in the first place.
It is not an individual’s responsibility to correct a societal failure by hurting themselves.
I remember some friends working in intensive care during the pandemic, I'll never forget their facial expressions after these 24hr shifts... I really wish someone would come up with a better way to do this
And that's the main reason why lock downs extended so far later than they should have. Our hospitals run at 120% during normal times; during abnormal times they're stretched to the breaking point. Our small local hospital had two nurse suicides during the pandemic. Not early in the pandemic, but well after vaccines were available.
Our societies should have expanded their healthcare capacity afterwards and maintained it to a high standard, but unfortunately it sounds like the political classes continue to treat healthcare as a cost centre that they can starve or pull money from for other projects.
> I had worked in a hospital network that covered 4 campuses and drove 500kms a week when covering these sites. I had worked in a hospital where I didn’t get home for days at a time, sleeping overnight in hospital quarters, outpatient clinic benches and in my car.
As a patient, I'd like the person performing surgery on me to be well-rested!
It gets worse:
> I used to be able to arrange the operating list because I know that some operations take longer than others. But now, the bookings office determine that that all my tonsillectomies take 14 minutes because that’s the average time recorded on the computer. The moment I scrub in, the timer starts. The moment I unscrub timer stops. Click. Click. Click. Because the theatre bookings does not take into account the interpreter time, pre-med period or transfer to ICU, the list is running late. The nurse in charge is breathing down my neck to finish on time.
And yet somehow that 14 minute tonsillectomy gets billed at ~$10,000.
This seems to me like a system that has been hyperoptimized in a way that grinds down the participants.
Would you say that people also need to be more responsible to be healthy themselves? Reducing pressure on the system and freeing capacity. E.g. healthy lifestyle to reduce diabetes.
Well let’s start with insurance actually acknowledging preventative care as a worthwhile investment. We have a system that incentivizes waiting until emergency care is necessary and that comes with massive cons.
I can’t even get basic foot stuff covered, they won’t care until my feet and knees land me under “disability,” so people like me - but unlike me they can’t afford to spend hundreds more a year on special inserts and shoes - just keep doing what they’re doing until they’re hurt.
People go to the grocery store and marketing teams are trying to sell them “vitamin water” which is neither of those things, so they have to do tons of research and pay constant attention to literally every food they buy. Then when they get hurt they can’t afford to go to a doctor and the insurance that is sucking up huge amount amounts of their annual pay doesn’t pay for it either.
Meanwhile we have a US administration that is telling everybody, a population that is incredibly predisposed to heart disease already, to go eat more red meat. Also, they have spent a decade telling people that vaccines are shady and maybe they shouldn’t get them. How much damage have we done to preventative care with that one?
I could go on and on, I’m barely covering the breadth and depth of this problem. We can’t just call it “personal responsibility” or whatever
Insurance is already required to cover preventive care services which are justified by a clear cost-benefit analysis at no cost to the patient. The list of those services should probably be expanded but in many cases we lack scientific and economic data to justify to more research is needed.
Most people don't understand the system well enough to even have an informed opinion on the subject. Commercial insurance companies get a lot of criticism for denying claims or prior authorization requests, and some of that criticism is well deserved due to errors or artificial friction. But for the most part they make very few decisions about what care is justified.
At a first level the federal government publishes a set of medically unlikely edits used to deny claims when procedure codes don't align with diagnosis codes. It's used by Medicare, and most Medicaid agencies and commercial health plans have also adopted it.
At the next level most commercial health plans have adopted clinical care guidelines published by vendors like MCG. These vendors take publications from specialist medical societies and codify them to determine what's medically justified and set step therapy requirements.
At the final level, providers can appeal denials to human nurses and doctors who do case review at insurance companies (peer-to-peer). In a huge healthcare system there are always patients with unique needs who don't fit the pattern in published care guidelines. Dealing with those appeals is a major administrative burden and often badly managed on both sides of the adversarial interaction.
Most US-based HN users are on commercial self-funded group health plans sponsored by their employers. The Affordable Care Act (ACA / Obamacare) establishes a baseline for what's covered but ultimately the decisions are made by employer HR departments. Insurance companies would be happy to offer custom health plans that paid every claim at 100% with zero denials or prior authorization requirements; it would mean less work and higher profits for them. But no employer wants to pay for that so the insurance companies take measures to hold down costs.
Are you sure you can find that many more doctors? That they'll be any good?
Speaking from Romania: here medicine is prestigious. So many parents push their kids towards medicine. There's a glut of newly minted doctors every year, but rumour has it that the quality drops every year. Sure, they pass the exams and residency and what not, but... They're just not into medicine as much.
Do you want to get treated by such a person?
This year I had to go to a neurologist. I went to one locally, they dismissed me in 5 minutes, told me to take some vitamins basically. Went to another one in a much bigger city, they talked to me for an hour, ordered a ton of tests.
Would it help if we get a lot more of the first kind of doctors?
Ah yes and when doctors give everyone expensive tests because the patients are a bunch of drama queens who think they know better because they have a doctorate in Google the costs go up.
I'll give you some N=1 sample on older doctors since I'm also from Romania: a lot of these older doctors haven't opened a book in a very long time and are still using older practices instead of providing their patients with the latest and most effective treatments available because they're too lazy and/or prestigious to go and learn new things. Would you say that they "into medicine"?
> Would it help if we get a lot more of the first kind of doctors?
It would certainly help hypochondriacs a lot. Ordering "a ton of tests" needs to have some basis behind it, and doing it just to make the patient "feel seen" is not a great way to do your profession. People being dismissed quickly also happens in the US quite a lot, sometimes with disastrous results though it's not incredibly common, it's typically labeled under "diagnostic error" https://qualitysafety.bmj.com/content/23/9/727.long
You get the same problems in the US with the attitudes of doctors.
In the US, medical school is extremely expensive (like $400,000 expensive). There are many people who are excellent doctors who are just priced out of the profession. If we could make medical school less expensive (by subsidizing it and by reducing the amount of instruction), we would probably get many more excellent doctors.
Half a million in debt is scary. Especially if you have any doubts that you can match and make it through residency at the end. It's even scarier if you come from a family making $50k/yr.
Don't they have to back these gigantic loans? That might deter people from going to medical school out of fear they're not gonna have what it takes and drop out halfway with huge debt.
Loans need to be repaid. I have many physician friends who graduated from medical school with 500k-750k in student loan debt (including debt from undergrad which compounded during medical school) with a combination of federal student aid as well as private loans anywhere from 8-10%. After graduating medical school, they completed 3-5 year residency programs earning somewhere in the ballpark of $50k-$60k salary. This is in an expensive northeast US market where such a salary barely covers basic living expenses, and as such their debt continued to compound. After completing residencies, they earn $175k-$200k salary which is about average for this area as an attending physician in their specialties (primary care related specialties like Family Medicine).
You do the math: over a 10 year repayment period with compound interest, their education cost them MILLIONS and they'll be well into their 40s before they start saving a dime for retirement. The cost and scarcity of medical education is extremely punitive to doctors and prices out many would-be great physicians. Many I know who have gone through this ended up regretting it due to the enormous financial burden they are saddled with for many years after becoming an attending.
Maybe folks believe these professions should be reserved to those who inherit great amounts of generational wealth.
My wife and most of our friends are physicians and I don’t know anyone with $750k in debt.
The average debt is a little over $200k. Only 30% of graduates have over $300k in debt and they are considered high debt graduates.
Family Medicine salaries are above $200k in every state in the nation for full time doctors.
None of the doctors I know come from families with generational wealth.
Here is the nationwide average for resident salaries by year
Program year 1—$68,166.
Program year 2—$70,499.
Program year 3—$73,301.
Program year 4—$77,593.
Program year 5—$81,807.
Program year 6—$84,744.
Program year 7—$89,187.
Program year 8—$94,215.
If "only" 30% of graduates are graduating with over $300k in debt, that means that of the 30,000 graduates that graduate from both allopathic and osteopathic programs each year [1] there are almost 9,000 physicians that are high debt graduates. At high interest rates, that debt can easily grow by hundreds of thousands of dollars while you complete a residency program.
The resident salaries that you listed are an average taken across all specialties. Family Medicine is the lowest paid specialty with 2026 PGY-1 salaries at $58,500 (representing an increase of over 15% since 2021) [2] That is simply not enough to pay the cost of living in a state like Massachusetts where the median household income is more than double that [3] and the average rent in Boston metro is almost $40,000 annually [4]. Not only can you not afford to pay down your student loan debt, you are extremely likely to accrue additional consumer debt on things like credits cards or vehicles.
My main point is that training to become a doctor carries so much financial risk that it selects against folks from poor socioeconomic backgrounds that would otherwise make great physicians. In 2018 the AAMC published a study showing that 51% of medical school matriculants were from families in the top quintile for family income [5] and if I were a betting man, I'd guess that proportion has only increased.
> At high interest rates, that debt can easily grow by hundreds of thousands of dollars while you complete a residency program.
Sure. But that’s not what you said. You said you had many fiends that graduated med school with $500k-$750k in debt. I think you were lying or your definition of many was highly exaggerated.
> That is simply not enough to pay the cost of living in a state like Massachusetts
$58k is the national average. Not the average in a high cost of living area like Massachusetts.
> My main point is that training to become a doctor carries so much financial risk that it selects against folks from poor socioeconomic backgrounds that would otherwise make great physicians.
There is almost zero financial risk.
Eventual graduation rate is 96%. Eventual match rate is around 99%.
Are there doctors that could have make more money going into finance sure. Are there doctors who are financially ruined, not meaningfully.
>In 2018 the AAMC published a study showing that 51% of medical school matriculants were from families in the top quintile for family income
1. Doctors kids are more likely to become doctors.
2. High income is correlated with intelligence and intelligence is partially heritable.
3. Kids from high income families are more likely to have extended family and friends who are editors who encourage them to become doctors.
4. Med school requires college and college and children from income families are much more likely to have college degrees.
5. Medical school entrance is competitive and high income kids are much more likely to go to better colleges.
6. High income kids are much more likely to have higher grades in college because they don’t have to work.
7. High income kids are much more likely to go to better high schools which impacts what college they get into and how well they do there.
The list goes on and on. The cost of medical school is so far down that list.
> I don’t think accusations of lying add anything productive to the conversation, but thanks. We have different circles of friends with different financial circumstances and that’s OK.
I think it’s more likely you’re just exaggerating. How many is many? If you personally know more than 5 doctors with $500k-$750k in debt after med school I’ll eat my hat.
> Residency match rates for American graduates from American MD or DO programs are more like 93%
That’s only after primary march. Match rate after SOAP is 98%. Roughly half of the unmatched 2% get marched in the next max cycle which is where I got 99%. Of the remaining 1% most of those want to eventually place somewhere.
>For American IMGs
Yeah don’t go to a factory medical school in the Caribbean. It’s a bad idea.
It’s definitely almost 0 financial risk. The only real risk is that you just hate being a a doctor. But even in that case med school unlocks tons of opportunities outside of clinical practice.
The chance of you ending up suffering financial hardship is too small to consider in your decision making.
The real out of your control risks would be severe disability that prevents you from finishing med school or working (before you can afford disability insurance). But in the case it really doesn’t matter whether you owe $50k from undergrad or $250k from med school. You’re not paying either one back and you can actually bankrupt out of student loan debt in those cases.
"Are you sure you can find that many more doctors? That they'll be any good?
Speaking from Romania: ..."
The prior post was specifically talking about the US. (I assure you, arrogant dismissive doctors are also a thing in the US)
In the US, there are a number of things that artificially increase the barriers to becoming a doctor.
1) You typically need a four year college degree to apply to medical school
2) Medical schools are accredited by the AMA, which is controlled by doctors. The AMA makes it very difficult to start a new MD-granting medical school.
3) Medical school in the US is very competitive to get in. They are likely turning away a lot of people who could complete the degree.
4) Since 1997, the federal government has a fixed number of Medicare (Medicare is a federal health insurance program for people over 65) supported residency positions. That number was basically flat for 25 years. We lost about 20% per capita of doctors being trained with support from this program. The caveat to this is that the total number of residents per capita has increased over time, particularly the past 15 years or so. My understanding is that they are less likely to be fully funded, so they spend more money getting trained, and then have higher students loans (on average graduating with debt above 200k going back to the late 2000s) that they need to pay off, so they charge more.
And you can add to this that it can be very difficult to be a doctor in another country and come to the US to practice here.
I totally dont by the "no medicare funds for training". A doctor will see you for 10min (perhaps another 10min prep) and bill $1000. If you doubt this, just check your EOB statements from the insurance company or check your deductible history.
The entire salary for the resident can be earned back in 3-4 days. You still have 360 days left to pay back admin overhead, facility overhead, supplies, etc. That is earned back in the next several weeks. After that, the next ~300 days of the year are profit.
In states with balance billing, the doctor can set any price and bill you for the remaining figure with a balance bill. In NY and NJ these can be thousands or tens of thousands. If you dont pay, it goes to collection and the provider still gets 10 to 15 cents on the dollar. So no...the $75k annuals alary of a resident is not a barrier to training more doctors.
What seems more likely is that supply is artificially constrained to increase scarcity and prices. What am I missing?
First, private practice docs see patients with very good employer provided insurance, but residents are largely seeing patients that private practices wont see - patients who are far too medically complex to fit into a 10 minute slot and who also have particularly stingy insurance.
So as opposed to a private practice doc who is seeing 30 patients per day and billing an a average of $250 to $300 per patient (certainly not $1000 - that is unrealistic in my experience), a resident is seeing more like 10 to 15 patients per day (30 minute slots) and billing less than $100 per patient.
Second, residents have to be supervised. You have not included the salary of the physicians supervising them in your calculation.
Third, and I have mentioned this many times before on HN, training is limited by chiefly by the number of training sites that can offer quality training. For example, most hospitals will not see a single case of Guillan-Barre in a single year. Would you want to be treated by a nuerologist who trained at such a hospital? This is why neurology training is generally limited to places with a high volume of neurologic cases that would be considered rare at the average hospital, and these hospitals can only accommodate so many residents. Even for general medicine, you probably do not want to be treated by a doctor who trained at a hospital where any case that passed a certain complexity was transferred out to a bigger center.
Basic american residency takes 3 years and the residents can’t see patients on their own until year 3. Year 1 they bring in 0 revenue because they’re just shadowing doctors. Year 2 they can take a small load from a doctor but it’s not more than their salary. Year 3 they make tons of money for the residency but it’s not enough to make up for all the extra doctors they need to train year 1 and 2 residents.
On top of these, a few things with the training process also jump out to me from a "can we attract smart and motivated people to this work" point of view: the sheer cost of medical school that creates an imperative for high pay down the line, coupled with a real chance that you can wind up without a residency match but still owe all that money for school, and in particular the grueling nature of the residency system, currently capped at only 80 hours/week since 2003, because people were working >100 and making mistakes.
There are arguments that these are factors that filter out the people who are not sufficiently motivated, but it's hard for me to imagine there aren't a lot of bright young people who might be interested in medicine, but see one of the various paths that exist today to making doctor-level money with only an undergraduate degree and in an environment that doesn't require a working schedule that actively harms your health.
Yep, it's a huge risk. If a student enters medical school and realizes halfway through that they don't want to be a doctor then they're still stuck with a huge debt and no way to pay it off. It's not like undergraduate education where you can fairly easily switch majors from chemistry to mathematics or whatever.
> Would it help if we get a lot more of the first kind of doctors?
Depends? Did the tests actually find anything, or did they just make you feel better?
I had a talk with my GP about this at some point, and he more or less told me that he can just say "Go home, rest, come back in two weeks if it doesn't get better.", and 95% of the time that'll be exactly what is necessary. The hard part of his job is figuring out which of the visits are those 5%.
So you're saying limiting the number of doctors work better?
Speaking from Poland, we see the same outcome: doctors rushing patients out after 5 minutes. The reasons may be different, though: since COVID, many doctors here have, in my view, become more arrogant and focused on money. Over the past few months, an uproar over doctors’ pay has swept through Polish social media.
Reports have emerged of doctors billing for overlapping work under multiple contracts. In one case, a doctor’s records showed 72 hours of work in a single day!
Meanwhile, the Polish Chamber of Physicians and Dentists (NIL) continues to defend caps on medical school admissions, adding fuel to the national debate.
> Their salaries need to be lower, training needs to be cheaper and faster, and we need a lot more of them.
We need to reduce the requirements to be a doctor. I think general ability is way way way more important than the specialisation. I don't think the speciality that doctors spend money and time on add that much value..
I don't think Dr salaries are even that high a percent of healthcare spending. Although, maybe better work life balance, lower salary escalation and less debt would help everyone.
Agree - one sensible start would be to at least hybridize the European model where students are a whole lot closer to getting there medical degree as an undergraduate.
In most countries that do this training is longer which that total training time is only 1-2 years shorter.
So you’re doing a few things.
1. Moving more training from cheaper colleges to more expensive medical schools.
2. Moving the filter from undergrad to medical school
3. There is no national curriculum in US high schools, so essentially the first 2 years is getting everyone on the same footing. Removing this without changing high school, puts students at poor high schools at an even greater disadvantage.
Many of the programs you listed don’t cut any time off. They’re just a special pipeline program that can help you get into med school.
Of the ones that do save time, most cut 1 year off not 2. And they do it by having students take more than a full time load during undergrad.
It’s essentially the same thing as taking an extra class or 2 every semester so you can finish undergrad in 3 years instead of 4.
I randomly sample 15 of the programs listed there and 14 were 8 year programs. Only 1 had an optional 7 year program (if you were willing to take more than full time load or go to school in summmer). And there were no 6 year programs.
I think you’re not sufficiently taking into account the demographic trajectory of age distribution [0], and the lag induced by the length of the human lifespan on health improvements. For the next few decades, more doctors will be needed.
That is a good analogy. Let us consider that there is a growing number of fire events in the recent years. Instead of finding out what is causing it, and fixing it we are asking for more firemen....
> The reality is we need more doctors. A lot more.
I think building a better prevention layer is more important.
Don't get me wrong, I agree that we need more doctors (and nurses, and physios, and dietetists, and ...), but it is much easier to scale a good prevention system than the number of workers in healthcare.
Prevention is not about age related diseases, but early onset cancer, diabetes, high blood pressure caused by alcohol and tobacco use, unhealthy diet, and sedentary lifestyle.
A significant amount of cases could be prevented before they need medical intervention (and put burden on the medical system). There are several researches about this, the number of people with type 2 diabetes doubled in the past decades.
Widespread use of GLP-1 agonist drugs will prove to be the most effective prevention layer. I absolutely support people living healthier lifestyles in order to delay the onset of the chronic diseases that drive the majority of medical care demand. But on a population basis, attempts at lifestyle interventions have been broadly ineffective. A lot of the chronic disease burden including type-2 diabetes, hypertension, heart failure, MSK, etc is downstream of obesity so if GLP-1 drugs can cause a lot of people to lose weight then we might see some real improvements within a decade.
To be clear I'm not suggesting that everyone should be on GLP-1 drugs, and it's obviously better to maintain a healthy lifestyle and body composition without those drugs. But for people who can't or won't do that on their own the drugs seem to work pretty well. There's also promising evidence that they cause reduction in alcoholism and other substance abuse disorders.
I think one issue is that the admissions for medicine are getting harder and harder. In many places you practically need a 4.0.GPA, volunteer work, great mcat scores, research experience, sometimes a post grad degree like an MSc and PhD etc. This selects for highly competitive and intense personalities that are not always suited for every medicine specialty. Most of them don't want to go into family medicine and pediatrics because it's more work, less money, less prestige etc. The friends I had who wanted to go into family medicine couldn't because of the admission requirements. Their only alternative was to have family money to pay for medical school in places like Ireland.
Edit: I should have mentioned that pediatrics and family medicine represent a large proportion of available residency spots each year and are rarely full.
General practitioners make something like 150k on average in the US. Specialists tend to make a lot more (upwards of double) and also tend to skew perceptions of doctors’ pay.
You could argue specialists should make less but considering how long it takes to become a doctor, how much work it takes to get there, how long you’re putting off real earning potential, school debt, etc., I do not consider 150k overpaid.
Other countries have double, even triple the number of physicians per capita. They also pay them a lot less. Are they all less competent? Are US filtering requirements actually all that predictive of future performance? Can we, say, see that MCAT scores really line up well with clinical performance? Because it's easy to be selective, but not so easy for the selectivity to be predictive of actual quality, especially when you are being selective before training starts.
They can make a lot more than 250K in less attractive places as well. But I believe the current cohorts of med students are more 'worldly' and in it for the money than in the past. They'll take getting paid 100K less so they can stay in a nice city and take another 50K less to work part time.
The author:
"Doctors are caught in a web of business, no longer a noble vocation. The altruism of young doctors have been replaced by the shackles of efficiency, productivity and key performance indicators."
The answer: here's some key performance indicator we can improve.
Speculating, but it could be a spiral where the shortage places more responsibilities on existing doctors, making the field less appealing to potential doctors. For too many people no amount of income compensates for a difficult lifestyle (we see this with air traffic control). If this were the case it would be productive to redesign medical systems to unburden doctors, but the current for-profit, scarcity-oriented system (in the US anyway) seems calibrated to squeeze everyone.
Most countries get good results with shorter training and much lower salaries. And, just like most other US university degrees, the majority of the filtering is done on entrance, not on training. So it's not that we are evaluating the best doctor, but the best diligent people that get great scores in the MCAT. Whether that actually lines up well with being a good doctor is not all that clear.
Here’s an excerpt from a study of more than 1m physicians:
> “Better examination performance was linked to improved adherence to mammography screening recommendations, appropriate prescribing practices, improved care of patients with diabetes, lower patient morbidity and mortality, fewer complaints to regulatory bodies, and lower malpractice payments. The association was observed across examination formats and medical specialties.”
It's low because there's no competition. MDs are like medieval guild: once you're in, you're set for life. Restrictive regulations are lobbied by MD associations, which limit competition.
Ha ha, but the joke is kind of wrong. While anyone with an MD degree is entitled to the honorific "doctor" that doesn't mean they can legally practice medicine. Becoming a licensed physician generally requires completing a residency program, and the worst students sometimes fail to get matched to the limited number of residency slots.
Yes it's a joke, but to quote some numbers in the US: something like 93% of the US graduates matched to a residency program [1], although the numbers were a lot lower for international students applying for US residency. So if you're talking about US medical students, you have to be in the bottom 10% to flunk out.
The attrition for lawyers is higher, neither has anything on PhDs where the number of "practicing" doctors drops off constantly during and after the degree, and only really levels off when O(10%) of them land faculty jobs.
Then you end up with students from places like Nepal and Pakistan, where cheating is so rampant that you can't really evaluate the quality of your medical student or applicant. Even standardized exams like the USMLE/STEP series have been gamed. You also end up with significant cultural mismatch. I don't believe this is a good solution.
anecdote alert: had a family member treated by a foreign doctor last year, and received advice from that doc that was both 1) highly dangerous, 2) bare minimum 20 years out of date.
Inconceivable that a domestically-trained doc would have made the same mistake.
Probably better solution is to upskill nurses + AI to do handle all the simpler tasks like prescribing standard treatments, etc. There's already a concept of mid-level practitioner which can be expanded.
This is so hilariously false and completely inverted that it shocks me that people not in medicine can believe it.
Out of respect for you as a fellow intelligent HN commenter — you are deeply misinformed, and I would urge you to reconsider your perspectives on this.
Every study shows that utilization of APPs and nurse practitioners Leads to decreased quality of care and a significant increase in utilization of other healthcare resources, like the emergency department and imaging, that better-trained physicians don't need.
Less-trained providers misdiagnose cancers, refer patients to the wrong specialists, overprescribe antibiotics, and generally cost the system significantly more in overall health load than if we had better-paid general practitioners. There is an argument that not enough physicians go into general practice, which is true, but it's because subspecialties are in such high demand that they're generally better paid. The unfortunate fix is that we need to find a way to better compensate primary care, even though Medicare physician reimbursement rates continually decline and our health insurance system is not well structured to support this kind of primary care model.
I've left a few links below if you'd like to read them:
There are several papers demonstrating AI is at least as good at diagnostics as fully qualified doctors. So why would NP + AI be worse? AI should compensate for the lack of knowledge.
And I'm not saying NP + ChatGPT - it should be properly calibrated system which would defer to a 'proper doctor' in more complex cases.
> AI is at least as good at diagnostics as fully qualified doctors
If the prompt is an expert-written board question! Not so with inferior prompts [0]. Critically, you need deep medical knowledge to interact correctly with the agent.
What you're asking is basically: "If we take someone out of a three month dev bootcamp, and have them prompt Claude, why can't they be as good as a four year CS grad?"
I doubt that you would feel similarly about expertise in your own field.
There have been a huge progress in AI reasoning in the past 2 years. GPT-4o mentioned in the article would struggle with high-school math problems, OTOH GPT-6 can solve problems beyond capability of professional mathematicians.
I'd wager GPT-6 would not depend on high-quality prompts, although it might still be good to get a trained person to enter information and do a sanity check.
The core problem still exists based on the clarity of the prompt. I am well aware of the intelligence explosion and I am very AI pilled.
However, seeing my wife's depth of intuition and expertise as a physician, compared to my comparatively caveman-like prompts when asking for health advice, there's a massive delta in accuracy.
Have you ever had a significant health issue and tried to get help from a model? Even something like GPT 6 Pro? The firehose and confusion you will generate trying to figure out answers are far less helpful than having directed interaction with a physician.
Following up on this because I've been thinking about why this is. I believe a big part of it is just that the intuitive parts of medicine are learned essentially by internship and therefore are not well encoded into the models. Unlike software, where you can have deterministic output that the models can train on, medical outputs are very fluid and dynamic. What works well in a paper, even though we claim to do evidence-based medicine, may be very far from what a "good" physician does in practice.
The issue is that the AI is at best what's in papers and medical records, which often forgoes the core thing that might lead a physician to uncover something or take a different approach with the patient.
It’s called physicians assistants and nurse practitioners. They are essentially exactly what’s you’re talking about. They make less and they have less training.
For a lot of specialties, we just don't have enough caseload to train doctors well enough. There is this meme that there's a cap on residency positions, which is the main limiter, but caseload is a significant limiter as well, especially for anything procedural or less knowledge-based.
> (speaking from US): The reality is we need more doctors. A lot more.
[Doctors only spend around 18% of their time with patients in the U.S.](https://pubmed.ncbi.nlm.nih.gov/40500897/) The rest is spent on administration. I respectfully contend that the bigger issue is not the number of doctors per patient (though I admit that it could be a contributing factors), but rather that successive bureaucracy and compliance and laws and insurance requirements and policies have resulted in a system which forces doctors away from patients and towards ass covering. Remove the bureaucracy and you instantly have 5x as many doctors, effectively. Add more doctors to the machine and the machine will only find more creative ways to waste their time and talents.
Re-engineer the entire US system or train more doctors…
> Remove the bureaucracy and you instantly have 5x as many doctors, effectively. Add more doctors to the machine and the machine will only find more creative ways to waste their time and talents.
That’s a huge leap and not at all evidenced by your comment.
I’m all for simplifying all these administrative stuff. But no, that will not solve the fact that we have way more people who are way sicker and fewer doctors for them.
Yes, that's true to an extent. Some administrative tasks can really only be done by the attending physician. Ultimately they're the ones taking legal accountability. But other tasks can be automated or shifted to cheaper employees or not done at all. The problem is that many health system managers and administrators treat physician time as an unlimited free resource and impose all sorts of extra burdens on them. This is one of the factors driving physicians to burn out and leave the profession, further exacerbating the shortage.
True, but the other side of that is a lot of primary care will be taken over by lower licensed PA/NP. We can't possibly train enough new physicians to meet the demand imposed by an aging population. It doesn't take a real doctor to deal with routine scrapes and sniffles.
Not enough doctors in the pipeline. The government gave doctor associations control over the pipeline and basically even encouraged reduction, because it increases wages. They don't want to many doctors. Lawyers do the same potentially even better.
I'm sure burnouts happen but the fundamental problem is the pipeline.
"I have lost control of my days. I had worked in a hospital where I was oncall 24/7, 12 days out of 14. I had fortnightly weekends off."
Medicine is ran by a bunch of creepy boards. "ACGME Review Committee for Dermatology." For example gets together and votes on how many Dermatologist we get, fun fact it doesn't go up much.
$They were so kind to add 400 more Dermatologist$ in the past decade to the student pipeline.$ What could the rea$son be?
What I would do if you are a doctor and don't hate humans - ask these boards to let more people in (hopefully Americans, but Americans have an uphill climb getting accepted with the flood of fraud applications from around the world).
How the US does scheduling is kind of insane. Doctors like pilots (and truck drivers in Europe) should have clear rules about how long they work with rest periods and so on. Giving people 24h shifts is nonsensical and insane.
And the interesting part is that health care is mostly privatized, while education is mostly public. So the private/public conversation may make very little sense.
I'm not suicidal and have never been suicidal or thought about suicide. I'm happy and in a good mood every day. If someone is thinking about suicide please reach out to me: rviragh@gmail.com I'll listen to your issues and concerns and we will find a better solution for you.
A suicidal feeling comes from persistent depression. Instead, if one immediately takes correct steps to revert one's unipolar depression, the suicidal feeling and unipolar depression both go away. In the case of this article, it stems from social factors, so maybe they should quit and find somewhere else to work with better hours.
Are these problems consistent all over the world, or are they particularly severe in certain countries? I assume there are many studies of this already so it would be good to understand whether this is a problem that has a solution.
I see a lot of comments that we need more doctors to be able to pay doctors less. There are of course exceptions but I really don't think 300k a year is unreasonable when coming out with nearly 600k in debt in a field with such high burn out and liability risk.
Unlike salary position that 300k, at least in my field, is all via private equity and we are all independent contractors--meaning does not include any vacation, any paid time off, any sick days, any retirement or medical care or insurance of any kind.
I have not seen a raise since I started which was prior to covid. I'm not saying I need a raise I am well paid but again to be 500k in debt with zero benefits and I see on Reddit buckees managers or UPS /fed ex drivers making 150 to 200k with benefits and the ability to call out sick and the ability to not lose everything because of a single case where you follow standard practices or guidelines followed around the country but something bad still happens.
I go to work everyday with the understanding that the majority of my colleagues have been sued and even if not career ending the stress is enormous. At work I wear a tracker so that every fart and cough and patent interaction can be tracked. A VIP club of patients that donates to the hospital can ruin me with some bad reviews. A stray comment about poor care by an ems crew can end my career (as they bring the hospitals patients).
I don't believe doctors are overpaid and we need more to bring their pay down. A patient will get billed 2000 dollars if they ask for a burrito out front in triage, walk in, are told by me that Taco Bell is across the street, and they promptly walk out without a single test done.
On the other hand I may see sixty people in a busy night which require procedures such as being intubated and put on a ventilator, fractures being reduced , etc.
A major problem is private equity in medicine. Everyone should be focused on removing these groups which skim money off everyone both doctors and patients included. Even if the argument that somehow their efficiency increases result in extra money to the system they can feed on there is no reason why hospitals can't group up and also be efficient and cut them out and pass down savings to the customer or not overwork us docs or treat us like expendable McDonald's employees. The lack of working directly for the hospital there is no metric for skill or seniority or anything like that you are an expendible piece of meat/fall guy that they load down with as many mid level providers as they can get away with
I wonder if "Dcotor" ought not be a short career—one where you transition out after, say, two decades. Perhaps they establish a role of mentor within hospitals where "aged-out" doctors can be a part of new surgeons surgeries.
> we need more doctors to be able to pay doctors less
I don't think this is really the point being raised. We need to relax the artificial constraints on the number of doctors. This would lead to more doctors. There's likely to be a side effect which is that doctors get paid less.
While the net effect is doctors getting paid less, it's not the reason.
> I see a lot of comments that we need more doctors to be able to pay doctors less. There are of course exceptions but I really don't think 300k a year is unreasonable when coming out with nearly 600k in debt in a field with such high burn out and liability risk.
Why would a doctor start their career with a 600k debt, though? THAT is the problem.
In Belgium you can start your career as a doctor with zero debt and around 75k salary, working 35 hours per week. It's comfortable and lets you live a normal life.
We still have a shortage of doctors though like everywhere else, regardless of how well or how bad doctors are paid.
Complicated question, speaking from the U.S. There are huge disparities in pay depending on specialties, and some specialties earn frankly far too much approaching $750,000 - $1,000,000 annual salary in some markets (think orthopaedic surgeons, neurosurgeons, interventional rediologists). The chance at obscenely high compensation convinces students to accrue huge amounts of debt and take on enormous personal risk. Meanwhile, few actually make it into these specialties and many end up in specialties with much lower compensation such as family and internal medicine. It's become a very high stakes system where the participants make huge sacrifices and take on enormous risk for enormous gain
I understand the point is not getting more doctors to pay doctors less.
However when people mention how getting more doctors will reduce physician pay naturally the argument they are putting forth is that somehow physician pay in America is higher than it should be.
That consumers are being gouged on scarcity. That physician pay is currently a "problem" that could be remedied if there was sufficient workforce and physician pay is responsible for your astronomical bills.
I do not think the salary has as much room to go down as people think given the 500k plus debt , years of schooling and residency , pressures of working the job , enormous liability , the fact the pay includes zero sick days /vacations , paid days of any kind , benefits, retirement, insurance etc.
My argument as a physician is this is the least of the problems in healthcare financing and your bill.
The two thousand dollar charge for waking into the hospital then promptly walking out was a real world example --not an exaggeration. The amount charged for that one patient would pay my wage for the night and it was 1 in 60 and took approximately 5 minutes. You can only imagine what the other 59 patients getting critical life saving procedures , CPR , etc are getting billed.
If anything reading this story made me think maybe physicians should be taken care of better and have vacations , time off , etc instead of everything being designed to grind them down.
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[ 18.7 ms ] story [ 1776 ms ] threadThere are are arguments to be made about private or public but that logic makes no sense.
Some system that have many private aspects outperform other public systems and the other way around. And even in a public system many people will profit as many of the companies that are your suppliers are still for profit.
Sounds like good logic to me, at least for essentials!
https://en.wikipedia.org/wiki/Holodomor
https://www.hrw.org/reports/2006/northkorea0506/1.htm
https://www.ebsco.com/research-starters/history/great-leap-f...
You can see a lot of the issues above from Mao's commune attempt (communes to manage food production, a system that also requires careful judgement). Studying the commune failures helps to shed light on gaps of the system and the issues of information flow.
The Doctor's post is arguing against an 'over-adminstrated' system that has become so efficient, it grinds the emotions of anyone who cares because they're left with no time for themselves.
As technologists: when we are burnt out we can step away (I'm oversimplifying, I know we have mouths to feed). When doctors burn out, people suffer: doctors or patients.
It may never be possible to fully patch the healthcare system because we simply cannot flow the patient diagnostic information into the doctors hear with 100% efficiency.
So we're left with looking at the problem as supply and demand....
There is a huge difference also between subsidizing demand with private supply and providing supply. Exactly the debate that is relevant in healthcare as well. A system can do both, or neither or a combination of the two.
Food is, in general, very accessible, cheap, and elastic (People's food decisions are easily changed depending on the price).
Healthcare in America is not accessible, extremely expensive, and inelastic.
We have not had a famine in the developed world in quite a long time, but the healthcare crises continues.
The fact remains clear: The number one cause of bankruptcy is medical debt.
Healthcare is the only service that is life and death, where the money paid by the patient is completely inelastic.
I'm not saying doctors shouldn't be paid well. But what is really clear is that while the rich pay for premium concierge VIP treatment, the poor are regularly turned away for treatment they can't afford. You health insurance here is tied to your job. Lose your job? Pay $2000/month for COBRA or you don't deserve to have healthcare.
Don't act like public healthcare, expanding access to primary care physicians, and reducing medical administrative bloat is some economic degeneration headed for the sickle and hammer. I'm tired of pretending Ayn Rand style libertarianism capitalism is the perfect solution that has worked for everything including healthcare.
Did I somehow make the argument that the US has a good health care system? I must have missed that.
> Healthcare is the only service that is life and death, where the money paid by the patient is completely inelastic.
Most healthcare spending isn't actually 'life and death' either. And even if it in the medium term is 'life and death' only a very small amount of health care is an emergency where you can not potentially consider different options.
Just as most time when you are going to the store its not 'life and death'. But still if don't do anything eventually you will starve.
> The fact remains clear: The number one cause of bankruptcy is medical debt.
My goal would be to achieve the best overall healthcare outcomes at reasonable cost. That's at least the first stab at a definition, I'm sure we could come up with a better criteria.
If you increase payroll taxes as much as a fully public system would required, you would just have more people default on their houses and cars instead. Because there is no world, no matter how many billionaires you disown, that you can implement a universal system without massive increases of income taxes.
Again I'm not even arguing that a universal system is bad or wrong thing to aim for. The argument that I actually made was that 'some people make profit' isn't actually a good argument against any system.
> Don't act like public healthcare, expanding access to primary care physicians, and reducing medical administrative bloat is some economic degeneration headed for the sickle and hammer. I'm tired of pretending Ayn Rand style libertarianism capitalism is the perfect solution that has worked for everything including healthcare.
You are literally just ranting about shit I have never argued. I guess I must have trigger something.
And it should be said that most 'small' farmers in the US are millionaire scions and shouldn't need subsidies to make a profit in most parts of the US (we have abundant natural resources).
More than half of all calories produced in the US are not even for human consumption. And globally enough calories to feed every human on earth are lost to inefficiency each year.
We can all benefit from a better system of distribution and production without getting lost in the magical thinking of a public/private false dichotomy.
Not sure why you are making an argument about food subsidizes to me, I have not argued in favor of them.
> More than half of all calories produced in the US are not even for human consumption.
Most of those go threw animals and are then consumed by humans. There is a lost factor there but saying its not for human consumption misses the point I would say. For Chicken, Pork and fish the lost factor is pretty small.
Yes, you can allow patients to go uncovered. This hero mentality is what leads the bosses to not properly staff and the politicians to not properly fund in the first place.
It is not an individual’s responsibility to correct a societal failure by hurting themselves.
Those nurses saved many people! It was worth it!
We all want more and better health services, but our economies do not have infinite resources.
And few people are reasonable about restrictions because how do we cost life or health?
Death is predictable, our responses are unreasonable.
> I had worked in a hospital network that covered 4 campuses and drove 500kms a week when covering these sites. I had worked in a hospital where I didn’t get home for days at a time, sleeping overnight in hospital quarters, outpatient clinic benches and in my car.
As a patient, I'd like the person performing surgery on me to be well-rested!
It gets worse:
> I used to be able to arrange the operating list because I know that some operations take longer than others. But now, the bookings office determine that that all my tonsillectomies take 14 minutes because that’s the average time recorded on the computer. The moment I scrub in, the timer starts. The moment I unscrub timer stops. Click. Click. Click. Because the theatre bookings does not take into account the interpreter time, pre-med period or transfer to ICU, the list is running late. The nurse in charge is breathing down my neck to finish on time.
And yet somehow that 14 minute tonsillectomy gets billed at ~$10,000.
This seems to me like a system that has been hyperoptimized in a way that grinds down the participants.
There's no solution other than training a lot, lot, lot, lot more doctors.
Their salaries need to be lower, training needs to be cheaper and faster, and we need a lot more of them.
I can’t even get basic foot stuff covered, they won’t care until my feet and knees land me under “disability,” so people like me - but unlike me they can’t afford to spend hundreds more a year on special inserts and shoes - just keep doing what they’re doing until they’re hurt.
People go to the grocery store and marketing teams are trying to sell them “vitamin water” which is neither of those things, so they have to do tons of research and pay constant attention to literally every food they buy. Then when they get hurt they can’t afford to go to a doctor and the insurance that is sucking up huge amount amounts of their annual pay doesn’t pay for it either.
Meanwhile we have a US administration that is telling everybody, a population that is incredibly predisposed to heart disease already, to go eat more red meat. Also, they have spent a decade telling people that vaccines are shady and maybe they shouldn’t get them. How much damage have we done to preventative care with that one?
I could go on and on, I’m barely covering the breadth and depth of this problem. We can’t just call it “personal responsibility” or whatever
https://www.healthcare.gov/coverage/preventive-care-benefits...
I think most people agree that insurance companies’ idea of what is “justified” is far too narrow. That’s the issue I’m pointing to.
And who cares if the analysis costs me nothing? Why is that something I should be grateful for?
At a first level the federal government publishes a set of medically unlikely edits used to deny claims when procedure codes don't align with diagnosis codes. It's used by Medicare, and most Medicaid agencies and commercial health plans have also adopted it.
https://www.cms.gov/medicare/coding-billing/national-correct...
At the next level most commercial health plans have adopted clinical care guidelines published by vendors like MCG. These vendors take publications from specialist medical societies and codify them to determine what's medically justified and set step therapy requirements.
https://www.mcg.com/solutions/care-guidelines/
At the final level, providers can appeal denials to human nurses and doctors who do case review at insurance companies (peer-to-peer). In a huge healthcare system there are always patients with unique needs who don't fit the pattern in published care guidelines. Dealing with those appeals is a major administrative burden and often badly managed on both sides of the adversarial interaction.
Most US-based HN users are on commercial self-funded group health plans sponsored by their employers. The Affordable Care Act (ACA / Obamacare) establishes a baseline for what's covered but ultimately the decisions are made by employer HR departments. Insurance companies would be happy to offer custom health plans that paid every claim at 100% with zero denials or prior authorization requirements; it would mean less work and higher profits for them. But no employer wants to pay for that so the insurance companies take measures to hold down costs.
Speaking from Romania: here medicine is prestigious. So many parents push their kids towards medicine. There's a glut of newly minted doctors every year, but rumour has it that the quality drops every year. Sure, they pass the exams and residency and what not, but... They're just not into medicine as much.
Do you want to get treated by such a person?
This year I had to go to a neurologist. I went to one locally, they dismissed me in 5 minutes, told me to take some vitamins basically. Went to another one in a much bigger city, they talked to me for an hour, ordered a ton of tests.
Would it help if we get a lot more of the first kind of doctors?
I'll give you some N=1 sample on older doctors since I'm also from Romania: a lot of these older doctors haven't opened a book in a very long time and are still using older practices instead of providing their patients with the latest and most effective treatments available because they're too lazy and/or prestigious to go and learn new things. Would you say that they "into medicine"?
> Would it help if we get a lot more of the first kind of doctors?
It would certainly help hypochondriacs a lot. Ordering "a ton of tests" needs to have some basis behind it, and doing it just to make the patient "feel seen" is not a great way to do your profession. People being dismissed quickly also happens in the US quite a lot, sometimes with disastrous results though it's not incredibly common, it's typically labeled under "diagnostic error" https://qualitysafety.bmj.com/content/23/9/727.long
Hard to tell when you don't let us know which of those doctors ended up solving the issues that made you seek a doctor.
Dismissive doctors are bad but so are those that waste your time and risk complications from unnecessary invasive tests.
In the US, medical school is extremely expensive (like $400,000 expensive). There are many people who are excellent doctors who are just priced out of the profession. If we could make medical school less expensive (by subsidizing it and by reducing the amount of instruction), we would probably get many more excellent doctors.
The average med school debt is half that and only 30% of borrowers end up owning $300k or more.
Fewer than 1% of us med school graduates never find a slot. And that includes people who start families, move into industry etc and voluntarily leave.
The bottleneck is residency slots not med school slots.
Right, because they are paying for it out of pocket
Also the bottleneck is residency slots, so even if this is the case, it wouldn’t change anything.
You do the math: over a 10 year repayment period with compound interest, their education cost them MILLIONS and they'll be well into their 40s before they start saving a dime for retirement. The cost and scarcity of medical education is extremely punitive to doctors and prices out many would-be great physicians. Many I know who have gone through this ended up regretting it due to the enormous financial burden they are saddled with for many years after becoming an attending.
Maybe folks believe these professions should be reserved to those who inherit great amounts of generational wealth.
The average debt is a little over $200k. Only 30% of graduates have over $300k in debt and they are considered high debt graduates.
Family Medicine salaries are above $200k in every state in the nation for full time doctors.
None of the doctors I know come from families with generational wealth.
Here is the nationwide average for resident salaries by year
Program year 1—$68,166. Program year 2—$70,499. Program year 3—$73,301. Program year 4—$77,593. Program year 5—$81,807. Program year 6—$84,744. Program year 7—$89,187. Program year 8—$94,215.
Your entire picture is inaccurate.
The resident salaries that you listed are an average taken across all specialties. Family Medicine is the lowest paid specialty with 2026 PGY-1 salaries at $58,500 (representing an increase of over 15% since 2021) [2] That is simply not enough to pay the cost of living in a state like Massachusetts where the median household income is more than double that [3] and the average rent in Boston metro is almost $40,000 annually [4]. Not only can you not afford to pay down your student loan debt, you are extremely likely to accrue additional consumer debt on things like credits cards or vehicles.
My main point is that training to become a doctor carries so much financial risk that it selects against folks from poor socioeconomic backgrounds that would otherwise make great physicians. In 2018 the AAMC published a study showing that 51% of medical school matriculants were from families in the top quintile for family income [5] and if I were a betting man, I'd guess that proportion has only increased.
1. https://www.kff.org/state-health-policy-data/state-indicator...
2. https://www.inspiraadvantage.com/blog/how-much-do-medical-re...
3. https://fred.stlouisfed.org/series/MEHOINUSMAA672N
4. https://www.zillow.com/rental-manager/market-trends/boston-m...
5. https://www.aamc.org/media/9596/download
Sure. But that’s not what you said. You said you had many fiends that graduated med school with $500k-$750k in debt. I think you were lying or your definition of many was highly exaggerated.
> That is simply not enough to pay the cost of living in a state like Massachusetts
$58k is the national average. Not the average in a high cost of living area like Massachusetts.
> My main point is that training to become a doctor carries so much financial risk that it selects against folks from poor socioeconomic backgrounds that would otherwise make great physicians.
There is almost zero financial risk.
Eventual graduation rate is 96%. Eventual match rate is around 99%.
Are there doctors that could have make more money going into finance sure. Are there doctors who are financially ruined, not meaningfully.
>In 2018 the AAMC published a study showing that 51% of medical school matriculants were from families in the top quintile for family income
1. Doctors kids are more likely to become doctors.
2. High income is correlated with intelligence and intelligence is partially heritable.
3. Kids from high income families are more likely to have extended family and friends who are editors who encourage them to become doctors.
4. Med school requires college and college and children from income families are much more likely to have college degrees.
5. Medical school entrance is competitive and high income kids are much more likely to go to better colleges.
6. High income kids are much more likely to have higher grades in college because they don’t have to work.
7. High income kids are much more likely to go to better high schools which impacts what college they get into and how well they do there.
The list goes on and on. The cost of medical school is so far down that list.
I think it’s more likely you’re just exaggerating. How many is many? If you personally know more than 5 doctors with $500k-$750k in debt after med school I’ll eat my hat.
> Residency match rates for American graduates from American MD or DO programs are more like 93%
That’s only after primary march. Match rate after SOAP is 98%. Roughly half of the unmatched 2% get marched in the next max cycle which is where I got 99%. Of the remaining 1% most of those want to eventually place somewhere.
>For American IMGs
Yeah don’t go to a factory medical school in the Caribbean. It’s a bad idea.
It’s definitely almost 0 financial risk. The only real risk is that you just hate being a a doctor. But even in that case med school unlocks tons of opportunities outside of clinical practice.
The chance of you ending up suffering financial hardship is too small to consider in your decision making.
The real out of your control risks would be severe disability that prevents you from finishing med school or working (before you can afford disability insurance). But in the case it really doesn’t matter whether you owe $50k from undergrad or $250k from med school. You’re not paying either one back and you can actually bankrupt out of student loan debt in those cases.
We have the Public Service Loan Forgiveness program where qualifying public servants pay 10 years of their loans and the rest is forgiven tax free.
Removing financial stress from doctors seems like a public good most people could get behind
https://students-residents.aamc.org/medical-school-admission...
The prior post was specifically talking about the US. (I assure you, arrogant dismissive doctors are also a thing in the US)
In the US, there are a number of things that artificially increase the barriers to becoming a doctor.
1) You typically need a four year college degree to apply to medical school
2) Medical schools are accredited by the AMA, which is controlled by doctors. The AMA makes it very difficult to start a new MD-granting medical school.
3) Medical school in the US is very competitive to get in. They are likely turning away a lot of people who could complete the degree.
4) Since 1997, the federal government has a fixed number of Medicare (Medicare is a federal health insurance program for people over 65) supported residency positions. That number was basically flat for 25 years. We lost about 20% per capita of doctors being trained with support from this program. The caveat to this is that the total number of residents per capita has increased over time, particularly the past 15 years or so. My understanding is that they are less likely to be fully funded, so they spend more money getting trained, and then have higher students loans (on average graduating with debt above 200k going back to the late 2000s) that they need to pay off, so they charge more.
And you can add to this that it can be very difficult to be a doctor in another country and come to the US to practice here.
The entire salary for the resident can be earned back in 3-4 days. You still have 360 days left to pay back admin overhead, facility overhead, supplies, etc. That is earned back in the next several weeks. After that, the next ~300 days of the year are profit.
In states with balance billing, the doctor can set any price and bill you for the remaining figure with a balance bill. In NY and NJ these can be thousands or tens of thousands. If you dont pay, it goes to collection and the provider still gets 10 to 15 cents on the dollar. So no...the $75k annuals alary of a resident is not a barrier to training more doctors.
What seems more likely is that supply is artificially constrained to increase scarcity and prices. What am I missing?
Anyone here should be familiar with the ""sAfEtY"" argument at this point.
Several things.
First, private practice docs see patients with very good employer provided insurance, but residents are largely seeing patients that private practices wont see - patients who are far too medically complex to fit into a 10 minute slot and who also have particularly stingy insurance.
So as opposed to a private practice doc who is seeing 30 patients per day and billing an a average of $250 to $300 per patient (certainly not $1000 - that is unrealistic in my experience), a resident is seeing more like 10 to 15 patients per day (30 minute slots) and billing less than $100 per patient.
Second, residents have to be supervised. You have not included the salary of the physicians supervising them in your calculation.
Third, and I have mentioned this many times before on HN, training is limited by chiefly by the number of training sites that can offer quality training. For example, most hospitals will not see a single case of Guillan-Barre in a single year. Would you want to be treated by a nuerologist who trained at such a hospital? This is why neurology training is generally limited to places with a high volume of neurologic cases that would be considered rare at the average hospital, and these hospitals can only accommodate so many residents. Even for general medicine, you probably do not want to be treated by a doctor who trained at a hospital where any case that passed a certain complexity was transferred out to a bigger center.
There are arguments that these are factors that filter out the people who are not sufficiently motivated, but it's hard for me to imagine there aren't a lot of bright young people who might be interested in medicine, but see one of the various paths that exist today to making doctor-level money with only an undergraduate degree and in an environment that doesn't require a working schedule that actively harms your health.
Depends? Did the tests actually find anything, or did they just make you feel better?
I had a talk with my GP about this at some point, and he more or less told me that he can just say "Go home, rest, come back in two weeks if it doesn't get better.", and 95% of the time that'll be exactly what is necessary. The hard part of his job is figuring out which of the visits are those 5%.
Speaking from Poland, we see the same outcome: doctors rushing patients out after 5 minutes. The reasons may be different, though: since COVID, many doctors here have, in my view, become more arrogant and focused on money. Over the past few months, an uproar over doctors’ pay has swept through Polish social media.
Reports have emerged of doctors billing for overlapping work under multiple contracts. In one case, a doctor’s records showed 72 hours of work in a single day!
Meanwhile, the Polish Chamber of Physicians and Dentists (NIL) continues to defend caps on medical school admissions, adding fuel to the national debate.
We need to reduce the requirements to be a doctor. I think general ability is way way way more important than the specialisation. I don't think the speciality that doctors spend money and time on add that much value..
So you’re doing a few things.
1. Moving more training from cheaper colleges to more expensive medical schools.
2. Moving the filter from undergrad to medical school
3. There is no national curriculum in US high schools, so essentially the first 2 years is getting everyone on the same footing. Removing this without changing high school, puts students at poor high schools at an even greater disadvantage.
https://students-residents.aamc.org/medical-school-admission...
Of the ones that do save time, most cut 1 year off not 2. And they do it by having students take more than a full time load during undergrad.
It’s essentially the same thing as taking an extra class or 2 every semester so you can finish undergrad in 3 years instead of 4.
I randomly sample 15 of the programs listed there and 14 were 8 year programs. Only 1 had an optional 7 year program (if you were willing to take more than full time load or go to school in summmer). And there were no 6 year programs.
No, the reality is we should be more healthy, so we need less doctors.
[0] https://www.calculatedriskblog.com/2013/08/us-population-dis...
I think building a better prevention layer is more important.
Don't get me wrong, I agree that we need more doctors (and nurses, and physios, and dietetists, and ...), but it is much easier to scale a good prevention system than the number of workers in healthcare.
A significant amount of cases could be prevented before they need medical intervention (and put burden on the medical system). There are several researches about this, the number of people with type 2 diabetes doubled in the past decades.
To be clear I'm not suggesting that everyone should be on GLP-1 drugs, and it's obviously better to maintain a healthy lifestyle and body composition without those drugs. But for people who can't or won't do that on their own the drugs seem to work pretty well. There's also promising evidence that they cause reduction in alcoholism and other substance abuse disorders.
Edit: I should have mentioned that pediatrics and family medicine represent a large proportion of available residency spots each year and are rarely full.
You could argue specialists should make less but considering how long it takes to become a doctor, how much work it takes to get there, how long you’re putting off real earning potential, school debt, etc., I do not consider 150k overpaid.
You certainly could if you were willing to accept people who are terrible at being a physician.
The notion that you can just throw more warm bodies at the problem is ludicrous
sucks but that's incentives for ya
The answer: here's some key performance indicator we can improve.
Sigh.
I have no idea what this might be.
The quality of the average physician is already so low I am not sure what you are hoping to accomplish with lower salaries and faster training.
Doctoring isn't a matter of more warm bodies
> “Better examination performance was linked to improved adherence to mammography screening recommendations, appropriate prescribing practices, improved care of patients with diabetes, lower patient morbidity and mortality, fewer complaints to regulatory bodies, and lower malpractice payments. The association was observed across examination formats and medical specialties.”
https://academic.oup.com/academicmedicine/article-abstract/1...
Unfortunately, it’s very clear.
Q: What do you call the worst student to be admitted to medical school?
A: Doctor.
The attrition for lawyers is higher, neither has anything on PhDs where the number of "practicing" doctors drops off constantly during and after the degree, and only really levels off when O(10%) of them land faculty jobs.
[1]: https://www.ama-assn.org/medical-students/preparing-residenc...
Seems like having doctors emigrate from other countries would work as well.
Inconceivable that a domestically-trained doc would have made the same mistake.
There's basically no need for GP to be a doctor.
Out of respect for you as a fellow intelligent HN commenter — you are deeply misinformed, and I would urge you to reconsider your perspectives on this.
Every study shows that utilization of APPs and nurse practitioners Leads to decreased quality of care and a significant increase in utilization of other healthcare resources, like the emergency department and imaging, that better-trained physicians don't need.
Less-trained providers misdiagnose cancers, refer patients to the wrong specialists, overprescribe antibiotics, and generally cost the system significantly more in overall health load than if we had better-paid general practitioners. There is an argument that not enough physicians go into general practice, which is true, but it's because subspecialties are in such high demand that they're generally better paid. The unfortunate fix is that we need to find a way to better compensate primary care, even though Medicare physician reimbursement rates continually decline and our health insurance system is not well structured to support this kind of primary care model.
I've left a few links below if you'd like to read them:
https://static1.squarespace.com/static/615326dd2c363f1e2a5c8...
https://www.ovid.com/journals/jaderm/abstract/10.1001/jamade...
https://pmc.ncbi.nlm.nih.gov/articles/PMC5047413/
And I'm not saying NP + ChatGPT - it should be properly calibrated system which would defer to a 'proper doctor' in more complex cases.
If the prompt is an expert-written board question! Not so with inferior prompts [0]. Critically, you need deep medical knowledge to interact correctly with the agent.
What you're asking is basically: "If we take someone out of a three month dev bootcamp, and have them prompt Claude, why can't they be as good as a four year CS grad?"
I doubt that you would feel similarly about expertise in your own field.
[0]: https://www.nature.com/articles/s41746-026-02428-5.pdf
I'd wager GPT-6 would not depend on high-quality prompts, although it might still be good to get a trained person to enter information and do a sanity check.
However, seeing my wife's depth of intuition and expertise as a physician, compared to my comparatively caveman-like prompts when asking for health advice, there's a massive delta in accuracy.
Have you ever had a significant health issue and tried to get help from a model? Even something like GPT 6 Pro? The firehose and confusion you will generate trying to figure out answers are far less helpful than having directed interaction with a physician.
The issue is that the AI is at best what's in papers and medical records, which often forgoes the core thing that might lead a physician to uncover something or take a different approach with the patient.
Not true.. according to most around here, it will be AI and robots all the way.
It’s called physicians assistants and nurse practitioners. They are essentially exactly what’s you’re talking about. They make less and they have less training.
[Doctors only spend around 18% of their time with patients in the U.S.](https://pubmed.ncbi.nlm.nih.gov/40500897/) The rest is spent on administration. I respectfully contend that the bigger issue is not the number of doctors per patient (though I admit that it could be a contributing factors), but rather that successive bureaucracy and compliance and laws and insurance requirements and policies have resulted in a system which forces doctors away from patients and towards ass covering. Remove the bureaucracy and you instantly have 5x as many doctors, effectively. Add more doctors to the machine and the machine will only find more creative ways to waste their time and talents.
> Remove the bureaucracy and you instantly have 5x as many doctors, effectively. Add more doctors to the machine and the machine will only find more creative ways to waste their time and talents.
That’s a huge leap and not at all evidenced by your comment.
I’m all for simplifying all these administrative stuff. But no, that will not solve the fact that we have way more people who are way sicker and fewer doctors for them.
At least as first line docs.
But what the author describes - fuck no, this is absolute unsustainable madness. Race to the bottom. I’d rather fix plumbing at my own pace.
This is Going to Hurt: Secret Diaries of a Junior Doctor by Adam Kay
https://en.wikipedia.org/wiki/This_Is_Going_to_Hurt_(TV_seri...
I'm sure burnouts happen but the fundamental problem is the pipeline.
Medicine is ran by a bunch of creepy boards. "ACGME Review Committee for Dermatology." For example gets together and votes on how many Dermatologist we get, fun fact it doesn't go up much.
$They were so kind to add 400 more Dermatologist$ in the past decade to the student pipeline.$ What could the rea$son be?
What I would do if you are a doctor and don't hate humans - ask these boards to let more people in (hopefully Americans, but Americans have an uphill climb getting accepted with the flood of fraud applications from around the world).
Why? Do you think Americans make better doctors?
I'm in the process of leaving the profession.
I don't feel guilty for the patients who will be left behind, they voted for this.
A suicidal feeling comes from persistent depression. Instead, if one immediately takes correct steps to revert one's unipolar depression, the suicidal feeling and unipolar depression both go away. In the case of this article, it stems from social factors, so maybe they should quit and find somewhere else to work with better hours.
Unlike salary position that 300k, at least in my field, is all via private equity and we are all independent contractors--meaning does not include any vacation, any paid time off, any sick days, any retirement or medical care or insurance of any kind.
I have not seen a raise since I started which was prior to covid. I'm not saying I need a raise I am well paid but again to be 500k in debt with zero benefits and I see on Reddit buckees managers or UPS /fed ex drivers making 150 to 200k with benefits and the ability to call out sick and the ability to not lose everything because of a single case where you follow standard practices or guidelines followed around the country but something bad still happens.
I go to work everyday with the understanding that the majority of my colleagues have been sued and even if not career ending the stress is enormous. At work I wear a tracker so that every fart and cough and patent interaction can be tracked. A VIP club of patients that donates to the hospital can ruin me with some bad reviews. A stray comment about poor care by an ems crew can end my career (as they bring the hospitals patients).
I don't believe doctors are overpaid and we need more to bring their pay down. A patient will get billed 2000 dollars if they ask for a burrito out front in triage, walk in, are told by me that Taco Bell is across the street, and they promptly walk out without a single test done.
On the other hand I may see sixty people in a busy night which require procedures such as being intubated and put on a ventilator, fractures being reduced , etc.
A major problem is private equity in medicine. Everyone should be focused on removing these groups which skim money off everyone both doctors and patients included. Even if the argument that somehow their efficiency increases result in extra money to the system they can feed on there is no reason why hospitals can't group up and also be efficient and cut them out and pass down savings to the customer or not overwork us docs or treat us like expendable McDonald's employees. The lack of working directly for the hospital there is no metric for skill or seniority or anything like that you are an expendible piece of meat/fall guy that they load down with as many mid level providers as they can get away with
I know, never gonna happen.
I don't think this is really the point being raised. We need to relax the artificial constraints on the number of doctors. This would lead to more doctors. There's likely to be a side effect which is that doctors get paid less.
While the net effect is doctors getting paid less, it's not the reason.
Their work and living conditions are probably quite different from those of American doctors.
Why would a doctor start their career with a 600k debt, though? THAT is the problem.
In Belgium you can start your career as a doctor with zero debt and around 75k salary, working 35 hours per week. It's comfortable and lets you live a normal life.
We still have a shortage of doctors though like everywhere else, regardless of how well or how bad doctors are paid.
I understand the point is not getting more doctors to pay doctors less.
However when people mention how getting more doctors will reduce physician pay naturally the argument they are putting forth is that somehow physician pay in America is higher than it should be.
That consumers are being gouged on scarcity. That physician pay is currently a "problem" that could be remedied if there was sufficient workforce and physician pay is responsible for your astronomical bills.
I do not think the salary has as much room to go down as people think given the 500k plus debt , years of schooling and residency , pressures of working the job , enormous liability , the fact the pay includes zero sick days /vacations , paid days of any kind , benefits, retirement, insurance etc.
My argument as a physician is this is the least of the problems in healthcare financing and your bill.
The two thousand dollar charge for waking into the hospital then promptly walking out was a real world example --not an exaggeration. The amount charged for that one patient would pay my wage for the night and it was 1 in 60 and took approximately 5 minutes. You can only imagine what the other 59 patients getting critical life saving procedures , CPR , etc are getting billed.
If anything reading this story made me think maybe physicians should be taken care of better and have vacations , time off , etc instead of everything being designed to grind them down.