Why doctors in America earn so much(economist.com)
economist.com
Why doctors in America earn so much
https://www.economist.com/united-states/2023/10/31/why-doctors-in-america-earn-so-much
592 comments
https://web.archive.org/web/20231101143856/https://www.econo...
There is absolutely a shortage of doctors. AMA is unwilling to fix this and instead rely on a system that drives many to suicide.
My wife is a doctor. I’m a software engineer. While she now makes more than I do, it took nearly 10 years. That whole time, we were racking up tuition/debt on tuition. Residency was demanding and severely underpaid.
Based on our math, we’ll be 25 to 30 years into our careers before her medical education with have a better ROI than my career choice. I didn’t even push for top-dollar jobs.
In other word, medical training had a huge opportunity cost. Even if you solve the bottleneck of residency placement, salaries need to offset the insane burden of training.
My wife is a doctor. I’m a software engineer. While she now makes more than I do, it took nearly 10 years. That whole time, we were racking up tuition/debt on tuition. Residency was demanding and severely underpaid.
Based on our math, we’ll be 25 to 30 years into our careers before her medical education with have a better ROI than my career choice. I didn’t even push for top-dollar jobs.
In other word, medical training had a huge opportunity cost. Even if you solve the bottleneck of residency placement, salaries need to offset the insane burden of training.
Similarly, my husband is a commercial pilot and is now starting to make more money than me in tech after his 10+ years of underpaid work and a high student loan debt load.
But, here's the deal: he's basically going to make top dollar until he's 65. Meanwhile, I'll likely be seen as a dinosaur in tech by that age and will be lucky to find work at all.
I imagine your wife will be seen the same way. She can comfortably work until retirement age, in an profession that sees experience as a positive thing, while you might be a pariah before you know it.
Yes, we make good money when we're young in tech. But we age out much more quickly due to the bias common in our industry.
But, here's the deal: he's basically going to make top dollar until he's 65. Meanwhile, I'll likely be seen as a dinosaur in tech by that age and will be lucky to find work at all.
I imagine your wife will be seen the same way. She can comfortably work until retirement age, in an profession that sees experience as a positive thing, while you might be a pariah before you know it.
Yes, we make good money when we're young in tech. But we age out much more quickly due to the bias common in our industry.
Maybe I am naïve but I don't get this age vibe really. I do backend java distributed system stuff for a large company. A lot of my peers and managers are "older" 40s and 50s with kids. A lot of the work is high collaborative and design focused. Maybe I am just in a bubble of an aging tech stack but it does seem like we are always using "new" (at least different) databases, caching, and network layers to stay somewhat current.
Its hard to imagine that 5,10,15 years of distributed systems and system design experience and knowledge along with domain knowledge and social skills will be all of a sudden be so irrelevant that it is worth phasing all of us "old guys" out for someone who happened to learn the newest programming language straight out of school.
We are constantly expected to learn the new stuff and will just a project assigned with a mandate "okay this is to be done in spring boot, using this DB, this HTTP layer, etc...
Its hard to imagine that 5,10,15 years of distributed systems and system design experience and knowledge along with domain knowledge and social skills will be all of a sudden be so irrelevant that it is worth phasing all of us "old guys" out for someone who happened to learn the newest programming language straight out of school.
We are constantly expected to learn the new stuff and will just a project assigned with a mandate "okay this is to be done in spring boot, using this DB, this HTTP layer, etc...
It’s the bubble of very online people and start up culture who think tech people age out at 40. I know plenty of devs in theirs 50s, after that they just take early retirement since they’ve earned enough.
Most devs aren’t terminally online, they treat coding as a job not a lifestyle and for them it’s just like any other industry - so you don’t hear from them.
Also, some devs retire into SQL and DBA like work since you can basically make yourself unfireable if you want to coast out the last decade of your career.
Most devs aren’t terminally online, they treat coding as a job not a lifestyle and for them it’s just like any other industry - so you don’t hear from them.
Also, some devs retire into SQL and DBA like work since you can basically make yourself unfireable if you want to coast out the last decade of your career.
> ... to coast out the last decade of your career.
Here right now the age vibe is coming from ;) It's not like a doctor can coast it out (or maybe I'm also naive).
(I'm an employer as of now)
Here right now the age vibe is coming from ;) It's not like a doctor can coast it out (or maybe I'm also naive).
(I'm an employer as of now)
Grey beard here. The last interview I had with a company was with the CEO (no beard) that could barely stay awake because he had been up all night (think Sam Altman with scurvy). I seriously doubt he remembered anything about me. That one experience let me know that I would not be doing the "coasting" being referred to in this thread. Instead I would be losing sleep repairing the mistakes from bad decisions and lack of experience which would ultimately lead to a dead startup. Thank you no.
There was a time when machismo was my middle name (much younger) and would have seen that as necessary for a successful startup. Now that I have several startups behind me I see it as simply bad management which decreases your chance for success which is stacked against you from the beginning anyway.
That was several years ago. I don't think that startup exist any longer.
There was a time when machismo was my middle name (much younger) and would have seen that as necessary for a successful startup. Now that I have several startups behind me I see it as simply bad management which decreases your chance for success which is stacked against you from the beginning anyway.
That was several years ago. I don't think that startup exist any longer.
I have often wondered if any VCs would allow a group of experienced devs to PE zombie startups, roll them up for pennies to see if any have an unexplored nugget of traction
I would argue that a coasting grey beard could easily be better than a mid level dev with maybe 5 years experience.
I run a contract shop and all my best DB guys are greybeards... coasting. It doesn't matter, after so many years with postgres & MySQL they are amazing.
I run a contract shop and all my best DB guys are greybeards... coasting. It doesn't matter, after so many years with postgres & MySQL they are amazing.
I take chill in-the-flow steady progress over hyper rah-rah-rah windmill attacks any day, week, and month.
Agree, with DBA or system administration it's possible. Not so with UI/frontend development, for some reason that's always a rush.
I would probably differentiate by work visibility: good work in DBA/sysadmin/security/accounting/quality is invisible, you only notice those folks when they have screwed up.
With product/UX/new features it's the other way around, coasting is not possible.
I would probably differentiate by work visibility: good work in DBA/sysadmin/security/accounting/quality is invisible, you only notice those folks when they have screwed up.
With product/UX/new features it's the other way around, coasting is not possible.
> With product/UX/new features it's the other way around, coasting is not possible.
That very much depends on the application. I maintain some enterprise solutions for customers. Clients get upset if UI has flow changes. Also, changes don't make me money unless they are required for a new customer. I will do it on request and invoice for the work but no one is interested in change for the most part. I think this is VERY common in enterprise software.
That very much depends on the application. I maintain some enterprise solutions for customers. Clients get upset if UI has flow changes. Also, changes don't make me money unless they are required for a new customer. I will do it on request and invoice for the work but no one is interested in change for the most part. I think this is VERY common in enterprise software.
I meant nothing negative with my "retire into SQL" comment :-) some of the most fun I've had in my career is picking through a 25 year old SQL database understanding how it all works.
Exactly, I work in enterprise and there are several guys past retirement age and they're the most productive and valuable guys we have. In other words, it probably makes sense to move away from startups as you age.
I've worked with plenty of folks that are well past 40 and are thriving!
> It’s the bubble of very online people and start up culture who think tech people age out at 40
Shhh... please don't tell the tech bros that there is a world outside of the Silicon Valley bubble!
Where you can raise a family and make a good living working 9-5.
Where you are not constantly trying to ruin and exploit the lives of normal people to make a short term gain.
Where most of the actual work keeping the world afloat happens.
It is better for us working dinosaurs that way.
Shhh... please don't tell the tech bros that there is a world outside of the Silicon Valley bubble!
Where you can raise a family and make a good living working 9-5.
Where you are not constantly trying to ruin and exploit the lives of normal people to make a short term gain.
Where most of the actual work keeping the world afloat happens.
It is better for us working dinosaurs that way.
It's still unfortunately common, because there are always young workers in the pipeline.
HP: https://news.ycombinator.com/item?id=38043552 ("It took seven years but over-40s fired by HP win $18M settlement")
IBM: https://www.diversityjobs.com/career-advice/team-building/ho... (Control-f "Sources")
https://features.propublica.org/ibm/ibm-age-discrimination-a... ("ProPublica: Cutting 'Old Heads' at IBM")
https://www.forbes.com/sites/jackkelly/2023/02/17/prior-agei... ("Prior Ageism Allegations At Google, Facebook And IBM Raise Concerns About Older Workers Being Targeted For Termination")
https://news.ycombinator.com/item?id=14932680 ("HN: Ageism is forcing many to look outside Silicon Valley")
https://www.orangecountyemploymentlawyersblog.com/dfeh-90-ag... ("DFEH: 90 Age Discrimination Complaints Filed Against Tech Firms Since 2012")
HP: https://news.ycombinator.com/item?id=38043552 ("It took seven years but over-40s fired by HP win $18M settlement")
IBM: https://www.diversityjobs.com/career-advice/team-building/ho... (Control-f "Sources")
https://features.propublica.org/ibm/ibm-age-discrimination-a... ("ProPublica: Cutting 'Old Heads' at IBM")
https://www.forbes.com/sites/jackkelly/2023/02/17/prior-agei... ("Prior Ageism Allegations At Google, Facebook And IBM Raise Concerns About Older Workers Being Targeted For Termination")
https://news.ycombinator.com/item?id=14932680 ("HN: Ageism is forcing many to look outside Silicon Valley")
https://www.orangecountyemploymentlawyersblog.com/dfeh-90-ag... ("DFEH: 90 Age Discrimination Complaints Filed Against Tech Firms Since 2012")
To be fair, you're comparing 55 year olds with 65 year olds. Every 55 year old in tech I've spoken with is talking about retiring "soon" (although soon always ends up being 2 years later every time they mention it). Every 55 year old doctor I know doesn't even have retirement on their radar and would probably work till they're 70+ if they could.
Ageism in tech starts at 50+ (probably even earlier). Ageism in healthcare probably starts at around 80 and at that point it's only because the doctor's not physically able to perform safely.
Ageism in tech starts at 50+ (probably even earlier). Ageism in healthcare probably starts at around 80 and at that point it's only because the doctor's not physically able to perform safely.
Thanks to compound interest, the money you can save early in life is exponentially more important than the money you can make later in life.
Many programmers started making money to invest in their teens, and save those who pursued other careers before pivoting, all were making money to invest by the time they are in their early 20s. Meanwhile, the doctors were racking up the debt until nearing 30. That decade plus is a huge setback – never mind the debt burden on top, and how the tax code greatly favours those who build up savings over a long period over receiving large lump sums in a single year.
In other words, 55 year old programmers are talking about retiring because they can. 55 year old doctors on the other hand, even with a higher income, need to work decades more to financially catch up.
Many programmers started making money to invest in their teens, and save those who pursued other careers before pivoting, all were making money to invest by the time they are in their early 20s. Meanwhile, the doctors were racking up the debt until nearing 30. That decade plus is a huge setback – never mind the debt burden on top, and how the tax code greatly favours those who build up savings over a long period over receiving large lump sums in a single year.
In other words, 55 year old programmers are talking about retiring because they can. 55 year old doctors on the other hand, even with a higher income, need to work decades more to financially catch up.
I don't think it's the case that experience is generally useless, but you need far fewer experienced people like this than you do cannon fodder to advance the front line a couple of centimetres.
There are people earning good scratch well into their "golden years" in the tech sector, but the demand for them is much weaker.
There are people earning good scratch well into their "golden years" in the tech sector, but the demand for them is much weaker.
Isn’t that always the way? You need far more front line workers (whatever that means in your industry) than you need managers, and at most businesses advancement equals moving to management because there really isn’t far to grow technically..
You hit it in your first para:
It's not "age" it's current-ness.
Since most people aren't expected / empowered to learn what's next 'on the job', currentness decays, making age a stereotypical proxy for dinosaur.
Here at HN, by virtue of being here reading these comments, "this isn't you". You are making yourself aware of what's going on outside your backlog. The stereotype arises because most devs aren't here or anywhere besides chopping wood.
It's not "age" it's current-ness.
Since most people aren't expected / empowered to learn what's next 'on the job', currentness decays, making age a stereotypical proxy for dinosaur.
Here at HN, by virtue of being here reading these comments, "this isn't you". You are making yourself aware of what's going on outside your backlog. The stereotype arises because most devs aren't here or anywhere besides chopping wood.
50 years old here and still on the top of my game - but believe me - this is my last high $ gig - after this it will be challenging to find another job at this level given the rampant age discrimination
If you don’t mind asking - what is the order of magnitude for your perception of “high $ gig”? I’m asking because I’ve seen wildly different opinions on what people consider highly-paid (from $100k+ to $1.5M)
People overestimate ageism in tech because the number of tech jobs has grown so rapidly. That means there are a lot more young people in the industry than there are old people, and they wrongly interpret that to mean the "missing" old people were pushed out, when the reality is they mostly were never there in the first place.
I’m 41 and I totally understand this sentiment. A silver lining is that the tech industry is just so much larger now than it was when we started, a trend I think will continue, and there are now tons of jobs where it’s really helpful to also be a developer. Some examples:
Developer and marketer/technical writer - selling to other devs is a giant business now and it often takes devs to make that content.
Developer and SRE - we live in the world of huge scaled our saas businesses where there are always support issues too advanced to be handled by non-devs
Developer and project manager - everybody has worked with non-dev project managers and it’s usually terrible.
Developer and people manager - there are so many more eng manager roles than there used to be, and moving to the management side is a well worn path now.
Developer and product manager - you have to develop a lot of new skills but in this role a past life as a developer can give you super powers.
That said, I moved first into people management and then into running a small software company which sort of demands a little bit of all of those skills
Developer and marketer/technical writer - selling to other devs is a giant business now and it often takes devs to make that content.
Developer and SRE - we live in the world of huge scaled our saas businesses where there are always support issues too advanced to be handled by non-devs
Developer and project manager - everybody has worked with non-dev project managers and it’s usually terrible.
Developer and people manager - there are so many more eng manager roles than there used to be, and moving to the management side is a well worn path now.
Developer and product manager - you have to develop a lot of new skills but in this role a past life as a developer can give you super powers.
That said, I moved first into people management and then into running a small software company which sort of demands a little bit of all of those skills
> I’m 41 and I totally understand this sentiment. A silver lining is that the tech industry is just so much larger now than it was when we started
I'd also point out that if people forget the growth-aspect, they will overestimate the problem of ageism in the industry.
Yes, there aren't that many grizzled 60-year-old programmers today... but much of that is because 40 years ago there were only a handful of 20-year-old programmers to start with.
Even if advancing age turned people into happy rockstars, they'd still be outnumbered today just because there are more jobs.
I'd also point out that if people forget the growth-aspect, they will overestimate the problem of ageism in the industry.
Yes, there aren't that many grizzled 60-year-old programmers today... but much of that is because 40 years ago there were only a handful of 20-year-old programmers to start with.
Even if advancing age turned people into happy rockstars, they'd still be outnumbered today just because there are more jobs.
As a 63 year old programmer, I can confirm the industry used to be much smaller.
A lot of people my age also retired because they had too much money to work :)
A lot of people my age also retired because they had too much money to work :)
And a good chunk of them probably hit it big at some point and retired early. I know so many software engineers my age (40s) that are effectively retired already.
Yep. Most of my friends work as software engineers and we're in our 40s. And most of them have/could retire if they wanted to.
One was working at Google and got shit for taking time off when he planned it 6 months out. He quit and decided to retire early instead of putting up with it. He's 42.
One was working at Google and got shit for taking time off when he planned it 6 months out. He quit and decided to retire early instead of putting up with it. He's 42.
I don't, but then again I didn't focus on maintaining job application loops against multiple giganto companies every single year...
> much of that is because 40 years ago there were only a handful of 20-year-old programmers to start with.
Which also explains that the more youth you see competing for the gigs helps crowd out those of us elderly tech folk who are left.
Which also explains that the more youth you see competing for the gigs helps crowd out those of us elderly tech folk who are left.
> Developer and SRE
I'd say these are pretty interchangeable in one's career if they wanted to. The others not so much.
I'd say these are pretty interchangeable in one's career if they wanted to. The others not so much.
Given the number of devs I’ve worked with who stare blankly when you say “cgroup” or “IOPS” I’m going to say no, Dev —> SRE is not an easy switch.
For a good dev it's an easy switch, the issue is that a lot of developers WANT to be treated like line workers. monkey grab task, monkey implement task.
I honestly find it shocking, but there it is.
I honestly find it shocking, but there it is.
> > Developer and SRE
> I'd say these are pretty interchangeable in one's career if they wanted to. The others not so much.
They are? Now I'm pretty new to this (despite my age) but my impression has always been, with the former you mostly focus on one project and maybe even just a small part of it, with the latter you are keeping an eye on half a dozen systems, have to know their ins and outs to babysit them, and occasionally firefight when something breaks in production.
> I'd say these are pretty interchangeable in one's career if they wanted to. The others not so much.
They are? Now I'm pretty new to this (despite my age) but my impression has always been, with the former you mostly focus on one project and maybe even just a small part of it, with the latter you are keeping an eye on half a dozen systems, have to know their ins and outs to babysit them, and occasionally firefight when something breaks in production.
If you can get one of these jobs, you can get the other, although not necessarily at the same level. You can certainly switch careers between these two, especially early career.
I don’t know about anybody else, but I would see experience in both as a plus on a resume. I think it’s a good idea for SREs in particular to get a dev job on their resume since the person hiring you is going to be a developer a massive amount of the time so it never hurts.
I don’t know about anybody else, but I would see experience in both as a plus on a resume. I think it’s a good idea for SREs in particular to get a dev job on their resume since the person hiring you is going to be a developer a massive amount of the time so it never hurts.
… they should be, but some people just seem markedly incapable of debugging.
(But I'd agree with you: you should be supporting, in the form of debugging & problem solving, the thing you're writing. Separate SREs are an anti-pattern in my book … somewhat comically since I'm basically an SRE at the moment…)
(But I'd agree with you: you should be supporting, in the form of debugging & problem solving, the thing you're writing. Separate SREs are an anti-pattern in my book … somewhat comically since I'm basically an SRE at the moment…)
If you're 20+ years experience and not any good as at least a project manager, I think your core skills are also pretty suspect.
You mean your core tech skills will be suspect if you aren't a decent project manager? Well that's a depressing thought.
Though in my experience so far we have dedicated project managers. But maybe you are right.
I think dedicated project managers are a good idea to keep people focused, but I also think if you've been buildings things for 20 years you should have absorbed enough of the process to be at least basically capable at it. That's not really true of people management (an entirely different skillset) or technical writing (though it's a bit closer) or even product management (but if you code mostly customer-facing features, probably you should have picked up a lot of this too).
If you've just been a "turn the crank" developer implementing someone else's sprint-scoped tickets for 20 years, you probably topped out after around five years. (Or you're doing all the interesting stuff outside work, in which case... you definitely have project management skills.)
If you've just been a "turn the crank" developer implementing someone else's sprint-scoped tickets for 20 years, you probably topped out after around five years. (Or you're doing all the interesting stuff outside work, in which case... you definitely have project management skills.)
Interesting about the tech writing too. I'm not good at this. I've seen this mentioned on hacker news
https://www.amazon.com/Docs-Developers-Engineers-Technical-W...
I'm think I could do with reading that. As could the team I'm on.
https://www.amazon.com/Docs-Developers-Engineers-Technical-W...
I'm think I could do with reading that. As could the team I'm on.
completely agree but I think it's more general than that.
A strong senior should be able to do any of the roles all the way up and down the chain, including "product manager", "business analyst", etc. It's an issue of time and scope rather than skill.
note: I'm aware that most business analysts are domain experts, my point there is that a senior can both analyze a problem and create a solution and can interface with domain experts where needed.
A strong senior should be able to do any of the roles all the way up and down the chain, including "product manager", "business analyst", etc. It's an issue of time and scope rather than skill.
note: I'm aware that most business analysts are domain experts, my point there is that a senior can both analyze a problem and create a solution and can interface with domain experts where needed.
Managers have to be youthful as well these days.
> But, here's the deal: he's basically going to make top dollar until he's 65. Meanwhile, I'll likely be seen as a dinosaur in tech by that age and will be lucky to find work at all.
Errr, I'm 64, generally get a title like "senior programmer", and have switched jobs a few times recently and didn't have a day out of work. I expect to be going for a few years yet - in fact I expect your husband will be forced into retirement, whereas I will chose my time.
Moreover, I have quite a few software engineering friends or about the same age. It's the same for them. Some are still working, some not. But in every case it's been their choice, they weren't forced into it by the industry.
Errr, I'm 64, generally get a title like "senior programmer", and have switched jobs a few times recently and didn't have a day out of work. I expect to be going for a few years yet - in fact I expect your husband will be forced into retirement, whereas I will chose my time.
Moreover, I have quite a few software engineering friends or about the same age. It's the same for them. Some are still working, some not. But in every case it's been their choice, they weren't forced into it by the industry.
Thanks for posting. It's something that concerns me as I head into my 40's, so it's really nice to read anecdotes from folks showing there are opportunities for those getting up there in age.
I'm 45 and have often wondered if I'm just lucky, based upon your post my experience isn't nearly as unique as many seem to think.
I wonder if it's more about skill level (certainly I'd like to think so :])
I wonder if it's more about skill level (certainly I'd like to think so :])
I question the aging out aspect of software dev on a career level. Yes you might get agism at trendy companies started by and heavily employing young people, but there are many software companies out there with many industries now employing software divisions, and the heavy demand I always see is for senior developers with experience.
One “problem” in software: it’s really difficult to coast for a long period of time without training up new skills. You can certainly do it, but eventually the industry shifts underneath you. So the cushy senior Java dev position in a particular service might be able to last you for a decade or more at some companies, but I think most developers agree that if you want to keep getting better salaries you need to stay on top of trends and keep reeducating yourself.
And I don’t really see this as a problem as much as a feature of tech, but if you’re looking for predictability in a career I think it’s a tough thing to get in tech.
One “problem” in software: it’s really difficult to coast for a long period of time without training up new skills. You can certainly do it, but eventually the industry shifts underneath you. So the cushy senior Java dev position in a particular service might be able to last you for a decade or more at some companies, but I think most developers agree that if you want to keep getting better salaries you need to stay on top of trends and keep reeducating yourself.
And I don’t really see this as a problem as much as a feature of tech, but if you’re looking for predictability in a career I think it’s a tough thing to get in tech.
> Meanwhile, I'll likely be seen as a dinosaur in tech by that age and will be lucky to find work at all.
I disagree. Go to some technical meetups.
At practically all of them I have seen people offering jobs to both juniors and greybeards. The biggest problem everybody is having right now is connecting. The garbage in the middle is clogging everything up. So, everybody is going back to the old tried and true, the weak social network of in-person acquaintances.
Yeah, you have to not suck and you have to keep your skills up-to-date. But, that's true whether you are 20 or 60.
I disagree. Go to some technical meetups.
At practically all of them I have seen people offering jobs to both juniors and greybeards. The biggest problem everybody is having right now is connecting. The garbage in the middle is clogging everything up. So, everybody is going back to the old tried and true, the weak social network of in-person acquaintances.
Yeah, you have to not suck and you have to keep your skills up-to-date. But, that's true whether you are 20 or 60.
> Meanwhile, I'll likely be seen as a dinosaur in tech by that age and will be lucky to find work at all
My dad is in his 60s and is still doing cutting edge work on Kubernetes, Golang, eBPF, etc in a big tech company in the Bay Area. It honestly isn't that hard to keep yourself up to date with technology looking at his experience.
If you can't get yourself interested in upskilling or learning the next new paradigm you're in the wrong field.
My dad is in his 60s and is still doing cutting edge work on Kubernetes, Golang, eBPF, etc in a big tech company in the Bay Area. It honestly isn't that hard to keep yourself up to date with technology looking at his experience.
If you can't get yourself interested in upskilling or learning the next new paradigm you're in the wrong field.
I think the ageism thing is not as big of an issue anymore. Yes, you will see it in startups that are run by 20somethings but I'm in my early 50s and haven't had any problem staying employed or getting offers.
If you stagnate skills wise or stop trying to grow/evolve your abilities then you definitely will have issues but that's true in many industries, not just ours.
If you stagnate skills wise or stop trying to grow/evolve your abilities then you definitely will have issues but that's true in many industries, not just ours.
As someone whose done a lot of hiring (at several companies), senior devs with a lot of (applicable) experience can always find work even if they’re “old” (40/50/60+).
But career changers will have a rough time - e.g. I remember a social worker who went back to school in his late 30s looking for an internship(as a developer), he had a much harder time getting hired than someone in the same position in their early 20s.
But career changers will have a rough time - e.g. I remember a social worker who went back to school in his late 30s looking for an internship(as a developer), he had a much harder time getting hired than someone in the same position in their early 20s.
I mean, mathematically speaking, having your high-income years happen earlier in life is significantly better because of the way compound interest works.
What do you do when 'high-earning' last decade is somewhat laughable to this one? Was compounding worth it when inflation just gobbled up all of the effort you out into those earnings faster than interest could compound?
It's been a rough couple of decades afterall.
It's been a rough couple of decades afterall.
Some napkin paper math. I googled "largest index fund" and got these 3 results:
Vanguard 500: 3x return over last 10 years
Vanguard total stock market index fund: 2x over last 10 years
SWPPX: 3x over last 10 years.
Google is telling me inflation from 2013 to 2023 is 41%.
So even with inflation accounted for you're looking at a 50-150% ROI over 10 years. Maybe I just got incredibly lucky picking index funds, so I googled the total market capitalization of US domestic companies and that grew from about 15 to 30 trillion. This stat seems to be wonkier, other estimates claim 45 trillion (probably a more inclusive estimate counting smaller companies).
But TL;DR: No, inflation did not gobble up the returns on investments
Vanguard 500: 3x return over last 10 years
Vanguard total stock market index fund: 2x over last 10 years
SWPPX: 3x over last 10 years.
Google is telling me inflation from 2013 to 2023 is 41%.
So even with inflation accounted for you're looking at a 50-150% ROI over 10 years. Maybe I just got incredibly lucky picking index funds, so I googled the total market capitalization of US domestic companies and that grew from about 15 to 30 trillion. This stat seems to be wonkier, other estimates claim 45 trillion (probably a more inclusive estimate counting smaller companies).
But TL;DR: No, inflation did not gobble up the returns on investments
It depends on how you measure "inflation".
The standard way is to measure the amount of stuff money can buy, where "stuff" is daily necessities and so on. But prices are just relative. It can be argued that such daily necessities like food, clothes, etc. have actually gotten "cheaper", and the increases in stock and other asset prices are a function of how much money is printed by central banks. (There's a strong correlation there, at least.)
It's not the standard narrative, but it's something to think about in such cases where these numbers are absolutely crucial to your life plans.
There's also the element of the US stock market basically outperforming everyone else in the past decade. (And it's mostly because of tech.) If you pick a couple non-US indices the numbers look much more shaky.
The standard way is to measure the amount of stuff money can buy, where "stuff" is daily necessities and so on. But prices are just relative. It can be argued that such daily necessities like food, clothes, etc. have actually gotten "cheaper", and the increases in stock and other asset prices are a function of how much money is printed by central banks. (There's a strong correlation there, at least.)
It's not the standard narrative, but it's something to think about in such cases where these numbers are absolutely crucial to your life plans.
There's also the element of the US stock market basically outperforming everyone else in the past decade. (And it's mostly because of tech.) If you pick a couple non-US indices the numbers look much more shaky.
Not to sound like a naive optimist, but the average age of somebody working in tech is going up over time, and that is likely going to make tech less exceptional in its ageism.
Tech is also slowing down in how much it is changing, which makes it easier to do the work while older, which again takes the edge off of ageism.
Tech is also slowing down in how much it is changing, which makes it easier to do the work while older, which again takes the edge off of ageism.
Your husband is also in the position where any mental issue and a lot of physical health issues will force an early retirement.
And if he wants to make the big bucks, there are not that many companies to work for (~10 mainline carriers in the US at the moment), and the seniority rules suck.
And if he wants to make the big bucks, there are not that many companies to work for (~10 mainline carriers in the US at the moment), and the seniority rules suck.
I'm almost 40, never made good money... this makes me sad
Join the club. I did good money once with tiny startup exit. Salary is just enough to pay for food, mortgage and vacations.
I am almost 50, and my partner (ophthalmologist) always made more than me as developer, and architect. But to be fair, I only worked for small startups in the Bay, and startups that did not make big.
Not complaining, but a bit worried for the next decade though. Especially as I am super busy at work, so much that I cannot spend time on programming anymore.
A case of the keeping up with the Joneses syndrome?
Recent figures are not readily available, but as of 10 years ago a yearly income of $32,000 was enough to put you in the global top 1%. Adjusted for inflation, that is around $42,000 today. Interestingly, the median income in the USA is $41,535, so it is likely that half of all Americans are in the top 1%.
Although I would think that "good money" would cast a larger net than just the top 1%. Surely at least a 75th percentile income would be considered "good" by most? As such, it is likely that a $20-30,000 income is "good money".
If you have not even made that much at some point over the past 25 or so years that you have been of working age, how can you afford to be here?
Recent figures are not readily available, but as of 10 years ago a yearly income of $32,000 was enough to put you in the global top 1%. Adjusted for inflation, that is around $42,000 today. Interestingly, the median income in the USA is $41,535, so it is likely that half of all Americans are in the top 1%.
Although I would think that "good money" would cast a larger net than just the top 1%. Surely at least a 75th percentile income would be considered "good" by most? As such, it is likely that a $20-30,000 income is "good money".
If you have not even made that much at some point over the past 25 or so years that you have been of working age, how can you afford to be here?
it's a bit disingenuous to compare US citizens to 3rd world countries.
yes, it's technically true, but no one with a 3rd world income would ever be able to afford to live in the US, they'd be homeless. its apples and oranges.
yes, it's technically true, but no one with a 3rd world income would ever be able to afford to live in the US, they'd be homeless. its apples and oranges.
Not at all. The topic is money made. That is independent of expenditures. We could go down the road of retained money (i.e. net income), but then clearly money made is no longer relevant. The guy who made $20,000 and spent $10,000 of it is the one who retained good money, not the guy who made $1,000,000 and spent $999,999.
right, and someone living paycheck to paycheck in NYC is somehow richer than someone living in a LCOL area with more buying power.
There's a reason why discussions of salary have to happen around the area the salary is made in.
There's a reason why discussions of salary have to happen around the area the salary is made in.
Again, the topic is money made. x made is x made.
One may need to spend more x to live in a certain location, sure, but that's a completely different topic. One where the money made is not relevant, for reasons already stated. As we are talking about money made, you know we are not talking about that.
One may need to spend more x to live in a certain location, sure, but that's a completely different topic. One where the money made is not relevant, for reasons already stated. As we are talking about money made, you know we are not talking about that.
this is clearly false.
10k USD/year is "good money" for many people in other countries but no one would ever describe that as "good money" for someone living IN the US.
and yet, the poster YOU chose to respond to said this:
> I'm almost 40, never made good money... this makes me sad
10k USD/year is "good money" for many people in other countries but no one would ever describe that as "good money" for someone living IN the US.
and yet, the poster YOU chose to respond to said this:
> I'm almost 40, never made good money... this makes me sad
> the poster YOU chose to respond to said this:
Yes, as you can clearly see, he added the operative word "made". A word you conveniently left out from your message in your ongoing quest to change the subject. Had you included it like in the original comment, it would completely change your message.
Yes, as you can clearly see, he added the operative word "made". A word you conveniently left out from your message in your ongoing quest to change the subject. Had you included it like in the original comment, it would completely change your message.
I have to conclude you're either under the influence of a mind altering substance or trolling.
either way I'm done with this conversation. Come back to this when you're sober and read my post more closely.
either way I'm done with this conversation. Come back to this when you're sober and read my post more closely.
Interesting that this has turned to be about me and not the content in play. Logically, they are independent of each other.
While I am not sure what you think you can be done with given that you have not yet joined the conversation that we were having before you arrived, no amount of drug use is going to give me interest in your off-topic tangent.
I get it. You misunderstood what was written earlier and now you are grasping at logical errors in order to avoid having to come back now and ask questions for clarification to save your pride. But, why are you letting your emotions drive you like that? Who cares if you made a mistake? I certainly don't. I don't care about you at all.
While I am not sure what you think you can be done with given that you have not yet joined the conversation that we were having before you arrived, no amount of drug use is going to give me interest in your off-topic tangent.
I get it. You misunderstood what was written earlier and now you are grasping at logical errors in order to avoid having to come back now and ask questions for clarification to save your pride. But, why are you letting your emotions drive you like that? Who cares if you made a mistake? I certainly don't. I don't care about you at all.
I think if you actually take the time to talk to some older dev people you will find that you are wrong, and when you actually get older you will find out how wrong. We are doing great - financially and professionally, despite having to face a small number of people with this attitude.
I hope you’re correct but the very realistic possibility of
SPO (single Pilot Operations) is what pushed myself - and many others like me - away from the career. The current pilot shortage was by design, as the airlines were well aware of the issue and had many ways to avoid it. I’m still of the mind the current shortage (and short term plans to mitigate it) are just to hold them over long enough to end the current 2-pilot system and bring the standard to single pilot operations
Wouldn't that require FAA complicity? And do you think pilot unions would allow it? Do they have power to stop it?
I think the biggest obstacle will be public acceptance of a single pilot at the helm. It would take some serious backup tech assurances and maybe a generation's worth of time before it happens.
> But, here's the deal: he's basically going to make top dollar until he's 65. Meanwhile, I'll likely be seen as a dinosaur in tech by that age and will be lucky to find work at all.
My grandfather made good money fixing systems for y2k in the 1990s and retired shortly after.
There's plenty of work for dinosaurs. Plenty of systems quickly hacked together today will be around for much longer than planned for.
My grandfather made good money fixing systems for y2k in the 1990s and retired shortly after.
There's plenty of work for dinosaurs. Plenty of systems quickly hacked together today will be around for much longer than planned for.
"he's basically going to make top dollar until he's 65" ...unless he fails the flight physical.
> he's basically going to make top dollar until he's 65
There's no such guarantee in any of the professions.
There's no such guarantee in any of the professions.
True but it's likely, unless fully-autonomous commercial airliners are developed. There's a shortage of pilots as well, and unlike most other careers, they have to retire at 65 (or maybe younger?).
They're one failed First Class Medical exam away from losing it.
Even if autonomous aircraft are developed, will the "old" planes be converted? Could they be converted without tons of changes? Sounds unlikely.
Planes are typically in service for decades but if they could eliminate the pilots, that could very well change the calculus.
But, public mistrust of a pilotless plane might very well put the kibosh on that for a long time. People have trouble trusting air travel as it is, doesn't matter if it's irrational, and they usually know that it is.
But, public mistrust of a pilotless plane might very well put the kibosh on that for a long time. People have trouble trusting air travel as it is, doesn't matter if it's irrational, and they usually know that it is.
Imagine a lottery where instead of winning, you die in a terrifying way.
That's flying. You enter into an aluminium can, and from that point you are completely helpless, whatever happens. The only thing you can do if something goes wrong is assume the fetal position and hope.
And yes, life is pretty much like that. You could get cancer or get hit by a car or a meteorite for that matter, but even these things feel more controlled. I can pay attention to my surroundings to avoid getting hit by a car. I can potentially treat cancer. I could probably not do much against a meteorite or gamma ray burst or whatever cosmic thing might happen but that stuff feels less real anyway.
I agree that the fear of flying is somewhat irrational, but at the same time I think it's a valid fear especially in light of things like Russia shooting down passenger planes, the whole Boeing Max 8 thing etc.
That's flying. You enter into an aluminium can, and from that point you are completely helpless, whatever happens. The only thing you can do if something goes wrong is assume the fetal position and hope.
And yes, life is pretty much like that. You could get cancer or get hit by a car or a meteorite for that matter, but even these things feel more controlled. I can pay attention to my surroundings to avoid getting hit by a car. I can potentially treat cancer. I could probably not do much against a meteorite or gamma ray burst or whatever cosmic thing might happen but that stuff feels less real anyway.
I agree that the fear of flying is somewhat irrational, but at the same time I think it's a valid fear especially in light of things like Russia shooting down passenger planes, the whole Boeing Max 8 thing etc.
Doesn't necessarily matter when its rich countries (or their carriers) that buy the new planes and out of a sudden, pilots have the choice of flying for an indonesian island hopper or not at all.
There is by necessity, nuance, and specialization.
But if someone wanted to be rich by capturing more of the value they could produce, it's highly unlikely as someone else's employee.
But if someone wanted to be rich by capturing more of the value they could produce, it's highly unlikely as someone else's employee.
Especially with machine learning engineers automating lines of work away :)
>But, here's the deal: he's basically going to make top dollar until he's 65. Meanwhile, I'll likely be seen as a dinosaur in tech by that age and will be lucky to find work at all.
People used to believe this, but it's not true at all in my experience.
People used to believe this, but it's not true at all in my experience.
It's not a matter of the goodness of the deal that a doctor has versus that of a software engineer. It's that the deal doctors get is emotionally scaring to them and it produces horrific social dysfunction.
> I'll likely be seen as a dinosaur in tech by that age and will be lucky to find work at all.
Can confirm, but it’s more like around 50. That is why you tend to not see a lot of senior folks wanting to bounce gigs every three years like the younger folk do. I hope to ride out another 7 years at my current gig and retire. Hopefully they won’t have other plans because at that point I’ll likely have to shift to WalMart greeter.
Can confirm, but it’s more like around 50. That is why you tend to not see a lot of senior folks wanting to bounce gigs every three years like the younger folk do. I hope to ride out another 7 years at my current gig and retire. Hopefully they won’t have other plans because at that point I’ll likely have to shift to WalMart greeter.
> Yes, we make good money when we're young in tech. But we age out much more quickly due to the bias common in our industry.
52. Gimme 10 more years, I won't care. I don't want to be working any job after that even though I love programming and it's all I ever wanted to do (for a living).
52. Gimme 10 more years, I won't care. I don't want to be working any job after that even though I love programming and it's all I ever wanted to do (for a living).
> But we age out much more quickly due to the bias common in our industry.
Just prove you lost a job or weren't hired due to age, and you'll have a lawsuit that results in a large enough settlement you will once again be paid more than your spouse and won't even need to work.
Just prove you lost a job or weren't hired due to age, and you'll have a lawsuit that results in a large enough settlement you will once again be paid more than your spouse and won't even need to work.
And how exactly would one do that?
Same way as any age discrimination lawsuit.
If you have reason to believe you were terminated or not hired because of age, meet with a lawyer. If a lawsuit it filed, discovery is a powerful tool in litigation to help gather evidence that is generally required to prove the claim. Often this will be data about the other employees they have let go or in the case you weren't hired the age of the person ultimately hired and those that were interviewed but not hired.
There are about 10,000-15,000 a year, like all areas of law probably about 90% settle pre-trial.
If you have reason to believe you were terminated or not hired because of age, meet with a lawyer. If a lawsuit it filed, discovery is a powerful tool in litigation to help gather evidence that is generally required to prove the claim. Often this will be data about the other employees they have let go or in the case you weren't hired the age of the person ultimately hired and those that were interviewed but not hired.
There are about 10,000-15,000 a year, like all areas of law probably about 90% settle pre-trial.
My point is that I don’t think it’s that easy to prove unless it’s blatantly obvious from an outside perspective and most lawyers wouldn’t take a case on contingency unless it was blatantly obvious to them that it was a winner.
So do you pursue it paying some lawyer an hourly rate to sift through a thousand emails just to find that the company hired a younger but still fully qualified candidate? If you are a person at the sunset of your career and still need a job it’s likely that you will not bankroll the effort…so you just move on.
So do you pursue it paying some lawyer an hourly rate to sift through a thousand emails just to find that the company hired a younger but still fully qualified candidate? If you are a person at the sunset of your career and still need a job it’s likely that you will not bankroll the effort…so you just move on.
I wouldnt be so sure. aviation is ripe for automation (and planes can even land on its own now.). I can see airline companies pushing for only 1 pilot in the cockpit.
If you were bringing in a competitive salary in tech for the last 20 years you don't even need to work anymore. So there is that..
BLS says US median programmer salary in the US was just under $100,000 last year.
20 years of a normal US tech salary won't let you retire. A top-few-percent one, maybe.
20 years of a normal US tech salary won't let you retire. A top-few-percent one, maybe.
First, Computer Programmer is a strange occupation. According to BLS there are just 147K positions in the US.
Instead I'd suggest looking at Software Developers (1.5M positions) with median income at $127K.
Second, by definition median is not a competitive salary. I'd think top 25% of devs are getting competitive salary. Which is $161K [1]
20 years of savings at 30% of income will get you $2M. Which is not a fat retirement, but still doable.
[1] https://www.bls.gov/oes/current/oes151252.htm#nat
Instead I'd suggest looking at Software Developers (1.5M positions) with median income at $127K.
Second, by definition median is not a competitive salary. I'd think top 25% of devs are getting competitive salary. Which is $161K [1]
20 years of savings at 30% of income will get you $2M. Which is not a fat retirement, but still doable.
[1] https://www.bls.gov/oes/current/oes151252.htm#nat
> Second, by definition median is not a competitive salary.
Yes, it is. For the field as a whole? Yes, it absolutely is. For specific segments of it? No. Some of those are higher. And others are lower.
> 20 years of savings at 30% of income will get you $2M. Which is not a fat retirement, but still doable.
Healthcare complicates early retirement badly in the US. Retire at (say) 45 with only $2m in the bank and you are... gambling. To put it mildly. Even if you live reasonably frugally.
Yes, it is. For the field as a whole? Yes, it absolutely is. For specific segments of it? No. Some of those are higher. And others are lower.
> 20 years of savings at 30% of income will get you $2M. Which is not a fat retirement, but still doable.
Healthcare complicates early retirement badly in the US. Retire at (say) 45 with only $2m in the bank and you are... gambling. To put it mildly. Even if you live reasonably frugally.
I do not agree. If someone said "bringing regular salary in tech" I'd agree that median should be used. "Competitive" means we are talking about higher percentile within the field.
> Healthcare complicates early retirement
You don't have to stay in the US when retired. With 4% SWR one will be getting $80K/year. Which is more than median household income in the US and majority of the other countries. I am not advocating retiring at 45 with $2M, I am just saying it is not that crazy.
> Healthcare complicates early retirement
You don't have to stay in the US when retired. With 4% SWR one will be getting $80K/year. Which is more than median household income in the US and majority of the other countries. I am not advocating retiring at 45 with $2M, I am just saying it is not that crazy.
I've always considered "competitive" to be a signal of "as close as possible to our average competitor". It doesn't mean good or high. When a job offer says "competitive salary", it's not a good sign. I assume they mean around average, maybe a little bit below average. If the job offer was offering a significantly great salary, the company would boast about it as more than "competitive."
"Competitive" is job listing filler IMO. Everybody is "competitive". I've seen "competitive" salaries wanting me to take a >30% pay cut.
Yes, absolutely - though it's a difference from colloquial English, where it does normally mean "good"/"better than average". Businesses just use it as a weasel-word.
> "Competitive" means we are talking about higher percentile within the field.
This is not a standard usage of the term in this context.
[EDIT] If you don't believe me, I'd encourage searching "competitive salary definition"
This is not a standard usage of the term in this context.
[EDIT] If you don't believe me, I'd encourage searching "competitive salary definition"
It is also not going to be the easiest, emigrating to a country with a robust healthcare and social safety net as a retiree in your 40s.
A lot of cheap countries provide good healthcare for a fraction of american costs. Also, not sure why one need a safety net when they already have a stable income which is multiple of what any such net can provide.
Very true. This is a very big reason I left the US in my 40s, while I'm still working and can acquire permanent residency and later citizenship by having a job with a local company. I didn't want to be stuck in the US when I'm at retirement age and healthcare costs are unaffordable even with a decent nest egg, where a major procedure could wipe out all my savings.
> Healthcare complicates early retirement badly in the US. Retire at (say) 45 with only $2m in the bank and you are... gambling. To put it mildly. Even if you live reasonably frugally.
100% this. I'm almost 50, and as I look towards retirement, I think I should try to find a cushy job that'll last me to 65 without causing too much stress, because until you qualify for Medicare it's really hard to afford health insurance premiums unless you're fashionably wealthy.
100% this. I'm almost 50, and as I look towards retirement, I think I should try to find a cushy job that'll last me to 65 without causing too much stress, because until you qualify for Medicare it's really hard to afford health insurance premiums unless you're fashionably wealthy.
> Healthcare complicates early retirement badly in the US. Retire at (say) 45 with only $2m in the bank and you are... gambling.
Uhh... Why? A very good health insurance is about $10k a year (PSA: the open enrollment period for 2024 has started today).
Even if you are unlucky to get a chronic condition that needs expensive care, that's still capped at around $6k a year by the out-of-pocket maximum.
So that's $16k a year per person maximum, over 20 years (until Medicare eligibility) that's $320k. If you want to include family, that's going to be around $500k. And that's the worst case.
It's going to be a huge chunk of the expense, but not insurmountable.
Uhh... Why? A very good health insurance is about $10k a year (PSA: the open enrollment period for 2024 has started today).
Even if you are unlucky to get a chronic condition that needs expensive care, that's still capped at around $6k a year by the out-of-pocket maximum.
So that's $16k a year per person maximum, over 20 years (until Medicare eligibility) that's $320k. If you want to include family, that's going to be around $500k. And that's the worst case.
It's going to be a huge chunk of the expense, but not insurmountable.
Heathcare could [again] get twice as expensive in the next 20 years: https://ourworldindata.org/grapher/price-changes-consumer-go...
As a retiree, you can probably arrange to qualify for a free silver plan under the ACA. There are no asset tests, only income. This is true for other subsidies too. If you've mostly accumulated assets in excluded locations, you can also qualify for college tuition subsidies.
[deleted]
Heh. I worked at a startup, and they were sponsoring a Green Card for me.
They had to raise my salary to $165k because this was the _minimal_ allowed competitive salary for my position ("Senior Software Developer"), and the USCIS doesn't take stock grants into account. This was 2 years ago.
They had to raise my salary to $165k because this was the _minimal_ allowed competitive salary for my position ("Senior Software Developer"), and the USCIS doesn't take stock grants into account. This was 2 years ago.
What's the distribution of experience though? In a fast growing field, most will be early in career, which will push this metric down relative to established fields with little growth.
The question's whether 20 years of a "competitive" tech salary is enough money to retire.
I think one must have a very-skewed, bubble-bound definition of "competitive" for that to be plausibly true. Programming jobs don't pay enough to grant easy-mode early retirement for most of our field—even in the US.
I think one must have a very-skewed, bubble-bound definition of "competitive" for that to be plausibly true. Programming jobs don't pay enough to grant easy-mode early retirement for most of our field—even in the US.
They classified people we don't think of as programmers as programmers. Classic job stats mistake.
Ok, sure, that's one category and some of the others do have a higher median. Some of what we think of as "programmers" or "developers" will actually land in other categories, and also some we don't, will too.
https://www.bls.gov/ooh/computer-and-information-technology/...
But still, even the top-median category, "Computer and Information Research Scientists", doesn't have "retire in 20 years" median wages.
https://www.bls.gov/ooh/computer-and-information-technology/...
But still, even the top-median category, "Computer and Information Research Scientists", doesn't have "retire in 20 years" median wages.
The median income is ~$30,000. That means you have ~$70,000 to invest each year. If we assume a 5% rate of return, you'll have ~$2MM after 20 years. At the same rate, that will continue to provide you $100,000 each year in retirement. Bad luck can happen, but generally speaking retirement should have been quite easy with that kind of income.
I love your optimism. Some may be able to live off software at 30k/yr making 100/yr "somewhere", but not most places. My rent started at around 40% of my take home and adding taxes alone, my pay rate was well under this 70% fantasy which doesn't even begin to address any other "incidental" living expenses like food, transport, children, elderly, school loans, etc......
> My rent started at around 40% of my take home
You were paying ~$3,000 per month for rent 20 years ago? I remember renting a place 22 years ago for $250 per month.
Maybe you were in some super insane cost of living area, but if that's the case, why would you accept just an average developer salary? Average salaries are for average places.
You were paying ~$3,000 per month for rent 20 years ago? I remember renting a place 22 years ago for $250 per month.
Maybe you were in some super insane cost of living area, but if that's the case, why would you accept just an average developer salary? Average salaries are for average places.
Median topped $40k in 2022.
The (just under) $100k is pre-tax.
You won't get much social security when you hit "retirement age" if you retire after only 20 years of working at that level of income, so you'll need more savings at that age than others do.
$100k/yr is a 5% withdrawal rate on $2 million, which might be a "safe" rate at normal retirement age (debatable) but is risky as hell if you start doing it at 45 and don't plan to die in your 60s.
If you've been saving that aggressively (as cash/investments), you won't own your own house, or at least, you definitely won't be anywhere near paying it off. That significantly raises your costs in retirement.
You have significant risk from healthcare costs until you hit medicare age (and even then...). You're probably looking at $5k-10k a year in premiums (individual) at age 45+, and still five figures of annual risk exposure despite already paying that much.
Retiring on $2m at 45 would be very likely to end in failure, even as an individual supporting only yourself.
The (just under) $100k is pre-tax.
You won't get much social security when you hit "retirement age" if you retire after only 20 years of working at that level of income, so you'll need more savings at that age than others do.
$100k/yr is a 5% withdrawal rate on $2 million, which might be a "safe" rate at normal retirement age (debatable) but is risky as hell if you start doing it at 45 and don't plan to die in your 60s.
If you've been saving that aggressively (as cash/investments), you won't own your own house, or at least, you definitely won't be anywhere near paying it off. That significantly raises your costs in retirement.
You have significant risk from healthcare costs until you hit medicare age (and even then...). You're probably looking at $5k-10k a year in premiums (individual) at age 45+, and still five figures of annual risk exposure despite already paying that much.
Retiring on $2m at 45 would be very likely to end in failure, even as an individual supporting only yourself.
> $100k/yr is a 5% withdrawal rate on $2 million
Yes, that's what the previous comment said. Of course, you don't need anywhere close to $100k, so you would still be reinvesting the bulk of it, just as you did throughout your career. That will see your returns continue to increase as you grow older.
> you won't own your own house, or at least, you definitely won't be anywhere near paying it off.
You'd have no trouble buying a home on a $30k income 20 years ago. They could barely give houses away back then.
> You have significant risk from healthcare costs
You still have $70k to play with each year. If you have to miss a year of reinvestment it won't hamstring you that much. As before, bad luck happens. It is possible you are the unlucky one. But generally speaking the money is there.
Yes, that's what the previous comment said. Of course, you don't need anywhere close to $100k, so you would still be reinvesting the bulk of it, just as you did throughout your career. That will see your returns continue to increase as you grow older.
> you won't own your own house, or at least, you definitely won't be anywhere near paying it off.
You'd have no trouble buying a home on a $30k income 20 years ago. They could barely give houses away back then.
> You have significant risk from healthcare costs
You still have $70k to play with each year. If you have to miss a year of reinvestment it won't hamstring you that much. As before, bad luck happens. It is possible you are the unlucky one. But generally speaking the money is there.
> You'd have no trouble buying a home on a $30k income 20 years ago. They could barely give houses away back then.
I made a bit more than that 20 years ago and can guarantee you it wasn't anywhere near enough money to buy a house. Finding affordable apartments to rent on that salary was difficult enough. I lived in New Orleans, which wasn't a high cost of living city at the time. Maybe if you lived in the middle of nowhere that would be doable, but almost certainly not in a city.
I made a bit more than that 20 years ago and can guarantee you it wasn't anywhere near enough money to buy a house. Finding affordable apartments to rent on that salary was difficult enough. I lived in New Orleans, which wasn't a high cost of living city at the time. Maybe if you lived in the middle of nowhere that would be doable, but almost certainly not in a city.
their username is randomdata, not accuratedata.
my experience agrees with yours.
my experience agrees with yours.
> You'd have no trouble buying a home on a $30k income 20 years ago.
You're absolutely right - the banks would give you a loan you couldn't actually afford. I seem to recall this leading to some sort of financial problem in 2008, unfortunately.
You're absolutely right - the banks would give you a loan you couldn't actually afford. I seem to recall this leading to some sort of financial problem in 2008, unfortunately.
That was a competitive salary when I started in 2005.
Well, it'd also represent a raise for about 50% of programmers in 2022.
[EDIT] Further:
"The lowest 10 percent earned less than $54,310, and the highest 10 percent earned more than $157,690." (in 2022, still).
The ones who can retire in 20 years are making (ballpark) top-5%-of-field wages most or all of that time.
[EDIT EDIT] I didn't pick the best category for this, but the numbers only skew up 25ish % for the most-relevant one. Not a single BLS computer job category has a median particularly close to "retire in 20 years at this income" money. FAANG, finance, and a small segment of the startup market that's in that same category—yeah. Almost all the rest? No.
[EDIT] Further:
"The lowest 10 percent earned less than $54,310, and the highest 10 percent earned more than $157,690." (in 2022, still).
The ones who can retire in 20 years are making (ballpark) top-5%-of-field wages most or all of that time.
[EDIT EDIT] I didn't pick the best category for this, but the numbers only skew up 25ish % for the most-relevant one. Not a single BLS computer job category has a median particularly close to "retire in 20 years at this income" money. FAANG, finance, and a small segment of the startup market that's in that same category—yeah. Almost all the rest? No.
What is a competitive salary? Do you mean the small fraction of programmers that work for FAANG companies? Or do you mean the more normal salaries the vast majority of programmers make at non-FAANG companies?
I’ve worked for the past 20 years and am as far from not needing to work anymore as my first day. Well, that isn’t strictly true, but my 401k only has about 33-50% of what it needs for me to retire. I have no savings beyond that.
I’ve worked for the past 20 years and am as far from not needing to work anymore as my first day. Well, that isn’t strictly true, but my 401k only has about 33-50% of what it needs for me to retire. I have no savings beyond that.
I didn't realize anyone could go to medical school.
Maybe a little overly sarcastic, but there's a real point there:
Not everyone can get into med school (~5% acceptance rate?), but even more disturbingly some people get out of med school with tons of debt, and then either fail their step 2 or don't pass quickly enough to get a residency. Or fail boards after residency. Then you're in a really shitty position, with hundreds of thousands of debt but no ability to practice medicine.
Not everyone can get into med school (~5% acceptance rate?), but even more disturbingly some people get out of med school with tons of debt, and then either fail their step 2 or don't pass quickly enough to get a residency. Or fail boards after residency. Then you're in a really shitty position, with hundreds of thousands of debt but no ability to practice medicine.
Thing is which med school you’ll go will determine your debt load. Not all med schools charge the same rate.
And also your board exams success rate!
That depends exclusively on your savings rate (which dictates your years-needed-to-retire): https://www.mrmoneymustache.com/2012/01/13/the-shockingly-si...
Most people aren't saving ~43% of their take-home pay, no matter how much they earn.
Most people aren't saving ~43% of their take-home pay, no matter how much they earn.
Until AI is flying planes...
I could not feel comfortable as a passenger on a commercial airliner without a human on board that could take over and fly the plane manually. There are all kinds of failure scenarios where a computer, AI or not, would get confused. Even just the specter of malware is enough for me to expect a human being, that values their own life, is able to take over.
>Even just the specter of malware is enough for me to expect a human being, that values their own life, is able to take over.
I'd be more concerned abouta human going insane than malware.
I'd imagine they're mostly fly by wire anyway, so a virus could theoretically just disable the human input.
I'd be more concerned abouta human going insane than malware.
I'd imagine they're mostly fly by wire anyway, so a virus could theoretically just disable the human input.
Airbus designs are substantially fly by wire, although supposedly with an isolated control system. Boeing designs are isolated electro-hydraulic.
There's a big difference between isolating a single control link vs an entire control system comprising of, at least, a corpus database and all the supporting code that streams inputs and actuates outputs.
There's a big difference between isolating a single control link vs an entire control system comprising of, at least, a corpus database and all the supporting code that streams inputs and actuates outputs.
I assume / hope that there still exists manual hydraulic controls for the control surfaces. Maybe not in the cockpit, but somewhere accessible in flight in an emergency.
Modern U.S. submarines are also fly-by-wire, but hydraulic overrides are in the engine room in case of emergency.
Modern U.S. submarines are also fly-by-wire, but hydraulic overrides are in the engine room in case of emergency.
>There are all kinds of failure scenarios where a computer, AI or not, would get confused.
but there may also be enough kinds of failure—and routine—scenarios where computers do a better job, so on balance they could be much better, just killing a few people in the most absurd situations that would never fool a human. You can't guesstimate reason these things, need statistics.
also, if automated systems have a bright future for us, maybe we have to sacrifice a few people on the QA team in order to get there.
but there may also be enough kinds of failure—and routine—scenarios where computers do a better job, so on balance they could be much better, just killing a few people in the most absurd situations that would never fool a human. You can't guesstimate reason these things, need statistics.
also, if automated systems have a bright future for us, maybe we have to sacrifice a few people on the QA team in order to get there.
> I could not feel comfortable as a passenger on a commercial airliner without a human on board that could take over and fly the plane manually. There are all kinds of failure scenarios where a computer, AI or not, would get confused.
"Person there just in case to take over in the rare case of emergencies" might not be as well paid as "person who's responsible for the plane at all times". Plus, if you're concerned about malware, you'll probably want a person still involved in vetting the code outputted by some hypothetical AI, so there would still be at least some engineering jobs.
"Person there just in case to take over in the rare case of emergencies" might not be as well paid as "person who's responsible for the plane at all times". Plus, if you're concerned about malware, you'll probably want a person still involved in vetting the code outputted by some hypothetical AI, so there would still be at least some engineering jobs.
The person to fly in case of an emergency will require the same kind of currency as a person flying all the time. The person flying all the time will be much more capable than the person watching the plane fly, and acquiring experience only in specific training.
> The person to fly in case of an emergency will require the same kind of currency as a person flying all the time.
Almost everyone requires the same "kind of currency", but that doesn't stop salaries from being different.
> The person flying all the time will be much more capable than the person watching the plane fly, and acquiring experience only in specific training.
If the plane can be piloted mostly automatically, that doesn't necessarily matter. What matters only is if the emergency person can handle the emergencies that do occur.
To be clear, I don't have any strong belief that human pilots will disappear any time soon; I just don't think the arguments people are making here are that compelling, because they seem to be assuming that the skill level of flying a plane is much too high for an automatic pilot. As someone who's been skeptical of fully automated driving for a long time now despite popular opinion seeming far more optimistic about it in the short term, it's kind of ironic to see "humans will always be better at flying" presented as axiomatic.
Almost everyone requires the same "kind of currency", but that doesn't stop salaries from being different.
> The person flying all the time will be much more capable than the person watching the plane fly, and acquiring experience only in specific training.
If the plane can be piloted mostly automatically, that doesn't necessarily matter. What matters only is if the emergency person can handle the emergencies that do occur.
To be clear, I don't have any strong belief that human pilots will disappear any time soon; I just don't think the arguments people are making here are that compelling, because they seem to be assuming that the skill level of flying a plane is much too high for an automatic pilot. As someone who's been skeptical of fully automated driving for a long time now despite popular opinion seeming far more optimistic about it in the short term, it's kind of ironic to see "humans will always be better at flying" presented as axiomatic.
I'm infinitely more comfortable with an AI flown plane than a AI driven vehicle. The issues the plane has to deal with are going to be much more predictable than the issues a vehicle has to deal with.
Certainly things like the ghimli glider are better for having a human at the helm, but those sorts of things shouldn't happen.
Certainly things like the ghimli glider are better for having a human at the helm, but those sorts of things shouldn't happen.
Given how good ChatGPT is at coding, I'd bet on software development being radically disrupted before we're boarding planes with zero pilots.
"I apologize for the mistake in my previous response. The altitude is indeed 1,200 feet, not 12,000 feet. The correct action to take is to increase pitc"
I don't think we'll ever be at zero pilots. But one pilot instead of 2(or more) would nearly halve the pilot market, no?
We're facing a really bad pilot shortage right now, even in the fun jobs like flying fighter jets for the Air Force. That change would allow more plains to fly, I doubt it'd hurt the market for pilots - salaries which are already depressed because the airlines have been able to get away with it.
The complaints I have heard from military pilots are that shortages are caused mainly by toxic leadership and unattractive career path options. Combat pilots don't appreciate taking orders from careerists or "shoe clerks". And they don't want to get stuck in staff or management assignments for years just because the service needs a warm body to fill a slot. Plus the day-to-day administrative workload is high even when they're not flying. So, a lot of them in the O-3 to O-5 range just get burnt out and quit. Air Force leadership could fix those retention problems if they actually wanted to, and it wouldn't even be very expensive.
Or a room of remote pilots that are signaled to take control in an emergency?
If a plane gets struck by lightning, the remote connection may cease functioning. So, too, might the onboard computer.
Regardless of what naive optimization might suggest, I doubt the airlines are going to risk the headline "217 Dead In Pilot-less Plane Crash" any time soon.
Regardless of what naive optimization might suggest, I doubt the airlines are going to risk the headline "217 Dead In Pilot-less Plane Crash" any time soon.
Flying the airplane is the easy part. The hard bit is responding to equipment failures and other emergencies. There is no way to predict all of the possible failure modes, nor do we have AI that can figure out how to manage unexpected problems in real time. That technology is likely at least several decades away.
There is also a sensing issue. If aircraft sensors fail then they might feed the AI faulty data. And sensor redundancy or fault detection logic can't necessarily cope with that. Whereas experienced human pilots have a pretty good record of using their organic senses to handle such failures safely.
There is also a sensing issue. If aircraft sensors fail then they might feed the AI faulty data. And sensor redundancy or fault detection logic can't necessarily cope with that. Whereas experienced human pilots have a pretty good record of using their organic senses to handle such failures safely.
The economics won't make sense any time in the foreseeable future. Pilots are a small fraction of the total cost of a flight, making the upfront cost to automate the extremely edge-case-laden final 10% of safety-critical operations they oversee a non-starter for now.
We'll have terrible Roomba boxes replacing flight attendants long before anything replaces pilots.
We'll have terrible Roomba boxes replacing flight attendants long before anything replaces pilots.
>We'll have terrible Roomba boxes replacing flight attendants long before anything replaces pilots.
For American-run airlines (and many European ones too), terrible Roomba-like boxes would be a big improvement in service.
Not for Asian airlines, though.
For American-run airlines (and many European ones too), terrible Roomba-like boxes would be a big improvement in service.
Not for Asian airlines, though.
Not sure about the replacements for flight attendants. I understand they have important tasks during emergencies.
they're a pretty big fraction for shorter range flights/smaller planes (somewhere around 10%?), and more importantly they are a cause of cascading delays. often major delay problems happen because the flight before was delayed requiring the pilots to stop working and you now need to reschedule all your pilots leading to more problems. pilots are more of a problem than flight attendants because there are more attendants, so you can more easily have a few in reserve.
Pilots are more of a problem than flight attendants because not only are there fewer pilots, they need to be certified for the plane you have available. If your reserve pilot is certified on a CRJ-900 and you need to fly a 737, those folks aren't going anywhere.
Here's the thing. There won't be "tech work" or any kind of work in 5 years due to AGI.
In fact any long term plans at this point seem silly. AI is going to make all human labor irrelevant.
In fact any long term plans at this point seem silly. AI is going to make all human labor irrelevant.
> Based on our math, we’ll be 25 to 30 years into our careers before her medical education with have a better ROI than my career choice. I didn’t even push for top-dollar jobs.
I just want to point out that - you landed (probably more random than intentional) into arguably the best career in the history of labor.
Compare a doctor to almost anything beside an engineer - and it won't seem so terrible.
Most people that have been in engineering for >10 years got into it because it's what they liked doing - and then it just so happened to be ridiculously lucrative and not require you to go into hundreds of thousands of debt to get trained to do the job (medical, lawyer, etc).
Even most trades (electrical, plumping, beauty, the taxi medallion system, etc) are designed similar to the medical industry - and require ever more schooling (debt, opportunity cost) to get the job - to artificially reduce the work force to benefit current workers at the cost of future workers and everybody who uses those services.
I think the particular problem with the medical industry is... it's particular detrimental to society to be overworking doctors to the bone and it not really paying off for them until they're in their 50s.
We're all gonna need medical help some day...
Maybe we can do our own plumping and cut our own hair and be good law abiding citizens and not need a lawyer. But we're all going to have severe medical problems at some point.
I just want to point out that - you landed (probably more random than intentional) into arguably the best career in the history of labor.
Compare a doctor to almost anything beside an engineer - and it won't seem so terrible.
Most people that have been in engineering for >10 years got into it because it's what they liked doing - and then it just so happened to be ridiculously lucrative and not require you to go into hundreds of thousands of debt to get trained to do the job (medical, lawyer, etc).
Even most trades (electrical, plumping, beauty, the taxi medallion system, etc) are designed similar to the medical industry - and require ever more schooling (debt, opportunity cost) to get the job - to artificially reduce the work force to benefit current workers at the cost of future workers and everybody who uses those services.
I think the particular problem with the medical industry is... it's particular detrimental to society to be overworking doctors to the bone and it not really paying off for them until they're in their 50s.
We're all gonna need medical help some day...
Maybe we can do our own plumping and cut our own hair and be good law abiding citizens and not need a lawyer. But we're all going to have severe medical problems at some point.
Your last point isn't correct.
While that is the result I think emphasizing that it isn't made easier is important.
Electricians need to install high voltage wires that are safe in the home for untrained individuals for potentially a century.
Plumbers need to install water tight pipes that can withstand significant pressure without leaking (which can be difficult to detect and very quickly devastating damage wise)
Doctors are expected to be able to catch nearly any disease in their specialty based on an honest consultation.
Lawyers need to know a phenomenal amount of information to meaningfully know what o research when it comes to prepping for court cases.
All of these jobs are hard to prepare for and their is value to everyone else that you can prove you actually prepared.
The problem is the incentives for encouraging more people to prepare are backwards (those supporting the newbies benefit from fewer of them) which causes no real help to be given and the labor shortages.
But it isn't made up boundaries just to benefit existing members.
While that is the result I think emphasizing that it isn't made easier is important.
Electricians need to install high voltage wires that are safe in the home for untrained individuals for potentially a century.
Plumbers need to install water tight pipes that can withstand significant pressure without leaking (which can be difficult to detect and very quickly devastating damage wise)
Doctors are expected to be able to catch nearly any disease in their specialty based on an honest consultation.
Lawyers need to know a phenomenal amount of information to meaningfully know what o research when it comes to prepping for court cases.
All of these jobs are hard to prepare for and their is value to everyone else that you can prove you actually prepared.
The problem is the incentives for encouraging more people to prepare are backwards (those supporting the newbies benefit from fewer of them) which causes no real help to be given and the labor shortages.
But it isn't made up boundaries just to benefit existing members.
I don’t think you can reasonably draw a comparison from medicine to home electrics and plumbing.
My dad was a plumber and I’m preparing to pass the certification that permits me to work on home electrics. They are, to be blunt, easy. An average person can pick up most of it in a couple of months. Electrics and gas plumbing carry a certification requirement because an error can kill someone, but it’s easier than passing a driving test.
Obviously, there are higher tiers of those trades that require a lot more training, but even those aren’t really comparable to the level of knowledge and study needed to become a qualified doctor, let alone a consultant.
In the UK, shortages of tradespeople are less to do with the difficulty of training, or lack of course capacity, and more to do with people really just not wanting to do the job, for various reasons.
My dad was a plumber and I’m preparing to pass the certification that permits me to work on home electrics. They are, to be blunt, easy. An average person can pick up most of it in a couple of months. Electrics and gas plumbing carry a certification requirement because an error can kill someone, but it’s easier than passing a driving test.
Obviously, there are higher tiers of those trades that require a lot more training, but even those aren’t really comparable to the level of knowledge and study needed to become a qualified doctor, let alone a consultant.
In the UK, shortages of tradespeople are less to do with the difficulty of training, or lack of course capacity, and more to do with people really just not wanting to do the job, for various reasons.
Medicine has more barriers to entry at least partly because we’ve decided to erect them. Doctors learn all kinds of things outside their direct specialty that they don’t really need to know, but nobody inside the system has an incentive to streamline medical education or to encourage more and earlier specialization.
For example, we force most doctors to take a 4 year degree before medicine (sometimes pre-med, but often an arts or non-biological science degree). Wasting 4 years of a future doctor’s prime career on an expensive and often irrelevant screening program is extremely wasteful for society as a whole.
For example, we force most doctors to take a 4 year degree before medicine (sometimes pre-med, but often an arts or non-biological science degree). Wasting 4 years of a future doctor’s prime career on an expensive and often irrelevant screening program is extremely wasteful for society as a whole.
> Wasting 4 years of a future doctor’s prime career on an expensive and often irrelevant screening program is extremely wasteful for society as a whole
I have a cousin who's doing his residency right now and he has an interesting take on this.
You don't want to have a 21 year old in a cancer ward directly treating patients. They may lack the personal skills and life experience needed to convey empathy. In addition, they will not be taken seriously by patients due to their youth.
He is speaking from experience as someone who is doing his residency at a slightly younger age than average.
I have a cousin who's doing his residency right now and he has an interesting take on this.
You don't want to have a 21 year old in a cancer ward directly treating patients. They may lack the personal skills and life experience needed to convey empathy. In addition, they will not be taken seriously by patients due to their youth.
He is speaking from experience as someone who is doing his residency at a slightly younger age than average.
> You don't want to have a 21 year old in a cancer ward directly treating patients. They may lack the personal skills and life experience needed to convey empathy. In addition, they will not be taken seriously by patients due to their youth.
I just don't buy this take.
You don't let the junior engineer wild in production. You place guardrails around them until they learn and prove themselves as capable. The exact same thing can be done in medicine.
I just don't buy this take.
You don't let the junior engineer wild in production. You place guardrails around them until they learn and prove themselves as capable. The exact same thing can be done in medicine.
There isn't enough staff to manage teaching AND medical care at hospitals.
Shadowing/Interning is already done in your MD program.
In Engineering, you will generally have 1 engineer paired with 1 intern/NCG. In a hospital setting that is an unrealistic ratio given the relative lack of staffing.
Add to that liability related issues because unlike CS, you as a medical professional can be held legally liable. This of course leads to high malpractice insurance rates subsidized by the hospital, who then in turn also need to show insurers that they are doing the needful.
Shadowing/Interning is already done in your MD program.
In Engineering, you will generally have 1 engineer paired with 1 intern/NCG. In a hospital setting that is an unrealistic ratio given the relative lack of staffing.
Add to that liability related issues because unlike CS, you as a medical professional can be held legally liable. This of course leads to high malpractice insurance rates subsidized by the hospital, who then in turn also need to show insurers that they are doing the needful.
> There isn't enough staff to manage teaching AND medical care at hospitals.
The complaint "we can't spend the time to train new employees" isn't specific to the medical field, but the solution is the same: they can't afford NOT to, and the lack of staff is proof of it.
The last plan ended in the failure we're at now (no staff available to train new staff). The best time for staff to start training more staff was before they ran out of staff. The next best time is now.
The rub is that lack of staff isn't what prevents this, nor is even lack of staff time. It's a conscious, short-term-focused decision by hospitals to focus efforts outwards on making more money, rather than inwards on training or changing the status quo. And honestly, the long-term herculean task of changing the existing resident system seems, in my opinion, out of scope and fantastical for the average hospital.
The complaint "we can't spend the time to train new employees" isn't specific to the medical field, but the solution is the same: they can't afford NOT to, and the lack of staff is proof of it.
The last plan ended in the failure we're at now (no staff available to train new staff). The best time for staff to start training more staff was before they ran out of staff. The next best time is now.
The rub is that lack of staff isn't what prevents this, nor is even lack of staff time. It's a conscious, short-term-focused decision by hospitals to focus efforts outwards on making more money, rather than inwards on training or changing the status quo. And honestly, the long-term herculean task of changing the existing resident system seems, in my opinion, out of scope and fantastical for the average hospital.
Residency positions are not paid for by hospitals. They're paid for and allocated by the federal government.
That is also correct, the task of changing the system just seems out of scope for any given hospital.
Maybe if a sufficient number of hospital systems were sufficiently motivated to sufficiently lobby the government for change. I don't know what that would take.
Maybe if a sufficient number of hospital systems were sufficiently motivated to sufficiently lobby the government for change. I don't know what that would take.
Residents unionizing is a good start.
> You don't let the junior engineer wild in production. You place guardrails around them until they learn and prove themselves as capable. The exact same thing can be done in medicine.
You mean like a residency?
You mean like a residency?
A residency is direct care of a patient. MDs already have internships and shadowing during their degree.
Residents provide direct care under supervision and have many guardrails, as the comment I was replying to stated.
Clinical clerkship is not an internship, interns are first year residents. Shadowing does not teach you medicine.
Clinical clerkship is not an internship, interns are first year residents. Shadowing does not teach you medicine.
Residency is one form of that. A form with extreme labor restrictions and no ability to move jobs.
Yes, the system as designed by a cocaine addict[1] is broken. Residency is still necessary in principle. In a specialty program one only starts to become competent in PGY4.
It's a difficult problem to fix, I finished my residency training in Canada where we don't have ACGME protections in place and while it was far more abusive than US programs (where I currently work) it certainly made us very competent at the end, better than I am seeing in the average US trainee I supervise.
I'm not sure what the solution is to be honest. Competency is almost entirely driven by clinical volumes and exposure, you don't train to handle the 90% of normal cases but the 9% that are challenging and the 1% that's incredibly complex. If you're not working long hours (or spending many more years in training) chances are you won't get that exposure.
With that said one could argue with the current expectation that everyone does 1-2 fellowships we're already training longer.
[1]https://en.wikipedia.org/wiki/William_Stewart_Halsted
It's a difficult problem to fix, I finished my residency training in Canada where we don't have ACGME protections in place and while it was far more abusive than US programs (where I currently work) it certainly made us very competent at the end, better than I am seeing in the average US trainee I supervise.
I'm not sure what the solution is to be honest. Competency is almost entirely driven by clinical volumes and exposure, you don't train to handle the 90% of normal cases but the 9% that are challenging and the 1% that's incredibly complex. If you're not working long hours (or spending many more years in training) chances are you won't get that exposure.
With that said one could argue with the current expectation that everyone does 1-2 fellowships we're already training longer.
[1]https://en.wikipedia.org/wiki/William_Stewart_Halsted
Practically the whole world educates doctors with a 6-year program straight out of high school, out of which 6 years are relevant to medical education, instead of the 8 years in the US, out of which 4 are barely relevant to medical education.
>The problem is the incentives for encouraging more people to prepare are backwards (those supporting the newbies benefit from fewer of them) which causes no real help to be given and the labor shortages.
>But it isn't made up boundaries just to benefit existing members.
I would argue that it largely is just made up boundaries to benefit existing members. That is to say, regulatory capture has increased the barriers so far that any benefit from additional quality of service is far outweighed by the increased scarcity.
It doesn't matter if you have the best doctors and electricians in the world, if they are so few and expensive that the public does not have access to them.
The fundamental problem is that is both easy and popular to error on the side of "caution", creating increasingly stringent licensing requirements. These benefit established interests and sound attractive to the public.
>But it isn't made up boundaries just to benefit existing members.
I would argue that it largely is just made up boundaries to benefit existing members. That is to say, regulatory capture has increased the barriers so far that any benefit from additional quality of service is far outweighed by the increased scarcity.
It doesn't matter if you have the best doctors and electricians in the world, if they are so few and expensive that the public does not have access to them.
The fundamental problem is that is both easy and popular to error on the side of "caution", creating increasingly stringent licensing requirements. These benefit established interests and sound attractive to the public.
I don't disagree but I like to distinguish between "there shouldn't be barriers" and "there should be fewer barriers" and the verbiage I responded to felt like the former.
> Plumbers need to install water tight pipes that can withstand significant pressure without leaking (which can be difficult to detect and very quickly devastating damage wise)
There is no shortage whatsoever of licensed plumbers who will do incompetent work. Fortunately there is a decent collection of companies making excellent plumbing products that are quite robust.
Current personal favorite failure modes:
Use of inappropriate water-insoluble flux. This usually doesn’t cause a leak, at least not quickly. It is, however, disgusting (petroleum crud and not-very-good salts being released slowly over months to years in cold water pipes) and is a code violation.
Use of copper in boiler condensate pipes.
Use of essentially arbitrary mixes of pipe tape and pipe dope.
Overtightening of plastic threaded connections.
Incorrect combinations of tapered threaded fittings and gasketed straight threaded fittings.
There is no shortage whatsoever of licensed plumbers who will do incompetent work. Fortunately there is a decent collection of companies making excellent plumbing products that are quite robust.
Current personal favorite failure modes:
Use of inappropriate water-insoluble flux. This usually doesn’t cause a leak, at least not quickly. It is, however, disgusting (petroleum crud and not-very-good salts being released slowly over months to years in cold water pipes) and is a code violation.
Use of copper in boiler condensate pipes.
Use of essentially arbitrary mixes of pipe tape and pipe dope.
Overtightening of plastic threaded connections.
Incorrect combinations of tapered threaded fittings and gasketed straight threaded fittings.
I once moved into a house and had a plumber come out to connect the fridge to the water (there was some custom work that needed to be done).
There was a plastic line there already and that line hadn't been used in atleast a year (previous tenants kept their fridge in the garage). I remember asking the plumber if we should replace that plastic line and he said no, I even told him it hadn't been used in over a year.
A week or so after he did this work I'm walking through my living room and my socks are getting wet. At first I couldn't figure out what was going on until I realized that line had split (as I expected it to) and was leaking, said leak having moved into the living room where it was making the wood floors damp.
To this day I don't understand why that plumber thought that would be ok when I, as a complete layman, understood what happens to plastic lines that go unused for that long (they dry and crack).
There was a plastic line there already and that line hadn't been used in atleast a year (previous tenants kept their fridge in the garage). I remember asking the plumber if we should replace that plastic line and he said no, I even told him it hadn't been used in over a year.
A week or so after he did this work I'm walking through my living room and my socks are getting wet. At first I couldn't figure out what was going on until I realized that line had split (as I expected it to) and was leaking, said leak having moved into the living room where it was making the wood floors damp.
To this day I don't understand why that plumber thought that would be ok when I, as a complete layman, understood what happens to plastic lines that go unused for that long (they dry and crack).
What kind of plastic line? I've used a decent amount of name brand LLDPE tubing, and I've never seen it fail or even appear to degrade.
I have had issues with compression connectors at the ends (they don't like to be too loose or too tight), and I've seen plenty of failures of the really crappy washers that get used in "female compression" connectors.
I have had issues with compression connectors at the ends (they don't like to be too loose or too tight), and I've seen plenty of failures of the really crappy washers that get used in "female compression" connectors.
I'm not a plumber so I couldn't say, but clearly it did degrade :)
"Doctors are expected to be able to catch nearly any disease in their specialty based on an honest consultation."
From my experience they don't. If you have any problem off the beaten path you may spend years and multiple doctors to figure out what's going on.
From my experience they don't. If you have any problem off the beaten path you may spend years and multiple doctors to figure out what's going on.
I've heard a quip from my wife, "When you hear hoofbeats behind you, don't expect to see a zebra." Essentially, you need to know that booth horses and zebras make hoofbeats, but zebras are rare (in the US). It'd be foolish to look for a zebra until you've ruled out the possibility of a horse.
In fact, it even has a wikipedia page: https://en.wikipedia.org/wiki/Zebra_(medicine)
In fact, it even has a wikipedia page: https://en.wikipedia.org/wiki/Zebra_(medicine)
I agree that happens, my point is about the intersection of speciality and expected.
Aka it doesn't always happen but that is the goal.
Honestly disease diagnosis is the one area I could see AI being super helpful in which might lower this burden from extreme memorization to facilitating collecting data for analysis and being a guard on false positives.
Aka it doesn't always happen but that is the goal.
Honestly disease diagnosis is the one area I could see AI being super helpful in which might lower this burden from extreme memorization to facilitating collecting data for analysis and being a guard on false positives.
AI has had the opposite effect on false positives. Statistically, most patients aren't (that) sick and don't have zebras.
Taking radiology as an example (because that's my specialty) ~90% of studies are normal and some types (e.g. CT for pulmonary embolism, CT for transient ischemic attack/vertigo) are closer to 98-99% normal.
Every diagnostic AI application I've seen implemented as of 2023 that merely replicates the work of a human has done nothing but increase false positives.
The extreme class imbalance makes this a non-trivial problem.
Taking radiology as an example (because that's my specialty) ~90% of studies are normal and some types (e.g. CT for pulmonary embolism, CT for transient ischemic attack/vertigo) are closer to 98-99% normal.
Every diagnostic AI application I've seen implemented as of 2023 that merely replicates the work of a human has done nothing but increase false positives.
The extreme class imbalance makes this a non-trivial problem.
Agree about AI. It would be way more patient and take its time to talk to the patient than doctors have these days.
That makes more sense. I interpreted the "catch" quote to mean that doctors are expected to literally come down with any contagious disease within their specialty.
There can be more schooling and training in engineering.
After undergrad, master’s, PhD, a postdoc or two, one would still make low income. After that, there is a never ending path where one has to constantly chase ever changing technologies. The older you get, the harder it will be to keep up and remain employed.
In medical science, you finish the residency (roughly equivalent to 1-2 postdoc in engineering), and you start to practice. Already, income is OK in residency. The older you get, the better!
After undergrad, master’s, PhD, a postdoc or two, one would still make low income. After that, there is a never ending path where one has to constantly chase ever changing technologies. The older you get, the harder it will be to keep up and remain employed.
In medical science, you finish the residency (roughly equivalent to 1-2 postdoc in engineering), and you start to practice. Already, income is OK in residency. The older you get, the better!
The income is most assuredly not okay in residency, or for that matter, fellowship. Most U.S. residencies and fellowships range from $60-$70K a year, basically the U.S. median income, and on a per hour basis is terrible.
To make it worse many of the big name institutions one would aspire to train in (e.g. 10 of the US News top 20 hospitals) are in expensive metros where you don't cross the "low-income line" until the third year of residency.
All the while spending 60-80 hours a week on clinical service and 5-10 hours on research and education so you can maybe get a job somewhere not remote when you're done.
All the while spending 60-80 hours a week on clinical service and 5-10 hours on research and education so you can maybe get a job somewhere not remote when you're done.
> I just want to point out that - you landed (probably more random than intentional) into arguably the best career in the history of labor.
I don't disagree. However, I certainly am not a top earner in the industry. Much of my career has been remote. My income is not out of line with most STEM fields. The main benefit for me was the ability to work remotely, moving with my wife to various small towns/cities.
Keep in mind, my wife had almost 10 years of med school and residency to start her career. I was making income the whole time. That's essentially a $1M difference 10 years into careers. It takes a while to overcome that gap.
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> I think the particular problem with the medical industry is... it's particular detrimental to society to be overworking doctors to the bone and it not really paying off for them until they're in their 50s.
Yep. There's also a huge personal burden of carrying that non-dischargable debt. If residency doesn't work out for some reason, you're in a huge hole.
We know many physicians who say they wouldn't do it again if they had know how shitty the journey would be.
I don't disagree. However, I certainly am not a top earner in the industry. Much of my career has been remote. My income is not out of line with most STEM fields. The main benefit for me was the ability to work remotely, moving with my wife to various small towns/cities.
Keep in mind, my wife had almost 10 years of med school and residency to start her career. I was making income the whole time. That's essentially a $1M difference 10 years into careers. It takes a while to overcome that gap.
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> I think the particular problem with the medical industry is... it's particular detrimental to society to be overworking doctors to the bone and it not really paying off for them until they're in their 50s.
Yep. There's also a huge personal burden of carrying that non-dischargable debt. If residency doesn't work out for some reason, you're in a huge hole.
We know many physicians who say they wouldn't do it again if they had know how shitty the journey would be.
Problems are doctors are unlikely to "help" with, and are highly likely to make matters much, much worse.
Also, contrary to popular opinion, there's little stigma or awareness of "bad doctoring", for a number of systemic reasons.
So you have someone who doesn't give a fuck about anything, certainly not your situation, not listening to you, and trying to prevent you from receiving medical treatment.
This doesn't look so necessary to me. I know there will still be medical experts and surgeons and so forth, but much of this medical infrastructure doesn't benefit the average citizen (I know there's an argument that it does or for a change in perspective, but that's a whole different can of worms.
Similar to policing, if you think of the typical way you interact with the medical system, you start to realize there's very little in there to help you. 99.99% of the infrastructure is built to benefit powerful people with tons of money; helping you is an after thought.
What happens when you're a victim of crime? Turns out there's very little in place to help. Oh, someone is actively trying to murder you? well give us a call after it happens and maybe we'll investigate.
How many of us have experienced something like this? I'm not saying there's no reason for the arrangement, but we should stop trying to pretend these people are looking out for the public.
I know people may be tempted to chime in regarding some situation a police officer or doctor helped you. I'm not saying you're wrong, just explaining why some people are asking questions; if you honestly think about it, your naive assumptions about safety and health will be shattered.
A doctor, in many ways, arguably has a patients WORST interests at heart, in a similar manor to a police officer, in it's interaction with the public. They have, as their most important responsibilities, to detect certain things, and take actions to hurt the person.
This is priority #1, virtually everything else comes after. This is an important observation, is not obvious, and should cause us to reconsider these institutions.
Also, contrary to popular opinion, there's little stigma or awareness of "bad doctoring", for a number of systemic reasons.
So you have someone who doesn't give a fuck about anything, certainly not your situation, not listening to you, and trying to prevent you from receiving medical treatment.
This doesn't look so necessary to me. I know there will still be medical experts and surgeons and so forth, but much of this medical infrastructure doesn't benefit the average citizen (I know there's an argument that it does or for a change in perspective, but that's a whole different can of worms.
Similar to policing, if you think of the typical way you interact with the medical system, you start to realize there's very little in there to help you. 99.99% of the infrastructure is built to benefit powerful people with tons of money; helping you is an after thought.
What happens when you're a victim of crime? Turns out there's very little in place to help. Oh, someone is actively trying to murder you? well give us a call after it happens and maybe we'll investigate.
How many of us have experienced something like this? I'm not saying there's no reason for the arrangement, but we should stop trying to pretend these people are looking out for the public.
I know people may be tempted to chime in regarding some situation a police officer or doctor helped you. I'm not saying you're wrong, just explaining why some people are asking questions; if you honestly think about it, your naive assumptions about safety and health will be shattered.
A doctor, in many ways, arguably has a patients WORST interests at heart, in a similar manor to a police officer, in it's interaction with the public. They have, as their most important responsibilities, to detect certain things, and take actions to hurt the person.
This is priority #1, virtually everything else comes after. This is an important observation, is not obvious, and should cause us to reconsider these institutions.
Perhaps a more diplomatic to phrase what I perceive as your thought there is that a good doctor or policeman is actually in some respects often acting that way regardless of the system -- they would've tried to help people as much as they could anyway. Meanwhile a bad or apathetic doctor, policeman, etc. will tend to receive little friction for it while you have to fight uphill to get basic care, all while being milked of as much of your money as possible and still having to wait unbearably long for useful treatment.
Likewise, there's such a range of outcomes, and when it's involving chronic diseases combined with an apathetic or bad doctor, you can be stuck realizing you've wasted months with no resolution (not even getting into any potential costs) only to now have to start all over again potentially several more times just for a sliver of hope that you'll find a doctor who's caring and competent enough to finally help you out. So sitting on the receiving end feels like being bled dry by people who couldn't care less about your suffering or if you die, so long as you keep paying them, with little realistic recourse other than accepting that you got burned and moving on.
In any case, just my two cents from what I think seems like a somewhat related view but with a different "spin".
Likewise, there's such a range of outcomes, and when it's involving chronic diseases combined with an apathetic or bad doctor, you can be stuck realizing you've wasted months with no resolution (not even getting into any potential costs) only to now have to start all over again potentially several more times just for a sliver of hope that you'll find a doctor who's caring and competent enough to finally help you out. So sitting on the receiving end feels like being bled dry by people who couldn't care less about your suffering or if you die, so long as you keep paying them, with little realistic recourse other than accepting that you got burned and moving on.
In any case, just my two cents from what I think seems like a somewhat related view but with a different "spin".
The point is that the "bad or apathetic" doctor doesn't exist; It's not distinct. This is just default.
People are treated based on convenience to the doctor and their moral judgements. EVERYTHING in medicine works the opposite from the propaganda. I've been convinced it's part of a trope.
Any time a profession tries to convince you it's not something (eg. do know harm, treat regardless of morality, ect.), it is ALWAYS because they were doing exactly that, people correctly detected it, and now they're doing damage control.
People are treated based on convenience to the doctor and their moral judgements. EVERYTHING in medicine works the opposite from the propaganda. I've been convinced it's part of a trope.
Any time a profession tries to convince you it's not something (eg. do know harm, treat regardless of morality, ect.), it is ALWAYS because they were doing exactly that, people correctly detected it, and now they're doing damage control.
>to artificially reduce the work force to benefit current workers at the cost of future workers
is that really the purpose? or is it that an entire industry has been built on top of the trades, and that industry does whatever to continue to grow?
is that really the purpose? or is it that an entire industry has been built on top of the trades, and that industry does whatever to continue to grow?
> We're all gonna need medical help some day...
95% of health is being proactive about your health: food, fitness, sleep, dentist, etcetera.
I wonder how much doctoring is due to negligence of a healthy lifestyle, or perhaps chronic choices (addictive substances like alcohol, shift-work).
> But we're all going to have severe medical problems at some point.
Which often are untreatable - and the doctoring is regularly prophylactic. Hip-replacements are an obvious outlier.
95% of health is being proactive about your health: food, fitness, sleep, dentist, etcetera.
I wonder how much doctoring is due to negligence of a healthy lifestyle, or perhaps chronic choices (addictive substances like alcohol, shift-work).
> But we're all going to have severe medical problems at some point.
Which often are untreatable - and the doctoring is regularly prophylactic. Hip-replacements are an obvious outlier.
I had rectal cancer at age 40. There were no indications that my lifestyle caused or contributed to it. I rarely drank, didn't do drugs, etc etc. I might have had a genetic predisposition, but who knows, cancer is a complex thing. If I didn't have insurance, my medical bills would have easily been over $800K. So enough with your BS statistics that you pulled out of your ass.
Obviously many people get critically ill for no reason, totally without apparent casualty.
https://bowelcancernz.org.nz/about-bowel-cancer/early-detect... says about prevention: While no cancer is completely preventable, a healthy diet and regular exercise can lower your risk of bowel cancer. Numerous studies have indicated that a diet too rich in red meat and processed foods can heighten the risk of bowel cancer. However I would guess the percentage amount you can lower your risk by is below 1%. Across all health outcomes, healthy food choices and a daily walk can have a large effect overall.
It seems to me a hell of a lot of our healthcare funding goes towards people that make no preventative effort towards health. I have friends and acquittances with chronic conditions due to alcohol (diabetes, excessive obesity, gout, Korsikov's, accidents), smoking (emphysema, cancers), severely damaged joints (impact sports, car accidents), drugs (hepC, OD, teeth, accidents and worse).
Personally I eat "risky" foods , occasionally I drink excessively, I heartily enjoy high risk sports and activities, and I definitely don't exercise enough. I am not trying to preach: my point is many close their eyes to known risks.
I certainly am not blaming your cancer on your lifestyle. I sincerely hope the best for remission.
> I didn't have insurance, $800k
I'm in New Zealand and our taxes pay for reasonable quality cancer care for all - probably not $800k worth often. The sticker price for the US insurance system is often grossly[1] overstated (for reasons). I've seen our healthcare system mostly work (and I've seen some failures too).
[1] e.g. Hospital billed $100K, insurance negotiated to about $20K. The actual doctor only got $2-3K. https://news.ycombinator.com/item?id=37977337
https://bowelcancernz.org.nz/about-bowel-cancer/early-detect... says about prevention: While no cancer is completely preventable, a healthy diet and regular exercise can lower your risk of bowel cancer. Numerous studies have indicated that a diet too rich in red meat and processed foods can heighten the risk of bowel cancer. However I would guess the percentage amount you can lower your risk by is below 1%. Across all health outcomes, healthy food choices and a daily walk can have a large effect overall.
It seems to me a hell of a lot of our healthcare funding goes towards people that make no preventative effort towards health. I have friends and acquittances with chronic conditions due to alcohol (diabetes, excessive obesity, gout, Korsikov's, accidents), smoking (emphysema, cancers), severely damaged joints (impact sports, car accidents), drugs (hepC, OD, teeth, accidents and worse).
Personally I eat "risky" foods , occasionally I drink excessively, I heartily enjoy high risk sports and activities, and I definitely don't exercise enough. I am not trying to preach: my point is many close their eyes to known risks.
I certainly am not blaming your cancer on your lifestyle. I sincerely hope the best for remission.
> I didn't have insurance, $800k
I'm in New Zealand and our taxes pay for reasonable quality cancer care for all - probably not $800k worth often. The sticker price for the US insurance system is often grossly[1] overstated (for reasons). I've seen our healthcare system mostly work (and I've seen some failures too).
[1] e.g. Hospital billed $100K, insurance negotiated to about $20K. The actual doctor only got $2-3K. https://news.ycombinator.com/item?id=37977337
> 95% of health is being proactive about your health: food, fitness, sleep, dentist, etcetera.
You're young, aren't you?
The percentage is significant, but nowhere near 95%.
You're young, aren't you?
The percentage is significant, but nowhere near 95%.
I'm middle-aged.
I might be over-estimating the percentage. I might also be over-estimating how much we can affect diabetes, weight, fitness, addiction.
I can say that the chronic health problems of my peer-group often appear to be self-inflicted.
Of my dead acquantances there are maybe a few groups: (1) health problems caused by childhoods of poverty, (2) health problems that we haven't solved yet which the medical system helps little, (3) suicides, (4) crashes/accidents, and (5) health problems caused by smoking, drinking and drugs (e.g. HepC).
Also acquaintances with chronic conditions often don't follow medical advice anyway e.g. diabetic friends that abuse their bodies. Or people told to quit drinking or smoking that do not stop.
I'm not saying it is easy. I am saying I know plenty of acquantances that have made difficult choices to improve their lifestyle choices (presuming cause not correlation), and others that have not made positive changes.
Context: I'm in New Zealand, so healthcare is mostly free and of reasonable quality. We have lots of immigrants so I have some exposure to people from other (often adjacent) cultures.
I might be over-estimating the percentage. I might also be over-estimating how much we can affect diabetes, weight, fitness, addiction.
I can say that the chronic health problems of my peer-group often appear to be self-inflicted.
Of my dead acquantances there are maybe a few groups: (1) health problems caused by childhoods of poverty, (2) health problems that we haven't solved yet which the medical system helps little, (3) suicides, (4) crashes/accidents, and (5) health problems caused by smoking, drinking and drugs (e.g. HepC).
Also acquaintances with chronic conditions often don't follow medical advice anyway e.g. diabetic friends that abuse their bodies. Or people told to quit drinking or smoking that do not stop.
I'm not saying it is easy. I am saying I know plenty of acquantances that have made difficult choices to improve their lifestyle choices (presuming cause not correlation), and others that have not made positive changes.
Context: I'm in New Zealand, so healthcare is mostly free and of reasonable quality. We have lots of immigrants so I have some exposure to people from other (often adjacent) cultures.
I have multiple problems with this comment
> 95% of health is being proactive about your health: food, fitness, sleep, dentist, etcetera.
This is a statistic pulled out of nowhere.
>> But we're all going to have severe medical problems at some point.
>Which often are untreatable - and the doctoring is regularly prophylactic. Hip-replacements are an obvious outlier.
Again this is pulled out of nowhere. All types of joint replacement, stents and heart surgery are major procedures which are common and not prophylactic. Prostate cancer surgery has an 85% success rate in eradication where I live, and no, I didn't get it from bad lifestyle choices.
> 95% of health is being proactive about your health: food, fitness, sleep, dentist, etcetera.
This is a statistic pulled out of nowhere.
>> But we're all going to have severe medical problems at some point.
>Which often are untreatable - and the doctoring is regularly prophylactic. Hip-replacements are an obvious outlier.
Again this is pulled out of nowhere. All types of joint replacement, stents and heart surgery are major procedures which are common and not prophylactic. Prostate cancer surgery has an 85% success rate in eradication where I live, and no, I didn't get it from bad lifestyle choices.
> 95% of health is being proactive about your health: food, fitness, sleep, dentist, etcetera.
Maybe 70%? Genetics play a huge role. You will likely need a doctor if your family has a long history of cancer.
Maybe 70%? Genetics play a huge role. You will likely need a doctor if your family has a long history of cancer.
Same here. I am a programmer with a wife who is a doctor. It took her about 12 years after she started her practice before her total earnings surpassed mine.
One thing that rarely discussed in this kind of conversation is taxes. A doctor spends 12 years earning next to nothing and going into debt for training costs. Then the second they start making a real doctor salary, the IRS thinks they are 'rich'. They are taxed at the highest tax bracket even though it might take them another 10 years to surpass someone who was earning barely a six-figure salary the whole time.
If you spend 9 years earning nothing and then make $1M in your tenth year, you will pay much more taxes than someone earning $100K for 10 years (even though both earned a total of $1M over those 10 years).
One thing that rarely discussed in this kind of conversation is taxes. A doctor spends 12 years earning next to nothing and going into debt for training costs. Then the second they start making a real doctor salary, the IRS thinks they are 'rich'. They are taxed at the highest tax bracket even though it might take them another 10 years to surpass someone who was earning barely a six-figure salary the whole time.
If you spend 9 years earning nothing and then make $1M in your tenth year, you will pay much more taxes than someone earning $100K for 10 years (even though both earned a total of $1M over those 10 years).
Not to mention that most retirement accounts have yearly maximums, if you where making 401k for 10 years at 100k you will have significantly lower effective taxes than a person who made nothing and then sees high earnings trying to put into retirement.
Who knows if software engineers will be paid the same in the future but doctors will most likely have a strong "moat" till the day they die. Software engineers lucked out in this era not because they are smarter / harder working than people like mechanical engineers but they just chose a profession that naturally scales, and scaling is really how you can make a lot money.
I'm actually expecting doctor's moat to break in our life time. We're already seeing the beginnings of it.
Essentially, physicians have been so bottlenecked for so long that a bunch of states has simply said "screw it" and started paving the way for mid-levels (NPs and PAs) to operate in certain roles physicians have previously covered. The physician lobbies seem unwilling to address this, so I expect that mid-levels will continue to move up the chain. They know the market is desperate for a solution and physician interest groups are completely unwilling to provide that.
Essentially, physicians have been so bottlenecked for so long that a bunch of states has simply said "screw it" and started paving the way for mid-levels (NPs and PAs) to operate in certain roles physicians have previously covered. The physician lobbies seem unwilling to address this, so I expect that mid-levels will continue to move up the chain. They know the market is desperate for a solution and physician interest groups are completely unwilling to provide that.
Midlevels don’t necessarily hurt doctor compensation, because they are supervised by the doctor, who gets a cut for managing them in private practice. In hospitals it frees up doctor to do more high value procedures instead of lower value follow up visits in clinic.
> they are supervised by the doctor
I think this is the part that's going to break.
IMO, a model where a doctor leads a group of mid-levels seems pretty much ideal. It's like the senior dev leading junior engineers.
Unfortunately, it seems AMA has been so resistant to any change that enough places are simply saying screw it to oversight and allowing mid-levels to practice independently (with limited scope). i
I think this is the part that's going to break.
IMO, a model where a doctor leads a group of mid-levels seems pretty much ideal. It's like the senior dev leading junior engineers.
Unfortunately, it seems AMA has been so resistant to any change that enough places are simply saying screw it to oversight and allowing mid-levels to practice independently (with limited scope). i
Midlevels are partly making up for the doctors who go part time / retire soon after finishing their training.
Yeah, rural areas that can’t support a full time doctor have no choice but to let midlevels practice medicine if they can even get a midlevel.
Yeah, rural areas that can’t support a full time doctor have no choice but to let midlevels practice medicine if they can even get a midlevel.
> [...] harder working than people like mechanical engineers but they just chose a profession that naturally scales
The product of mechanical engineering also naturally scales. Once you design a machine, you can build it an infinite number of times. However, in neither case does the labour scale. One engineer, whether their focus be on software or mechanical, can only do so much in a day.
Software engineers lucked out in this era because it is a new, relative to other industries, field that saw a rapid rise in demand for labour, with comparatively few people able to fulfill the need for that labour. By virtue of supply and demand, incomes had to run high to attract workers.
> and scaling is really how you can make a lot money.
That is true, but engineering doesn't scale. It is highly doubtful that engineers will continue to benefit into the long future. The owners of the software built by engineers will be able to continue to reap the benefits of scalability, but the labourer – who does not scale – will undoubtedly start to get squeezed as the industry matures and demand is no longer growing exponentially.
The product of mechanical engineering also naturally scales. Once you design a machine, you can build it an infinite number of times. However, in neither case does the labour scale. One engineer, whether their focus be on software or mechanical, can only do so much in a day.
Software engineers lucked out in this era because it is a new, relative to other industries, field that saw a rapid rise in demand for labour, with comparatively few people able to fulfill the need for that labour. By virtue of supply and demand, incomes had to run high to attract workers.
> and scaling is really how you can make a lot money.
That is true, but engineering doesn't scale. It is highly doubtful that engineers will continue to benefit into the long future. The owners of the software built by engineers will be able to continue to reap the benefits of scalability, but the labourer – who does not scale – will undoubtedly start to get squeezed as the industry matures and demand is no longer growing exponentially.
>e. Software engineers lucked out in this era not because they are smarter / harder working than people like mechanical engineers
do you believe this is the case now?
do you believe this is the case now?
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eventually, the cost of a team of software engineers will be the monthly fee to chatGPT
At that point, the same will likely be true of most doctors, with DoctorGPTs making most of the cognitive decisions and a team of lower knowledge technicians and nurses doing most of the hands on work.
Other than surgeons, a ton of what we would traditionally think of as doctoring has already been abstracted away and work specialized and divvied up to technicians, with MDs pulling strings in the background.
Other than surgeons, a ton of what we would traditionally think of as doctoring has already been abstracted away and work specialized and divvied up to technicians, with MDs pulling strings in the background.
Maybe, but how longs is eventually? I love GPT, use it every day but it is pretty flawed. 10 years?
The machine building itself is end game. At that point you're suggesting singularity. I don't see how any profession survives that.
There's so much hype around AI right now, it's absolutely unhinged. Yes, we have semi-conversational AI. Yes, image detection is pretty good. It's all supervised.
Can we please touch grass?
There's so much hype around AI right now, it's absolutely unhinged. Yes, we have semi-conversational AI. Yes, image detection is pretty good. It's all supervised.
Can we please touch grass?
who knew what chatGPT was 2 years ago? things are moving fast, and gaining speed. will they plateau before getting to being ubiquitously useful?
Thing is, GPT is just another programming language. It no doubt brings a leap forward in approachability, like Javascript was a leap forward from assembly, but at the end of the day it still relies on programmers to use it. No matter how advanced it becomes, as long as it exists to serve the interests of humans, and not other machines, it is going to require programmers to describe what humans want to see carried out.
It is possible that everyone will become a programmer, like everyone has become an elevator operator, but unlike an elevator button press that takes milliseconds and you're done, does it behoove "the boss" to spend their day describing their ideas to GPT? I suspect, like today, they will still want to hire other humans to bridge that gap so that they can spend time doing more important things.
It is possible that everyone will become a programmer, like everyone has become an elevator operator, but unlike an elevator button press that takes milliseconds and you're done, does it behoove "the boss" to spend their day describing their ideas to GPT? I suspect, like today, they will still want to hire other humans to bridge that gap so that they can spend time doing more important things.
LLMs have been around since the 50s. Chomsky has plenty to say on them [1]. It's not half as rosy as the current hype cycle.
1. https://www.nytimes.com/2023/03/08/opinion/noam-chomsky-chat...
1. https://www.nytimes.com/2023/03/08/opinion/noam-chomsky-chat...
> they just chose a profession that naturally scales, and scaling is really how you can make a lot money.
They chose a profession that appears to scale to investors. When software _actually_ scales rather than being a subpar substitute for an existing mechanism is when the people involved were indeed smarter and worked much harder (typically).
They chose a profession that appears to scale to investors. When software _actually_ scales rather than being a subpar substitute for an existing mechanism is when the people involved were indeed smarter and worked much harder (typically).
> salaries need to offset the insane burden of training
A cycle here is that student loans rise with expected earnings and banks are fairly open ended about it, institutions happy to justify the use of the cash.
Salaries wouldn't need to be nearly as high if you didn't walk out of residency with 200k+ [medical school ] debt at a point that is effectively mid-career. As a society we'd probably be better off if the both the median salary and median debt was much lower. I've also seen the "guarantee" of a high salary later lead many young doctors and med students to be foolish with money, as "eh, what's a little more debt" is easy to fall into.
It's also part of the driver to overspecialization, more available GP's and fewer people reliant on emergency visits would obviously improve the system, but the economics and QOL for a general practice keep getting harder.
Residency bottleneck and the high barrier for foreign trained mid-career people are the two other areas for potentially major impact.
A cycle here is that student loans rise with expected earnings and banks are fairly open ended about it, institutions happy to justify the use of the cash.
Salaries wouldn't need to be nearly as high if you didn't walk out of residency with 200k+ [medical school ] debt at a point that is effectively mid-career. As a society we'd probably be better off if the both the median salary and median debt was much lower. I've also seen the "guarantee" of a high salary later lead many young doctors and med students to be foolish with money, as "eh, what's a little more debt" is easy to fall into.
It's also part of the driver to overspecialization, more available GP's and fewer people reliant on emergency visits would obviously improve the system, but the economics and QOL for a general practice keep getting harder.
Residency bottleneck and the high barrier for foreign trained mid-career people are the two other areas for potentially major impact.
The question is, does it really cost 200k to train each doctor? Surely the main input is the student's own time and effort, which isn't even included.
It probably costs more than that.
As a baseline, university education in Finland costs about €10k/year on the average. Medical education is more expensive than the average, probably between €15k and €20k a year. Universities in the US are generally better funded than those in Finland, which allows them to provide more personal attention to the students. And university salaries are higher in the US than in Finland.
Overall, I would estimate something like $20k/year for the undergraduate degree and $30k to $40k/year for the medical school, for a total of $200k to $240k. And that's just for the education, not including costs of living as a student.
As a baseline, university education in Finland costs about €10k/year on the average. Medical education is more expensive than the average, probably between €15k and €20k a year. Universities in the US are generally better funded than those in Finland, which allows them to provide more personal attention to the students. And university salaries are higher in the US than in Finland.
Overall, I would estimate something like $20k/year for the undergraduate degree and $30k to $40k/year for the medical school, for a total of $200k to $240k. And that's just for the education, not including costs of living as a student.
Sounds great, but my wife’s state-funded public medical school cost $85k/yr usd before cost of living.
There are a handful of state medical schools near the $40k/r, but they are on the much cheaper end
There are a handful of state medical schools near the $40k/r, but they are on the much cheaper end
I was estimating the costs of providing the education, not the prices of getting it. (The latter would be €0/year in Finland.) If a university can charge more, it can usually find a way to spend the extra money.
I wasn't wording things clearly. The 200k is just the median residual debt from medical school alone. People don't tend to pay it off much during residency years though, since residency pay is relatively low (50-70k). Lots of them acquire extra personal debt during residency. Doctors aren't typically considered "trained" until after residency.
My wife had $210k in debt from medical school. It's basically impossible to pay it off durning residency, so it just balloons.
All in, at the end of my wife's training, we would have been $1M ahead if she had simply worked a normal career. That's huge in your 20's and 30's when your trying to establish a house/family/etc.
All in, at the end of my wife's training, we would have been $1M ahead if she had simply worked a normal career. That's huge in your 20's and 30's when your trying to establish a house/family/etc.
Why are you expecting the AMA to fix this? The primary bottleneck on producing more physicians today is lack of residency program slots. Every year some doctors graduate from medical school but are unable to practice medicine because they can't get matched to a residency program. The AMA has been lobbying Congress to increase Medicare funding for those programs.
https://savegme.org/
https://savegme.org/
Why on earth would medicare have anything to do with residency spots to start with? Why wouldn't the hospitals use this as an apprenticeship program and pay the residents and charge appropriately for their services?
Because hospitals generally don't have the funding (in the case of rural or urban trauma barely balancing the books) or inclination (in the case if wealthy suburb, managed facilities trying to maximize profit by running minimal staff) to do this.
Ergo, like education in general, it's funded from the federal government.
Ergo, like education in general, it's funded from the federal government.
You just need to look at an EoB statement to realize the sheer volume of revenues earned by Residents (thought not retained by residents). They are huge profit centers for the medical system with millions in earned revenue annually.
Medicare does not need to pay for residents, they are massively net positive revenue. The AMA boards create artificial scarcity and "medicare" is the boogeyman word.
Medicare does not need to pay for residents, they are massively net positive revenue. The AMA boards create artificial scarcity and "medicare" is the boogeyman word.
But if those residents were paid by hospitals, they wouldn't be huge profit centers.
Or, to put it another way, if hospitals have difficulty balancing the books with free resident labor, adding additional paid residents wouldn't necessarily fix the financial problem in most hospitals.
Or, to put it another way, if hospitals have difficulty balancing the books with free resident labor, adding additional paid residents wouldn't necessarily fix the financial problem in most hospitals.
>> But if those residents were paid by hospitals, they wouldn't be huge profit centers.
Paying residents is not the blocker here, Residents are already paid by hospitals. They are paid a fraction of revenues, which is normal for any profitable business.
https://www.ziprecruiter.com/Salaries/First-Year-Medical-Res...
Paying residents is not the blocker here, Residents are already paid by hospitals. They are paid a fraction of revenues, which is normal for any profitable business.
https://www.ziprecruiter.com/Salaries/First-Year-Medical-Res...
If hospitals don't have the revenue, they should charge the cost of services to balance their books.
I think government involvement in the residency program is problematic distortion, causing hospitals to chase a scarce resource instead of working to expand the supply pipeline.
I think government involvement in the residency program is problematic distortion, causing hospitals to chase a scarce resource instead of working to expand the supply pipeline.
This is not a free market and you won't accomplish anything by telling hospitals what they "should" do. Prices are largely fixed by Medicare/Medicaid reimbursement rates. Whenever prices are fixed, shortages are pretty much inevitable.
Relying on Medicare to pay for residency programs isn't an ideal situation. But the reality is that there are no other major players in the system with both the money and incentive to cover those costs. That won't change without a complete restructuring of the entire system, and achieving the political consensus to do that will be extremely difficult.
If you have a few million dollars to spare then feel free to donate it to your local teaching hospital. They'll be happy to take your money to expand their residency program. There is an opportunity for philanthropists to do some real good in reducing the physician shortage.
Relying on Medicare to pay for residency programs isn't an ideal situation. But the reality is that there are no other major players in the system with both the money and incentive to cover those costs. That won't change without a complete restructuring of the entire system, and achieving the political consensus to do that will be extremely difficult.
If you have a few million dollars to spare then feel free to donate it to your local teaching hospital. They'll be happy to take your money to expand their residency program. There is an opportunity for philanthropists to do some real good in reducing the physician shortage.
I dont think I agree. Medicare/medicaid rates change constantly. The cost of retaining physicians is part of cost of providing healthcare, so there is no reason to carve it out. Hospitals have a natural incentive to have doctors on staff. The only reason they dont have incentive today is because there is someone else taking on the cost.
I would argue that it is easier and more realistic to simply include it in the price than expect congress accurately predict future demand, and continually pass legislation to that effect. We dont need a congressional act to subsidize hospital janitors- Somehow hospitals figure out how to include them in their operational expenses because they need them.
Furthermore, it wouldnt break the bank of most of these hospitals. Take one of the largest teaching hospitals in the world, Cleveland clinic, with 2000 residents. at typical resident grant of 100k, that is 200 million. The Cleavland clinic annual revenue is >13 Billion.
I would argue that it is easier and more realistic to simply include it in the price than expect congress accurately predict future demand, and continually pass legislation to that effect. We dont need a congressional act to subsidize hospital janitors- Somehow hospitals figure out how to include them in their operational expenses because they need them.
Furthermore, it wouldnt break the bank of most of these hospitals. Take one of the largest teaching hospitals in the world, Cleveland clinic, with 2000 residents. at typical resident grant of 100k, that is 200 million. The Cleavland clinic annual revenue is >13 Billion.
That is not a realistic or sensible proposal. Only a subset of hospitals do graduate medical education. If teaching hospitals raised their prices to cover the overhead of residency programs then that would put them at a competitive disadvantage relative to hospitals that don't train residents at all. In order to keep residency programs financially sustainable there has to be a separate revenue source.
Cleveland Clinic is a non-profit. Their total revenue is irrelevant. If you'd like them to spend an extra $200M on their residency program then they would have to spend less on other stuff. Take a look at their financial statements and then you can tell them exactly where they ought to cut back in order to fund your proposal. Please be specific.
https://my.clevelandclinic.org/about/overview/financial-info...
Cleveland Clinic is a non-profit. Their total revenue is irrelevant. If you'd like them to spend an extra $200M on their residency program then they would have to spend less on other stuff. Take a look at their financial statements and then you can tell them exactly where they ought to cut back in order to fund your proposal. Please be specific.
https://my.clevelandclinic.org/about/overview/financial-info...
Of course their revenue is relevant? IF they can stack 2 billion per year onto their endowment every year, they could spend 200 million on residents.
That is my specific proposal. If they refuse to raise prices, then they should grow the endowment by 200 million less per year and provide the same services. It is bad enough that a non-profit charges 20% more than the cost of their services. They would be fine if they were only making 18% more than their costs.
It is basicity the same as if Harvard college claimed it cant afford to train teachers aids while charging students more than enough to cover expenses and sitting on a 50 billion endowment that grows ever larger each year.
That is my specific proposal. If they refuse to raise prices, then they should grow the endowment by 200 million less per year and provide the same services. It is bad enough that a non-profit charges 20% more than the cost of their services. They would be fine if they were only making 18% more than their costs.
It is basicity the same as if Harvard college claimed it cant afford to train teachers aids while charging students more than enough to cover expenses and sitting on a 50 billion endowment that grows ever larger each year.
> We dont need a congressional act to subsidize hospital janitors- Somehow hospitals figure out how to include them in their operational expenses because they need them.
Observation that the lead/training time for additional hospital janitors is a couple weeks.
An additional resident takes 4+4=8 years.
Observation that the lead/training time for additional hospital janitors is a couple weeks.
An additional resident takes 4+4=8 years.
My point was with respect to billing, and the idea that hospitals couldn't use revenue to pay for residents and offset their cost. The idea that medicare costs are "fixed" and doesn't include residents is besides the point. Hence, medicare doesn't janitors, but hospitals figure out a way to pay them as an operational expense
They’ll take your money, and it will go straight to exec bonuses.
Among other laws, there's the EMTALA that prevents charging the cost of services.
https://en.m.wikipedia.org/wiki/Emergency_Medical_Treatment_...
https://en.m.wikipedia.org/wiki/Emergency_Medical_Treatment_...
Hospitals absolutely have the funding. Residents make a shit load of money for the hospitals they work for.
Some hospitals allow residents to moonlight (e.g. practice in off hours) and pay $300+/hour.
Some hospitals allow residents to moonlight (e.g. practice in off hours) and pay $300+/hour.
There are a lot of bizarre path dependence issues and misaligned financial incentives in the US healthcare system. Most teaching hospitals are non-profits, often run by university systems or governments. Those hospitals get much of their revenue from Medicare/Medicaid. Reimbursement rates are fixed and hospitals have no ability to raise prices to cover increased training expenses. So, the only solution has been to get separate GME funding from Medicare.
There are other GME funding sources such as private charitable foundations but still the majority of the money comes from Medicare.
There are other GME funding sources such as private charitable foundations but still the majority of the money comes from Medicare.
Residencies lose money, so they're reliant on federal subsidies.
> Residencies lose money,
Do they though? Or is that mostly creative accounting. I've heard claims in both directions but like anything in medical billing in the US, it's all pretty murky.
Do they though? Or is that mostly creative accounting. I've heard claims in both directions but like anything in medical billing in the US, it's all pretty murky.
Medicare pays for the residency spots.
https://www.cms.gov/medicare/payment/prospective-payment-sys...
https://crsreports.congress.gov/product/pdf/IF/IF10960
https://www.cms.gov/medicare/payment/prospective-payment-sys...
https://crsreports.congress.gov/product/pdf/IF/IF10960
Not that long ago (through at least 1997), the AMA was doing the opposite. They were instrumental (but not alone) in creating the shortage.
Residency slots are the bottle neck because the AMA requires residency to be the bottleneck.
There is literally no path to becoming a physician other than the blessed med school + residency path. By contrast, you can become a lawyer simply by passing the bar exam.
Some states are starting to allow physicians to practice without residency and the AMA is vehemently against it.
There is literally no path to becoming a physician other than the blessed med school + residency path. By contrast, you can become a lawyer simply by passing the bar exam.
Some states are starting to allow physicians to practice without residency and the AMA is vehemently against it.
The general impression is that AMA is basically giving lip service to that goal. In public, that may be their goal. In private, it's certainly not happening.
Most states are begging for more qualified providers. Many are looking to mid-levels to fill the gaps. If the AMA were serious, they'd be working with all of these states to fill those gaps with physicians.
Most states are begging for more qualified providers. Many are looking to mid-levels to fill the gaps. If the AMA were serious, they'd be working with all of these states to fill those gaps with physicians.
The primary bottleneck today is caused by lack of residency slots. The AMA isn't doing anything to prevent states from putting more money into residency programs. In fact they are actively encouraging it.
https://www.ama-assn.org/education/gme-funding
And if you think they're saying something else in private then let's see proof. This is not a place for baseless conspiracy theories.
https://www.ama-assn.org/education/gme-funding
And if you think they're saying something else in private then let's see proof. This is not a place for baseless conspiracy theories.
> And if you think they're saying something else in private then let's see proof. This is not a place for baseless conspiracy theories.
With all due respect, not everything that lacks proof is a conspiracy theory. I've spent a bunch of time in discussions with physicians. There's a consensus that AMA is largely ineffective and it's implied that it's ineffectiveness is valuable for inflating physician salaries.
This is a great write up that highlight how the AMA created the situation to begin with: https://blog.petrieflom.law.harvard.edu/2022/03/15/ama-scope...
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I did find a great example of AMA's double speak on this issue. A bunch of states have started looking for alternatives for providing care to their populations. Some states are now loosening regulation to allow mid-levels to practice. 6 states are now allowing physicians to practice (in certain fields) without completing residency.
That sounds great right? All of these groups have completed 3 to 4+ years of graduate medical education. They might not be as skilled as a physician, but they can certainly provide basic care. AMA doesn't think that's great.
> The AMA opposes enactment of legislation to authorize the independent practice of medicine by any individual who has not completed the state’s requirements for licensure to engage in the practice of medicine and surgery.
https://www.ama-assn.org/sites/ama-assn.org/files/corp/media...
The AMA doesn't actually want to engage in any of these solutions because it threatens their golden goose.
With all due respect, not everything that lacks proof is a conspiracy theory. I've spent a bunch of time in discussions with physicians. There's a consensus that AMA is largely ineffective and it's implied that it's ineffectiveness is valuable for inflating physician salaries.
This is a great write up that highlight how the AMA created the situation to begin with: https://blog.petrieflom.law.harvard.edu/2022/03/15/ama-scope...
------
I did find a great example of AMA's double speak on this issue. A bunch of states have started looking for alternatives for providing care to their populations. Some states are now loosening regulation to allow mid-levels to practice. 6 states are now allowing physicians to practice (in certain fields) without completing residency.
That sounds great right? All of these groups have completed 3 to 4+ years of graduate medical education. They might not be as skilled as a physician, but they can certainly provide basic care. AMA doesn't think that's great.
> The AMA opposes enactment of legislation to authorize the independent practice of medicine by any individual who has not completed the state’s requirements for licensure to engage in the practice of medicine and surgery.
https://www.ama-assn.org/sites/ama-assn.org/files/corp/media...
The AMA doesn't actually want to engage in any of these solutions because it threatens their golden goose.
[deleted]
Sounds like the system is basically set up to enrich loan companies, and to a lesser degree universities.
Who is lobbying for this system to be improved? Because almost certainly loan companies and universities are lobbying against that.
Who is lobbying for this system to be improved? Because almost certainly loan companies and universities are lobbying against that.
Medical schools absolutely want to expand, they make tons of money and have many applicants who are qualified and willing to pay. The problem is there aren't enough residency seats. If there were more med school grads without expanding residences many competent graduates would go unmatched.
In the us, there are almost 3 residency spots for every 2 us medical students.
Right, but then half of all med students apply only to derm residency or other lucrative and competitive field with nice hours, leaving us in the situation we are in now where 18% of all emergency med department residencies went unmatched: https://www.aliem.com/mismatch-unfilled-emergency-medicine-r...
There was rampant expansion of emergency medicine residency spots in the prior years without an associated increase in demand for new EM docs. People noticed the market there and chose to go elsewhere. Also, the unfilled positions are also the low quality ones where your education would be questionable (linked article mentions corporate owned which imo is a red flag).
Emergency med has decent flexibility in terms of hours. The problem was Covid and remote work reduced infections and accidents and heart attacks, and they lost turf to physician assistants manning urgent care centers.
Not during residency, and I have not idea what the second part has to do with the match going underfilled. Are you saying med students saw this phenomena and decided emergency med was best left to PAs, and did not apply to match?
What I heard was emergency departments suffered brutally during covid, and that has had a chilling effect on anyone wanting to go into it. The med students matching now were all rotating through departments during covid.
What I heard was emergency departments suffered brutally during covid, and that has had a chilling effect on anyone wanting to go into it. The med students matching now were all rotating through departments during covid.
yes, there are periodic oversupply and undersupply of various medical specialties (just like oil, labor, money, real estate agents), and medical students do react and choose accordingly. ER was hot for a while, and radiology was not so hot for a few years after 2008. Now surprisingly radiology has held up despite AI fears, because of baby boomers starting to get cancer, and ER is down, because private equity went nuts investing in urgent care centers before covid.
Source?
This is overall not per speciality and doesn’t include overall people who did not apply, the article even says itself it’s a all time match high.
Look no further: https://www.nrmp.org/wp-content/uploads/2023/03/Match-Rates-...
Look no further: https://www.nrmp.org/wp-content/uploads/2023/03/Match-Rates-...
The person i was responding to said that residency spots are the bottle neck, and not medical school spots. While residency spots have not kept pace with population growth also, the medical student spots are a much worse bottle neck. Specialties have their own periodic undersupply and oversupply, but that was not the topic of discussion in the post i was responding to.
Now, I don't know how you would ever include people who don't apply. I mean there are 5 million americans of age every year, so i guess that's a denominator.
what's a all time match high ? The number of spots and students ? Yeah, so ? The concern was that the number isn't high enough, and where the bottleneck is.
The real answer to why doctors in america earn so much, is that everyone in america earns so much. If you compare doctor to median salaries in the us, vs. doctor to median salaries in europe, maybe its not so different ?
Now, I don't know how you would ever include people who don't apply. I mean there are 5 million americans of age every year, so i guess that's a denominator.
what's a all time match high ? The number of spots and students ? Yeah, so ? The concern was that the number isn't high enough, and where the bottleneck is.
The real answer to why doctors in america earn so much, is that everyone in america earns so much. If you compare doctor to median salaries in the us, vs. doctor to median salaries in europe, maybe its not so different ?
> the medical student spots are a much worse bottle neck.
No, they are absolutely not. About 5% of medical school graduates do not placed into a residency program. There's a slew of Caribean medical schools that take only US based students. They have about a 20% non-placement rate.
Med schools have a lot more flexibility in slots. Once established, it's far easier to increase class size by 10% than it to get 10% more residency slots.
No, they are absolutely not. About 5% of medical school graduates do not placed into a residency program. There's a slew of Caribean medical schools that take only US based students. They have about a 20% non-placement rate.
Med schools have a lot more flexibility in slots. Once established, it's far easier to increase class size by 10% than it to get 10% more residency slots.
[deleted]
> Sounds like the system is basically set up to enrich loan companies, and to a lesser degree universities.
It's pretty foolish to take out private loans for medical school. Most people avoid it unless they need to cover living costs.
Federal loans have the chance of being forgiven with PSLF.
It's pretty foolish to take out private loans for medical school. Most people avoid it unless they need to cover living costs.
Federal loans have the chance of being forgiven with PSLF.
[deleted]
What “loan companies?” For more than a decade, medical school loans have been provided directly by the federal government.
I have no source for it, but I read once that (GP) doctors make less than software devs on average, simply because devs get that decade head-start with much less debt. It makes sense.
This is such a hard problem to fix. I doubt anyone is interested in hearing any solutions that involve worse-trained doctors, or longer training schedules, or massive pay increases for what are viewed as some of the highest-paid people in the nation. There is a lot of talk about opening up medical care for more people - which, naturally, means there will be a surge in demand. I can only imagine this would exacerbate the problem. It feels like we're running out of time to fix this.
This is such a hard problem to fix. I doubt anyone is interested in hearing any solutions that involve worse-trained doctors, or longer training schedules, or massive pay increases for what are viewed as some of the highest-paid people in the nation. There is a lot of talk about opening up medical care for more people - which, naturally, means there will be a surge in demand. I can only imagine this would exacerbate the problem. It feels like we're running out of time to fix this.
GP is a pretty shit field right now. Pay is stagnating and mid-levels are starting to take over an increasing number of general practice roles.
Based on the workload of medical students and residents, I do not believe that even if the AMA relaxed the standards for entry that unless they relaxed the standards for exit we would have more doctors.
And by workload, I don't mean just hours on the job, I mean amount of material to learn. It is overwhelming to most
And by workload, I don't mean just hours on the job, I mean amount of material to learn. It is overwhelming to most
Is it all really necessary? As an outsider it looks like letting the perfect be the enemy of the good. That, or it's just tradition / an elaborate hazing ritual.
I don't see how the ability to work long hours is necessary to heal the sick. They don't train airline pilots like this, or nuclear plant operators. What's so special about doctors?
I don't see how the ability to work long hours is necessary to heal the sick. They don't train airline pilots like this, or nuclear plant operators. What's so special about doctors?
Residency certainly seems like an elaborate hazing ritual. I believe there is something to be said for errors made when handing off patients between doctors at the end of a shift, which is why you would want to train physicians to maintain good performance even over long shifts. But in general, modern residency was invented by a morphine- and cocaine-addicted surgeon who decided, hey, I want you to undergo a grueling residency for an arbitrary number of years and you'll be a doctor when I say you are: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7828946/
Sleep deprivation in the service of error prevention always seemed a bit illogical. Other professions have shift handovers
Perfect? Hardly...
The long hours are much less now, though nowhere close to pilot or trucker hours. they're trying to give the future the most experience they can while still under supervision.
It'd be better to have a 5 year residency and go back to a 3 year med school, but that would reduce med school income so not likely.
The long hours are much less now, though nowhere close to pilot or trucker hours. they're trying to give the future the most experience they can while still under supervision.
It'd be better to have a 5 year residency and go back to a 3 year med school, but that would reduce med school income so not likely.
I know a guy who accrued $400k+ of med school debt and dropped out last quarter. Insane system. I didn't even consider medicine, despite being a top science student, because of the stress.
And god forbid you think you can handle it at 18 years old and then being stuck on the medical track for... decades.
And god forbid you think you can handle it at 18 years old and then being stuck on the medical track for... decades.
That’s a year of their salary. The salary/debt ratio in engineering is lower.
But it's not a year of salary for a med school dropout.
There is a reason why most med schools have like a 5% acceptance rate. They have a much bigger moat than most software engineers. They are guaranteed a lot of money even if they aren't that good. They don't have to worry about leet code grinding and learning the newest random framework either.
Here’s a secret: if you’re a good software engineer, you don’t have to worry about those things either.
Leet code grinding is maybe like USMLE and board grinding?
Life will always get you. There’s no way around work if you are a well paid professional. Maybe nepotism or fraud can get you there.
I’m not sure what leet code entails but these tests required a lot of preparation:
MCAT (hundreds of hours, thousands of questions, 10 practice exams)
USMLE Step 1 (hundreds of hours, 5,000 questions, 1 practice test)
USMLE Step 2 (maybe 40-60 hours, probably less than 2,000 questions)
USMLE Step 2 CS (4 hours a few dozen practice clinical scenarios. this thing doesn’t exist anymore)
USMLE Step 3 (30 hours, less than a 1,000 questions
Radiology CORE 1st board licensing exam (hundreds of hours, 5,000+questions)
Radiology Certifying 2nd board licensing exam (8 hours, 2,500 questions)
My next one is the CAQ and I haven’t started grinding for that yet. I do wake up every morning and do practice q’s though.
I still have a deeply negative networth and hate my job. Maybe others don’t, good for them.
Life will always get you. There’s no way around work if you are a well paid professional. Maybe nepotism or fraud can get you there.
I’m not sure what leet code entails but these tests required a lot of preparation:
MCAT (hundreds of hours, thousands of questions, 10 practice exams)
USMLE Step 1 (hundreds of hours, 5,000 questions, 1 practice test)
USMLE Step 2 (maybe 40-60 hours, probably less than 2,000 questions)
USMLE Step 2 CS (4 hours a few dozen practice clinical scenarios. this thing doesn’t exist anymore)
USMLE Step 3 (30 hours, less than a 1,000 questions
Radiology CORE 1st board licensing exam (hundreds of hours, 5,000+questions)
Radiology Certifying 2nd board licensing exam (8 hours, 2,500 questions)
My next one is the CAQ and I haven’t started grinding for that yet. I do wake up every morning and do practice q’s though.
I still have a deeply negative networth and hate my job. Maybe others don’t, good for them.
The amount of studying described here may be what you did but is not a minimum requirement by any means.
I'm not even sure where you're getting 5000+ questions for the ABR Core.
-Another radiologist.
I'm not even sure where you're getting 5000+ questions for the ABR Core.
-Another radiologist.
I actually did 3 months for Core, i think that’s pretty average.
Kevlar Radprimer Board vitals
Radprimer has probably more than 5,000 basic and intermediate questions by itself. Are you saying I lowballed it? I was pulling numbers out of my ass
Kevlar Radprimer Board vitals
Radprimer has probably more than 5,000 basic and intermediate questions by itself. Are you saying I lowballed it? I was pulling numbers out of my ass
RADPrimer isn't board prep and the question have little to no relevance for the ABR Core. Basic is designed to be completed in R1 and intermediate during R2-3.
The 5000 questions are how you're supposed to learn radiology, as an alternative to reading a textbook.
The 5000 questions are how you're supposed to learn radiology, as an alternative to reading a textbook.
You trying to be abrasive or no? It seems like yes but I’ll respond.
Everyone I know from multiple residencies and in fellowship all reset radprimer and redid the questions for core. It’s not like people save it, they do it twice. Anyways, like I said, I was pretty average for prep. Also I forgot to add - everyone I know also used the Radiology Core Physics app, that’s like an additional 300 or 500 questions.
Ben White is pretty well known, he pretty much gives a road map that includes rad primer
https://www.benwhite.com/radiology/approaching-the-abr-core-...
“Looking back, in an ideal world: I would have read Core Radiology and started RadPrimer in the fall. Done CTC and physics Feb/March and then filled in the rest of the time with questions, probably primarily via the A Core Review Series. Qevlar is nice for the phone app with offline capabilities and probably would’ve made it in too. Most of the latter would have been important mostly for anxiolysis or possibly long-term retention, as passage wasn’t an issue.”
I felt like Radprimer and the physics app were the highest yield Then board vitals Last Kevlar
Highest yield book was War machine. Crack did OK. Essentials books were solid, especially nucs.
Later gator
Everyone I know from multiple residencies and in fellowship all reset radprimer and redid the questions for core. It’s not like people save it, they do it twice. Anyways, like I said, I was pretty average for prep. Also I forgot to add - everyone I know also used the Radiology Core Physics app, that’s like an additional 300 or 500 questions.
Ben White is pretty well known, he pretty much gives a road map that includes rad primer
https://www.benwhite.com/radiology/approaching-the-abr-core-...
“Looking back, in an ideal world: I would have read Core Radiology and started RadPrimer in the fall. Done CTC and physics Feb/March and then filled in the rest of the time with questions, probably primarily via the A Core Review Series. Qevlar is nice for the phone app with offline capabilities and probably would’ve made it in too. Most of the latter would have been important mostly for anxiolysis or possibly long-term retention, as passage wasn’t an issue.”
I felt like Radprimer and the physics app were the highest yield Then board vitals Last Kevlar
Highest yield book was War machine. Crack did OK. Essentials books were solid, especially nucs.
Later gator
Not being abrasive, I have written questions for RADPrimer. We’re not instructed to write board style questions and that roadmap is the officially stated guidance.
When I was in residency most of us just did BoardVitals, Crack the Core and War Machine or the physics app you mentioned. That’s sufficient to pass the exam hence why I said this may be what you did but not the minimum necessary.
Resetting RADPrimer is a good way to review all of radiology but as you may remember the intermediate questions are much harder than the exams, almost all image based, and generally have many image sets and long stems.
It’s a completely different style and aim than BV, ACR DXIT or ABR Core which are generally either quick hitters or don’t have images.
Most people don’t study for the cert exam which is considerably easier. ABR doesn’t give statistics but I’ve never heard of someone failing it.
When I was in residency most of us just did BoardVitals, Crack the Core and War Machine or the physics app you mentioned. That’s sufficient to pass the exam hence why I said this may be what you did but not the minimum necessary.
Resetting RADPrimer is a good way to review all of radiology but as you may remember the intermediate questions are much harder than the exams, almost all image based, and generally have many image sets and long stems.
It’s a completely different style and aim than BV, ACR DXIT or ABR Core which are generally either quick hitters or don’t have images.
Most people don’t study for the cert exam which is considerably easier. ABR doesn’t give statistics but I’ve never heard of someone failing it.
Basic and intermediate RP “what is the diagnosis” with just images and no history are very similar to what’s on core - with basic being higher yield.
Crack the Core is now lower yield but War Machine is still go to for physics. Things could change in the future though. Board vitals gives way too much history and text without enough just image based questions, so it’s lower yield but still worth it I think. Maybe they changed qbank up since I used it. Qevlar was a waste - could be different now.
The certifying is easy diagnostically but the nucs/RISE/NIS documents need a read. Those don’t take a huge amount of time but they’re not 0 hours. If someone is confident in their ability to be passed by ABR then not looking at anything is a strategy I suppose.
Anyways, fun time over
Crack the Core is now lower yield but War Machine is still go to for physics. Things could change in the future though. Board vitals gives way too much history and text without enough just image based questions, so it’s lower yield but still worth it I think. Maybe they changed qbank up since I used it. Qevlar was a waste - could be different now.
The certifying is easy diagnostically but the nucs/RISE/NIS documents need a read. Those don’t take a huge amount of time but they’re not 0 hours. If someone is confident in their ability to be passed by ABR then not looking at anything is a strategy I suppose.
Anyways, fun time over
> Basic and intermediate RP “what is the diagnosis” with just images and no history are very similar to what’s on core - with basic being higher yield.
Again, basic is intended for first year radiology residents not as board prep. You may have used it for this purpose, but it is neither a prerequisite to pass the ABR Core nor is it the most efficient way to prepare.
You can make the statement that a lot of work goes into becoming a radiologist without the inaccurate claim that the one exam requires 5000+ practice questions.
The official description:
"RADPrimer helps radiologists fine tune their diagnostic skills and enhance their knowledge:
Comprehensive radiology training for all levels
RADPrimer allow physicians to customize their educational path, focusing on the topics that matter most. RADPrimer allows radiologists to use their time efficiently as they work toward professional advancement. Topic-focused lessons present specific diagnoses, anatomy, differential diagnoses, and assessment questions related to the topic. RADPrimer provides over 5,300 case-based learning and traditional questions."
Again, basic is intended for first year radiology residents not as board prep. You may have used it for this purpose, but it is neither a prerequisite to pass the ABR Core nor is it the most efficient way to prepare.
You can make the statement that a lot of work goes into becoming a radiologist without the inaccurate claim that the one exam requires 5000+ practice questions.
The official description:
"RADPrimer helps radiologists fine tune their diagnostic skills and enhance their knowledge:
Comprehensive radiology training for all levels
RADPrimer allow physicians to customize their educational path, focusing on the topics that matter most. RADPrimer allows radiologists to use their time efficiently as they work toward professional advancement. Topic-focused lessons present specific diagnoses, anatomy, differential diagnoses, and assessment questions related to the topic. RADPrimer provides over 5,300 case-based learning and traditional questions."
I don't know what you want me to tell you - but my experience as a recent graduate is reflected below. You may have had a different path but everyone in my training cohort is doing this and passing this down as the standard prep.
Rad Primer Basic 2,173 Qevlar - 2,000 Board vitals - 1300 PhysicsApp - 572
At University of Texas we did this for prep and in fellowship at the University of Washington I checked with their residents and they were doing that too.
Ben White from UTSW gives something like that as road map for study questions (which I already linked to you).
Here's another random perspective that matches mine https://www.nellymd.com/2015/07/american-board-of-radiology-...
> You can make the statement that a lot of work goes into becoming a radiologist without the inaccurate claim that the one exam requires 5000+ practice questions.
I keep providing links and data and you keep providing quotes about the definition of RadPrimer and what exactly it is and how exactly residents are supposed to utilize it - without any deviation. I don't know where you did your training but perhaps you're at a more prestigious institution and the trainees had to prepare less to pass the exam. Maybe you're just that much smarter.
Rad Primer Basic 2,173 Qevlar - 2,000 Board vitals - 1300 PhysicsApp - 572
At University of Texas we did this for prep and in fellowship at the University of Washington I checked with their residents and they were doing that too.
Ben White from UTSW gives something like that as road map for study questions (which I already linked to you).
Here's another random perspective that matches mine https://www.nellymd.com/2015/07/american-board-of-radiology-...
> You can make the statement that a lot of work goes into becoming a radiologist without the inaccurate claim that the one exam requires 5000+ practice questions.
I keep providing links and data and you keep providing quotes about the definition of RadPrimer and what exactly it is and how exactly residents are supposed to utilize it - without any deviation. I don't know where you did your training but perhaps you're at a more prestigious institution and the trainees had to prepare less to pass the exam. Maybe you're just that much smarter.
On the other hand, you want doctors to be well rewarded because it's a high stress, high work hours, high responsibility, high liability, high effort and high opportunity cost profession. If it doesn't pay well, very few people are going to bust ass in medical school and residency for 10 years to do it.
In my country the government flooded the market with doctors and the results weren't pretty to say the least.
In my country the government flooded the market with doctors and the results weren't pretty to say the least.
[deleted]
I would prefer to see a reasonable paid, not stressed and not overbooked and not over worked doctor.
Most doctors I know would rather be overworked than underpaid.
And not to mention that doctors usually have no work life balance. I have many doctors in my family/friends here in the US and most of them have no time for anything including weeknights and weekends. It is crazy.
Most of my friends who became doctors have rich parents. The ones without rich parents funnily enough dated software engineers who were the main breadwinners during their med school/residency.
We don't have a shortage. We have too much regulation by AMA limiting number of doctors.
Just because the shortage is intentionally engineered doesn't make it not a shortage.
You’re making the comparison with software engineering in the US which is one of the biggest outliers in terms of income.
[deleted]
> Based on our math, we’ll be 25 to 30 years into our careers before her medical education with have a better ROI than my career choice. I didn’t even push for top-dollar jobs.
This has quite frankly zero relevance to anything. The analysis depends on what you her husband does (I mean seriously how does that prove a point at all) and your choice and abilities (totally arbitrary based on a host of factors especially given the tech scene over the last decade.
I mean ROI? So someone makes a career decision by comparing to what their partner makes or what ROI is?
> AMA is unwilling to fix this
This has to do with residency slots and residency slots are determined by how many hospitals can accept residents. Now you can say AMA is a roadblock to that but there are a slew of other roadblocks in addition (if true not sure it is) to having more residency slots.
You can think idealistically that you can re-imagine the whole system but massive change in something entrenched like that (where lives matter) most likely is not practical.
This has quite frankly zero relevance to anything. The analysis depends on what you her husband does (I mean seriously how does that prove a point at all) and your choice and abilities (totally arbitrary based on a host of factors especially given the tech scene over the last decade.
I mean ROI? So someone makes a career decision by comparing to what their partner makes or what ROI is?
> AMA is unwilling to fix this
This has to do with residency slots and residency slots are determined by how many hospitals can accept residents. Now you can say AMA is a roadblock to that but there are a slew of other roadblocks in addition (if true not sure it is) to having more residency slots.
You can think idealistically that you can re-imagine the whole system but massive change in something entrenched like that (where lives matter) most likely is not practical.
i dont get ageism in tech at all if anything i would hire the most experienced programmers tf would i hire a less experienced person.
People worry a lot about ageism here. I'm not seeing it be a problem in the real world.
At every company I've been at, the most senior people are the ones with the most pull, with the strongest direction and advice.
I've worked with a few people 60+ who suck. I bet they sucked at age 30, though.
At every company I've been at, the most senior people are the ones with the most pull, with the strongest direction and advice.
I've worked with a few people 60+ who suck. I bet they sucked at age 30, though.
Ageism in tech is based on the premise if you aren’t already a multimillionaire dabbling in angel investing by 30, you don’t have the “it” (ambition, skill, etc) to really contribute at a high level, and a young programmer can do similar work but be more familiar with latest tools and langs
While true, in my experience, many much more experienced developers can do a lot of things the less experienced ones think they can.
What about the people who did make a lot of money but like to work and create things?
What about the people who did make a lot of money but like to work and create things?
The assumption would be if you are someone who likes to work and create you will be a founder or maybe work on some mission specific passion career.
>Based on our math, we’ll be 25 to 30 years into our careers before her medical education with have a better ROI than my career choice. I didn’t even push for top-dollar jobs.
Depending on if you're married or brought a home, her education and status already paid off with special rates for doctors/lawyers/high earners/professional mortgages:
https://www.studentloanplanner.com/professional-mortgage-loa...
Depending on if you're married or brought a home, her education and status already paid off with special rates for doctors/lawyers/high earners/professional mortgages:
https://www.studentloanplanner.com/professional-mortgage-loa...
Will you mind breaking out the typical educational costs and earnings potential.
I have a child I’m encouraging to become a doctor, and it’d be great to know some actual economics before I push too hard this profession.
I have a child I’m encouraging to become a doctor, and it’d be great to know some actual economics before I push too hard this profession.
On some quick googling the mean debt at graduation from medical school is about 250,000 (this includes undergrad). This number is trending upward. There is also the opportunity cost of 4 years additional school and 3-7 years of getting paid 60-70k.
Most doctors end up making between 265k and 382k per year, this varies wildly (from pediatrician on the low end to brain surgeon on the high end).
Here is a good article: https://www.whitecoatinvestor.com/how-much-do-doctors-make/
Most doctors end up making between 265k and 382k per year, this varies wildly (from pediatrician on the low end to brain surgeon on the high end).
Here is a good article: https://www.whitecoatinvestor.com/how-much-do-doctors-make/
It varies wildly depending on the medical school (state school in Texas is affordable for example), scholarships, program (MD/PhD programs, MD only, MD/JD programs), and terminal specialization.
That would be helpful to me as well
My teenager wants to be a radiologist but I have no idea if it’s even possible to do that in a way that isn’t a path to depression and burnout
My teenager wants to be a radiologist but I have no idea if it’s even possible to do that in a way that isn’t a path to depression and burnout
The difference being a doctor is a lifestyle business requiring performance of service while a software developer can potentially make passive income. There is, however, a lack of essentialism to being a software developer that AI can replace, whereas caregivers will be the last to be automated away. It is likely software development incomes have peaked and will decline long term.
Hmm, are you turning both your wages into hourly rates and then comparing? My wife is a physician (me a SWE) and at face value she makes more but after considering hours worked it’s not even close.
She is regularly pulling 65-90 hrs/wk with little flexibility in her schedule.
She is regularly pulling 65-90 hrs/wk with little flexibility in her schedule.
Is your spouse still in residency?
I ask because I didn’t know 65-90 hrs/week (13 hr days / 7 days per week) was typical for non-residents.
I ask because I didn’t know 65-90 hrs/week (13 hr days / 7 days per week) was typical for non-residents.
I'd say that the law of one price applies here. Doctors need to be making this much to compensate for living in debt their whole youth and early adulthood. Also having money is probably more enjoyable when you're younger.
Not necessarily. The demand for doctors is generally greater than the supply. Because the profession gatekeeps.
The law of one price requires free market competition.
The law of one price requires free market competition.
Yeah, for real, the whole residency/shifts they are submitted into are borderline abusive, and I don't think any other profession accepts their professionals going though this
It's basically a firm of hazing
It's basically a firm of hazing
America needs tuition-free state universities and trade schools. Full-stop. We're encountering endless problems, sending our entire economy (and living standards) out of whack, because we don't.
Who pays for tuition free universities and trade schools?
The same people that pay for tuition free primary education....
Local taxpayers/property owners?
That model doesn’t really work to fund higher education. The public won’t accept doubling or tripling their property tax.
That model doesn’t really work to fund higher education. The public won’t accept doubling or tripling their property tax.
> That model doesn’t really work to fund higher education. The public won’t accept doubling or tripling their property tax.
[citation needed]
And I can give you a citation against. In my local municipality the tax base is roughly $1.5 billion. The annual expenditures for the local vo-tech school for that municipality is $30 million. If all of the state and tuition funding for the vo-tech school suddenly vanished the property owners would see a rise of ... wait for it ... a grand total of 2%. Certainly a far cry from the doubling or tripling you suggested.
Amortizing the tuition across all public post-secondary institutions in the state via income and property tax bases of the entire state would likely be somewhere in the neighborhood of 1-2% total every year. Based on that analysis it seems monumentally stupid to NOT publicly fund post-secondary education.
Ditch the NCAA sports programs and it probably gets cheaper. The whole sales pitch for sports is that scholarships provide a pathway for some students to go to college that otherwise could not afford it. Get rid of tuition and suddenly that reason goes away, too.
[citation needed]
And I can give you a citation against. In my local municipality the tax base is roughly $1.5 billion. The annual expenditures for the local vo-tech school for that municipality is $30 million. If all of the state and tuition funding for the vo-tech school suddenly vanished the property owners would see a rise of ... wait for it ... a grand total of 2%. Certainly a far cry from the doubling or tripling you suggested.
Amortizing the tuition across all public post-secondary institutions in the state via income and property tax bases of the entire state would likely be somewhere in the neighborhood of 1-2% total every year. Based on that analysis it seems monumentally stupid to NOT publicly fund post-secondary education.
Ditch the NCAA sports programs and it probably gets cheaper. The whole sales pitch for sports is that scholarships provide a pathway for some students to go to college that otherwise could not afford it. Get rid of tuition and suddenly that reason goes away, too.
Colleges/Universities absolutely do not need more money...they need more accountability.
I'm not arguing with your numbers, I guess my point is that I don't think taxpayers will accept a huge "freebie" for one group which results in their taxes going up. The optics are terrible.
I'm not arguing with your numbers, I guess my point is that I don't think taxpayers will accept a huge "freebie" for one group which results in their taxes going up. The optics are terrible.
In reality (and historically), it's the state taxes and not property taxes.
Still, if I had 2 kids, doubling my property tax would be cheaper for me than my paying for their tuition at current rates.
Still, if I had 2 kids, doubling my property tax would be cheaper for me than my paying for their tuition at current rates.
> The same people that pay for tuition free primary education....
Are you suggesting that people should be locked to the school in their district? Because that's the way primary education works.
Are you suggesting that people should be locked to the school in their district? Because that's the way primary education works.
Public community colleges primarily attract and accept students from the local community and are usually supported by local tax revenue - from Wikipedia.
They aren't locked in. That's the one provided for free. It doesn't seem to stop private schools and homeschooling at all.
Public universities are generally run by the state, not a local government so sure, free in state tuition sounds reasonable.
Who pays for them in Germany? In Germany, universities are free for everyone even foreigners.
Since GP says State Universities I would assume the State they were in would, through whatever tax policy they like.
Since GP says State Universities I would assume the State they were in would, through whatever tax policy they like.
In Germany, taxes are 39.5% of GDP. In the US, they are 26.6% of GDP. There’s no realistic proposal that has ever been advanced, not even from the Bernie/AOC/Warren types, on how to raise the extra $2.8 trillion annually that would be required. Elizabeth Warren’s proposed wealth tax wouldn’t even raise that much money over a decade, much less annually.
"extra $2.8 trillion" is incredibly dishonest. Nothing in any universal/single-payer healthcare proposal magically adds $2.8 trillion in actual medical expenses to the system. It's fundamentally an accounting change, akin to a married couple with a joint banking account deciding who'll pay the restaurant bill this time.
To be like Germany, you would have to take $2.8 trillion from the private sector and put it into the public sector by taxing and spending an extra $2.8 trillion. That’s not an accounting change—the government doesn’t have a joint bank account with the private sector.
> To be like Germany, you would have to take $2.8 trillion from the private sector and put it into the public sector by taxing and spending an extra $2.8 trillion.
And those taxes would replace the insurance premiums employers and individuals are currently paying out the ass for. It's a difference in who writes the checks, not how much actually goes out of individuals' pockets.
Claiming "$2.8B in new taxes" is like claiming "I Venmo you $5, you Venmo me $10" costs me five bucks.
> That’s not an accounting change—the government doesn’t have a joint bank account with the private sector.
That "joint account" is the GDP you're on about.
And those taxes would replace the insurance premiums employers and individuals are currently paying out the ass for. It's a difference in who writes the checks, not how much actually goes out of individuals' pockets.
Claiming "$2.8B in new taxes" is like claiming "I Venmo you $5, you Venmo me $10" costs me five bucks.
> That’s not an accounting change—the government doesn’t have a joint bank account with the private sector.
That "joint account" is the GDP you're on about.
If they were free, more people would take advantage of them, potentially earning more, bumping them into higher tax brackets, where their taxes would be used to fund tuition free education, and the cycle would continue.
The money moves in a circle, thus creating the self-sustaining economy we’ve been looking for.
This question is important and needs to be asked because nobody's already solved this problem. We'd be moving into uncharted territory.
[deleted]
We literally had tuition free universities and trade schools for decades until desegregation. I'll let you figure out what happened after that.
This sounds like less accountability when fixing the problem requires more.
America needs to stop letting their University systems bloat everything unrelated to actual education and research.
America needs to stop letting their University systems bloat everything unrelated to actual education and research.
Agreed. American universities need a two-pronged fix.
- Implement ACA-style budget efficiency minimums
This much of tuition must be spent on direct-teaching expenses. Only this much may be spent on everything else. Otherwise the university in ineligible for any federal educational assistance grant/loan.
- Increase funding via increased state contributions to public universities (returning to historical averages), to lower tuition costs
- Implement ACA-style budget efficiency minimums
This much of tuition must be spent on direct-teaching expenses. Only this much may be spent on everything else. Otherwise the university in ineligible for any federal educational assistance grant/loan.
- Increase funding via increased state contributions to public universities (returning to historical averages), to lower tuition costs
Full-stop? Hardly. Who would gatekeep so that universities and trade schools aren't just continuing the babysitting in high school?
She has better job security than you, however.
And career longevity. A 40 year old developer is "old". At 50 you're ancient.
A 40 year old doctor is insanely young. A doctor in his late 60s can easily be in their prime, especially in some practice areas or research. Provided they are okay health-wise, even an 80 year old doctor can still be working, especially if they have a strong team. They'll probably be in a mentorship role or a more laid-back practice, but they'll still be earning a meaningful income and having a very real impact on their patients.
And generally speaking, doctors in the West live longer than the general population, so that longevity is better as well.
A 40 year old doctor is insanely young. A doctor in his late 60s can easily be in their prime, especially in some practice areas or research. Provided they are okay health-wise, even an 80 year old doctor can still be working, especially if they have a strong team. They'll probably be in a mentorship role or a more laid-back practice, but they'll still be earning a meaningful income and having a very real impact on their patients.
And generally speaking, doctors in the West live longer than the general population, so that longevity is better as well.
You are absolutely correct.
So far, that really hasn't been a factor for us. It is worth noting that job security becomes much less important as you build wealth. It's a lot easier to build wealth when you're not racking up debt and being underpaid in your 20's.
So far, that really hasn't been a factor for us. It is worth noting that job security becomes much less important as you build wealth. It's a lot easier to build wealth when you're not racking up debt and being underpaid in your 20's.
Programmers face much more ageism than doctors. Actually they face the reverse ageism (against younger ones).
Really helps to come from money so that you don't have that huge college debt to crawl out from under.
Yeah but doctors also get social cachet, and get to feel like they’re doing something positive.
> Residency was demanding and severely underpaid.
Wait, you're getting paid?
Wait, you're getting paid?
Just want to expand on that "tuition/debt/time" bit.
TL;DR: Becoming a physician requires sacrificing an additional 6-10 years of your life to education and training beyond what you'd expect for most careers, and assuming something like $250K in additional debt. It'll take the average physician about 16-years out of college before they start to out-earn the average engineer.
Details:
Let's imagine that two smart people start college in the United States. One goes into engineering, the other into med school.
The day they graduate, on average the engineer will get job that pays them $74k their first year.
Year 4, the engineer is likely making $84k/yr, and they have earned a total of about $315k in their career.
Meanwhile, our doctor friend has so far accrued about $250k in debt. A delta of about $560k in just 4 years, but it's gonna' get worse before it gets better.
For the next ~3-5-years (for most specialties, there are outliers), our doctor friend is gonna make about $50k/yr . (Yay, positive cashflow!) We'll generously assume their debt doesn't accrue interest in this period.
Assuming our engineer friend assumes an average career path, he's gonna be up to $92k/yr at the end of this period, with a lifetime total earnings of $669k, while our doctor friend has clawed their lifetime earnings all the way back up to -$52k.
This is also the biggest delta between the two careers. At year 8, our engineer friend has out-earned our doctor friend by a delta of $720k.
Now, on average, our doctor friend starts making $202k/yr. Good money, right!
To make the math easy, we'll assume that their debt still doesn't accrue interest.
With all that, it's not until 16-years out of college that the average American physician will start to out-earn the average American engineer.
So if they both graduated at 23, our Engineer friend is gonna out-earn our doctor friend until they both hit just about 40.
Of course, if our doctor friend has to pay some interest on their med school debt, and our engineer friend is able to invest a chunk of their salary in those early years, the magic of compound interest will be on their side as well.
And that says nothing of the fact that our doctor friend probably had to sacrifice about 4-years of mandatory 80+ hour work weeks. It also assumes that our doctor friend doesn't drop out/fail out of med school and manages to match to and complete a residency. None of which are givens.
Which is a very long way of saying: physician compensation is wonky because it's a career where you sacrifice a ton and take a ton of career risk very early on, for the promise of higher compensation and quite high job security later on in your career.
TL;DR: Becoming a physician requires sacrificing an additional 6-10 years of your life to education and training beyond what you'd expect for most careers, and assuming something like $250K in additional debt. It'll take the average physician about 16-years out of college before they start to out-earn the average engineer.
Details:
Let's imagine that two smart people start college in the United States. One goes into engineering, the other into med school.
The day they graduate, on average the engineer will get job that pays them $74k their first year.
Year 4, the engineer is likely making $84k/yr, and they have earned a total of about $315k in their career.
Meanwhile, our doctor friend has so far accrued about $250k in debt. A delta of about $560k in just 4 years, but it's gonna' get worse before it gets better.
For the next ~3-5-years (for most specialties, there are outliers), our doctor friend is gonna make about $50k/yr . (Yay, positive cashflow!) We'll generously assume their debt doesn't accrue interest in this period.
Assuming our engineer friend assumes an average career path, he's gonna be up to $92k/yr at the end of this period, with a lifetime total earnings of $669k, while our doctor friend has clawed their lifetime earnings all the way back up to -$52k.
This is also the biggest delta between the two careers. At year 8, our engineer friend has out-earned our doctor friend by a delta of $720k.
Now, on average, our doctor friend starts making $202k/yr. Good money, right!
To make the math easy, we'll assume that their debt still doesn't accrue interest.
With all that, it's not until 16-years out of college that the average American physician will start to out-earn the average American engineer.
So if they both graduated at 23, our Engineer friend is gonna out-earn our doctor friend until they both hit just about 40.
Of course, if our doctor friend has to pay some interest on their med school debt, and our engineer friend is able to invest a chunk of their salary in those early years, the magic of compound interest will be on their side as well.
And that says nothing of the fact that our doctor friend probably had to sacrifice about 4-years of mandatory 80+ hour work weeks. It also assumes that our doctor friend doesn't drop out/fail out of med school and manages to match to and complete a residency. None of which are givens.
Which is a very long way of saying: physician compensation is wonky because it's a career where you sacrifice a ton and take a ton of career risk very early on, for the promise of higher compensation and quite high job security later on in your career.
Maybe I'm missing something but why does the engineer not have any educational debt and why does the doc in your example have no income?
Looks like he's starting a the end of a bachelor's degree. It's a sane simplification since it should be the same for both fields.
For medicine, undergrad debt is pretty tough since you really have no way to pay it off. It just accrues.
For medicine, undergrad debt is pretty tough since you really have no way to pay it off. It just accrues.
Yeah, exactly right. Whether you do pre-med or an engineering undergrad, you should have the same amount of debt/time. Though of course I simplified everything to not really account for interest.
Assumedly, an engineer would be able to pay off their undergrad debt much quicker than an MD.
Assumedly, an engineer would be able to pay off their undergrad debt much quicker than an MD.
chad?
socialism needs to offset the cost.
it's that simple.
it's that simple.
"In 1997 federal funding for residencies was capped, forcing hospitals to either limit programmes or shoulder some of the financial burden of training their doctors. Some spots have been added back, but not nearly enough. Many potential doctors are being left behind. “Not everyone who would be willing to go through that training and could do it successfully is being allowed to,” says Professor Gottlieb, the economist."
I regularly hear it is the AMA that is creating an artificial shortage, but this seems to indicate that the logjam is at the level of residency funding.
Does anyone have a good insight or data about this?
I regularly hear it is the AMA that is creating an artificial shortage, but this seems to indicate that the logjam is at the level of residency funding.
Does anyone have a good insight or data about this?
It is the same issue.
The AMA has lobbied to limit federal funding for medical residency. This is the bottleneck.
The fundamental problem is that the US government should not be in the business of funding residencies to begin with. That should the on the hospitals.
Right now the problem is that no hospitals want pay the 150k cost for residency when there is the option for the federal government or another hospital to pay it. It basically leads to a tragedy of the commons/prisoners dilemma, where all the hospitals defect and try to fight for limited grants.
This article has some general details: https://thesheriffofsodium.com/2022/02/04/how-much-are-resid....
The AMA has lobbied to limit federal funding for medical residency. This is the bottleneck.
The fundamental problem is that the US government should not be in the business of funding residencies to begin with. That should the on the hospitals.
Right now the problem is that no hospitals want pay the 150k cost for residency when there is the option for the federal government or another hospital to pay it. It basically leads to a tragedy of the commons/prisoners dilemma, where all the hospitals defect and try to fight for limited grants.
This article has some general details: https://thesheriffofsodium.com/2022/02/04/how-much-are-resid....
Do you have evidence of this lobbying? It does not stand to reason, since care provided by residents is quite cheap to hospitals from the perspective of labor.
Hospitals have no obligation to hire the residents they produce, so an optimal behavior would seem to be training many residents and not hiring them.
Hospitals have no obligation to hire the residents they produce, so an optimal behavior would seem to be training many residents and not hiring them.
>It does not stand to reason, since care provided by residents is quite cheap to hospitals from the perspective of labor.
The AMA represents doctors, not hospitals, and doctors benefit from scarcity. Hospitals benefit from residency grants, existing doctors do not.
>Do you have evidence of this lobbying?
Here is a source [1]
>Hospitals have no obligation to hire the residents they produce, so an optimal behavior would seem to be training many residents and not hiring them.
Optimal only if they can make money from the residents. Due to the bizarre natures of US medical reimbursement, resident physicians do not bill for their services [2]. While they may provide value in other ways, they are viewed as cost on the balance sheet. This is further complicated by the fact that hospitals dont want to bear this cost if they can get a grant, or simply hire a doctor away from another hospital. Getting rid of the grants would be a step in the right direction.
https://blog.petrieflom.law.harvard.edu/2022/03/15/ama-scope...
https://thesheriffofsodium.com/2022/02/04/how-much-are-resid....
The AMA represents doctors, not hospitals, and doctors benefit from scarcity. Hospitals benefit from residency grants, existing doctors do not.
>Do you have evidence of this lobbying?
Here is a source [1]
>Hospitals have no obligation to hire the residents they produce, so an optimal behavior would seem to be training many residents and not hiring them.
Optimal only if they can make money from the residents. Due to the bizarre natures of US medical reimbursement, resident physicians do not bill for their services [2]. While they may provide value in other ways, they are viewed as cost on the balance sheet. This is further complicated by the fact that hospitals dont want to bear this cost if they can get a grant, or simply hire a doctor away from another hospital. Getting rid of the grants would be a step in the right direction.
https://blog.petrieflom.law.harvard.edu/2022/03/15/ama-scope...
https://thesheriffofsodium.com/2022/02/04/how-much-are-resid....
Residents are not fully qualified physicians, so it does make sense that they cannot bill for their work.
Further, residents, by and large, are paid for by Medicare.
> While they may provide value in other ways, they are viewed as cost on the balance sheet.
Are you saying that replacing residents with physicians would be more advantageous to hospitals? I don't have a sense of the numbers or billing processes involved
Further, residents, by and large, are paid for by Medicare.
> While they may provide value in other ways, they are viewed as cost on the balance sheet.
Are you saying that replacing residents with physicians would be more advantageous to hospitals? I don't have a sense of the numbers or billing processes involved
no, Im saying if it costs 200k to train a physician, They should include that in the cost of their in what they charge for their licensed physicians. It is basically how it works in every other job in the world that requires on the job training or licensing.
I again don’t have a sense of how this works, but the activities performed by a resident are overseen by a qualified doctor. Eventually, the residents are able to supervise other residents and only consult the qualified doctor for important matters.
This would seem to increase the potential productivity of a hospital. So I am confused by why you say residents are a cost on balance sheets (again, considering that their pay comes from Medicare/Medicaid)
This would seem to increase the potential productivity of a hospital. So I am confused by why you say residents are a cost on balance sheets (again, considering that their pay comes from Medicare/Medicaid)
Hospitals claim that residents take more work than they do, and that hospitals would loose somewhere between 75-100k/year on each resident if the federal governments didn't pay them. I think this is likely bullshit, but if if it is true, that still doesnt mean the government paying for residents is a good solution. Employers take a loss all the time to train worker in other industries, and there are many ways for them to recoup their losses.
> Residents are not fully qualified physicians, so it does make sense that they cannot bill for their work.
Residents are actually more qualified than many other "mid level" professions aka Medical Providers.
Would I rather see a resident, or a nurse practicioner? The resident of course, because he/she actually completed medical school, whereas an NP may have a nursing oriented (no emphasis on diagnosis) masters or terminal degree.
Residents are actually more qualified than many other "mid level" professions aka Medical Providers.
Would I rather see a resident, or a nurse practicioner? The resident of course, because he/she actually completed medical school, whereas an NP may have a nursing oriented (no emphasis on diagnosis) masters or terminal degree.
It's interesting how truth can disappear over time. They were out and proud about it back then.
Here: https://www.washingtonpost.com/archive/politics/1997/03/09/r...
> Last week a powerful coalition of medical groups, including the American Medical Association and the Association of American Medical Colleges -- the umbrella group for medical schools -- proposed their own plan. Their idea is to limit residency slots financed by Medicare to the number needed for the 17,000 annual graduates of U.S. medical schools.
There's other things like this that folks say "Well, where's the evidence?" and the truth is that the evidence was all around us back then. Now that people have changed their minds on this stuff, it's harder to find as the perpetrators go quiet about it. And you have to search the past which isn't that easy.
I'm sure the pandemic response will be similarly rewritten, especially the business about telling people masks don't work because they wanted to make sure that average people won't take masks that they wanted to keep for healthcare people. That's being rewritten in front of me to say "Oh there's no evidence that masks ever worked and that's why they said that".
Where's the evidence? Well, in many cases, it was everywhere. Truth casts a small shadow on time. The motivated sceptic stands purely in the light.
Here: https://www.washingtonpost.com/archive/politics/1997/03/09/r...
> Last week a powerful coalition of medical groups, including the American Medical Association and the Association of American Medical Colleges -- the umbrella group for medical schools -- proposed their own plan. Their idea is to limit residency slots financed by Medicare to the number needed for the 17,000 annual graduates of U.S. medical schools.
There's other things like this that folks say "Well, where's the evidence?" and the truth is that the evidence was all around us back then. Now that people have changed their minds on this stuff, it's harder to find as the perpetrators go quiet about it. And you have to search the past which isn't that easy.
I'm sure the pandemic response will be similarly rewritten, especially the business about telling people masks don't work because they wanted to make sure that average people won't take masks that they wanted to keep for healthcare people. That's being rewritten in front of me to say "Oh there's no evidence that masks ever worked and that's why they said that".
Where's the evidence? Well, in many cases, it was everywhere. Truth casts a small shadow on time. The motivated sceptic stands purely in the light.
This is a difficult issue - if we accept the statements on their face (and I don't have enough information to accept or reject the statements), it seems that there was waste by hospitals that were doing just what I mentioned, soliciting residents that were not needed.
From the article: "But why should hospitals be interested in this when, under current law, they automatically get sizable government subsidies for training residents who as part of their education take care of many of the hospitals' patients, work long hours and collect meager salaries?"
If this issue were to arise again in today's political climate, I imagine there would be a redistribution of seats away from in-demand specialties to primary care.
From the article: "But why should hospitals be interested in this when, under current law, they automatically get sizable government subsidies for training residents who as part of their education take care of many of the hospitals' patients, work long hours and collect meager salaries?"
If this issue were to arise again in today's political climate, I imagine there would be a redistribution of seats away from in-demand specialties to primary care.
Yeah, this is one of those things you had to be there for. When you're just reading a picture from history, and that's the only insight you have into it, you're going to get a particular view of it. It can't be helped, especially if one is searching for evidence to support one's own beliefs.
I find myself reading comments like this in disbelief (or assuming the author is not in good faith responding), as if there can be any doubt where political lobbying is possible that there doesnt exist a tremendous apparatus to exploit it.
Yes, here it is. With citations:
https://blog.petrieflom.law.harvard.edu/2022/03/15/ama-scope....
https://blog.petrieflom.law.harvard.edu/2022/03/15/ama-scope....
You can look up things for yourself, you know
My understanding is that at least at one point in the past the AMA lobbied either for the cap or to not fix the problem. Also inversely speaking, you don't really hear much about the AMA lobbying to -fix- the problem and given the frequency of this theory, you would think they would publicise it more.
There is also the weird thing where, my understanding is that the hospitals can 'sell' the slots to each other and strangely they can fetch more than the funding in question.
But really, so much of the medical residency industrial complex reminds me of a hazing ritual in and of itself.
There is also the weird thing where, my understanding is that the hospitals can 'sell' the slots to each other and strangely they can fetch more than the funding in question.
But really, so much of the medical residency industrial complex reminds me of a hazing ritual in and of itself.
The program was started by a guy hopped up on cocaine the whole time, that's why the hours alone suck:
"William Stewart Halsted developed a novel residency training program at Johns Hopkins Hospital that, with some modifications, became the model for surgical and medical residency training in North America. While performing anesthesia research early in his career, Halsted became addicted to cocaine and morphine" https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7828946/#:~:tex....
"William Stewart Halsted developed a novel residency training program at Johns Hopkins Hospital that, with some modifications, became the model for surgical and medical residency training in North America. While performing anesthesia research early in his career, Halsted became addicted to cocaine and morphine" https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7828946/#:~:tex....
>reminds me of a hazing ritual in and of itself
It's absolutely abusive and I cannot believe there's never been more of a push around patient advocacy. It's bad enough for the residents working 100 hours a week and getting fits of sleep in a shitty spare hospital room they share with multiple other residents. It's even worse for the patients receiving care from a tired, overworked resident.
It's absolutely abusive and I cannot believe there's never been more of a push around patient advocacy. It's bad enough for the residents working 100 hours a week and getting fits of sleep in a shitty spare hospital room they share with multiple other residents. It's even worse for the patients receiving care from a tired, overworked resident.
There has been a push back, and hours are now capped well below 100 hours (maybe 60 hours a week now?) with limits on duration of shifts, also. When I trained the cap was 80 hours/week with a limit of 30 hours in a row.
The cap is still 80 hours/week. I'm not sure about the consecutive hour limit. It's at least 24 hours. That doesn't stop the residents I know from frequently having duty hour violations. In one case I know a resident had his hours manipulated by admin to under report them.
Where? I still see/hear of residents in the states working 80+. Many pulling 20-24 hours a day for 3 or more days a week, then additional coverage beyond that.
There is theoretically a cap, but my wife (a doctor) knows many peers who either:
* Been made clear in no uncertain terms (mafia style) that they were never to log more than the regulated hours, regardless of actual hours worked.
* Weird things started to happen if they did log more than the required hours.
* Been made clear in no uncertain terms (mafia style) that they were never to log more than the regulated hours, regardless of actual hours worked.
* Weird things started to happen if they did log more than the required hours.
And yet in my few experiences, the residents are actually the ones that will talk to you and tell you what is going on. As opposed to the super important Attendings who you only see when it's time to talk about things with legal repercussions like pulling the plug.
Residency funding, and the fact that even fully trained foreign doctors have to redo residency to practice here.
An American can marry a foreign doctor with 10 years experience, get their spouse a green card and everything, and they still can't work as a doctor without redoing residency like a fresh graduate.
An American can marry a foreign doctor with 10 years experience, get their spouse a green card and everything, and they still can't work as a doctor without redoing residency like a fresh graduate.
That depends on the state. Some states such as Tennessee now offer more flexible options for foreign trained doctors to practice there.
https://www.medscape.com/viewarticle/993693
https://www.medscape.com/viewarticle/993693
Globalism for thee, protectionism for me.
That's not an example of globalism hypocrisy
Bring in foreign programmer: here's dozens of laws and programs to make that easy.
Bring in foreign doctor: here's dozens of laws and programs to make that hard.
Bring in foreign low skill labor: Laws? No human is illegal!
Bring in foreign doctor: here's dozens of laws and programs to make that hard.
Bring in foreign low skill labor: Laws? No human is illegal!
Coding, farming and medicine have different stakes (in general). It makes sense to be pickier with the last than the first two.
Millions are protected to die simply due to lack of access to medical care. The doctors would have to be actively malicious to be worse than the alternative of no doctor.
> doctors would have to be actively malicious to be worse than the alternative of no doctor
There is so much low-hanging fruit to pick before we create a two-class medical system.
Also, “millions” is hyperbole. It’s tens of thousands a year [1]. Two million or so in a lifetime. But half as many as from alcohol [2].
[1] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2323087/
[2] https://www.cdc.gov/nchs/fastats/leading-causes-of-death.htm
There is so much low-hanging fruit to pick before we create a two-class medical system.
Also, “millions” is hyperbole. It’s tens of thousands a year [1]. Two million or so in a lifetime. But half as many as from alcohol [2].
[1] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2323087/
[2] https://www.cdc.gov/nchs/fastats/leading-causes-of-death.htm
> From link: although some studies stated that people aged 25 to 64 were 25% more likely to die if they lacked health insurance, the risk of death was probably higher because uninsured people are less healthy than insured people.
The interesting point is that the early deaths are mostly due to selection - people that can't get insurance are more likely to die early e.g. lifestyle choices. Giving them access to the medical system might not help as much as we might hope.
> Upthread: willcipriano said: Millions are pro[j]ected to die simply due to lack of access to medical care.
No. The risk of death is 100%. People can die earlier than otherwise due to lack of medical access - or better said we can delay death but it usually gets harder and harder to delay as we accumulate chronic health conditions. And some people avoid chronic conditions better than others.
Aside: Meanwhile the richer your country, the more you can take the best doctors and nurses from the poorer countries. New Zealand trains a lot of great doctors and nurses for the USA. And we take a lot from other countries too.
The interesting point is that the early deaths are mostly due to selection - people that can't get insurance are more likely to die early e.g. lifestyle choices. Giving them access to the medical system might not help as much as we might hope.
> Upthread: willcipriano said: Millions are pro[j]ected to die simply due to lack of access to medical care.
No. The risk of death is 100%. People can die earlier than otherwise due to lack of medical access - or better said we can delay death but it usually gets harder and harder to delay as we accumulate chronic health conditions. And some people avoid chronic conditions better than others.
Aside: Meanwhile the richer your country, the more you can take the best doctors and nurses from the poorer countries. New Zealand trains a lot of great doctors and nurses for the USA. And we take a lot from other countries too.
Feel free to at any point in the last twenty years. It wasn't done so now drastic action is required to save lives.
> now drastic action is required to save lives
You realise it’s this sort of rhetoric that inhibits moderate progress? If I wanted to kill a residency expansion proposal, and a lawmaker were saying we should let doctors trained in the worst medical systems in the world treat poor Americans, I would run that framing on billboards.
You realise it’s this sort of rhetoric that inhibits moderate progress? If I wanted to kill a residency expansion proposal, and a lawmaker were saying we should let doctors trained in the worst medical systems in the world treat poor Americans, I would run that framing on billboards.
I've been hearing that for twenty years. #ForceTheVote most recently. Drug reimportation under Trump. The public option with Obama. It's never the right time.
> been hearing that for twenty years
That extremist policy positions backfire? Yes. Because it’s consistently true. See: defund the police and abortion.
What you’re suggesting is lower impact and still more radical than a public option or drug price regulation.
That extremist policy positions backfire? Yes. Because it’s consistently true. See: defund the police and abortion.
What you’re suggesting is lower impact and still more radical than a public option or drug price regulation.
You are precisely correct - this is not an AMA issue. Funding for this is tied to Medicare/Medicaid and thus a political issue that does not turn based on what the AMA may request. In searching for the below table, it seems that there is some effort to use funds from other sources to pay for targeted slots[1]
1. https://www.aha.org/news/headline/2023-07-27-hhs-awards-15-g...
Here's a breakdown for funding for one year in the recent past: https://www.ncbi.nlm.nih.gov/books/NBK248024/table/tab_3-1/?...
1. https://www.aha.org/news/headline/2023-07-27-hhs-awards-15-g...
Here's a breakdown for funding for one year in the recent past: https://www.ncbi.nlm.nih.gov/books/NBK248024/table/tab_3-1/?...
A former roommate of mine was a doctor in residency. They were paying him peanuts and grinding as much work out of him as they could. I think this was maybe 5 years ago and he was at 65k or so in a major metro in the US.
So if you're a hospital, and you can get cheap doctors in residency who basically need to work whatever workload you give them, why wouldn't they hire as many of them as they could? I figure the limiting factor should be their ability to manage them, not federal funding. They are paying pennies on the dollar for doctor labor that they are NOT giving patients a discount on.
So if you're a hospital, and you can get cheap doctors in residency who basically need to work whatever workload you give them, why wouldn't they hire as many of them as they could? I figure the limiting factor should be their ability to manage them, not federal funding. They are paying pennies on the dollar for doctor labor that they are NOT giving patients a discount on.
Residencies all lose money. That's why they're subsidized. My family member is a chair of a residency and the business analysts are constantly trying to close it because it takes time away from the doctors and doesn't provide anything to the bottom line.
My partner did a second residency. Medicare doesn't fund second residencies, so she had to get an unfunded spot. At least with her second residency, they have those unfunded spots precisely because they're profitable. Maybe it's not all programs, but certainly some of them are profitable.
You figure wrong. Hospitals require residents to do a lot of work, but they can't bill Medicare/Medicaid or private insurers for much of that work. Hospitals can't afford to just hire more.
Residents are still doing work. The notion that they should be federally-funded, rather than just getting paid for doing that work directly through the proceeds of whatever patients get charged for that work, seems dubious to me. I'd also be skeptical of a claim that available slots are more of a limiter compared to the fact that propective physicians are looking at 4 years of post-graduate education followed by 3-9 years of working 100 hour weeks for $30-40k a year before they can get licensed.
I once considered becoming a doctor when I was still a teen, and I'm quite confident I could have gotten into medical school and qualified for a residency somewhere, but it was the decade of hazing while being paid like a ranch hand that dissuaded me.
I once considered becoming a doctor when I was still a teen, and I'm quite confident I could have gotten into medical school and qualified for a residency somewhere, but it was the decade of hazing while being paid like a ranch hand that dissuaded me.
This has led to is a rise in PAs and ARNPs for primary care, and scary things like CRNAs asking MDs for sign offs without a supervising anesthesiologist.
Is there a reason other than fear to think that CRNAs are ineffective at their jobs?
Not quite the question-- the real question is why would they be effective at the jobs of others? Doctors have 10-15 years of training, there's a reason for that.
They need a supervising physician, which should be an anesthesiologist. Surgical MDs do not have the same qualifications to sign off on their orders. The liability with CRNAs flows to the supervising physician, so most MDs tend to be very uncomfortable working with only CRNAs.
Here's a recent report from the Congressional Research Service about this that provides a very detailed summary of how this works: https://crsreports.congress.gov/product/pdf/IF/IF10960
I'm a bit of a radical on this, but we should basically remove traditional college from the whole medical school pipeline. When I think of my friends that went to med school, they all took the MCAT after two years of school. That seems like a great indication that the last two years aren't important[1]. Two years of fundamental sciences, and then right into med school.
Also, we have some many people that want to be doctors. We should let them all start medical school, and let them get weeded out from there.
[1] the caveat here is research. But MD/PhD fits far better into the traditional college pipeline.
Also, we have some many people that want to be doctors. We should let them all start medical school, and let them get weeded out from there.
[1] the caveat here is research. But MD/PhD fits far better into the traditional college pipeline.
That's not a radical proposal.
The US and Canada are globally unique in requiring a 4 year bachelors before 4 more years of med school. Every other OECD country has a single 5-6 year program available straight out of high school.
https://www.niskanencenter.org/the-case-for-shortening-medic...
The US and Canada are globally unique in requiring a 4 year bachelors before 4 more years of med school. Every other OECD country has a single 5-6 year program available straight out of high school.
https://www.niskanencenter.org/the-case-for-shortening-medic...
Other nations have longer post-graduate training requirements, sometimes including compulsory national service. For many specialties, a US high school grad will be fully qualified before her UK peer
It'd be an amazing start.
A stupid amount of my wife's medical education was completely wasted for two reasons:
* "To make sure you know what career to go into". No. You don't need 2 years to see every possible option. Everyone has some idea before they even go to med school. Focus on the 2 to 6 that you care about.
* Residency application. 4th year was a complete joke. Most of it was consumed with travel/distractions while applying to residency. Maybe 2 or 3 months of actual learning fit in their.
----
The med school my wife's residency is associated with is actually a 3 year program. They skip summers and condense a lot of information.
A stupid amount of my wife's medical education was completely wasted for two reasons:
* "To make sure you know what career to go into". No. You don't need 2 years to see every possible option. Everyone has some idea before they even go to med school. Focus on the 2 to 6 that you care about.
* Residency application. 4th year was a complete joke. Most of it was consumed with travel/distractions while applying to residency. Maybe 2 or 3 months of actual learning fit in their.
----
The med school my wife's residency is associated with is actually a 3 year program. They skip summers and condense a lot of information.
Wow, that seems so short then. In Europe medical school is 6 years, with a 7th year spent on preparing for residency. At least in Spain. And it doesn't start off easy. All student are required to have spent the last 2 years of high school in a science-focused baccalaureate program, which in my experience is similar to early American undergraduate in terms of academic rigour.
In Europe you go to medical school immediately after high school, but it takes longer, so ends up similar to what you're proposing I think.
I think that they have a much harder high school process, but yes
I strongly agree. That's what the European system is like, as others have mentioned. Even the 2 years of fundamental science preparation. In Spain, what I would say is the academic equivalent of high-school ends at 16. 16-18 is then spent in "baccalaureate", an optional university preparation program, which is more rigorous and ends in nationally-administered university preparedness exam. A prospective medical student would need to do the science-based variant of this program.
I agree, and I also think it would be OK if there are different “levels” of doctors. I also think that diagnostic tests will have to carry more of the load as opposed to relying on the doctors judgment. This could mean more imaging processed by AI.
We think of doctors as healers because that’s the traditional role they grew out of. But with the institutionalization of medicine in the 20th century, they became accessory bureaucrats. Their job is to approve or deny access to institutional services, per institutional policy, and they go through many years of learning how to do that. Their pay is scaled with the cost of the institutional services they safeguard, those costs in some markets being obscene and arguably corrupt.
But people still need genuine healers for everyday ills, and so we see the institution move towards restoring that role to those with a less critical role in the institution, like nurses, pharmacists, physical therapists, etc
But people still need genuine healers for everyday ills, and so we see the institution move towards restoring that role to those with a less critical role in the institution, like nurses, pharmacists, physical therapists, etc
From my experience as both a patient and a spouse to a general practitioner the opposite is generally true. Doctors are grossly unaware of both costs to patients and insurance eligibility of procedures. They push for the solution that they believe will resolve the issue with the best health outcomes while minimizing their own risks of lawsuits without considering other factors. Next, a faceless bureaucracy on both the medical and medical insurance side of things (few of whom are medical doctors) will slowly spin into motion to maximize profit and minimize costs, all while you have very little recourse/leverage/knowledge to fight the outcome.
I will grant you that in some specialties and smaller private practices what you describing is probably true.
I will grant you that in some specialties and smaller private practices what you describing is probably true.
It's really an indictment of how far HN has fallen to Redditification* that you see this kind of low-brow ignorance so prevalently and so often.
Yes, the greedy doctors who are lucky to get a couple hours of medical coding training when they start practicing and get needled constantly by their billing department for underbilling actually have "years of learning" in how to screw over their patients.
Maybe they mean the man-years of time wasted arguing with insurance companies, shuffling around medications and care plans to please them, evenings and weekends spent in the EHR finishing up patient notes (because there's no time to get them done during the working day with 20 minute visits) and correcting and signing off on patient care for the PAs and NPs (cold-heartedly taking 100% of the malpractice risk burden for the nurses who actually care about "healing").
I'd encourage people this far gone on the deep end of visualizing physicians as hand-rubbing greed machines to spend a day actually shadowing one. Because you are very ignorant about how they spend their time and the amount of effort they put into caring for patients in spite of continual soul-crushing roadblocks put in their path.
* Yeah I know it's against site rules to say but I don't care it's true
Yes, the greedy doctors who are lucky to get a couple hours of medical coding training when they start practicing and get needled constantly by their billing department for underbilling actually have "years of learning" in how to screw over their patients.
Maybe they mean the man-years of time wasted arguing with insurance companies, shuffling around medications and care plans to please them, evenings and weekends spent in the EHR finishing up patient notes (because there's no time to get them done during the working day with 20 minute visits) and correcting and signing off on patient care for the PAs and NPs (cold-heartedly taking 100% of the malpractice risk burden for the nurses who actually care about "healing").
I'd encourage people this far gone on the deep end of visualizing physicians as hand-rubbing greed machines to spend a day actually shadowing one. Because you are very ignorant about how they spend their time and the amount of effort they put into caring for patients in spite of continual soul-crushing roadblocks put in their path.
* Yeah I know it's against site rules to say but I don't care it's true
I don't get the vitriol or where you assume I see doctors as "greedy" or determined to "screw over their patients". I assume you've read a lot of stuff here that gets under your skin, and that my post somehow reminds you of those. But you read a lot of things into it that I didn't write and wouldn't write.
Doctors are brilliant individuals and often deeply invested in patient care. Many if not most of them pursued the career because they wanted to be healers. But as you beautifully describe, a lot of their actual job is now committed to navigating endless bureaucracy because they are the only people who have been institutionally blessed to do so. Given that many of them do care so much about patients on a personal level, and pursued the field for that reason, it's tragic that paperwork takes so much away from their opportunity to do so.
My perspective even goes so far as to argue that their pay isn't a product of greed at all, but simply a necessary outcome of institutionally mediated medical goods, of which they've been tasked as front-line guardian, being grossly expensive. Reduce the cost of what they control access to, as we see in non-US health care markets, and their pay naturally reduces.
In lieu of that, the US solution is to cleave out the responsibilities that don't require 8+ years of education and residency to get right and allow them to be dispensed by others.
There's no indictment of doctors here, friend. None at all. It's all just mechanisms in a system much much bigger than them, and these mechanisms (as you describe!) frustrate them at least as much as anyone else.
Doctors are brilliant individuals and often deeply invested in patient care. Many if not most of them pursued the career because they wanted to be healers. But as you beautifully describe, a lot of their actual job is now committed to navigating endless bureaucracy because they are the only people who have been institutionally blessed to do so. Given that many of them do care so much about patients on a personal level, and pursued the field for that reason, it's tragic that paperwork takes so much away from their opportunity to do so.
My perspective even goes so far as to argue that their pay isn't a product of greed at all, but simply a necessary outcome of institutionally mediated medical goods, of which they've been tasked as front-line guardian, being grossly expensive. Reduce the cost of what they control access to, as we see in non-US health care markets, and their pay naturally reduces.
In lieu of that, the US solution is to cleave out the responsibilities that don't require 8+ years of education and residency to get right and allow them to be dispensed by others.
There's no indictment of doctors here, friend. None at all. It's all just mechanisms in a system much much bigger than them, and these mechanisms (as you describe!) frustrate them at least as much as anyone else.
Whenever I run into a doctor like this I just assume they're willfully ignorant because they don't want to rock the boat. How can you not be curious about such a large part of your profession?! It's a pretty negative signal in a person in my opinion.
I've spent considerable time tracking down why X costs Y, explaining it to a doctor, only to have the reply be "woah, you should tell people!" No, you should tell people, that's part of your job! Mind blown at some of these people.
I've spent considerable time tracking down why X costs Y, explaining it to a doctor, only to have the reply be "woah, you should tell people!" No, you should tell people, that's part of your job! Mind blown at some of these people.
While I agree that this would be nice to be able to do, it's very difficult for a physician to figure this out in many care systems.
(1) the cost is intentionally not displayed to the physician when tests are ordered;
(2) the cost is not provided to the patient before services are rendered;
(3) the price being charged varies by insurance plan; and
(4) the number of different insurance plans is vast
How exactly do you expect physicians to be able to provide these estimates for each of their patients? There are certainly simple examples where the physician ordering a test is also the one providing it, but those simple examples don't really exist in major healthcare systems.
(1) the cost is intentionally not displayed to the physician when tests are ordered;
(2) the cost is not provided to the patient before services are rendered;
(3) the price being charged varies by insurance plan; and
(4) the number of different insurance plans is vast
How exactly do you expect physicians to be able to provide these estimates for each of their patients? There are certainly simple examples where the physician ordering a test is also the one providing it, but those simple examples don't really exist in major healthcare systems.
A lot of doctors are fee for service in Canada/USA. So especially in a clinic setting, they would know roughly how much certain procedures/consults impact their bottom line (i.e. how much they're getting paid). It's like a consultant not knowing their hourly billable rate.
Yes, I do agree that in that case, they can know the price. I tried to account for that in my comment. Having never worked outside of a major academic medical center, my impression is that this is not how most people get care, but I know my experience is limited.
Interesting, would you say your work compensation model at a major academic medical center is not the norm then? Most hospitalists I've talked to (non-academic) have told me they get paid based on volume
Physicians just have a different utility function drilled into their heads. I strongly disagree with this utility function but they really are trying to strictly maximize health outcomes for their patients. Knowing billing information would be unlikely to change care, so they aren't really interested in learning about it. If it might effect care then they would end up in court one day, because the law shares the same narrowly-defined utility function.
I wish they would, both to "rock the boat" administratively and to empower patients to include price sensitivity in their own choices. They already spend half their time arguing with insurance companies though.
I wish they would, both to "rock the boat" administratively and to empower patients to include price sensitivity in their own choices. They already spend half their time arguing with insurance companies though.
Of course doctors are often committed to the wellness of their patients, but I'd argue that the point of their extensive training is to help them align "best health outcomes while minimizing their own risks" with very specific institutional understandings of what that looks like. And that's what their pay is ultimately based on. They need to make the correct decisions, per the AMA/government/etc, about very expensive things and with minimal supervision. And it needs to authentically feel like it's for a good reason.
But when it comes to the broad swath of everyday ills, someone with far less alignment training and who therefore hasn't been entrusted with the "MRI approved" stamp can often do a perfectly comparable job of taking care of people. That's what most practical medical care demands and it's what US doctors are now too overqualified and overpaid to provided.
But when it comes to the broad swath of everyday ills, someone with far less alignment training and who therefore hasn't been entrusted with the "MRI approved" stamp can often do a perfectly comparable job of taking care of people. That's what most practical medical care demands and it's what US doctors are now too overqualified and overpaid to provided.
This is not at all true.
There is bureaucracy surrounding what insurance companies and medicare will pay for, given specific diagnoses (medical necessity guidelines).
But the actual process of diagnosing a patient is not trivial and that function can not be described as that of a "bureaucrat".
Yes, you need a specific diagnosis X to justify procedure Y, and that can feel bureaucratic, but there is nothing bureaucratic about getting to diagnosis X in the first place.
There is bureaucracy surrounding what insurance companies and medicare will pay for, given specific diagnoses (medical necessity guidelines).
But the actual process of diagnosing a patient is not trivial and that function can not be described as that of a "bureaucrat".
Yes, you need a specific diagnosis X to justify procedure Y, and that can feel bureaucratic, but there is nothing bureaucratic about getting to diagnosis X in the first place.
AussieWog93(1)
I always find it funny when people say that we'd have less doctors under 'socialized medicine'. This article clearly shows that other countries have more doctors per capita. Not only that, but by and large those doctors are happier working under that system than our doctors are working under ours
https://image.slideserve.com/488686/physician-satisfaction-w...
My guess is that not dealing with a mercurial insurance industrial complex that tries to constantly deny medically necessary treatment to your patients makes your day to day work more enjoyable.
https://image.slideserve.com/488686/physician-satisfaction-w...
My guess is that not dealing with a mercurial insurance industrial complex that tries to constantly deny medically necessary treatment to your patients makes your day to day work more enjoyable.
Socialized medicine has nothing to do with this problem.
You can squarely place the blame on the AMA who (proudly) lobbied for years to cap Federal funding for medical Dr education and residency.
You can squarely place the blame on the AMA who (proudly) lobbied for years to cap Federal funding for medical Dr education and residency.
The AMA is a leading reason that we don't have socialized medicine, though. They were one of the largest bodies that opposed single-payer for Obamacare.
They're certainly not happy in Britain!
Cuba is out here with probably the most socialist system and the most doctors per capita.
Cuba is a weird case though where doctors are essentially one of their most important exports where they send them to other countries, primarily in Latin America.
When I use the word 'socialized medicine' I'm referring to a system of universal healthcare, not communist authoritarianism. It irritates me to no end that the two are conflated.
For the sake of clarity I think reserving the term socialized medicine for situations where the government is the one providing service such as in the UK and not when the government is providing funding such as Canada. There is also universal healthcare systems like Singapore that still provide a strong private component.
Although even that's contentious - in the UK GPs, pharmacies, dentists, and most other frontline medical jobs are privately owned and run. Only really hospitals are government-operated, and even then there are private hospitals, insurance, and healthcare.
I believe it's because "universal healthcare" is so non-political, it's basically meaningless in the context of this conversation. Universal healthcare just means "everyone has access to healthcare". Well, 92.1%[0] of Americans have health insurance, and close to 100% of Californians have health insurance with a public option[1]. The city of San Francisco even adds coverage[2] on top of what California and federal programs can offer, which basically means everyone has access to healthcare, even those 400% over the federal poverty line. Oh, and there are more people in the state of California than all of Canada, which is especially interesting when Canada's system enters the debate.
[0]: https://www.census.gov/library/publications/2023/demo/p60-28...
[1]: https://www.coveredca.com/health/medi-cal/
[2]: https://healthysanfrancisco.org/
[0]: https://www.census.gov/library/publications/2023/demo/p60-28...
[1]: https://www.coveredca.com/health/medi-cal/
[2]: https://healthysanfrancisco.org/
There is more authoritarianism in your life in the US than there is for the average person in Cuba. I know it's hard to believe, but it turns out spending almost half your waking hours selling your labor for a wage to a much richer person than you doesn't actually end up with a life defined by agency.
Cuba isn't poor because of an inefficient command economy. Cuba is poor because it has been denied access to its largest trading partner (and more) for over half a century. And people _still_ have a better healthy life expectancy in that country than in the US. Imagine what it could be like there if the US did more than pay lip service to world prosperity and peace.
Cuba isn't poor because of an inefficient command economy. Cuba is poor because it has been denied access to its largest trading partner (and more) for over half a century. And people _still_ have a better healthy life expectancy in that country than in the US. Imagine what it could be like there if the US did more than pay lip service to world prosperity and peace.
Cuba leases theirs into medical slavery. Not sure that's a model we want to imitate.
They don't, this is a lie from the country that's been embargoing Cuba into oblivion for sixty years.
It's not a lie. It's well-documented, and happens outside of the bubble in which Cuba can keep its slavery quiet.
"Host" nations agree to pay Cuba for the doctor's work, agree not to pay the doctor directly, and agree to deport them back to Cuba if they attempt to negotiate being paid directly. This is slavery by anyone's definition.
"Host" nations agree to pay Cuba for the doctor's work, agree not to pay the doctor directly, and agree to deport them back to Cuba if they attempt to negotiate being paid directly. This is slavery by anyone's definition.
Sounds like agency work with a visa thrown in. The doctor is ultimately paid by cuba, no?
The slave is ultimately fed by the slaveowner, eh?
One of the worst requirements is mandating that medical students spend four years getting their bachelor's degree before entering med school. Realistically, the essential prerequisites for med school could be covered in two years. This would allow graduates to start their careers younger and with less debt.
The "bachelor for everything even if it has no direct correlation with the work" mentality is a real plague. It's causing issues with airline pilots too. From what I understand the FAA does NOT mandate it, they "only" ask that you get a PPL and 1500 hours of flight to get your ATP and then you can work for an airline. But airlines want to hire college educated people for some reason...
The FAA has no such educational criteria requirements for being able to get your commercial license. In fact, a great deal of pilots often get a bachelors degree in an unrelated field just in case working as a pilot doesn't pan out for them for various reasons (poor pay, medical issues, etc).
Yes, and some US medical colleges are doing exactly that with combined baccalaureate/MD programs.
https://www.aamc.org/news/combined-bachelor-s-and-md-program...
https://www.aamc.org/news/combined-bachelor-s-and-md-program...
Yes. Other countries don't do this - you go directly from HS to a 6 year medical school. It not just saves time, but increases your useful career length by over 10%, probably more if we weigh age-effectiveness.
Plus it would let many more people do MD-related jobs like medical researcher.
Plus it would let many more people do MD-related jobs like medical researcher.
At the same time, a more holistic educational experience could help to reduce long-standing social biases. For example a significant portion of doctors, to this day, think that for some reason having more melanin in your skin increases your ability to tolerate/process pain. The two phenomena are entirely unrelated from a scientific standpoint, but are intertwined in the social fabric.
Yeah, but it makes a lot more sense to just incorporate that into the medical school curriculum than to make students sit through 4 years of Chemistry classes and hope that the dance class they took to fulfill the university core curriculum will erase all of their intrinsic biases
A bit orthogonal to the article, the answer to why someone makes "so much" or "so little" boils down to how badly people need that work done and how many people can do it. IE, supply and demand.
Consider a doctor or even a plumber. When you have a problem that needs one, that problem is usually important and urgent, and it's not a job you can "afford" to be poorly done by an amateur. So you end up paying a lot to get it done quickly by someone from a small pool of qualified providers.
On the flip side of that is something like a barista. My 3 year old has figured out how to operate the Keurig and while obviously a high-end barista can make a way better coffee, the second-best and "nearly free" option is totally acceptable, putting a hard ceiling on how much a barista can make. That option doesn't exist for doctors and plumbers so they make a lot.
Consider a doctor or even a plumber. When you have a problem that needs one, that problem is usually important and urgent, and it's not a job you can "afford" to be poorly done by an amateur. So you end up paying a lot to get it done quickly by someone from a small pool of qualified providers.
On the flip side of that is something like a barista. My 3 year old has figured out how to operate the Keurig and while obviously a high-end barista can make a way better coffee, the second-best and "nearly free" option is totally acceptable, putting a hard ceiling on how much a barista can make. That option doesn't exist for doctors and plumbers so they make a lot.
There are insane controls on supply. It’s not a free market. Everyone has to choose a Ferrari treatment or not go to the doctor. There’s no budget option.
Note also the last line of the article: "This looks a lot like a labour market that has been rigged in favour of the insiders." That's exactly right. In the U.S., the medical profession is an AMA-led cartel.
>There's no budget option
What do you say to things like shopping around using newly-transparented prices, telehealth, minute/community clinic visits, and nurse help lines?
What do you say to things like shopping around using newly-transparented prices, telehealth, minute/community clinic visits, and nurse help lines?
That isn't actually a thing. Those prices aren't transparent, and there's no guarantee that an up-front price quote will be the price you're actually billed for.
You might enjoy one of my all-time favorite episodes of econtalk: https://www.econtalk.org/keith-smith-on-free-market-health-c...
The guest is the head of the Surgical Center of Oklahoma. You can see prices of procedures very easily on their website. That's what you'll pay, even if something goes wrong. Surgeons earn more when working there than they earn at a regular hospital while patients pay less. However, no insurance wants to work with them. Supposedly because they have a price and won't negotiate with insurance who get part of their money as reward from large customers for negotiating prices down.
The guest is the head of the Surgical Center of Oklahoma. You can see prices of procedures very easily on their website. That's what you'll pay, even if something goes wrong. Surgeons earn more when working there than they earn at a regular hospital while patients pay less. However, no insurance wants to work with them. Supposedly because they have a price and won't negotiate with insurance who get part of their money as reward from large customers for negotiating prices down.
Something like 25% of healthcare visits are now done by nurses and PAs. https://hms.harvard.edu/news/fourth-us-health-visits-now-del...
That doesn’t mean we have a market. I was billed $1000 for en ECG for example. I wouldn’t have paid for it. It’s a simple procedure that doesn’t require a genius or advanced equipment. I’d rather an immigrant with a foreign degree look at it for $80 than a licensed American doctor for $1000. I’m not allowed to do so. I can’t choose the quality of care I get.
I hate to be the bearer of bad news, but specific to ECG, it does not actually require a trained physician or even a nurse to read, legally within the US. It can be basically anybody that the overseeing physician deems appropriate. Could be basically anybody.
The law of supply and demand is not dependent on a free market. It is merely observance of the social dynamic between humans (as well as other living creatures!) that plays out when scarcity is a factor.
Indeed, in this case the scarcity is, at least in part, artificial, but the cost still comes down to supply and demand at the end of the day.
Indeed, in this case the scarcity is, at least in part, artificial, but the cost still comes down to supply and demand at the end of the day.
I think the "how many people can do it" part is where things go astray. "Can" can mean "are capable of doing it" or it can mean "allowed to do it" and those are conflated under the current system.
Plumbing is maybe a good example, in the sense that if I own a home and feel comfortable with something, I can do whatever repairs I want. I could hire my friend John Smith to do it if I trusted him. The limit is the inherent risk I take, and knowing that if I screw something up, I could cause problems that cause problems to me. There are code issues, but that gets complicated and is orthogonal to the issue of who does the work that meets code.
In healthcare though, even if you are entirely capable of doing something yourself, you are not able to legally. If there's a medication that you have been taking your entire life, and has been deemed safe in the primary scientific literature, you are still not able to just go buy it from the pharmacy without a prescription. If you want help or advice with the medication, you also can't just go to a provider that you want. You can't take the drug yourself, under the advice of the pharmacist for example — even though the pharmacist often knows more about drugs than an average physician — and you can't take it from a different type of provider that you trust more, for whatever reason.
Plumbing is maybe a good example, in the sense that if I own a home and feel comfortable with something, I can do whatever repairs I want. I could hire my friend John Smith to do it if I trusted him. The limit is the inherent risk I take, and knowing that if I screw something up, I could cause problems that cause problems to me. There are code issues, but that gets complicated and is orthogonal to the issue of who does the work that meets code.
In healthcare though, even if you are entirely capable of doing something yourself, you are not able to legally. If there's a medication that you have been taking your entire life, and has been deemed safe in the primary scientific literature, you are still not able to just go buy it from the pharmacy without a prescription. If you want help or advice with the medication, you also can't just go to a provider that you want. You can't take the drug yourself, under the advice of the pharmacist for example — even though the pharmacist often knows more about drugs than an average physician — and you can't take it from a different type of provider that you trust more, for whatever reason.
I mean yes... My point is that it's supply and demand, not that the friction to enter the profession is identical across plumbers and doctors.
The point still stands... the number of people who are willing to take plumbing matters into their own hands is pretty low. I am one of them sometimes but 99.9% of households are still competing for the handful of "capable and available when I need him" plumbers.
The point still stands... the number of people who are willing to take plumbing matters into their own hands is pretty low. I am one of them sometimes but 99.9% of households are still competing for the handful of "capable and available when I need him" plumbers.
I've seen more than a few $100,000 bills for surgeries.
The fee paid to the surgeon is something like 2-4% on the ones I've seen. So, a few grand to save someone's life. I don't think they're paid so much at all. What they are paid seems more than earned to me. We might instead ask why so little of the money paid for procedures seems to be paid to the doctors, and so much to the medical bureaucracy.
Most of what people complain about isn't the plumber charging $500 to fix plumbing, so to speak, but why the Plumbing Center adds another $40,000 to the bill and itemizes things like "$50 Miscellaneous Paper Towels".
The fee paid to the surgeon is something like 2-4% on the ones I've seen. So, a few grand to save someone's life. I don't think they're paid so much at all. What they are paid seems more than earned to me. We might instead ask why so little of the money paid for procedures seems to be paid to the doctors, and so much to the medical bureaucracy.
Most of what people complain about isn't the plumber charging $500 to fix plumbing, so to speak, but why the Plumbing Center adds another $40,000 to the bill and itemizes things like "$50 Miscellaneous Paper Towels".
Dig deeper and you will find that much of this infrastructure is owned by the physicians as well
Often high pay is related to competition in hiring or demand/need by the employer, but not always. In my town like in many others they have lots of help wanted signs. All they need to do it pay more and they’d have a much better chance of hiring people. They just don’t want to pay that much. Starbucks apparently pays over $20/hr starting, and they have benefits if you work enough (something like >20hrs/week) but they seem to manipulate people’s work hours so they don’t work enough. And they are evil union busters, but that’s another issue.
The are significant structural reasons behind pay. Teachers can’t be paid more because they are govt jobs and the govt almost always doesn’t do that. So programmers in govt are underpaid too, and they can’t raise rates. Or they raise them a little but they don’t have anything like market rates.
The pay of real estate agents, where each side commonly gets 3% of the sale price (shared usually with your firm) is a rediculuous cartel that needs to be destroyed. In my city avg home price is over a million, so the seller/buyer each pay a 30k commission for a few hours work? That high pay comes from a cartel.
Some people are paid high amounts because that’s the expectation. Parity with other jobs might be a support for high pay, but maybe not. I’m skeptical of this argument applied to doctors. I had more years of college than a doctor plus medical school plus a year or two of hospital / internship. I used to be paid less than them by a large margin, probably I make more than most now. It’s market rates. Am I doing more important things for society than teachers in my town? (where they can’t find enough and now they recruit parents to be subs because they don’t pay enough for that either). What I’m doing is useful but probably not more important than public school teachers.
The are significant structural reasons behind pay. Teachers can’t be paid more because they are govt jobs and the govt almost always doesn’t do that. So programmers in govt are underpaid too, and they can’t raise rates. Or they raise them a little but they don’t have anything like market rates.
The pay of real estate agents, where each side commonly gets 3% of the sale price (shared usually with your firm) is a rediculuous cartel that needs to be destroyed. In my city avg home price is over a million, so the seller/buyer each pay a 30k commission for a few hours work? That high pay comes from a cartel.
Some people are paid high amounts because that’s the expectation. Parity with other jobs might be a support for high pay, but maybe not. I’m skeptical of this argument applied to doctors. I had more years of college than a doctor plus medical school plus a year or two of hospital / internship. I used to be paid less than them by a large margin, probably I make more than most now. It’s market rates. Am I doing more important things for society than teachers in my town? (where they can’t find enough and now they recruit parents to be subs because they don’t pay enough for that either). What I’m doing is useful but probably not more important than public school teachers.
Hi, I am the person you replied to. I think all of your points go along my point that it all boils down to supply and demand.
// In my town like in many others they have lots of help wanted signs. All they need to do it pay more and they’d have a much better chance of hiring people.
Right... so apparently they don't "demand" that labor badly enough to pay "whatever it takes" - as you would with a doctor when you're sick or a plumber when your house is flooding.
// Teachers can’t be paid more because they are govt jobs and the govt almost always doesn’t do that. So programmers in govt are underpaid too, and they can’t raise rates.
But it seems like the "government rate" is sufficient to attract the kinds of people that become public school teachers and government programmers, right? Supply and demand...
// The pay of real estate agents... so the seller/buyer each pay a 30k commission for a few hours work
Yeah but how many agents are you competing with and how many houses are you moving a year? The top realtor in my town moved over 20M of property a few years ago, so she cleared 600K in commissions that year. The bottom bunch of realtors in my town sold $0 worth of house and got $0 worth of commission. The reason the first woman made that $600K is because there's a demand for her services... and the reason those other guys made $0 is because there isn't.
I get the point you're making about fixed fees, but these fees don't guarantee you any profit for just becoming a relator.
// Some people are paid high amounts because that’s the expectation
What is an example of that? To whom do you pay more than you have to in the market because of "expectations"
// I used to be paid less than them by a large margin, probably I make more than most now. It’s market rates.
Right, it's supply and demand as I am saying because someone needs you to do the thing you do whatever it is, and they can't find someone to do it for less.
// In my town like in many others they have lots of help wanted signs. All they need to do it pay more and they’d have a much better chance of hiring people.
Right... so apparently they don't "demand" that labor badly enough to pay "whatever it takes" - as you would with a doctor when you're sick or a plumber when your house is flooding.
// Teachers can’t be paid more because they are govt jobs and the govt almost always doesn’t do that. So programmers in govt are underpaid too, and they can’t raise rates.
But it seems like the "government rate" is sufficient to attract the kinds of people that become public school teachers and government programmers, right? Supply and demand...
// The pay of real estate agents... so the seller/buyer each pay a 30k commission for a few hours work
Yeah but how many agents are you competing with and how many houses are you moving a year? The top realtor in my town moved over 20M of property a few years ago, so she cleared 600K in commissions that year. The bottom bunch of realtors in my town sold $0 worth of house and got $0 worth of commission. The reason the first woman made that $600K is because there's a demand for her services... and the reason those other guys made $0 is because there isn't.
I get the point you're making about fixed fees, but these fees don't guarantee you any profit for just becoming a relator.
// Some people are paid high amounts because that’s the expectation
What is an example of that? To whom do you pay more than you have to in the market because of "expectations"
// I used to be paid less than them by a large margin, probably I make more than most now. It’s market rates.
Right, it's supply and demand as I am saying because someone needs you to do the thing you do whatever it is, and they can't find someone to do it for less.
A couple of comments here are touching on the fact that being a doctor is hard in terms of that the profession is very difficult (IQ-wise), competitive and challenging.
I tend to disagree. There is a very strong halo effect which I just kind of ‘hate’. Let me explain.
Here in the Netherlands we have a numerus fixus (about 500 spots each year on each university). Getting in is part luck and part skill. The skill required is to show eagerness and motivation in an interview with a commitee. That’s the hard part.
Once in, you are very unlikely to drop out. The drop out rates are extremely low compared to other studies. The education is very long and intense: this is very needed, you need to be highly trained.
If you compare the academic level to other studies, it’s quite moderate. Basically, it’s a very pratical education with a lot of “hands on” in 6-8 years (and more if you specialize). For the dutch: people jokingly say that we need to rebrand the education to HBO-G.
I have a friend who started out in Economics, finished the study with a degree with honours and decided to follow his dream to become a doctor. He said: the education was so easy compared to economics, it was a total joke. Mind you: the level of education for doctor is very good in the NL compared to othet countries.
Now, in the NL we have a quite good health care system and still the doctors make an extremely good living. I have friends who are 40- and live in an 1 million+ house, drive a porsche and do luxury vacations three times a year.
And I think it’s fine: you are highly trained, you work shit and long hours and have an very very big responsibility.
But is it a difficult and challenging job? I disagree, you are a highly trained production employee doing 95% on experience because you did this a 1000+ times before.
The elephant in the room is, with the rising care costs here in NL, is this still viable? Earning high 6 figures while the system is under pressure? Also: why is the gap between doctors and nurses so big? Is that fair?
(Sorry for my rant :-))
I tend to disagree. There is a very strong halo effect which I just kind of ‘hate’. Let me explain.
Here in the Netherlands we have a numerus fixus (about 500 spots each year on each university). Getting in is part luck and part skill. The skill required is to show eagerness and motivation in an interview with a commitee. That’s the hard part.
Once in, you are very unlikely to drop out. The drop out rates are extremely low compared to other studies. The education is very long and intense: this is very needed, you need to be highly trained.
If you compare the academic level to other studies, it’s quite moderate. Basically, it’s a very pratical education with a lot of “hands on” in 6-8 years (and more if you specialize). For the dutch: people jokingly say that we need to rebrand the education to HBO-G.
I have a friend who started out in Economics, finished the study with a degree with honours and decided to follow his dream to become a doctor. He said: the education was so easy compared to economics, it was a total joke. Mind you: the level of education for doctor is very good in the NL compared to othet countries.
Now, in the NL we have a quite good health care system and still the doctors make an extremely good living. I have friends who are 40- and live in an 1 million+ house, drive a porsche and do luxury vacations three times a year.
And I think it’s fine: you are highly trained, you work shit and long hours and have an very very big responsibility.
But is it a difficult and challenging job? I disagree, you are a highly trained production employee doing 95% on experience because you did this a 1000+ times before.
The elephant in the room is, with the rising care costs here in NL, is this still viable? Earning high 6 figures while the system is under pressure? Also: why is the gap between doctors and nurses so big? Is that fair?
(Sorry for my rant :-))
To me the defining trait of doctors is their persistence not iq (although some doctors have an ample degree of both). You really really have to want to become a doctor.
> But is it a difficult and challenging job? I disagree, you are a highly trained production employee doing 95% on experience because you did this a 1000+ times before.
Unlike software, where you don't even need an education to get started, but you'll be expected to learn a different framework every year
Unlike software, where you don't even need an education to get started, but you'll be expected to learn a different framework every year
Entry to medical school is also extremely competitive in Western Europe and there are also limits on number of places in some countries. And there are shortages of doctors as well.
I don't think that's key.
In Europe healthcare tends to be socialised and heavily regulated so that I would argue that average salaries are kept "artificially" low.
Medical services are highly valued by society for obvious reasons, and the level of required training is extremely high. If the market was left to its own devices I have little doubt that doctors in Europe would earn much more than they do now. Of course that does not mean that healthcare would be better on average, in fact most likely the opposite, but the question is about doctors' income.
I don't think that's key.
In Europe healthcare tends to be socialised and heavily regulated so that I would argue that average salaries are kept "artificially" low.
Medical services are highly valued by society for obvious reasons, and the level of required training is extremely high. If the market was left to its own devices I have little doubt that doctors in Europe would earn much more than they do now. Of course that does not mean that healthcare would be better on average, in fact most likely the opposite, but the question is about doctors' income.
> Entry to medical school is also extremely competitive in Western Europe and there are also limits on number of places in some countries. And there are shortages of doctors as well.
USA has much less doctors per capita than Europe though, so the problem isn't the same. It would be nice to have more doctors in Europe, but in USA it is a critical problem.
USA has much less doctors per capita than Europe though, so the problem isn't the same. It would be nice to have more doctors in Europe, but in USA it is a critical problem.
Maybe so but the point is that in Europe if the number of doctors per capita dropped salaries would not go up, that would require a political decision. But since admissions are already ultra competitive there would be no need to attract even more candidates, rather they would try to lower the bar or 'import' more foreign doctors where possible. So that's why salaries in Europe are lower than in the US.
Conversely, I am not convinced that more doctors in the US would lead to a big drop in earnings assuming the market there is 'freer' than in Europe. It's a rich country and healthcare is very valuable with high barriers to entry in any case.
Conversely, I am not convinced that more doctors in the US would lead to a big drop in earnings assuming the market there is 'freer' than in Europe. It's a rich country and healthcare is very valuable with high barriers to entry in any case.
Where do doctors in Europe end up in terms of salary compared to other professions in Europe? Are they in the same percentile as US doctors, but just everyone in Europe earns less or do European doctors also earn less than some other professions that earn less in the US than US doctors?
> Are they in the same percentile as US doctors, but just everyone in Europe earns less
Europe is a big target, and there is quite a bit of variability country-to-country, but in general I would say yes. For example, in France the median physician salary is €120k/year and the median software engineer salary is €55k/year. So the median physician makes 2.1x the median developer.
In the US you have a median of $110k for SWE and a median of $255k for physicians (NOT 350k, as I've addressed on HN previously - see the US CES data [1]). So about 2.3x.
[1] https://www2.census.gov/ces/wp/2020/CES-WP-20-23.pdf
Europe is a big target, and there is quite a bit of variability country-to-country, but in general I would say yes. For example, in France the median physician salary is €120k/year and the median software engineer salary is €55k/year. So the median physician makes 2.1x the median developer.
In the US you have a median of $110k for SWE and a median of $255k for physicians (NOT 350k, as I've addressed on HN previously - see the US CES data [1]). So about 2.3x.
[1] https://www2.census.gov/ces/wp/2020/CES-WP-20-23.pdf
Well, if doctors' salaries in the US are in line with general salaries compred to Europe then the whole article is moot. And that might be the case, indeed.
The USA also has significantly more doctors per capita than the ither Anglophone countries (Canada, UK, Australia, NZ) and still has higher cost of care and worse healthcare outcomes than any of them.
I've been saying this for a long time: doctor scarcity is a red herring. Training more physicians or nurse practitioners or physician assistants will not bring down healthcare costs.
I've been saying this for a long time: doctor scarcity is a red herring. Training more physicians or nurse practitioners or physician assistants will not bring down healthcare costs.
Source for your first claim? All the charts I’ve seen online (see [1] for an example) show that the other Anglophone countries you’ve listed now have more doctors per capita than the US. (It looks like this was not the case in the past.)
[1] https://www.oecd-ilibrary.org/sites/b39949d7-en/index.html?i...
[1] https://www.oecd-ilibrary.org/sites/b39949d7-en/index.html?i...
Interesting. I was going off of 2009 data. I am quite surprised that the situation reversed in such a short period of time.
It’s not as competitive. I had classmates who were rejected by every Canadian and US medical school and ended up going to Ireland or France instead. (The one who went to France was a French national. The ones who went to Ireland were not Irish.)
Article says:
> Lots of people want to train as doctors: over 85,000 people take the medical-college admission test each year, and more than half of all medical-school applicants are rejected
But I believe that this means applications with a Bachelor degree.
In France, the system is different. Students go to 1st year medical school after highschool where there is a massive selection with limited number of places to get to 2nd year. Only 15-25% of students get to 2nd year, taking into account that only good students will attend 1st year to start with.
In the UK admission rate in 1st year (afte highschool) is about 15%, again taking into account that those who are not straight-As students probably don't bother applying to start with.
This does not sound less competitive. If your French classmate had a bachelor degree but went back to 1st year in France that might have given him an advantage over students fresh out of highschool.
In any case, according to the article it is the shortage of qualified profesisonals that should ultimately impact salaries, and there are shortages. But, again, salaries tend to be in effect regulated one way of another, which I think has much more of an impact.
> Lots of people want to train as doctors: over 85,000 people take the medical-college admission test each year, and more than half of all medical-school applicants are rejected
But I believe that this means applications with a Bachelor degree.
In France, the system is different. Students go to 1st year medical school after highschool where there is a massive selection with limited number of places to get to 2nd year. Only 15-25% of students get to 2nd year, taking into account that only good students will attend 1st year to start with.
In the UK admission rate in 1st year (afte highschool) is about 15%, again taking into account that those who are not straight-As students probably don't bother applying to start with.
This does not sound less competitive. If your French classmate had a bachelor degree but went back to 1st year in France that might have given him an advantage over students fresh out of highschool.
In any case, according to the article it is the shortage of qualified profesisonals that should ultimately impact salaries, and there are shortages. But, again, salaries tend to be in effect regulated one way of another, which I think has much more of an impact.
I like the Economist in general but I press the back button when the instant they start shilling for wealth inequality.
It’s called “anchoring”.
350k a year was a ton of money that bought you home ownership, supporting a family, saving for retirement, and some if not all of the finer things even in a desirable geography.
15-25 years ago.
350k is relatively a ton of money compared to dystopian nightmare of constant insecurity at the median.
350k is a damned sight better than typical household income, take home is $19,319.25, which is very comfortable but not “lavish” for a childless bachelor with no debt most anywhere.
But throw in funding your 401k, ~18k, renting a single-family home in a desirable geo in a neighborhood you’d park your car on the street: ~13k, couple of car payments/reg/insurance/maintenance, ~11.5k, 4 decent mobile phone plans, decent internet, utilities: 10.5k, couple of grand in student loans: maybe like ~8k, a year’s worth of school clothes and supplies, replace a piece of furniture or two or a TV that craps out, a laptop or iPad or whatever someone broke or lost or was stolen because they’re kids, and the long tail of “major expenses” that you never see coming amortized over a year: ~7k, fund college savings for two public universities: ~5k, healthy groceries you don’t have to ruthlessly optimize and the occasional dinner out with your partner: ~3.5k, save up a robust emergency fund and then build a portfolio that will let you retire before 70 with a life expectancy pushing 90: zero. Hope you’re not passionate about any hobbies that cost money and never want to go on vacation.
You did a STEM-heavy undergrad, passed the MCAT, did years of extremely technical advanced degree education, took years off your life pulling crazy hours in a residency, built a practice. You’re among the most highly educated and indispensable members of society.
And your “lavish” profligate conspicuous consumption is living in California, sending your kids to public universities, and retiring ever?
No, it’s the median that’s barbaric, not a modestly comfortable middle-class lifestyle you worked your ass of for that was pretty mundane for educated folks even a few decades ago.
It’s called “anchoring”.
350k a year was a ton of money that bought you home ownership, supporting a family, saving for retirement, and some if not all of the finer things even in a desirable geography.
15-25 years ago.
350k is relatively a ton of money compared to dystopian nightmare of constant insecurity at the median.
350k is a damned sight better than typical household income, take home is $19,319.25, which is very comfortable but not “lavish” for a childless bachelor with no debt most anywhere.
But throw in funding your 401k, ~18k, renting a single-family home in a desirable geo in a neighborhood you’d park your car on the street: ~13k, couple of car payments/reg/insurance/maintenance, ~11.5k, 4 decent mobile phone plans, decent internet, utilities: 10.5k, couple of grand in student loans: maybe like ~8k, a year’s worth of school clothes and supplies, replace a piece of furniture or two or a TV that craps out, a laptop or iPad or whatever someone broke or lost or was stolen because they’re kids, and the long tail of “major expenses” that you never see coming amortized over a year: ~7k, fund college savings for two public universities: ~5k, healthy groceries you don’t have to ruthlessly optimize and the occasional dinner out with your partner: ~3.5k, save up a robust emergency fund and then build a portfolio that will let you retire before 70 with a life expectancy pushing 90: zero. Hope you’re not passionate about any hobbies that cost money and never want to go on vacation.
You did a STEM-heavy undergrad, passed the MCAT, did years of extremely technical advanced degree education, took years off your life pulling crazy hours in a residency, built a practice. You’re among the most highly educated and indispensable members of society.
And your “lavish” profligate conspicuous consumption is living in California, sending your kids to public universities, and retiring ever?
No, it’s the median that’s barbaric, not a modestly comfortable middle-class lifestyle you worked your ass of for that was pretty mundane for educated folks even a few decades ago.
I'm guessing you make close to 350k or over it. 80k a year is a ton of money. It's not so great in the bay area, but in the vast majority of the country, and even in the bay area it's life changing money.
It covers a lot. I'm sick of reading defenses of people making 250k+ acting like they're in the poor house. I get families are expensive, but lifestyles have inflated to such an absurd degree.
I've been on both sides of this argument, but it's so frustrating. I def agree with the median sucking, however I know plenty of people IN the median that feel differently.
It's so strange to hear all this doom and gloom from people like me. I get that we don't have all the luxeries we were promised. In the 90s it would have been $90-150k and you would have a vacation house. These were really prosperous times if you were in the middle class.
I get that we've experienced a bit of a "darth vader I changed the deal moment". There seems to be more expenses and we're getting less out of the deal (though more in some other ways). All that said, you're comparing against very prosperous people who were getting a pretty good deal.
It covers a lot. I'm sick of reading defenses of people making 250k+ acting like they're in the poor house. I get families are expensive, but lifestyles have inflated to such an absurd degree.
I've been on both sides of this argument, but it's so frustrating. I def agree with the median sucking, however I know plenty of people IN the median that feel differently.
It's so strange to hear all this doom and gloom from people like me. I get that we don't have all the luxeries we were promised. In the 90s it would have been $90-150k and you would have a vacation house. These were really prosperous times if you were in the middle class.
I get that we've experienced a bit of a "darth vader I changed the deal moment". There seems to be more expenses and we're getting less out of the deal (though more in some other ways). All that said, you're comparing against very prosperous people who were getting a pretty good deal.
> 350k is a damned sight better than typical household income
This is an absolutely baffling statement. Median income in the USA is $76,000:
https://www.census.gov/library/publications/2023/demo/p60-27...
Perhaps it makes more sense if you limited this comparison to top-20 college graduates that could realistically work for top law firms or tech companies. But $350K is still not remotely a slight better than the typical household income.
This is an absolutely baffling statement. Median income in the USA is $76,000:
https://www.census.gov/library/publications/2023/demo/p60-27...
Perhaps it makes more sense if you limited this comparison to top-20 college graduates that could realistically work for top law firms or tech companies. But $350K is still not remotely a slight better than the typical household income.
People are gonna bash for complaining about 350k, but you're directionally right; the system is fucked up. The question is whether people can expect a reasonable retirement by working within the system. I think you can make the same argument just by comparing the median income with median expenses, and then actually seeing: can those people max out their 401k's? Do they even have 401k's? Can they max out their Roth's? If they do, what will they have when they retire? Is it enough?
I would bet that in those sorts of scenarios, we're further away from "enough" than we used to be.
I would bet that in those sorts of scenarios, we're further away from "enough" than we used to be.
The numbers dont jibe with reality. Yes, 80k (or whatever the median is) feels low, but people are constantly - in reality - retiring, vacationing, sending their kids to school, buying cars, eating out, ... on that income.
There's a huge disconnect, I don't know where it stems from. The average/median american is not living in destitution, at the brink of collapse.
The fact that 350k feels low, is, I don't know, weird (although, like you, I understand that directionally it _feels_ about right).
There's a huge disconnect, I don't know where it stems from. The average/median american is not living in destitution, at the brink of collapse.
The fact that 350k feels low, is, I don't know, weird (although, like you, I understand that directionally it _feels_ about right).
I met with a fee-only fiduciary financial planner a while back. This was after several years of making income that I knew was above average, even somewhat above average in tech. We plotted out our expenses (which aren't exorbitant), plugged in our account balances, talked about wanting to retire maybe in our mid-late 50s rather than 65. Mind you, this is me maxing out 401k and Roth almost every year, and saving excess into a taxable "retirement" account as well. We answer a bunch more advanced questions, they press the button that runs all the Monte Carlo scenarios, and the result was... we were basically on target. We weren't on the road to fuck-you money, but we were on a road to be able to retire in the desired timeframe and meet our current expenses, maybe with a couple of vacations per year added on top.
And I can't explain the emotional reaction I had. Like, I was relieved and proud that I had done a good job saving, but... I also knew that I was far above average in income and saving, and even with that was only "on target" rather than exceeding. I eventually spluttered out my words to the financial planner, asking about all the other people out there that make less and aren't in a position to see financial planners, and with a sad look on his face, he simply said:
"It is going to change society."
And I can't explain the emotional reaction I had. Like, I was relieved and proud that I had done a good job saving, but... I also knew that I was far above average in income and saving, and even with that was only "on target" rather than exceeding. I eventually spluttered out my words to the financial planner, asking about all the other people out there that make less and aren't in a position to see financial planners, and with a sad look on his face, he simply said:
"It is going to change society."
It's scary. But are families really now more poor than ever, that unlike today/before nobody will be able to retire?
I think there's a huge difference in baseline cost. A lot of people on high incomes have huge spending jumps, that most just don't. e.g. the vacation is international, the house is twice as big, or in the "good" neighborhood, the car is big, the school is private, the kids have trusts, ...
At all that up, and yeah, 350k is barely enough. Take all that away, and 80k is solid.
> "It is going to change society."
socialism (we'll take from thee) or fascism (don't you dare take from me). America is in for a rough ride if he's right.
I think there's a huge difference in baseline cost. A lot of people on high incomes have huge spending jumps, that most just don't. e.g. the vacation is international, the house is twice as big, or in the "good" neighborhood, the car is big, the school is private, the kids have trusts, ...
At all that up, and yeah, 350k is barely enough. Take all that away, and 80k is solid.
> "It is going to change society."
socialism (we'll take from thee) or fascism (don't you dare take from me). America is in for a rough ride if he's right.
I think I'm also a bit sensitized because my partner is a medical social worker and regularly comes across the people that don't retire. People that can retire don't tend to hear about the experiences of the people that don't. It's a long slog of scrambling to survive and earn while physically able, cutting expenses, cutting them more, qualifying for aid, getting into medical difficulties, spending down, qualifying for medicaid, and then... well, it's a journey that a lot of people would wave off as a normal way to live and die. Big question: does that happen to people who made median income? More than before?
Exactly, with this topic it's impossible to have a calibrated discussion because everyone has a different baseline.
Agree that "you need a lot more money" feels directionally correct, but at the same time complaining about $350k is dumb. At that level of income it's entirely down to your lifestyle choices.
A lot of things people spending money on feels like status signalling. "I make $x, therefore I need to look like I made $x". Cars, private school, massive house, yearly international vacations, etc all feel over the top to me. If you want to have it all, yes it costs a shit ton.
Agree that "you need a lot more money" feels directionally correct, but at the same time complaining about $350k is dumb. At that level of income it's entirely down to your lifestyle choices.
A lot of things people spending money on feels like status signalling. "I make $x, therefore I need to look like I made $x". Cars, private school, massive house, yearly international vacations, etc all feel over the top to me. If you want to have it all, yes it costs a shit ton.
If the income is contingent on showing up to work in a high-cost region, I don't think we can explain away the payment/interest/taxes/insurance on a modest, reasonably located home in that region as "lifestyle choice."
Don't doctors make more money in low-cost rural areas?
I never said 350k was low, I said it was very comfortable for someone without a family and doable for a comfortable middle-class life with raising a family and retiring.
The fucking economist hit piece said that 350k was "lavishly" high for an absurdly educated and highly socially useful professional because it's connected to a bunch of think tanks that are part of a concerted and coordinated effort funded by Bond Villains to organize society around one goal and one goal only: to drive wealth inequality arbitrarily high as fast as possible no matter if all of mankind has to strain every sinew and destroy the planet to do so.
No cost is too high to have people flying around daily in custom Gulfstream jets carrying a single passenger.
Fuck that.
The fucking economist hit piece said that 350k was "lavishly" high for an absurdly educated and highly socially useful professional because it's connected to a bunch of think tanks that are part of a concerted and coordinated effort funded by Bond Villains to organize society around one goal and one goal only: to drive wealth inequality arbitrarily high as fast as possible no matter if all of mankind has to strain every sinew and destroy the planet to do so.
No cost is too high to have people flying around daily in custom Gulfstream jets carrying a single passenger.
Fuck that.
No family, huh?
I'm getting evicted two days after my birthday and not one of my patrilineal relations will help me.
Could you put me up? You absolutely could and it would not burden you at all.
And don't even start because you and the rest have profited greatly.
I know, I know: how dare I.
CMB.
I'm getting evicted two days after my birthday and not one of my patrilineal relations will help me.
Could you put me up? You absolutely could and it would not burden you at all.
And don't even start because you and the rest have profited greatly.
I know, I know: how dare I.
CMB.
Pretty much any political entity focused on reducing inequality or promoting egalitarianism has the outsized compensation of professionals like doctors and software engineers as its primary target.
The median American lives in exurban Dayton, OH or something. Living somewhere with growing industry and career prospects is a completely different thing.
The typical homeowner in a coastal metro doesn't have a massive income, but does have a million plus in home equity. You as a young adult will need dramatically more labor income to reach the same lifestyle on ~$0 wealth. You will even need more labor income than they had capital gains, because high-end labor is taxed much more heavily (~40% effective) than capital gains on primary residence ($500k exemption then ~20%).
The typical homeowner in a coastal metro doesn't have a massive income, but does have a million plus in home equity. You as a young adult will need dramatically more labor income to reach the same lifestyle on ~$0 wealth. You will even need more labor income than they had capital gains, because high-end labor is taxed much more heavily (~40% effective) than capital gains on primary residence ($500k exemption then ~20%).
I don't disagree. Come to think of it, Dave Chapelle lives in exurban Dayton. Must not be too shabby.
After tax takehome for a married $350k income in California would be $230k/yr.
Your list of expenses totaled to $58,500.
What happened to the other $171,500/yr??
Your list of expenses totaled to $58,500.
What happened to the other $171,500/yr??
doctors can move to any low col city and make similar amounts to living in CA (which is certainly not available to software engineers wanting to make the big bucks), not to mention a lot of them marry high income spouses as well. Just a FYI, i don't believe wealth inequality really stems from the people making 350-700k working jobs, it really stems from the minority of people / corporations who seem to own a ton of capital.
The cost numbers make no sense without a denominator. Take home looks like per month, 401l per year. Rental, per ..? 13k per month for rent is insane, per year is super cheap.
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Black pill for me: the doctors that are paid extremely well (surgeons, complex specialties) are doing work that is extremely challenging and realistically only a tiny amount of people are able to do. Increasing med school and residency slots wouldn’t impact these specialties because the gating is due to innate qualities like IQ/drive/etc. The people who are currently excluded from these job roles are intentionally excluded due to a lack of these qualities and it is good.
The US has fewer residency seats per capita than almost anyone else in the civilized world. Are American students less capable than everywhere else? Are Europeans dying in droves because getting into med school is marginally easier?
Looking at health outcomes in other countries, your argument just doesn't hold
Looking at health outcomes in other countries, your argument just doesn't hold
It’s not residency slots that gate complex specialties it’s fellowship slots. At the end of residency, a “general surgeon” can do common and basic things like appendectomies. Those that go on to do organ transplants, complex cancer cases, etc do a fellowship that is another 1-3 years of training in a further sub field. We don’t need more internists or family med doctors, most of that caseload can be handled by NPs and PAs. Family med MDs make maybe 160k/year, they are not high earning.
> Family med MDs make maybe 160k/year, they are not high earning
The mean wage is 224k/year. https://www.bls.gov/oes/current/oes291215.htm Definitely high earning.
> We don’t need more internists or family med doctors, most of that caseload can be handled by NPs and PAs.
Ok. When someone in your family dies from horrible substandard care from an NP, we'll talk. I don't let anyone in my family deal be under the care of an NP, I've seen them make far too many serious mistakes.
The mean wage is 224k/year. https://www.bls.gov/oes/current/oes291215.htm Definitely high earning.
> We don’t need more internists or family med doctors, most of that caseload can be handled by NPs and PAs.
Ok. When someone in your family dies from horrible substandard care from an NP, we'll talk. I don't let anyone in my family deal be under the care of an NP, I've seen them make far too many serious mistakes.
> We don’t need more internists or family med doctors
Pretty sure the big shortage is precisely in FM, because it's low-status and not as stimulating intellectually/too routine
Pretty sure the big shortage is precisely in FM, because it's low-status and not as stimulating intellectually/too routine
The obvious question I have then is why you think the current system is selecting exactly the right number of surgeons? How do you know the next 10% of potential surgeons who don't make it under the current system wouldn't have the IQ/drive/etc to be high quality, effective surgeons?
Fellowships are the last 1-3 year stint of training for specialist docs. There are unfilled training slots in competitive/complex fellowships in many disciplines. The fellowships are choosing not to train because they don’t have qualified applicants.
You are describing a bias in terms of expected traits of a doctor. You can imagine (and attempt to measure) that there are a good number of people who share these traits who are not doctors and a good number of doctors who do not share these traits.
Yes. The 3 dominant features are (1) income and (2) ability, (3) alternative opportunities. Highly specialized doctors in the US get paid a lot because they have great alternatives because they are some of the smartest and most driven people alive. If we increase the number of training slots, that doesn't increase then number of qualified applicants to train because we are already at an equilibrium where marginal slots are unfilled in competitive fields. If we want to increase the number of qualified doctors we need to increase training slots AND increase pay for these docs. This will move some of the top talent pool from drug discovery/finance/law/software back to medicine. Will a law partner become a top surgeon ever? No. Will a highly capable 18 year old who is choosing their path be more likely to take the "highly compensated surgeon" route over the "highly compensated finance worker" route? Yes. Some of the best folks I know in the field have previously worked in business services/legal routes before settling on medicine relatively late in their career.
Lots of things stated as fact that isn’t necessarily supported. How do you know they are the smartest and most driven people alive? How do you know we are at equilibrium? I open up 100 spots and pick a terrible qualifying criteria I can still have a shortage of “qualified candidates” but it doesn’t mean there aren’t qualified candidates, it just means I have a shitty filter.
> surgeons... are doing work that is extremely challenging and realistically only a tiny amount of people are able to do
As a medical student, I'd like to dispel this myth. The surgeons tell us all the time that they could teach a monkey to do surgery. What matters is putting in the 10,000 hours if takes to become proficient at surgery, and not everyone has the time/resources/opportunity to get that training. However, I believe that almosy anyone taken from the streets and given 10,000 hours of training could become a world-class surgeon
As a medical student, I'd like to dispel this myth. The surgeons tell us all the time that they could teach a monkey to do surgery. What matters is putting in the 10,000 hours if takes to become proficient at surgery, and not everyone has the time/resources/opportunity to get that training. However, I believe that almosy anyone taken from the streets and given 10,000 hours of training could become a world-class surgeon
It's common for someone who finished his 10,000 hours to look back and say "I'm actually not that smart. It's simpler than it looks. It just takes time. Anyone can do it, really."
Good luck finding those monkeys willing to put in the 10,000 grueling hours, endless practice questions always criticizing your performance, and a social environment that make you feel like you're the only one who is dumb, to get there in such a competitive field.
"Drive" in terms of motivation to do medicine specifically and nothing else, sure. But plenty of people who could succeed in medicine choose fields like tech instead due to work-life balance. Medicine could potentially attract this talent if it were willing to split its classic 24-hour shifts among two or three doctors instead of only one.
Your statement is not wrong, but most of the need is not in the advanced specialities.
There's a huge need for basic, primary care.
There's a huge need for basic, primary care.
Becoming a doctor through service in the armed forces is a legitimate alternative path in the U.S.:
https://veteran.com/military-doctor/
Wouldn’t it be great if this program were expanded to include “civilian service,” as in “rural community and inner city” assignments? e.g. psychiatry?
Oh wait, there are programs for this, as well /s:
https://www.usphs.gov/students/
https://www.ruralhealthinfo.org/topics/scholarships-loans-lo...
Other options: nurse practitioner, social worker, physician assistant, nurse anesthetist, etc.
Bottom line: if a teen wants to be a doctor or healthcare provider, there are many paths to getting there. It’s a lot of hard work and it takes the right person to do it. Good luck and thank you to all of you considering this career choice-it’s your gift to humanity.
And you deserve to be paid well!
https://veteran.com/military-doctor/
Wouldn’t it be great if this program were expanded to include “civilian service,” as in “rural community and inner city” assignments? e.g. psychiatry?
Oh wait, there are programs for this, as well /s:
https://www.usphs.gov/students/
https://www.ruralhealthinfo.org/topics/scholarships-loans-lo...
Other options: nurse practitioner, social worker, physician assistant, nurse anesthetist, etc.
Bottom line: if a teen wants to be a doctor or healthcare provider, there are many paths to getting there. It’s a lot of hard work and it takes the right person to do it. Good luck and thank you to all of you considering this career choice-it’s your gift to humanity.
And you deserve to be paid well!
> Becoming a doctor through service in the armed forces is a legitimate alternative path in the U.S.:
This is just med school with military branding. Every year, at the start of med school, the military recruiters rain down on med schools providing the exact same offer.
This is just med school with military branding. Every year, at the start of med school, the military recruiters rain down on med schools providing the exact same offer.
So you're saying if poor people want quality education, they ned to join the army? And you don't see how that's a problem?
Salaries are a red herring. So are the number of physicians per se. We don't have a physician shortage per se, we have a provider shortage, and more generally, we have a healthcare provision shortage.
What you really want to know is, if you deregulated healthcare in general, and removed a lot of the medical licensing restrictions around care provision, what would be the expected decrease in healthcare costs? What if you increased care access?
For example, let's say you dramatically opened access to large classes of drugs that are basically safe, and made various procedures and medicines available through, say, pharmacists or psychologists, or created opportunities for different provider models that don't exist now. What would be the expected decrease in cost, both in absolute dollar amounts and in "intangibles" such as time?
For me the problem is this hierarchical view of healthcare provision, where we assume a physician is omnicient and omniskilled in all areas of medicine, more so than other types of providers who specialize more, and the only safe training path is bachelors -> MD -> residency.
I don't buy the safety argument either because having practicing power so concentrated in one professional group also leads to safety problems. Those highly skilled and trained physicians didn't save us from things like the fentanyl crisis, even though it was literally their job under the current paradigm. If someone was really concerned about safety regulation, you would regulate on a skill basis, not on a degree basis.
There a whole host of problems in US healthcare, including increasing consolidation of healthcare companies, healthcare management and administration, and so forth. But I do think a hierarchical provider model characterized by intense regulatory capture is a big, nonignorable part of it.
What you really want to know is, if you deregulated healthcare in general, and removed a lot of the medical licensing restrictions around care provision, what would be the expected decrease in healthcare costs? What if you increased care access?
For example, let's say you dramatically opened access to large classes of drugs that are basically safe, and made various procedures and medicines available through, say, pharmacists or psychologists, or created opportunities for different provider models that don't exist now. What would be the expected decrease in cost, both in absolute dollar amounts and in "intangibles" such as time?
For me the problem is this hierarchical view of healthcare provision, where we assume a physician is omnicient and omniskilled in all areas of medicine, more so than other types of providers who specialize more, and the only safe training path is bachelors -> MD -> residency.
I don't buy the safety argument either because having practicing power so concentrated in one professional group also leads to safety problems. Those highly skilled and trained physicians didn't save us from things like the fentanyl crisis, even though it was literally their job under the current paradigm. If someone was really concerned about safety regulation, you would regulate on a skill basis, not on a degree basis.
There a whole host of problems in US healthcare, including increasing consolidation of healthcare companies, healthcare management and administration, and so forth. But I do think a hierarchical provider model characterized by intense regulatory capture is a big, nonignorable part of it.
Reality Check [FAIL] - Both from many things I've heard & read over the years, and some quick web searches just now - it sure looks like "American doctor" earnings vary vastly depending on the doctor's specialty. With the GP's and similar "keep 'em healthy" specialties often paid ~3X less than the MD's who get to bill lots of cool, expensive "procedures".
(The frequent blindness of The Economist to such critical basic facts was ~80% of why I cancelled my print subscription.)
(The frequent blindness of The Economist to such critical basic facts was ~80% of why I cancelled my print subscription.)
Medicine has thrived on limiting its intake of Doctors in the same way law has not. The legal profession went the way of opening Law Schools all over the place whereas medical schools are far and few between. Obviously medical schools are much more expensive to open, but having organizations that limit opening those schools also helps.
Medical schools are so far and few between that it is one of the rare places students seek admission in the Caribbean and Latin America to get certified with the hope of clobbering their USMLE exams and getting into a good residency program to make up for it.
The fact that someone can have 2 points lower on the MCAT and not qualify for a good medical school tells you how messed up the priorities are.
Medical schools are so far and few between that it is one of the rare places students seek admission in the Caribbean and Latin America to get certified with the hope of clobbering their USMLE exams and getting into a good residency program to make up for it.
The fact that someone can have 2 points lower on the MCAT and not qualify for a good medical school tells you how messed up the priorities are.
I'm not an expert on this topic, but the article confuses a handful of issues that should be separated.
There is a limit on the number of seats in US medical schools but this does not affect the number of new practicing physicians in the US directly. Thus the article's discussion of MD matriculations and of DO programs should be ignored.
The article correctly states that all physicians must complete residency programs. The US Medicare and Medicaid programs fund the vast majority of residency slots. Residency slots preferentially are awarded to US medical graduates (i.e., new MDs) but they are available to any graduate of an accredited MD program. Thus, if a bottleneck exists, it exists here.
However, hospitals can - and do - use other funds to train medical graduates in their residency programs. I do not know the thinking about how many such slots a residency program operates, but this would have been a far more interesting area for the article to examine.
There is a limit on the number of seats in US medical schools but this does not affect the number of new practicing physicians in the US directly. Thus the article's discussion of MD matriculations and of DO programs should be ignored.
The article correctly states that all physicians must complete residency programs. The US Medicare and Medicaid programs fund the vast majority of residency slots. Residency slots preferentially are awarded to US medical graduates (i.e., new MDs) but they are available to any graduate of an accredited MD program. Thus, if a bottleneck exists, it exists here.
However, hospitals can - and do - use other funds to train medical graduates in their residency programs. I do not know the thinking about how many such slots a residency program operates, but this would have been a far more interesting area for the article to examine.
The perhaps more informative framing is: Why do doctors in America earn so much more than their peers in other countries (i.e., those with roughly equivalent systems).
Pulling on that thread is pretty interesting in how broad it goes. I'm certain I don't understand it well and the experts are pretty argumentative also.
Pulling on that thread is pretty interesting in how broad it goes. I'm certain I don't understand it well and the experts are pretty argumentative also.
We need more doctors, physician assistants, nurse practitioners. Most are burning out and overworked. I have overheard a business conversation in which one person said, "the only way to solve this is to make doctors work more hours" ... I do not think that is the solution either.
We need to increase the supply. There are so many smart, motivated people that are not able to get into med school because of these self-serving limits.
This is just a plot of American insurance companies and hospital CEOs all raking in billions to redirect attention elsewhere
> The profession is lavishly paid: $350,000 is the average salary according to a recent paper
Plenty of people in tech getting TC like this.
Plenty of people in tech getting TC like this.
This is the average salary of all kinds of doctors in all parts of the United States. A relatively subpar doctor in South Dakota makes as much as a highly skilled engineer in one of the largest corporations in the world. Silicon Valley is not the exemplary of the nation’s software engineering industry, many of us are making much meeker TC than $350,000.
Is this really true? Define plenty of people. An average doctor in America would probably make much more than an average software engineer. If you are comparing the top 10% of software engineers, then we should probably compare them the top 10% of doctors (who probably make close to a million dollars).
Why?
There's a clear skill and education floor between the fields. It's probably reasonable to compare the top 90% of doctors to the top 10% software engineers. In fact, I'd suspect most doctors would be 1% engineers if they put the same effort being a great engineer as they do for med school/residency.
There's a clear skill and education floor between the fields. It's probably reasonable to compare the top 90% of doctors to the top 10% software engineers. In fact, I'd suspect most doctors would be 1% engineers if they put the same effort being a great engineer as they do for med school/residency.
At the top tech companies, yes. [1]
That would be standard TC for a senior level engineer. But not at at a typical fortune 500, bank, or any other traditional type company that does not have tech as their main strategic business offering.
[1] https://www.levels.fyi/
That would be standard TC for a senior level engineer. But not at at a typical fortune 500, bank, or any other traditional type company that does not have tech as their main strategic business offering.
[1] https://www.levels.fyi/
yes but comparing the top x percent of software engineers to the "average doctor" seems a bit misleading.
Median TC for SWE in the US is $170k according to levels.fyi.
keep in mind, normal swe don't even know levels.fyi exists so the self reporting is done by people who probably know what leet code is (which means they know the "game" to some extent).
Plenty of doctors make >1,000,000.
only a robot would click that button so many times
The single biggest factor is the cost of medical education. Once a person spends a fortune getting their degree, it creates a gated community that works to preserve its privileges, deny entry to other cheaper alternatives, and keep prices high across the eco-system.
You will see this in any field that transacts with high value goods: real-estate, enterprise software, weapons of war, investment bankers handling M&A ... the higher the cost of the product, the more the people dealing in it feel entitled to charge for their services.
You will see this in any field that transacts with high value goods: real-estate, enterprise software, weapons of war, investment bankers handling M&A ... the higher the cost of the product, the more the people dealing in it feel entitled to charge for their services.
The article was disappointing. It’s the first time in a while I’ve read the Economist but I feel the quality has really gone down.
Why did the Department of Health state there was a surplus? What policy decisions allowed them to make that recommendation? What mechanisms meant medical schools, who have an incentive to increase class size, reacted the way they did? What is the difference in salary for “DO’s”? What part do HMOs and insurance companies play, who surely have an incentive to lower the cost of medicine?
One argument is tacit collusion to “inflate salaries” which may be part of it, but if this accounts for all of the impact then it is a scandal and evidence of institutional corruption that should be paraded in the streets. I’d imagine a class action lawsuit by students who didn’t make it into med school against the DoH. I don’t think this answers it all.
In any case, I think the uppermost level of medicine will get decimated by AI. It’s mostly knowledge work with a focus on experience. It feels like the perfect use case for generative AI. On the other hand having more people doing the manual work (putting in a catheter etc) will likely last a lot longer as robotics has seemed to stall in advancements.
Why did the Department of Health state there was a surplus? What policy decisions allowed them to make that recommendation? What mechanisms meant medical schools, who have an incentive to increase class size, reacted the way they did? What is the difference in salary for “DO’s”? What part do HMOs and insurance companies play, who surely have an incentive to lower the cost of medicine?
One argument is tacit collusion to “inflate salaries” which may be part of it, but if this accounts for all of the impact then it is a scandal and evidence of institutional corruption that should be paraded in the streets. I’d imagine a class action lawsuit by students who didn’t make it into med school against the DoH. I don’t think this answers it all.
In any case, I think the uppermost level of medicine will get decimated by AI. It’s mostly knowledge work with a focus on experience. It feels like the perfect use case for generative AI. On the other hand having more people doing the manual work (putting in a catheter etc) will likely last a lot longer as robotics has seemed to stall in advancements.
> One argument is tacit collusion to “inflate salaries” which may be part of it, but if this accounts for all of the impact then it is a scandal and evidence of institutional corruption that should be paraded in the streets.
The role of the AMA in restricting the supply of doctors has been paraded for decades, but it just doesn't catch on. People like their personal doctors and refuse to think ill of doctors, though they'll happily blame others in the medical industry. I find it quite believable that the doctors industry would err on the side of undersupply, making their own salaries high, rather than risk oversupply and a drop in salaries.
Is that "collusion"? That's just terminology. It's the standard "regulatory capture", as government officially delegates accreditation to the medical industry, despite the obvious conflict of interest. The AMA argues they're protecting doctor quality, even though they overtly worry about oversupply.
The role of the AMA in restricting the supply of doctors has been paraded for decades, but it just doesn't catch on. People like their personal doctors and refuse to think ill of doctors, though they'll happily blame others in the medical industry. I find it quite believable that the doctors industry would err on the side of undersupply, making their own salaries high, rather than risk oversupply and a drop in salaries.
Is that "collusion"? That's just terminology. It's the standard "regulatory capture", as government officially delegates accreditation to the medical industry, despite the obvious conflict of interest. The AMA argues they're protecting doctor quality, even though they overtly worry about oversupply.
Either the AMA will reform, or super nurses will do everything.
Ideal outcome is accelerated MD for nurses as continuing education. Not having this is plain classist af.
Ideal outcome is accelerated MD for nurses as continuing education. Not having this is plain classist af.
https://en.wikipedia.org/wiki/Mustang_(military_officer) the military is unsurprisingly miles ahead on this
It's not classism. Nursing school is a different form of training than physician training that teaches a different skillset.
This is like asking an air traffic controller to fly a plane. Air traffic controllers are smart, highly educated, highly technical people. But as a passenger on a flight, would you trust one to fly your plane, even if they just finished a 2-year accelerated training course? No, because a career in ATC doesn't teach you much at all about the actual mechanics of flying a plane. Nor does a career in nursing teach you how to diagnose a patient or formulate a care plan.
So why are so many people willing to accept non-physicians who completed an accelerated training course instead of physicians who completed a residency? It's just bonkers to me.
This is like asking an air traffic controller to fly a plane. Air traffic controllers are smart, highly educated, highly technical people. But as a passenger on a flight, would you trust one to fly your plane, even if they just finished a 2-year accelerated training course? No, because a career in ATC doesn't teach you much at all about the actual mechanics of flying a plane. Nor does a career in nursing teach you how to diagnose a patient or formulate a care plan.
So why are so many people willing to accept non-physicians who completed an accelerated training course instead of physicians who completed a residency? It's just bonkers to me.
Aircraft controllers work in a physically different space.
Nurses and doctors work right next to each other. Years in, how much do you think school long ago vs on-the-job experience informs behavior?
Nurses and doctors work right next to each other. Years in, how much do you think school long ago vs on-the-job experience informs behavior?
> Years in, how much do you think school long ago vs on-the-job experience informs behavior?
It's not medical school that makes the difference, it's residency, which is > 10,000 hours of on-the-job experience, more or less in an apprenticeship model.
Sure, a nurse can accumulate 10,000 hours of on-the-job experience experience as well, but it doesn't translate when that experience is doing a completely different set of tasks.
Working right next to each other doesn't change things. If a concert violinist and a concert pianist play in the same orchestra for 30 years, does that raise the concert pianist's violin ability to professional level?
I work with nurses every day. They ask questions about treatment plans that, if a resident with more than 3 months experience were to ask me the same question, I would have serious concerns. It's not because the nurses are stupid; it's because they don't have > 10,000 hours formulating treatment plans and (critically) being held accountable for those plans, as a residency graduate does. They see the recipes, but they don't understand how the ingredients are put together.
It's not medical school that makes the difference, it's residency, which is > 10,000 hours of on-the-job experience, more or less in an apprenticeship model.
Sure, a nurse can accumulate 10,000 hours of on-the-job experience experience as well, but it doesn't translate when that experience is doing a completely different set of tasks.
Working right next to each other doesn't change things. If a concert violinist and a concert pianist play in the same orchestra for 30 years, does that raise the concert pianist's violin ability to professional level?
I work with nurses every day. They ask questions about treatment plans that, if a resident with more than 3 months experience were to ask me the same question, I would have serious concerns. It's not because the nurses are stupid; it's because they don't have > 10,000 hours formulating treatment plans and (critically) being held accountable for those plans, as a residency graduate does. They see the recipes, but they don't understand how the ingredients are put together.
The fact that it is apprenticeship more than school I feel bolsters my point.
Do the doctor(s) like go to a different room when they come up with the treatment plans? My lay understanding is everyone is around each other a large portion of the time, at least at the hospital (outpatient maybe is more different?).
Perhaps some nurses are happy to not care about "where the recipes come from" and "just mix ingredients, follow the plan", but surely others are just a bit more naturally curious how those come from.
I am not saying they can just instantly become MDs, but If I spent 10,000 being a line cook, I think I would be pretty well prepared to go to culinary school.
Do the doctor(s) like go to a different room when they come up with the treatment plans? My lay understanding is everyone is around each other a large portion of the time, at least at the hospital (outpatient maybe is more different?).
Perhaps some nurses are happy to not care about "where the recipes come from" and "just mix ingredients, follow the plan", but surely others are just a bit more naturally curious how those come from.
I am not saying they can just instantly become MDs, but If I spent 10,000 being a line cook, I think I would be pretty well prepared to go to culinary school.
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> For many Americans, the doctor shortage has already arrived. More than 100m people today live in an area without enough primary-care doctors (the problem is particularly bad in rural areas). For mental health things are even worse: half of Americans live in an area with a shortage of mental-health professionals.
I agree with many of the points made here (doctors aren't overpaid, schooling is too long, etc) but how about addressing how many people constantly believe they need to see a doctor. How much time in the doctors office is actually necessary? There are probably more hypochondriacs today than ever before and I know many IRL. I've gone to the doctor probably less than 5 times in my adult life, but I have friends my age (late 30s) who go dozens of times per year, and don't have chronic issues! Some people suggesting a single payer system would fix this but I see it the opposite, just like in Canada, our system will be flooded for people seeking care for every single thing.
I agree with many of the points made here (doctors aren't overpaid, schooling is too long, etc) but how about addressing how many people constantly believe they need to see a doctor. How much time in the doctors office is actually necessary? There are probably more hypochondriacs today than ever before and I know many IRL. I've gone to the doctor probably less than 5 times in my adult life, but I have friends my age (late 30s) who go dozens of times per year, and don't have chronic issues! Some people suggesting a single payer system would fix this but I see it the opposite, just like in Canada, our system will be flooded for people seeking care for every single thing.
I normally frown when people suggest that tech will fix medicine, but I actually believe it for the singular use case of triaging whether or not a problem needs medical attention. The biggest barrier is that the false negative is a very dangerous situation (i.e., telling a patient it can wait when it's actually emergent), so no tech company with a functioing legal department will want to take on that liability.
So for now, the second best solution is the "doc-in-a-box"/urgent care outfit that doesn't have all the expensive machines and can therefore charge less, or you can see an NP/PA who can charge less because they have less formal education.
So for now, the second best solution is the "doc-in-a-box"/urgent care outfit that doesn't have all the expensive machines and can therefore charge less, or you can see an NP/PA who can charge less because they have less formal education.
There are just so many factors in play, and many statements in this articles can spawn their own large-scale discussions.
> More than 100m people today live in an area without enough primary-care doctors
I have several friends who are primary care doctors, and their patient panels are 2000-3000 people. That is an absurd number of people, and requires a ton of work on their part, leading to poor work/life balance. Being a primary care physician is becoming more difficult and less attractive, even for people who otherwise would be really interested in being generalists and building the kinds of relationships that come with being a PC.
> the problem is particularly bad in rural areas
Generally, highly-educated people tend to live in urban areas (there are many sources that track this trend). In addition, rural areas tend to imply private practices (because there aren't as many large hospitals in those places), and private practices are even harder to work at — whereas a hospital has an entire department dedicated to billing and dealing with the myriad insurance types their patients have, private practices have to mostly manage on their own with minimal staff. This winds up taking a ton of their time, and is a major reason some folks I know have not gone that route.
> As the baby-boomers age the need for medical care rises and the doctors among them retire
This may be a "usual suspect", but it is a real one.
> it takes 10-15 years after arriving at university to become a doctor in America
IMO, this alone largely answers the question in the title. While training, physicians don't generally earn a lot of money (relatively, and especially since many of them train in large hospitals, which are based in large cities, which have higher costs of living). The expected reward for spending a 10-15 years of your life studying and working hard, long hours, in schools and then residency programs that are short-staffed and have multi-day shifts, must be high enough to justify the cost, even for those that go into it with a very idealistic mindset.
> More than 100m people today live in an area without enough primary-care doctors
I have several friends who are primary care doctors, and their patient panels are 2000-3000 people. That is an absurd number of people, and requires a ton of work on their part, leading to poor work/life balance. Being a primary care physician is becoming more difficult and less attractive, even for people who otherwise would be really interested in being generalists and building the kinds of relationships that come with being a PC.
> the problem is particularly bad in rural areas
Generally, highly-educated people tend to live in urban areas (there are many sources that track this trend). In addition, rural areas tend to imply private practices (because there aren't as many large hospitals in those places), and private practices are even harder to work at — whereas a hospital has an entire department dedicated to billing and dealing with the myriad insurance types their patients have, private practices have to mostly manage on their own with minimal staff. This winds up taking a ton of their time, and is a major reason some folks I know have not gone that route.
> As the baby-boomers age the need for medical care rises and the doctors among them retire
This may be a "usual suspect", but it is a real one.
> it takes 10-15 years after arriving at university to become a doctor in America
IMO, this alone largely answers the question in the title. While training, physicians don't generally earn a lot of money (relatively, and especially since many of them train in large hospitals, which are based in large cities, which have higher costs of living). The expected reward for spending a 10-15 years of your life studying and working hard, long hours, in schools and then residency programs that are short-staffed and have multi-day shifts, must be high enough to justify the cost, even for those that go into it with a very idealistic mindset.
[deleted]
It's interesting that the argument I've heard most often for the American healthcare model is the quick access to doctors and specialists.
When you consider that there are less doctors per people in the US compared to some countries where healthcare is partially or entirely public, it's quite revealing how this result is achieved: by decreasing the population who can offer one. So that if you were re-adjusting the graph to the population with insurance or sufficient needs, the US would probably be higher than the rest.
I don't know how you can argue to yourself that limiting access to health care is better because now some people can get what they want faster (because others can't get what they need at all).
When you consider that there are less doctors per people in the US compared to some countries where healthcare is partially or entirely public, it's quite revealing how this result is achieved: by decreasing the population who can offer one. So that if you were re-adjusting the graph to the population with insurance or sufficient needs, the US would probably be higher than the rest.
I don't know how you can argue to yourself that limiting access to health care is better because now some people can get what they want faster (because others can't get what they need at all).
It's easy enough to justify if you are in the group of people that can get it faster.
Typical to focus on the pipeline, the Economist is culturally conditioned not to question the context of the system.
A lot the distribution, efficiency, and particularly the burnout are due to corporatization and over regulation. The "medical" system is a self-licking ice cream cone of non normal demand curves being served by inefficient systems the generate reasons to intermediate money between the end players of patient and doctor.
So typical to focus on the "doctor" as the problem.
We had a much more robust distributed national system before the"smart" people made it "efficient".
A lot the distribution, efficiency, and particularly the burnout are due to corporatization and over regulation. The "medical" system is a self-licking ice cream cone of non normal demand curves being served by inefficient systems the generate reasons to intermediate money between the end players of patient and doctor.
So typical to focus on the "doctor" as the problem.
We had a much more robust distributed national system before the"smart" people made it "efficient".
I would probably trust a nurse with AI augmentation more than a regular doctor, which I'm sure would help relieve a lot of pressure on the system.
But i'm sure the doctors and the AMA would do everything in their power to stop that from happening
But i'm sure the doctors and the AMA would do everything in their power to stop that from happening
1/4 of all hospital visits are delivered by non-physicians [1]
That number should rise with reduced regulation and sentiments toward what affordable healthcare means.
In the meantime, AI offers promise to assist both physicians and non-physicians.
Should our goal be to replace most hospital general checkups, triage, oncology, select emergency room visits, and a number of other medical fields with a non-physician who is trained to use specialized AI technology to deliver with a patient together.
YES.
[1] https://hms.harvard.edu/news/fourth-us-health-visits-now-del...
That number should rise with reduced regulation and sentiments toward what affordable healthcare means.
In the meantime, AI offers promise to assist both physicians and non-physicians.
Should our goal be to replace most hospital general checkups, triage, oncology, select emergency room visits, and a number of other medical fields with a non-physician who is trained to use specialized AI technology to deliver with a patient together.
YES.
[1] https://hms.harvard.edu/news/fourth-us-health-visits-now-del...
The US often prides itself on its world renowned universities, but this is usually due to the prestige of its research arms. In terms of actual education, the US school system is quite inefficient compared to other developed nations. What takes some countries 16 years takes the US 18-22. We spend a lot of time focusing on trivia and irrelevant courses for the sake of a "rounded" education, though retention is low and most people willfully forget anything they learned that doesn't have any use in their day to day lives
This article is political and can and should be ignored. Being a doctor is extremely difficult, and pays about as much as a sinecured, pseudo-academic "economist" who sells analysis and lightly dressed up op-eds in the Economist to the highest bidder. These articles get picked up by people who are predisposed towards the argument it is making because they have had a bad health care experience or want to take someone else down. It pits patients against doctors, when the real money is being made by the hospital systems and insurers who add little value but have massive influence over policy (much more than AMA).
The AMA should stop opposing single payer, though. That is the key difference in the US health system and other national health systems with better outcomes.
also: just look at the section of the Economist it is in: United States | Medicine’s gilded age - very professional.
also: What percentage of the total healthcare costs in the US are attributed to physician salaries? That is the theoretical maximum improvement to the cost of care delivery, if you dropped it to zero. And is that net or gross take home? Is the data before or after paying malpractice insurance of administrators to navigate the intentional bureaucracy created by providers?
The AMA should stop opposing single payer, though. That is the key difference in the US health system and other national health systems with better outcomes.
also: just look at the section of the Economist it is in: United States | Medicine’s gilded age - very professional.
also: What percentage of the total healthcare costs in the US are attributed to physician salaries? That is the theoretical maximum improvement to the cost of care delivery, if you dropped it to zero. And is that net or gross take home? Is the data before or after paying malpractice insurance of administrators to navigate the intentional bureaucracy created by providers?
Being a doctor is difficult, and doctors should earn a market clearing income.
However, the market supply is excessively constrained by legal licensing requirements which exceed the public's best interest. There is a point where improving the education or quality of doctors is a net negative, because having a less competent doctor is still better than having no doctor at all.
Of course the AMA looks out for the benefit of its own members, which benefit from scarcity, as is reasonable. It is up to the public and their legislators to act in their own interest to increase supply of medical professionals (which is counter to the interests of existing medical practitioners)
Of course the AMA looks out for the benefit of its own members, which benefit from scarcity, as is reasonable. It is up to the public and their legislators to act in their own interest to increase supply of medical professionals (which is counter to the interests of existing medical practitioners)
Spot on
Thanks. I'm arguing against the HN group think on this one, clearly. The antipathy to the medical profession here is odd and also a little gross, because it comes off as professional insecurity or jealousy. Most of what people say here about salaries could easily be said about most software development position and will be, probably in the same section of The Economist, before you know it.
There are nuances here the article misses. For one thing, pay disparity between specialties is huge -- compare a radiologist to a pediatrician, for example. In part this is because we have an insurance system that rewards (monetarily) people who perform procedures compared to those who don't.
I feel terrible for my doctors, especially my vetenarians and primary care providers. They just seem so exhausted every time I meet them. And many doctors book out weeks if not months, which tells you how insanely busy they are and showcases a lack of doctors.
The work performed by doctors is not much more difficult than that of a mechanic or some trade skill. The difference in pay, at least in the US, is due to the artificial barriers of entry such as requiring 12 years of education, 4 years of which (undergrad) is almost entirely irrelevant to the actual skill of practicing medicine.
In addition to this constraint on supply, the demand is inflated by medical insurance which makes consumers price insensitive and produces a "use it or lose it" mentality where people are compelled get certain services they don't really need to not let the unused budget expire.
The solution is to increase supply by making medical education a 4 year program that has no undergrad prerequisite and no residency postrequisite like it is in many parts of the world and also reducing the unnecessary demand by removing any government requirement that employers provide medical insurance or any subsidy towards getting medical insurance.
In addition to this constraint on supply, the demand is inflated by medical insurance which makes consumers price insensitive and produces a "use it or lose it" mentality where people are compelled get certain services they don't really need to not let the unused budget expire.
The solution is to increase supply by making medical education a 4 year program that has no undergrad prerequisite and no residency postrequisite like it is in many parts of the world and also reducing the unnecessary demand by removing any government requirement that employers provide medical insurance or any subsidy towards getting medical insurance.
I agree with removing undergrad but not residency. The things I learned in undergrad are largely useless. However, residency is important because it allows freshly minted doctors to practice under some degree of supervision for the first 3-7 years of seeing patients. The gradual increase in autonomy during residency is important, and it's my main gripe with the PA system that makes no distinction between a PA fresh out of school and one that's been practicing for 30 years.
I seem to recall a study that showed, per hour worked to get into medicine, that being a physician did not pay particularly well.
Consider opportunity costs for all those hours spent studying. Salary, in isolation, is not a sufficient measure.
Consider opportunity costs for all those hours spent studying. Salary, in isolation, is not a sufficient measure.
The AMA issue is not new. In “capitalism and freedom” 1962, Milton Friedman wrote that it will turn into a cartel, then it did.
Was going to say exactly what you said. The whole approach the AMA takes seems very much in-line with cartel behavior. Through lobbying and other similar actions, their behavior is quite similar to OPEC and Latin American drug traffickers.
They have their own interests to protect, and those interests aren't 100% aligned with the medical needs of the American population at large, nor with doctors struggling to make ends meet after taking on a ton of debt to go to med school.
Is it any wonder that those who enter med school (or residency) with a deep sense of altruism get burned out rather quickly? I think not.
They have their own interests to protect, and those interests aren't 100% aligned with the medical needs of the American population at large, nor with doctors struggling to make ends meet after taking on a ton of debt to go to med school.
Is it any wonder that those who enter med school (or residency) with a deep sense of altruism get burned out rather quickly? I think not.
The fault is not with the AMA, which can be expected to act in it's own interest. The fault is with the capitulation of government institutions which enable regulatory capture at the expense of the general public.
Hearing HNers talk about their massive software salary is so depressing when you’re in your 30s struggling on a job hunt.
What is the best place outside the country for Americans to get good healthcare? I have heard about Algodones, Mexico
Maybe the next question is why software engineers earn so much and when this trend will plateau and then reverse.
Mismanaged? I'd say managed perfectly for just this outcome.
Regulatory capture and cartel structures.
It is weird, because aside from surgeons, dentists, ER docs, paramedics, and nurses, the work they do is trivial/clerical
Paywalled article but I'm wondering if the stat for Canada's "Doctors per 1000 people" is actually lower due to emigration?
regulatory capture in action
TLDR it's a demanding and sometimes shitty job that requires a lot of debt and delayed earnings. Ie there are easier jobs that have similar lifetime earning potential.
They dont.
I think that medical systems in what we usually consider the global north are all suffering from the same illness that presents different symptoms in different countries' political, financial and social climates.
Disclaimer: this is my lived anecdotal experience as an undergrad engineering student in Slovenia. I am a 20-something yo male, with some chronic illnesses. It's ex-Yugoslav status is somewhat important in considering the social safety nets. We've been part of the EU for most of my life. What I'm describing here is probably not completely true, and lacks some nuance. I think you'll nevertheless find some common points with other healthcare systems and other countries. My English can be a bit confusing at times.
In my opinion, we're dealing with a fusion of for-profit and semi-profit insurance companies, private and public practitioners, waiting list manipulation and ever-increasing bureaucracies coming together to create a special sort of hell that you could not imagine creating even if you strove to.
PAY: Where I come from, the salaries for medical staff vary wildly. Doctors, especially dentists, surgeons and other specialists, are getting very well off, while a lot of newcomers and nurses are working under extremely strenuous conditions while paid rather poorly. In Europe, this became especially obvious during the past (hopefully) epidemic. This problem rarely improves despite numerous strikes. In most cases, everyone gets somewhat adjusted for inflation, the top dogs get even better salaries, and the pay gap widens somewhat, with the politically underrepresented majority being about as well off as before.
PUBLIC vs PRIVATE INSURANCE: Mandatory or basic health insurance is mandated and provided by my state, and is valid for all public health service providers and some private ones under a public-private partnership deal. The system is plagued by long waiting lists and endless optimization by the latter public-private "amphibious" health providers (more on them later). A lot of people I know (including a close family member) have relied on paying a private specialist out of pocket to have some emergent issue looked at in an acceptable time, sometimes paying extra for a private insurance plan that keeps a group of specialists at hand. Public waiting lists seems to be shortening a bit at the moment, but this trend, while welcome, isn't expected to persist.
It's also important to notice the ever growing populations of elderly people requiring frequent care and increasingly non-working migrant groups, which both tend to strain our rather thin social safety nets, remaining from our former socialist system where being a NEET was not a state of existence favored by past state institutions, unlike current ones which are rather lenient at providing free services to non-working, non-educating, non-retired persons.
A lot of these "amphibious" providers work half-time public waiting lists (very busy) and half-time private practices (not so much), often luring the wealthier of the public lists patients to the private practice hours to earn more. A peculiar phenomenon of space-time continuity apparently permits them to somehow produce wildly different waiting times for the exact same services. Keep in mind that we're far from US pricing here, so both lists are comparably full. The private half just makes them a lot more money. Forcing these practitioners to pick a side has been a considerable talking point of many election campaigns that has always remained unfulfilled because of endless lobbying, strikes and political pressure.
EDUCATION: As education is 100% free here, it might be a surprise that no-one from my grammar school enrolled in a medical field. I can imagine that bad future pay security, long study program, and miserable stipends are a prevailing reason for that.
SHORTAGE: We could hire from ex-Yugoslav area to relieve our overworked public health centers and hospitals, but most of the admissions get gridlocked by language proficiency requirements (in my opinion an idiotically pedantic edge condition that is killing people as we speak). Unfortunately, a lot of nationalists like to codify their self importance into law, and as a result, some countries suffer a lot more than others.
The end result is, that state-sponsored solutions are degrading at a glacial, but non-zero pace, while private practices get consulted more and more, day by day. Bureaucratic management perpetuated by lukewarm money-loving policies are probably the way affordable public healthcare dies for everyone. It really seems to me like healthcare is one of the things you can't fence-sit about; picking a public or private side is necessary to create a stable and affordable system.
Disclaimer: this is my lived anecdotal experience as an undergrad engineering student in Slovenia. I am a 20-something yo male, with some chronic illnesses. It's ex-Yugoslav status is somewhat important in considering the social safety nets. We've been part of the EU for most of my life. What I'm describing here is probably not completely true, and lacks some nuance. I think you'll nevertheless find some common points with other healthcare systems and other countries. My English can be a bit confusing at times.
In my opinion, we're dealing with a fusion of for-profit and semi-profit insurance companies, private and public practitioners, waiting list manipulation and ever-increasing bureaucracies coming together to create a special sort of hell that you could not imagine creating even if you strove to.
PAY: Where I come from, the salaries for medical staff vary wildly. Doctors, especially dentists, surgeons and other specialists, are getting very well off, while a lot of newcomers and nurses are working under extremely strenuous conditions while paid rather poorly. In Europe, this became especially obvious during the past (hopefully) epidemic. This problem rarely improves despite numerous strikes. In most cases, everyone gets somewhat adjusted for inflation, the top dogs get even better salaries, and the pay gap widens somewhat, with the politically underrepresented majority being about as well off as before.
PUBLIC vs PRIVATE INSURANCE: Mandatory or basic health insurance is mandated and provided by my state, and is valid for all public health service providers and some private ones under a public-private partnership deal. The system is plagued by long waiting lists and endless optimization by the latter public-private "amphibious" health providers (more on them later). A lot of people I know (including a close family member) have relied on paying a private specialist out of pocket to have some emergent issue looked at in an acceptable time, sometimes paying extra for a private insurance plan that keeps a group of specialists at hand. Public waiting lists seems to be shortening a bit at the moment, but this trend, while welcome, isn't expected to persist.
It's also important to notice the ever growing populations of elderly people requiring frequent care and increasingly non-working migrant groups, which both tend to strain our rather thin social safety nets, remaining from our former socialist system where being a NEET was not a state of existence favored by past state institutions, unlike current ones which are rather lenient at providing free services to non-working, non-educating, non-retired persons.
A lot of these "amphibious" providers work half-time public waiting lists (very busy) and half-time private practices (not so much), often luring the wealthier of the public lists patients to the private practice hours to earn more. A peculiar phenomenon of space-time continuity apparently permits them to somehow produce wildly different waiting times for the exact same services. Keep in mind that we're far from US pricing here, so both lists are comparably full. The private half just makes them a lot more money. Forcing these practitioners to pick a side has been a considerable talking point of many election campaigns that has always remained unfulfilled because of endless lobbying, strikes and political pressure.
EDUCATION: As education is 100% free here, it might be a surprise that no-one from my grammar school enrolled in a medical field. I can imagine that bad future pay security, long study program, and miserable stipends are a prevailing reason for that.
SHORTAGE: We could hire from ex-Yugoslav area to relieve our overworked public health centers and hospitals, but most of the admissions get gridlocked by language proficiency requirements (in my opinion an idiotically pedantic edge condition that is killing people as we speak). Unfortunately, a lot of nationalists like to codify their self importance into law, and as a result, some countries suffer a lot more than others.
The end result is, that state-sponsored solutions are degrading at a glacial, but non-zero pace, while private practices get consulted more and more, day by day. Bureaucratic management perpetuated by lukewarm money-loving policies are probably the way affordable public healthcare dies for everyone. It really seems to me like healthcare is one of the things you can't fence-sit about; picking a public or private side is necessary to create a stable and affordable system.
We have a problem - that American's cannot afford and cannot obtain reasonable medical care. Where I live - in the US - the medical care is comparable to many third world countries.
The Economist has framed this problem in terms of "Doctors Earn So Much". It is not framed in terms of corporations making unconscionable profit, buying up medical practices. It is not framed in terms of drug companies charging so much that many people cannot afford medications and so end up going to the doctor many more times than should be necessary. They do not frame the problem in terms of hospitals paying doctors primarily based on how many patients they see rather than how effectively they treat patients.
Many doctors are now leaving primary care because the corporate drive for profits has made their work unbearable.
Our elected officials of both parties are so busy posturing and providing political theater that they have no time to solve the people's problems.
The Economist has framed this problem in terms of "Doctors Earn So Much". It is not framed in terms of corporations making unconscionable profit, buying up medical practices. It is not framed in terms of drug companies charging so much that many people cannot afford medications and so end up going to the doctor many more times than should be necessary. They do not frame the problem in terms of hospitals paying doctors primarily based on how many patients they see rather than how effectively they treat patients.
Many doctors are now leaving primary care because the corporate drive for profits has made their work unbearable.
Our elected officials of both parties are so busy posturing and providing political theater that they have no time to solve the people's problems.