Physician burnout widespread, especially among those midcareer, report says(wsj.com)
wsj.com
Physician burnout widespread, especially among those midcareer, report says
https://www.wsj.com/articles/physician-burnout-widespread-especially-among-those-midcareer-report-says-11579086008
280 comments
My father was a MD and he discouraged me as well of pursuing that path.
My friends who are now doctors make much more money that I do, they are more respected, they don't have to deal with some annoying hierarchy, and their job is meaningful. As for working hours, it really depends on the speciality, and the hours they chose to work. I know some dermatologists who work 4 days a week for instance.
In the end, I don't regret that I chose a different path as I loved maths and programming and I did some interesting things as well. But nowadays I feel just like a worthless pawn, developing crappy programs, who is starting to suffer from age discrimination...
My friends who are now doctors make much more money that I do, they are more respected, they don't have to deal with some annoying hierarchy, and their job is meaningful. As for working hours, it really depends on the speciality, and the hours they chose to work. I know some dermatologists who work 4 days a week for instance.
In the end, I don't regret that I chose a different path as I loved maths and programming and I did some interesting things as well. But nowadays I feel just like a worthless pawn, developing crappy programs, who is starting to suffer from age discrimination...
As an MD, I can tell you that your view is extremely skewed. There absolutely is an annoying hierarchy. Endless departmental rules that get in the way of your practice, constant messages from the billing department asking you to edit old notes so the hospital can bill for more, fighting with insurance companies, fighting with pharmacies, fighting with patients...it doesn't really end.
For your friends in derm, I would ask them how hard they had to work to earn their careers. Dermatology is consistently one of the few hardest subspecialties within medicine to get into. You may be able to work 4 days/week later on in your career, but you'll be working non-stop through medical school pumping out research papers and studying for top board scores just to get in to derm. These days, a huge percentage of medical students end up taking an extra year just to get more research out before applying to derm.
For your friends in derm, I would ask them how hard they had to work to earn their careers. Dermatology is consistently one of the few hardest subspecialties within medicine to get into. You may be able to work 4 days/week later on in your career, but you'll be working non-stop through medical school pumping out research papers and studying for top board scores just to get in to derm. These days, a huge percentage of medical students end up taking an extra year just to get more research out before applying to derm.
Why is it so difficult to get into dermatology compared to other specialties?
Because of the working hours and you can easily create a private practice that specializes in beauty treatments such as Botox. Very little work, short hours and very high pay. There are also very, very few residencies.
> they don't have to deal with some annoying hierarchy
Even MD's still have to deal with some annoying hierarchy or another, unless they own their own practice.
Even MD's still have to deal with some annoying hierarchy or another, unless they own their own practice.
The hierarchy can get super regimented in a lot of medicine -- university labs, especially hospitals, etc. Think med student / resident / intern / fellow / attendings / chief / etc., and nurses / nurse practitioners running on the side. My wife (md/phd fellow) currently works ~6 days a week, ~7a-7p, and with constant dangers of patients dying, being sued, and over-worked colleagues flipping out. Imagine everyone is on ops: everything is permanently on fire, you spend the morning learning about the latest fires, legal issues surrounding almost every action you take & hand-off, and getting waked up at night to deal with whatever went wrong with the day's plan.
Startups, and especially big tech, are relatively easy. More money etc., but no imminent risk of say death or infection.
Startups, and especially big tech, are relatively easy. More money etc., but no imminent risk of say death or infection.
That sounds gruelling, but, as long as life is on the line, then it can be much more satisfying than, say, fixing some critical server issue at 3am. It's all a matter of perspective.
I've heard the same from law firm "lifers" that left behind the goal of becoming a partner to join a startup. They thought startup life was a life in the park comparatively.
> But nowadays I feel just like a worthless pawn, developing crappy programs, who is starting to suffer from age discrimination...
You can join open source. For example, at dlang.org we don't care how old you are, and we won't pull crappy code.
You can join open source. For example, at dlang.org we don't care how old you are, and we won't pull crappy code.
How's the pay?
$0.00
It is, after all, open source and we make it all available for free.
However, having great contributions to D have landed several contributors very nice jobs. The sponsors of the annual D conference, past and present, did so to look for crackerjack D programmers. I expect it's the same for other open source conferences.
It is, after all, open source and we make it all available for free.
However, having great contributions to D have landed several contributors very nice jobs. The sponsors of the annual D conference, past and present, did so to look for crackerjack D programmers. I expect it's the same for other open source conferences.
FWIW, my current dermatologist, the best I've ever had, has to stitch together a living by working two separate (world class) clinics as well as reviewing pathologies as a side hustle.
It isn't just the time and money side. I personally feel the solution is that most of the time we don't really need a doctor. How many appointments at a primary care are for colds/flu?
We have to switch to largely seeing mid-level providers like PAs or RNs and maybe push even lower. The doctors can be there for the tough cases and to consult and monitor. It is already starting to happen and is one way we can reduce the cost of health care.
We have to switch to largely seeing mid-level providers like PAs or RNs and maybe push even lower. The doctors can be there for the tough cases and to consult and monitor. It is already starting to happen and is one way we can reduce the cost of health care.
Or, you know, switch to one of the systems used at other developed countries that are significantly cheaper.
EDIT: > It is already starting to happen and is one way we can reduce the cost of health care.
To the downvoters, I'm replying to this part of the comment, not the overall thread.
EDIT: > It is already starting to happen and is one way we can reduce the cost of health care.
To the downvoters, I'm replying to this part of the comment, not the overall thread.
I suspect a big part of what's different under systems used at other developed countries that are significantly cheaper is that they do exactly what the parent proposed.
Another would be that you don't necessarily have the country's largest industry association behaving like a medieval guild and choking off access to the profession in order to deliberately drive up costs.
Another would be that you don't necessarily have the country's largest industry association behaving like a medieval guild and choking off access to the profession in order to deliberately drive up costs.
This * 100. I made many comments on HN about this because I know quite a bit about both the US system and the one that is NOT. My late data is a doctor. I went to med school in a SE Asian country (dropped out after 3rd year because studying medicine is not my thing; I hate rote learning and memorizing a lot of things like 200+ bone names on human body). I am married to a current medical resident (in the US) who graduated from the same medical school in SE Asia.
Both my wife and I were very much surprised at how much it costs and how many more hurdles one has to overcome to become a doctor in the US. Sure, we would like our brain surgeons and orthopedics to be trained extremely well. But we really don't need 8 years of schooling, 3-8 years of residency+fellowship training on top of many, many exams (Step 1, 2 CK, 2 CS, 3, state licenses) to become a competent doctor. After all, the doctors in the US have to follow the code/guidance set mostly by insurance companies to avoid being sued (meaning, they don't have a lot of leeway to use their intelligence in treating patients; they simply try to not get sued, so they would tell you to get tested on everything possible in order to avoid malpractice lawsuits later, which actually do happen much much higher than in other countries that I know of). The trust between doctors and patients is very, how do I say it, much impersonal and money based.
AMA, test prep companies (Kaplan, UWorld, AMBOSS), residency programs and everyone in the field are (either intentionally or unintentionally) making the bar to entry as high as possible (higher than necessary) to keep the number of doctors available low (my sister who lives in Rochester, NY cannot book a physician for annual check-up until May). India produces plenty of qualified doctors. So does my country (I'd say my country has produced so many doctors for Singapore, Australia and the US; they, like my wife, came to the US and AUS because they can make so much more money here). The field of medicine in the US is paved with money and has become very transactional (I pay you a lot, you'd better treat me and not mess up or else I'll sue you) and impersonal.
Both my wife and I were very much surprised at how much it costs and how many more hurdles one has to overcome to become a doctor in the US. Sure, we would like our brain surgeons and orthopedics to be trained extremely well. But we really don't need 8 years of schooling, 3-8 years of residency+fellowship training on top of many, many exams (Step 1, 2 CK, 2 CS, 3, state licenses) to become a competent doctor. After all, the doctors in the US have to follow the code/guidance set mostly by insurance companies to avoid being sued (meaning, they don't have a lot of leeway to use their intelligence in treating patients; they simply try to not get sued, so they would tell you to get tested on everything possible in order to avoid malpractice lawsuits later, which actually do happen much much higher than in other countries that I know of). The trust between doctors and patients is very, how do I say it, much impersonal and money based.
AMA, test prep companies (Kaplan, UWorld, AMBOSS), residency programs and everyone in the field are (either intentionally or unintentionally) making the bar to entry as high as possible (higher than necessary) to keep the number of doctors available low (my sister who lives in Rochester, NY cannot book a physician for annual check-up until May). India produces plenty of qualified doctors. So does my country (I'd say my country has produced so many doctors for Singapore, Australia and the US; they, like my wife, came to the US and AUS because they can make so much more money here). The field of medicine in the US is paved with money and has become very transactional (I pay you a lot, you'd better treat me and not mess up or else I'll sue you) and impersonal.
Up to a point I agree with you. I worked with an Indian guy that had been pushed into medicine by his parents and had moved to the US (with an arranged marriage) to escape their influence and quit being a doctor since he really disliked medicine. He had 2 years of secondary education then a residency. Every time I had a medical problem he was able to quickly and correctly diagnose it and tell me what I needed to do. He obviously wasn't able to prescribe anything to me here in the States, but when I went to my regular doctor they arrived at the same conclusion he had. Heck most PA's and NP's here have more medical education than him, but he could get the bulk of diagnoses correct. Why do we need so many physicians struggling under crippling debt to diagnose arm fractures, ear infections, and ring worm? Let the more exotic things trickle up to specialists instead.
How does that increase the supply of doctors, which is what's actually being discussed here?
If the medical system become more efficient, more money is freed to
1: increase doctor salaries so there can be more doctors and
2: develop things around doctors so their efficiency improves. (Hire assistants, write software, design better hospitals).
1: increase doctor salaries so there can be more doctors and
2: develop things around doctors so their efficiency improves. (Hire assistants, write software, design better hospitals).
I would be quite shocked if increasing the number of people who can go see a doctor, for free (or some incredibly reduced rate), somehow resulted in doctors working less.
>2: develop things around doctors so their efficiency improves. (Hire assistants, write software, design better hospitals).
As for this note, a doctors time is more valuable than basically all 3 of these. If you assume medical corporations desire making more money, then they would already be looking into this step. It's not something that would be improved by increasing the number of customers.
>2: develop things around doctors so their efficiency improves. (Hire assistants, write software, design better hospitals).
As for this note, a doctors time is more valuable than basically all 3 of these. If you assume medical corporations desire making more money, then they would already be looking into this step. It's not something that would be improved by increasing the number of customers.
I don't think your "for free" comment accurately reflects what happens in a country with federally provided insurance.
> I would be quite shocked if increasing the number of people who can go see a doctor, for free (or some incredibly reduced rate), somehow resulted in doctors working less.
Preventative care is far easier than complex "shit, you've got stage four cancer because you didn't get that lump checked out". For uninsured folks, ERs wind up functioning as primary care, which is immensely wasteful use of resources.
> If you assume medical corporations desire making more money, then they would already be looking into this step.
They are. Some hospitals hire scribes for doctors, for example.
Preventative care is far easier than complex "shit, you've got stage four cancer because you didn't get that lump checked out". For uninsured folks, ERs wind up functioning as primary care, which is immensely wasteful use of resources.
> If you assume medical corporations desire making more money, then they would already be looking into this step.
They are. Some hospitals hire scribes for doctors, for example.
I would guess that it reduces the workload of certain doctors (like ER/Urgent Care) if more people have access to preventative care. From what I've heard, being an internist isn't as well paying/sexy so fewer residents are going that direction which might be bad since there's where a lot of the workload would shift.
I was under the impression the lack of doctors is actually due to a lack of residency training spots.
Hospitals will pay their own money for residencies in specialties that are wildly profitable. Usually, some fancy types of surgeons. Primary care, endocrinology, rheumatology, and a lot of other needed specialists are not so the limited slots are whatever the government will pay for.
Yes, that is what I've heard. During Obama's presidency, they increased the number of medical schools or openings at the existing schools but did not increase the number of residency positions.
Is there data on this?
Another solution is allow more doctors to be licensed so they don't need to be as overworked.
The medical cartel will never allow that. They have a complete stranglehold on both licensing and education.
By "medical cartel" are you referring to the US Congress? Because the actual bottleneck in physician production is in the shortage of residency training slots, and the vast majority of those are funded by the Federal government. The American Medical Association has been lobbying for more residency slots. Every year students graduate from medical schools but are unable to practice medicine because they can't get matched to a residency program.
https://www.ama-assn.org/press-center/press-releases/ama-fun...
https://www.ama-assn.org/press-center/press-releases/ama-fun...
Why do we need the federal government to fund these slots at all? Hospitals work resident physicians to the bone and bill patients exorbitantly for it. Their hours are capped at 80 per week yet they receive no overtime pay[1]. Yes, the residents are "in training" but it's not like it's a burden for a hospital to take them on - they are the workhorses that handle a huge number of cases and drive hospital revenue.
[1] - https://en.wikipedia.org/wiki/Medical_resident_work_hours
[1] - https://en.wikipedia.org/wiki/Medical_resident_work_hours
Residents are closely supervised by another physician. So it's not just paying for the resident, it's paying for the supervisor as well. And early on, the supervisor is going to be combing through the details of each patient to make sure mistakes aren't made.
That plus the throughput of residents is going to be much lower than a trained physician.
As such, Medicare pays a "training institution" premium for all billing. It's a small bomb (5%?) but pays for the resident.
That plus the throughput of residents is going to be much lower than a trained physician.
As such, Medicare pays a "training institution" premium for all billing. It's a small bomb (5%?) but pays for the resident.
Why can't the resident sign a contract with the hospital promising to work there a certain number of years after finishing residency? That's what other industries with a training period do.
Most hospitals operate at a loss.
The ones that don't nickel and dime their patients, or even engage in outright billing fraud.
Do you really want to move more hospitals to the latter form of doing business? Because they would be a huge net loss for everyone except the hospital CEOs.
The ones that don't nickel and dime their patients, or even engage in outright billing fraud.
Do you really want to move more hospitals to the latter form of doing business? Because they would be a huge net loss for everyone except the hospital CEOs.
Do they truly operate at a loss, or do they operate at a loss in the same way Hollywood films never make money?
That's absolutely fascinating if so.
That's absolutely fascinating if so.
It's the latter. Whenever they would make money, they hike pay for senior administrators, of which there are a huge number (and maybe doctors and nurses too).
Given the medical costs in the US, this really begs the question: why?
To receive federal and state funding as well as accept residents hospitals have to run an ER and accept patients regardless of payment ability. Some facilities will do their best to help a patient that will be unable to pay. Others will simply stabilize the patient until they're not going to die immediately and then kick them out. Since medical care is very expensive a single non-covered ED patient could EASILY cost the hospital 250k+ per visit. For example maybe a homeless person is found and brought in unconscious. They're then discovered to have untreated diabetes, rot in their feet, and psychiatric issues. They'll be in the hospital for at least a week, surgery to clean up any rotten tissue, and then maybe a stay in the psych ER or other facility. Every day wracking up huge charges which the hospital will never be compensated for..except by spreading the loss around to others.
This looks like a crude version of socialised healthcare to me. Other socialised healthcare systems around the world should in theory face the same problem, wouldn't they? But AFAIK they do not nearly have the same cost issues as the US, at least I'm not aware of this here in Germany.
One theory I've heard that sounds plausible is that
a) insurers do not pay anywhere near what hospitals bill to uncovered patients
b) hospitals do not even expect patients to pay the whole bill, but more like 20% of it, so it is always good to contest the bill
So the problem is that hospitals are cash-strapped for systemic reasons, but can't get it from insurers or the state because those have contracts in place. So hospitals try to squeeze uninsured patients as much as they can with inflated bills, with predictably horrifying consequences. Insurers don't mind because that makes the case for buying insurance even stronger.
So one solution might be to pay for poor/homeless care via state/federal budgets. This could cover poor people up to an income level that can afford insurance.
One theory I've heard that sounds plausible is that
a) insurers do not pay anywhere near what hospitals bill to uncovered patients
b) hospitals do not even expect patients to pay the whole bill, but more like 20% of it, so it is always good to contest the bill
So the problem is that hospitals are cash-strapped for systemic reasons, but can't get it from insurers or the state because those have contracts in place. So hospitals try to squeeze uninsured patients as much as they can with inflated bills, with predictably horrifying consequences. Insurers don't mind because that makes the case for buying insurance even stronger.
So one solution might be to pay for poor/homeless care via state/federal budgets. This could cover poor people up to an income level that can afford insurance.
Most/many of the homeless that come in are eligible for Medicaid or other government benefits (veteran healthcare for instance). However figuring that out can be very difficult. Many of them are incapable or unwilling to give up their names or stay long enough for social workers to get their paperwork in order. Or they're afraid of being located (for example they have warrants out for their arrest). Then you have regular uninsured people who are simply incapable of paying that come in and give fake information.
Fun fact, if you're unable to pay the full amount most hospitals will do almost ANYTHING to stop from having to send your bill to collection. Even if you say 'I'll pay $50/month forever' thats way better than they'll get from the debt agency that buys your debt.
Fun fact, if you're unable to pay the full amount most hospitals will do almost ANYTHING to stop from having to send your bill to collection. Even if you say 'I'll pay $50/month forever' thats way better than they'll get from the debt agency that buys your debt.
Thanks for the explanation. Hospitals shouldn't be left alone with this, I can't imagine forwarding the costs to Medicaid would be a worse solution than the accountability problems that arise when having patients with no names, like fraud.
No hospital is going to pay for long tern psychiatric treatment unless it consists of pills during a short ER visit until social services can take over.
Many tech startups also operate at a loss. Plenty provide valuable services. Few have millions of dollars billables per workers, as doctors do. I wish the government would pay my junior engineers’ salaries.
Generally, any random doctor at a hospital provides valuable services.
I honestly can't name more than a handful of large or small startups that do anything remotely valuable. And the ones that do provide actual value don't operate at a loss...
I honestly can't name more than a handful of large or small startups that do anything remotely valuable. And the ones that do provide actual value don't operate at a loss...
Startups are experiments. Sometimes, you learn something really valuable in the process. Often, you don't.
Not doubting you (because I know that the mergers are happening a lot often these days, but could be partly because it's the natural conclusion of capitalism). Could you share any reference to the claim that most hospitals operate at a loss?
these are tough search terms to use with all the blogspam these days, but here is an article from a few years ago. huge losses in 2016 at least.
https://hbr.org/2017/10/how-u-s-hospitals-and-health-systems...
https://hbr.org/2017/10/how-u-s-hospitals-and-health-systems...
Similarly you have both prospective residents not matching into any program, but also programs having unmatched slots. These students then have a week to call around and try to get one of these slots, very often changing specialties in the process (usually to family medicine). Imagine spending $200k to go to college, get good enough grades for med school, get into med school, want to practice anesthesia or rheumatology or internal medicine only to not match and then have to choose between either waiting a year and trying again or going to the middle of nowhere Montana to a family medicine program.
Residency is a job and should be interviewed for and selected like any other job.
Residency is a job and should be interviewed for and selected like any other job.
Would changing the interview and selection process to look like other jobs alleviate the case you're laying out?
In a similar way, there are students who spend $200k to go to college, then go to law school, wanting to practice in a certain area of law, and find out at the end that the only job they can get is poorly paying or in an area they don't want to live.
In a similar way, there are students who spend $200k to go to college, then go to law school, wanting to practice in a certain area of law, and find out at the end that the only job they can get is poorly paying or in an area they don't want to live.
The difference is that even if you fail to get a job as a lawyer, you can start your own practice. With medicine if you cannot get residency first year, your chances of getting in drop significantly after that and you can never go out and practise medicine on your own.
Why is that a responsibility of the federal government? Why not the AMA? Of course they are lobbying for more spots, they want someone else to foot the bill. This seems like very short-term thinking. If Hospitals and practices paid for their own residencies, they could lower overall costs, and perhaps work on deals with people to encourage them to stay, etc.
I think it is because the government finds it valuable to have a well trained workforce to take care of its Medicare patients. Do you want physicians to pay for the opportunity to work for hospitals taking care of their patients?
Should the government pay me to study computer science? Should they pay for there to be more computer science training slots in universities? CS is also a valuable workforce, with massive shortages in the US. I don't really think the govt should pay for me to train, or pay to improve the number of educational spots.
At the same time, it does seem like medical internship conditions and pay are ridiculously terrible, underpaid, way overworked.
At the same time, it does seem like medical internship conditions and pay are ridiculously terrible, underpaid, way overworked.
PhD programs in CS are generally paid, largely by the government via orgs like the NSF. I think this a good thing; you would have many fewer PhD grads otherwise and I think they are generally an asset to the country and the companies they work for.
I don't see why they shouldn't fund more CS and STEM spots and universities in general. They will probably see a good return on investment. AFAIK higher education is subsidized in other countries but I'm not super knowledgeable about that.
On second thought maybe it would make sense to only subsidize the residency programs that are financially unsustainable but necessary, like family medicine or non-subspecialty internal medicine. Downside to this could be that hospitals could choose to not have residents and exacerbate the physician shortage.
On second thought maybe it would make sense to only subsidize the residency programs that are financially unsustainable but necessary, like family medicine or non-subspecialty internal medicine. Downside to this could be that hospitals could choose to not have residents and exacerbate the physician shortage.
[deleted]
I've from a country with free higher education and a living stipend, it seems to work pretty well. So I'd say yes, they should.
...
looks at the two grant proposals I'm on right now arguing for exactly that
looks at the two grant proposals I'm on right now arguing for exactly that
The AMA is the association of doctors. Why should they be responsible for paying for the training of more doctors?
If Hospitals and practices paid for their own residencies, they could lower overall costs, and perhaps work on deals with people to encourage them to stay, etc.
This is simply false. Paying for their own residencies would increase hospital costs since they don't currently pay for residency positions, and they're already free to work on deals to encourage residents to stay post-residency, including, for example, supplementing residents' pay.
If Hospitals and practices paid for their own residencies, they could lower overall costs, and perhaps work on deals with people to encourage them to stay, etc.
This is simply false. Paying for their own residencies would increase hospital costs since they don't currently pay for residency positions, and they're already free to work on deals to encourage residents to stay post-residency, including, for example, supplementing residents' pay.
>The AMA is the association of doctors. Why should they be responsible for paying for the training of more doctors?
Because an Association of Doctors with no Doctors to represent seems like a rather sad sight doesn't it?
Also, considering it is the main force behind setting the barrier to entry, it seems like a bad idea to cut them off from the consequences of the policies they push for by letting them off the hook in terms of not having a fundamental part to play in the training up of new medical talent.
Because an Association of Doctors with no Doctors to represent seems like a rather sad sight doesn't it?
Also, considering it is the main force behind setting the barrier to entry, it seems like a bad idea to cut them off from the consequences of the policies they push for by letting them off the hook in terms of not having a fundamental part to play in the training up of new medical talent.
Amazing how the rest of the developed world has none of these issues, no? And yet doctors are quite well-respected and high earners even in those countries.
Given the low resident pay, long line of graduates wanting a residency match, absurdly high Billings generated by residents, and AMA Boards supposedly willing (ahem) to train residents — I’d think this would be a solved problem.
It isn’t a solved problem because not all above is the case. The catch is that Boards will not train more than a few people in order to limit supply and keep wages up
Excuses like “oh the government won’t pay the resident” are shallow excuses — these are highly profitable (for the hospital) positions, not volunteer positions. They are self financing assuming the barriers to spots are removed.
It isn’t a solved problem because not all above is the case. The catch is that Boards will not train more than a few people in order to limit supply and keep wages up
Excuses like “oh the government won’t pay the resident” are shallow excuses — these are highly profitable (for the hospital) positions, not volunteer positions. They are self financing assuming the barriers to spots are removed.
The AMA is not without culpability, especially after they shut down medical schools in the 90s.
Non-matching graduates constitute a miniscule percentage, and almost none are from US medical schools. And something like 96% of them (cannot find the journal study at the moment) find physician work within 3 years of graduating.
Non-matching graduates constitute a miniscule percentage, and almost none are from US medical schools. And something like 96% of them (cannot find the journal study at the moment) find physician work within 3 years of graduating.
The way to do it is to tax hospitals.
Revenue or profit, who cares, but tax them and then spend the money on residencies.
Or just stop funding any residencies through Medicare and VA. Of course, that relies on the industry deciding to avoid the doctor shortage getting worse.
Revenue or profit, who cares, but tax them and then spend the money on residencies.
Or just stop funding any residencies through Medicare and VA. Of course, that relies on the industry deciding to avoid the doctor shortage getting worse.
As one of the most widespread high wage earners, doctors are probably the biggest dollar weighted constituency out there.
Why doesn't government intervene? Say, by handing out green cards on arrival to every doc from a certain list of "rich" countries, filling the void very quickly? Or even by making medical education a state monopoly and leave it up to the state to decide who to license?
The recent Indian government has been doing something loosely on these lines - drastically increasing the number of student capacity in public medical colleges [1]
[1] https://www.livemint.com/news/india/15-700-more-mbbs-seats-s...
[1] https://www.livemint.com/news/india/15-700-more-mbbs-seats-s...
You mean stop intervening.
The state is acting by not allowing the immigration of doctors and not recognizing education abroad
Why don't people protest? I mean, the U.S. is a democratic country and has a strong system designed to lobby for or against anything. Most people except docs themselves should be concerned with this, why is there no lobbying movement to change things? It should be a no-brainer to fund.
tutuca(1)
Is that from lowering educational requirements or from lowering standards?
Doctors, by way of Boards, limit supply as a way of keeping up wages. They are not overworked because of some lack of sufficiently interested individuals — they are overworked because few others are let into the club.
I love this in theory, but there's a lot of externalities that prevent that from happening. Apologies if I'm missing something, I'm a medical student (soon to be resident) that tries not to think about this too hard. I've thought to comment on this in the past, as this conversation pops up on HN relatively often.
I think we need a solution to two problems: First, figure out how to pay people (the hospital, the students/residents themselves, and the hospital attending physicians who spend their time teaching) to train physicians. Second, figure out how many clinical/surgical encounters a physician in training needs to truly be competent when they complete their training. This is more of a problem for surgeons, as they need x number of cases before they feel comfortable doing that procedure on their own.
For the first problem, there are smarter people than myself who pose solutions. CMS (and DHHS) pay for most of this in the US, and is a fixed amount each year with few changes since 1995. So an obvious solution without trashing our current system would be to just have Congress authorize more funding, about $100k/yr/new resident they are willing to pay for. Hospitals should also consider adding their own funding to pay for more residency spots, which is already happening. Note that hospitals bid on the hahnemann hospital (drexel) residents for about the $100k asking price ($55m for ~550 residents).
For the second, you have to decide how many years you want doctors to be training for, at their reduced salary. If you increase training time, you can achieve the clinical/surgical volume needed to become proficient, at the risk of keeping residents at the hospital for longer than they really want. You could seek out more volume at satellite clinics, but then you force the trainees to have to travel, which makes that specific training program less desirable (at least, it does for me)
Grossly over-simplified, I know.
I think we need a solution to two problems: First, figure out how to pay people (the hospital, the students/residents themselves, and the hospital attending physicians who spend their time teaching) to train physicians. Second, figure out how many clinical/surgical encounters a physician in training needs to truly be competent when they complete their training. This is more of a problem for surgeons, as they need x number of cases before they feel comfortable doing that procedure on their own.
For the first problem, there are smarter people than myself who pose solutions. CMS (and DHHS) pay for most of this in the US, and is a fixed amount each year with few changes since 1995. So an obvious solution without trashing our current system would be to just have Congress authorize more funding, about $100k/yr/new resident they are willing to pay for. Hospitals should also consider adding their own funding to pay for more residency spots, which is already happening. Note that hospitals bid on the hahnemann hospital (drexel) residents for about the $100k asking price ($55m for ~550 residents).
For the second, you have to decide how many years you want doctors to be training for, at their reduced salary. If you increase training time, you can achieve the clinical/surgical volume needed to become proficient, at the risk of keeping residents at the hospital for longer than they really want. You could seek out more volume at satellite clinics, but then you force the trainees to have to travel, which makes that specific training program less desirable (at least, it does for me)
Grossly over-simplified, I know.
> Second, figure out how many clinical/surgical encounters a physician in training needs to truly be competent when they complete their training.
This seems like the sort of thing that should be widely studied, but I can't find the terms to get nice Google Scholar results. In my field we do this sort of assessment for the users of (fairly low-risk) medical devices. It requires a team and is quite work-intensive to assess, but the stakes for insurance providers are high enough that this must already be known....
This seems like the sort of thing that should be widely studied, but I can't find the terms to get nice Google Scholar results. In my field we do this sort of assessment for the users of (fairly low-risk) medical devices. It requires a team and is quite work-intensive to assess, but the stakes for insurance providers are high enough that this must already be known....
The accrediting body for residency program sets minimum numbers for some procedures and clinical encounters
AAMC will never let this happen.
Having waited several months to get an appointment with a urologist in the PNW, I thought of a solution to this problem. Anytime the waiting time to see a practitioner of a particular specialty exceeds some predetermined time, the top marginal income tax rate for those who practice that specialty becomes 90% until the wait times are within the desired range of 2-4 weeks. It won't take long for the current practitioners to demand that schools produce more graduates. The artificial scarcity is bullshit and we shouldn't put up with it.
This is the most insane idea I’ve ever heard. That’s like taxing teachers for overcrowded classrooms to induce them to lobby teaching schools.
What a useless step. Why not just have these wait times (and other info) publicly available so people can look them up?
Doctors can decide to set up practices in the area in their own.
Patients can see and ask who’s the hold up is. Is the pay too low? Some crazy liability laws? Whatever.
With this publicly available, it’s much easier to compare service across the state/nation/world without having to be on the inside.
What a useless step. Why not just have these wait times (and other info) publicly available so people can look them up?
Doctors can decide to set up practices in the area in their own.
Patients can see and ask who’s the hold up is. Is the pay too low? Some crazy liability laws? Whatever.
With this publicly available, it’s much easier to compare service across the state/nation/world without having to be on the inside.
> That’s like taxing teachers for overcrowded classrooms to induce them to lobby teaching schools.
If the NEA restricted the number of teachers the same way the medical industry limits the number of doctors I'd say yes, this is a perfect analogy. Since they don't, then it's a bad analogy.
> Doctors can decide to set up practices in the area in their own.
Not sure about private practices, but hospitals can't just open up without the current hospitals in an area agreeing that it's under served.
> Patients can see and ask who’s the hold up is. Is the pay too low? Some crazy liability laws? Whatever.
> With this publicly available, it’s much easier to compare service across the state/nation/world without having to be on the inside.
If your city limited the number of auto mechanics and granted the guild of car repair persons control over who was allowed to become a mechanic and they only allowed one garage to open up in your town, you would correctly identify this as rent seeking behavior and not a market failure. The choices at that point would be to dissolve their monopoly on auto repair or to create conditions that would encourage their normal human behavior to attenuate the rent seeking. Do you really want to dissolve the AMA? Or would you rather encourage the AMA membership to change their behavior to not artificially limit the supply of doctors?
My solution doesn't give central orders about how to fix the problem, it simply creates a penalty when there is a problem. If the various practitioners realized they could be 20% more efficient while still maintaining quality that would be fine. Or they could create more practitioners. That would also be fine. The problem was created by the industry, the industry can fix the problem.
If the NEA restricted the number of teachers the same way the medical industry limits the number of doctors I'd say yes, this is a perfect analogy. Since they don't, then it's a bad analogy.
> Doctors can decide to set up practices in the area in their own.
Not sure about private practices, but hospitals can't just open up without the current hospitals in an area agreeing that it's under served.
> Patients can see and ask who’s the hold up is. Is the pay too low? Some crazy liability laws? Whatever.
> With this publicly available, it’s much easier to compare service across the state/nation/world without having to be on the inside.
If your city limited the number of auto mechanics and granted the guild of car repair persons control over who was allowed to become a mechanic and they only allowed one garage to open up in your town, you would correctly identify this as rent seeking behavior and not a market failure. The choices at that point would be to dissolve their monopoly on auto repair or to create conditions that would encourage their normal human behavior to attenuate the rent seeking. Do you really want to dissolve the AMA? Or would you rather encourage the AMA membership to change their behavior to not artificially limit the supply of doctors?
My solution doesn't give central orders about how to fix the problem, it simply creates a penalty when there is a problem. If the various practitioners realized they could be 20% more efficient while still maintaining quality that would be fine. Or they could create more practitioners. That would also be fine. The problem was created by the industry, the industry can fix the problem.
[deleted]
Your solution is to use punitive tax rates on people so they'll lobby the people who actually decide how many slots there are?
Really?
Really?
It's industry trade organizations that limit the number of slots at medical schools and residencies. A punitive tax on the members of the organization that has artificially limited the number of practitioners seems perfectly targeted.
Why wouldn't they respond by raising prices until they always have free spots available?
If you taxed 90% of the doctor's top marginal rate, wouldn't they just work long enough to get to that rate, then take the rest of the year off? You overestimate the lobbying power of doctors and underestimate how much suffering this would cause.
[deleted]
The real problem is the profit-driven hospitals that are overworking doctors. More doctors don’t mean hospitals suddenly employing more doctors.
Most hospitals are non-profits.
Only in name.
And tax status. And business structure. And decision-making. And liability. And every other measure that determines it.
If you can't differentiate between hospitals and the healthcare system, you should probably spend more time reading comments in this thread than writing them.
If you can't differentiate between hospitals and the healthcare system, you should probably spend more time reading comments in this thread than writing them.
Yes, that is how it is supposed to work, I am aware thank you.
I have 2 friends in their 40s who are primary care physicians at Kaiser (one in Bay Area, one in Sacramento). Both have dropped down to 60% time (3 days per week), explaining that 60% time is actually 40 hours. In the last few years Kaiser has added both EHR work and e-medicine work without reducing the number of appointment slots. So, it's about 7 hours per day of appointments and then catching up on all of the deferred paperwork and emails.
Kaiser a shit place to work at for any doctor. Classic standard american BigCorp stereotypes everywhere.
Kaiser is a shit place to work....until you compare them to the alternatives.
I know a number of doctors who love working for Kaiser after having worked in private practice or at other hospital chains.
I know a number of doctors who love working for Kaiser after having worked in private practice or at other hospital chains.
I've found a opposite experience. They seemed to like sutter the best, a bunch of others not bad and kaiser was so-so. It might be a case-by-case issue depending on the specialty.
But they still make 10x more than the average American.
Not true. A primary care physician at Kaiser makes a bit over $200K if they work full time AFAIK. Average American makes about $50K. Considering the 4 years of med school and 3 years of residency they are not overpaid. Specialists are the people making $500K+
$50K is household income.
Average income is more like $32K.
Average income is more like $32K.
Median full-time individual income is $48,000. (Weekly earnings of $923 from [1] times 52.). The mean is even higher.
[1] https://www.bls.gov/news.release/wkyeng.t01.htm
[1] https://www.bls.gov/news.release/wkyeng.t01.htm
Median personal income in 2018 was estimated to be $33.7k (https://fred.stlouisfed.org/series/MEPAINUSA672N).
And the BLS gives mean wages for family and general practitioner at $211,780 (https://www.bls.gov/ooh/healthcare/physicians-and-surgeons.h...).
Also, while I don't know about the competitiveness of jobs in certain locations, rural states can have some of the higher mean wages for fam and gen practioners (https://www.bls.gov/oes/current/oes291062.htm).
Also, while I don't know about the competitiveness of jobs in certain locations, rural states can have some of the higher mean wages for fam and gen practioners (https://www.bls.gov/oes/current/oes291062.htm).
[deleted]
Not that much. They have half a million dollar student loans; they pay thousands of dollars a month in malpractice. And doctoes are very overworked.
Its not that great of a profession.
Its not that great of a profession.
Then where is all this money going? Why does my health insurance cost $10,000/person of coverage, on top of deductibles and co-pays?
https://www.cms.gov/files/document/highlights.pdf
33% to hospitals
20% to physicians and clinical services
9% to retail prescription drugs
5% for other health, residential and personal care services
5% for nursing care facilities and continuing care retirement communities
4% for dental services
I can't find any clear answer to what proportion doctors earn themselves:
https://www.medicalbag.com/home/finance/health-care-costs-in...
33% to hospitals
20% to physicians and clinical services
9% to retail prescription drugs
5% for other health, residential and personal care services
5% for nursing care facilities and continuing care retirement communities
4% for dental services
I can't find any clear answer to what proportion doctors earn themselves:
https://www.medicalbag.com/home/finance/health-care-costs-in...
In addition, you pay for profit for the insurance companies
Mostly admin. You could make healthcare a lot cheaper with cheaper doctors though, but its not that great a racket
Primary care doc is making 10x 55k? Doubt it's even 5x
[deleted]
Not the person you replied to, but how is that relevant to the discussion?
But overtime I think doctors will earn more than software engineers. Also doctors are more valued the more senior they are, while software engineers not as much, need to move to management, ageism, etc.
Compared to what's on levels.fyi, most specialties will earn less than software engineers. Only cardiologists, gastroenterologists, radiologists, anesthesiologists, and the surgical specialties will have a chance at out earning someone at FAANG.
To be fair, levels.fyi is a very poor indicator of salary levels across the industry, whereas salary reporting on physicians isn't.
Median salary for physicians is almost certainly significantly higher than for software engineers, but it is less obvious what happens when you factor in length of career, debt load etc.
Neither group tend to work nominal (40h) weeks either...
Median salary for physicians is almost certainly significantly higher than for software engineers, but it is less obvious what happens when you factor in length of career, debt load etc.
Neither group tend to work nominal (40h) weeks either...
> most specialties will earn less than software engineers
Nah. The average salary of a software engineer is about $104k per year (remember, <10% of IT people work at FAANGs).
The average earnings of doctors according to Medscape is around $290k, and even primary care doctors earn $237k per year on average. [1]
> Only [1/10th of docs] will have a chance at out earning someone at FAANG.
And FAANG is a similarly small highly-paid fraction of the software workforce as well, so it is comparing like-for-like again. And average pay for those medical specialties according to [1] is $350k to $500k per year, which I bet beats the average pay of even FAANG individual contributors pretty handsomely...
[1]https://www.medscape.com/slideshow/2019-compensation-overvie...
Nah. The average salary of a software engineer is about $104k per year (remember, <10% of IT people work at FAANGs).
The average earnings of doctors according to Medscape is around $290k, and even primary care doctors earn $237k per year on average. [1]
> Only [1/10th of docs] will have a chance at out earning someone at FAANG.
And FAANG is a similarly small highly-paid fraction of the software workforce as well, so it is comparing like-for-like again. And average pay for those medical specialties according to [1] is $350k to $500k per year, which I bet beats the average pay of even FAANG individual contributors pretty handsomely...
[1]https://www.medscape.com/slideshow/2019-compensation-overvie...
Hmm interesting, I didn't know that
There are some specialties that are actively pretty poor financial decisions. Family Medicine and Infectious Diseases are two of them.
Ironically, since the field has become harder to get into recently - newer doctors are more likely to be better.
Physicians, not all doctors have the physician monopoly.
On average, doctors earn far more than software engineers. Only a small portion of software engineers can compete with doctors and it's clustered in a few select regions of the US.
I ran into the oncologist that took care of someone close to me in a social setting and we ended up talking for awhile. We were talking about getting ready for the holidays, etc and she expressed a fairly significant guilt about being absent for so many things. That's no wa to live.
It struck me as very sad, as I've heard similar things from other physicians.
It struck me as very sad, as I've heard similar things from other physicians.
On the other hand, a friend of mine is a dermatologist who works three 8-hour days for week and makes 200k+, one yeah after residency. In the end I still prefer doing what I'm doing, but it's not an obviously bad choice.
Meanwhile my dad is an ophthalmologist and at the age of 66 he is talking about how he wants to keep working full time until 70 and then half time after that. Some people are just made for the lifestyle of a physician I guess...
Ophthalmology is one of the "lifestyle" medical specializations - it doesn't have the high hours/stress of many of the other medical paths
I’m still not sure why most US medical schools want an undergraduate degree. I see lots of people trying to go pre-med doing research in the lab when we should really just cut out the middleman and have medachool admit straight out of high school or the military [in the USA not sure how other countries work]. This would really reduce the amount of time wasted of people that don’t want to go into research. Right now you can go to school for 4+2(MS degree) and make just as much [total comp] as a GP at FAANG+MSFT and get much, much better working hours.
Ideally we would increase the amount of Medicare residencies too. Then everyone could get a residencie and we would also be able to import MD from around the world.
Ideally we would increase the amount of Medicare residencies too. Then everyone could get a residencie and we would also be able to import MD from around the world.
I find this is a common refrain with any profession that regularly has to deal with insurance. I've seen it in medical, home repair and even long standing family auto shops.
The more layers get forced in between the people providing a service and the people receiving the service, the worse things seem to get.
The more layers get forced in between the people providing a service and the people receiving the service, the worse things seem to get.
But the flip side to tech is also ageism, which is a serious issue.
Maybe things will get better down the road, 20-30 years from now; But as it is now, a lot of the good paying companies will be very hesitant in hiring you once you're old enough.
Maybe things will get better down the road, 20-30 years from now; But as it is now, a lot of the good paying companies will be very hesitant in hiring you once you're old enough.
What is old enough? 30? 27? 25?
Completely depends on the company.
I'd say 35 - 45 is the period when age starts to become a question. With some young startups on the lower and, and more regular (but relatively young) companies on the upper end.
By the time you're 50, it becomes even more apparent. Hell, by then you're not even safe outside the tech-world - I've worked with good people (in their 50's) who were some of the first to get cut when recession / busts hit, and have struggled to find anything comparable ever since.
I'd say 35 - 45 is the period when age starts to become a question. With some young startups on the lower and, and more regular (but relatively young) companies on the upper end.
By the time you're 50, it becomes even more apparent. Hell, by then you're not even safe outside the tech-world - I've worked with good people (in their 50's) who were some of the first to get cut when recession / busts hit, and have struggled to find anything comparable ever since.
Here's a question I've always had: does it help if you try looking young? (e.g., be thin, dress stilishly, keep your teeth, skin, and hair in great condition, etc.) These things help in Hollywood. Do they help in Silicon Valley?
If so, I wonder what is the ROI of expertly done plastic surgery.
If so, I wonder what is the ROI of expertly done plastic surgery.
It's not that tough of a sell when you consider that many/most medical students are math-phobic and would most likely be unable to obtain a high-paying SWE gig in lieu of becoming a doctor.
There is a significant difference between the skillset that produces a medical student (work ethic and drive) and a SWE (analytical reasoning).
There is a significant difference between the skillset that produces a medical student (work ethic and drive) and a SWE (analytical reasoning).
That doesn't seem right to me. They have to get through chemistry and physics. They have to memorize a giant decision tree that they employee when evaluating people, questions to ask. They have to adjust that over time, then they get a speciality and they learn new things.
There's a difference in skill set that is developed over time, but doctors have to be able to have mental models of how bodies work, how things work in the body, "just like us".
There's a difference in skill set that is developed over time, but doctors have to be able to have mental models of how bodies work, how things work in the body, "just like us".
Please lobby the AMA to not artificially limit the supply of doctors by creating regulations around residency. I personally know of many people with MDs from India who don't work here as physicians because they could not get a residency 'slot' in the Bay Area where their family lives.
Relevant thread with links on StackExchange: https://skeptics.stackexchange.com/questions/4561/does-the-a...
The AMA isn't limiting the supply of doctors. The actual limit is in the number of residency program slots funded by the US Federal government. If you actually want to increase the supply of doctors then lobby Congress for higher residency funding.
https://www.ama-assn.org/press-center/press-releases/ama-fun...
https://www.ama-assn.org/press-center/press-releases/ama-fun...
The AMA backs the residency requirement. In my opinion it potentially gives doctors bad habits: Tolerating a miserable sleep schedule, placing too much value on quick diagnosis, equating long hours with effectiveness, and perhaps not placing enough value on teamwork with nurses.
jac241(2)
Apprenticeships in many (most?) fields are sponsored by the professional organization (akin to a guild) and paid for by laborers at lower-than-master wages. And yet, here is the AMA itself saying the problem lies with federal government funding. Curious. Seems like a convenient scapegoat.
I think you are significantly underestimating how much a medical residency costs.
Also, most apprentices end up working for/with the company/professional that trained them. I'm not sure there are many doctors who employ "apprentice/junior" doctors to work along side them the way a plumber/bricklayer/blacksmith/electrician would.
Also, most apprentices end up working for/with the company/professional that trained them. I'm not sure there are many doctors who employ "apprentice/junior" doctors to work along side them the way a plumber/bricklayer/blacksmith/electrician would.
[deleted]
This is propaganda by the AMA. They are the primary lobbying force on this issue to Congress and they help write most of the legislation. The AMA is the negotiating partner you'd deal with to get this issue corrected.
It sounds like AMA is working against the interest of Doctors. Sure they make more money, but they have a shitty quality of life.
The doctors they're probably working in the interests of are no longer residents. It'd be altruism to make prospective life better for prospective doctors.
Nice of them to change their minds after lobbying for that rule in the first place.
https://www.washingtonexaminer.com/thanks-to-doctors-there-a...
https://www.washingtonexaminer.com/thanks-to-doctors-there-a...
That's a common misconception quoted by the medical cartel (i.e. MDs), among other ones such as "we should pay doctors 3x the amount Europeans get[1] because they study and burn out so much", which is a self-imposed problem. Congress funding for residency slots is a small part of the puzzle. The larger issues is the medical cartel making it so expensive to go through residency in the first place through excessive requirements. Here's an incomplete list of anti-competitive behaviors of medical cartel that push healthcare prices up in the US:
1. Restricting scope of practice for NPs and other midlevels
2. Restricting new facilities through Certificates of Need
3. Restricting immigration of foreign medical professionals from OECD countries through NCFMEA
4. Increasing costs & duration of medical education
5. Restricting patient's ability to obtain their open record digitally with the purpose of switching providers, or taking control of their health (good luck getting your imaging data from Kaiser if you ever want to leave them and seek better alternatives)
6. Restricting OTC availability of simple drugs available without doctor middlemen in other OECD countries
7. Restricting development of AI systems through data BAAs
8. Restricting scope and speed of processing for de novo and breakthru devices that automate work performed by physicians
None of these have a valid patient safety counter-argument because essentially in every case there is a precedent of safe operation in other OECD countries.
Other honorable mentions include:
1. Fighting against surprise billing legislation
2. Fighting against government's ability to negotiate rates
3. Fighting against public option
4. Fighting against any mention of moving away from fee-for-service
[1] https://www.medscape.com/slideshow/2019-international-compen...
1. Restricting scope of practice for NPs and other midlevels
2. Restricting new facilities through Certificates of Need
3. Restricting immigration of foreign medical professionals from OECD countries through NCFMEA
4. Increasing costs & duration of medical education
5. Restricting patient's ability to obtain their open record digitally with the purpose of switching providers, or taking control of their health (good luck getting your imaging data from Kaiser if you ever want to leave them and seek better alternatives)
6. Restricting OTC availability of simple drugs available without doctor middlemen in other OECD countries
7. Restricting development of AI systems through data BAAs
8. Restricting scope and speed of processing for de novo and breakthru devices that automate work performed by physicians
None of these have a valid patient safety counter-argument because essentially in every case there is a precedent of safe operation in other OECD countries.
Other honorable mentions include:
1. Fighting against surprise billing legislation
2. Fighting against government's ability to negotiate rates
3. Fighting against public option
4. Fighting against any mention of moving away from fee-for-service
[1] https://www.medscape.com/slideshow/2019-international-compen...
to be fair, there are very few residency spots in the bay area in any specialty anyway. My wife went through the residency match program last year and the bay area programs are ultra competitive because it is a desireable place to live. Adding more residency slots is a good idea, but they're going to be spread across the US.
Dean Baker has been arguing against this medical protectionism for years. Also as a factor why costs are so high.
People underestimate how much of a problem is... There are so many qualified MDs who are underutilized or unable to go into the residency that they'd be most productive in simply because the supply of programs is kept artificially low
My wife just graduated medical school and started residency.
The burn-out affected both of us and we're just starting to get over it.
* Med school is a freaking grind. She was either at class, at rotations, or studying. Pretty much 80+ hours/week for 4 years.
* We had to move a lot, which has limited my social life. Ended up spending a lot of time just "working" while she'd study in the evenings.
* Major life impacting tests nearly every year. Low scores or failures on a single exam can kill any career aspirations.
* Insane debt load. We're looking at total payback costs around $310k. That was with no undergrad debt and my job paying for all living expenses. If you don't become an attending, you're fucked financially.
* Not enough residency spots for the number of medical schools. Less than 80% of candidates matched into a residency spot. Follow on matching is very low.
* That's right, pretty much 1 in 5 doctors will not go on to practice medicine because they cannot get a residency position.
* Residency salaries are complete shit. It's not unheard of for residents to have to take out loans to payback loans during residency.
* Resident have absolutely no leverage. They are literally slaves to the program they're "matched" to. Program director changes, hospital gets bought out, peers are insufferable - sucks to be you, you're stuck until you graduate.
* Financially being a doctor doesn't make any sense. Everyone looks at doctor's salaries, but completely forgets about the 8 to 10 years doctors (a) make nothing (b) pay for education (c) make pennies. Even with the "doctor salaries", it will take my wife well into our 50's to be financially ahead had simply pursued a career in her STEM field. There's a lot of life that can be live in 30 years that a "big house and a fancy car" doesn't make up for.
* Mid-levels and lesser credentialed, like PA's and NP's, providers are being allowed to take on more and more responsibility. For medicine overall, I think this is the right direction. I believe technology means mid-levels can function at a much higher level than in the past. For physicians, it sucks because it's killing any financial incentives.
I could rant for hours about all of the bullshit my wife went through (and, lesser myself). If you're thinking of becoming a doctor, do yourself a favor and do something else.
If you really want to work in medicine, becoming an NP or PA is a looking like an increasingly attractive route.
The burn-out affected both of us and we're just starting to get over it.
* Med school is a freaking grind. She was either at class, at rotations, or studying. Pretty much 80+ hours/week for 4 years.
* We had to move a lot, which has limited my social life. Ended up spending a lot of time just "working" while she'd study in the evenings.
* Major life impacting tests nearly every year. Low scores or failures on a single exam can kill any career aspirations.
* Insane debt load. We're looking at total payback costs around $310k. That was with no undergrad debt and my job paying for all living expenses. If you don't become an attending, you're fucked financially.
* Not enough residency spots for the number of medical schools. Less than 80% of candidates matched into a residency spot. Follow on matching is very low.
* That's right, pretty much 1 in 5 doctors will not go on to practice medicine because they cannot get a residency position.
* Residency salaries are complete shit. It's not unheard of for residents to have to take out loans to payback loans during residency.
* Resident have absolutely no leverage. They are literally slaves to the program they're "matched" to. Program director changes, hospital gets bought out, peers are insufferable - sucks to be you, you're stuck until you graduate.
* Financially being a doctor doesn't make any sense. Everyone looks at doctor's salaries, but completely forgets about the 8 to 10 years doctors (a) make nothing (b) pay for education (c) make pennies. Even with the "doctor salaries", it will take my wife well into our 50's to be financially ahead had simply pursued a career in her STEM field. There's a lot of life that can be live in 30 years that a "big house and a fancy car" doesn't make up for.
* Mid-levels and lesser credentialed, like PA's and NP's, providers are being allowed to take on more and more responsibility. For medicine overall, I think this is the right direction. I believe technology means mid-levels can function at a much higher level than in the past. For physicians, it sucks because it's killing any financial incentives.
I could rant for hours about all of the bullshit my wife went through (and, lesser myself). If you're thinking of becoming a doctor, do yourself a favor and do something else.
If you really want to work in medicine, becoming an NP or PA is a looking like an increasingly attractive route.
Thank you so much for posting this. If you rant on about this for hours in this thread, I for one would be interested.
I have a feeling that your observation that, "Mid-levels and lesser credentialed, like PA's and NP's, providers are being allowed to take on more and more responsibility. For medicine overall, I think this is the right direction. I believe technology means mid-levels can function at a much higher level than in the past. For physicians, it sucks because it's killing any financial incentives." is dead on.
Further I think the technology side really has to start servicing the physician. A GP's office doesn't have to be the place to get an ECG, and a GP doesn't even necessarily have to see the readout barring some kind of change over time. So much of that should be automated and/or done in specialized clinics. I know how it's complicated by data format standardization, privacy, security, and regulation but it's a shame that we can help doctors be more efficient. I will spare the rant about slightly (and slighty justified if I'm being fair) Luddite tendencies among physicians.
I have a feeling that your observation that, "Mid-levels and lesser credentialed, like PA's and NP's, providers are being allowed to take on more and more responsibility. For medicine overall, I think this is the right direction. I believe technology means mid-levels can function at a much higher level than in the past. For physicians, it sucks because it's killing any financial incentives." is dead on.
Further I think the technology side really has to start servicing the physician. A GP's office doesn't have to be the place to get an ECG, and a GP doesn't even necessarily have to see the readout barring some kind of change over time. So much of that should be automated and/or done in specialized clinics. I know how it's complicated by data format standardization, privacy, security, and regulation but it's a shame that we can help doctors be more efficient. I will spare the rant about slightly (and slighty justified if I'm being fair) Luddite tendencies among physicians.
Speaking as someone who quit after medical school and codes professionally (going on 10 years), I'd suggest temperance on the recommendation. Debt is high but so is salary, if they are in it for the long haul they'll be just fine. If you think you want to be a physician, shadow some. If you like what they do, you might like being a physician. I met many doctors who I think would be happier not being a physician, but also many that I think wouldn't be happy doing anything else. I'm happy with my decision overall but frankly i couldn't imagine going back as an NP, PA, Dentist... or anything in the field that wasn't an MD. Those all have much better work life balance, but you need to realistically understand what it means to do each if you want to be happy, and select the one that feels right. (And if it doesn't feel right, Dentistry has the absolute best work life balance, pay, and ability to help people who legitimately need it).
> Debt is high but so is salary, if they are in it for the long haul they'll be just fine.
This is exactly why I recommend against medicine. You have to be in it for the long haul. If you find you hate medicine in your 3rd year (when rotations typically start), you're already $100k in debt.
This is exactly why I recommend against medicine. You have to be in it for the long haul. If you find you hate medicine in your 3rd year (when rotations typically start), you're already $100k in debt.
Hi, do you have an email I could reach you/your wife at? I'd like to include what you wrote above in a post on my career website (http://www.kareerday.com), with your permission, as well as ask you/her about her job.
FYI: posts on the site are anonymous.
If you'd prefer not posting your email here, you can reach me at [email protected]
FYI: posts on the site are anonymous.
If you'd prefer not posting your email here, you can reach me at [email protected]
My wife just got her NP. After her BSN an MSN/NP she has like $200k in debt. Last year was really busy with her training schedule plus school plus life with kids. From where I'm standing our picture isn't a whole lot rosier than yours.
I was interested in medicine in high school. I was able to shadow a few physicians and talk about career options. At the time I was shocked that most of the physicians I talked to said they would take a different career path if they could do it over again.
The common theme was that they felt it used to be a respected profession but now they’re broadly just cogs in a healthcare system that given them little freedom for professional discretion and lots of paperwork.
I ultimately didn’t pursue medicine.
The common theme was that they felt it used to be a respected profession but now they’re broadly just cogs in a healthcare system that given them little freedom for professional discretion and lots of paperwork.
I ultimately didn’t pursue medicine.
I would like to see the data sliced by employed vs independent physicians.
Independents (a majority of physicians) need to deal with all the billing and insurance headaches that now come with the industry, and have to deal with setting up their own EHR to deal with it.
Employed physicians in an integrated health system and plan (like Kaiser or Geisinger), in theory don't have to deal with those aspects as much, and can concentrate more on the patient.
Would be good to see if there is a correlation there.
Independents (a majority of physicians) need to deal with all the billing and insurance headaches that now come with the industry, and have to deal with setting up their own EHR to deal with it.
Employed physicians in an integrated health system and plan (like Kaiser or Geisinger), in theory don't have to deal with those aspects as much, and can concentrate more on the patient.
Would be good to see if there is a correlation there.
>Employed physicians in an integrated health system and plan (like Kaiser or Geisinger), in theory don't have to deal with those aspects as much, and can concentrate more on the patient.
"Employed" physicians no longer deal with patients, they are called customers. Helps to keep customers happy and physicians focused on the profit motive.
"Employed" physicians no longer deal with patients, they are called customers. Helps to keep customers happy and physicians focused on the profit motive.
Wouldn't the profit motive be stronger for an independent physician since they actually directly profit, rather than facing indirect pressure based on your employer's profit motive?
Independent physicians are free to act as they see fit, some are very profit motivated, some aren't.
Employed physicians are pushed to be as profit motivated as their employer wants them to be, or they get canned.
Employed physicians are pushed to be as profit motivated as their employer wants them to be, or they get canned.
> Independents (a majority of physicians)...
Is this still true?
It seems like the days of the independent physician are drawing to a close. Many independent practices have become physician groups which in turn have been bought by hospitals. (Perhaps specialists are still largely independent, but general outpatient medicine seems to have become largely corporate.)
Many physicians I know have a boss, and have to meet metrics about how many patients they see ever year in order to get their incentive bonus. Physicians who work for hospitals are viewed as "loss leaders", and find their appointment times squeezed to twenty, fifteen, or even twelve minutes per patient. (The idea is that for every n visits, a patient will be referred to a profitable service provided by the hospital.)
Is this still true?
It seems like the days of the independent physician are drawing to a close. Many independent practices have become physician groups which in turn have been bought by hospitals. (Perhaps specialists are still largely independent, but general outpatient medicine seems to have become largely corporate.)
Many physicians I know have a boss, and have to meet metrics about how many patients they see ever year in order to get their incentive bonus. Physicians who work for hospitals are viewed as "loss leaders", and find their appointment times squeezed to twenty, fifteen, or even twelve minutes per patient. (The idea is that for every n visits, a patient will be referred to a profitable service provided by the hospital.)
You can't be independent anymore and bear the cost of electronic records, so the options are to stop accepting insurance (cash only) or join a large practice, usually run by, or at least associated with, a hospital, for access to their records system.
Every physician deals with billing and insurance. EHR setup is trivial compared to the daily burden of using it.
Independents likely have it easier as their EMR are less complex and they have fewer people to coordinate with.
EMRs in general have little to do with patient care. They are glorified billing systems.
Independents likely have it easier as their EMR are less complex and they have fewer people to coordinate with.
EMRs in general have little to do with patient care. They are glorified billing systems.
This would be interesting to see.
I know it's only anecdotal but my brother in law is a doctor at a large hospital (employed physician) and he sees patients 9-5 but he's at the hospital from 7am-8pm doing prep, research and patient notes. That also doesn't count the nights/weekends when he's on call for the ER (usually takes calls from home but occasionally has to go in too). He basically only sees his kids on the weekend.
I worked similar hours for a few years while coding and I expect he will (but hope he doesn't) burn out eventually. It's obviously not sustainable.
I know it's only anecdotal but my brother in law is a doctor at a large hospital (employed physician) and he sees patients 9-5 but he's at the hospital from 7am-8pm doing prep, research and patient notes. That also doesn't count the nights/weekends when he's on call for the ER (usually takes calls from home but occasionally has to go in too). He basically only sees his kids on the weekend.
I worked similar hours for a few years while coding and I expect he will (but hope he doesn't) burn out eventually. It's obviously not sustainable.
On the other hand employed physicians in an integrated health system have to deal with their bosses and lack control over their working conditions.
Hey, welcome to the working world of the rest of us. If this is the complaint, doesn't seem worthy of a WSJ article.
I realize from the comments here that I wasn't as clear as I intended. I conflated "employed" with "employed in an integrated system with a health plan." Having an integrated insurance plan run by the provider in theory aligns incentives to keep patients healthy rather than fight over billing.
Here's the full report: https://www.medscape.com/slideshow/2020-lifestyle-burnout-60...
Strangely, this "report" is a set of slides. It would have been useful if there was more information about how the Medscape authors conducted this study. On slide 28, it says the sampling size was "15,181 physicians across 29+ specialties met the screening criteria and completed the survey". What was the screening criteria and how many physicians did Medscape initially reach out?
I wish the WSJ asked these types of questions.
Strangely, this "report" is a set of slides. It would have been useful if there was more information about how the Medscape authors conducted this study. On slide 28, it says the sampling size was "15,181 physicians across 29+ specialties met the screening criteria and completed the survey". What was the screening criteria and how many physicians did Medscape initially reach out?
I wish the WSJ asked these types of questions.
I'm sure this isn't the case for every doctor, but what I've observed is that scale seems to be killing everything. When you have 10 minutes with a patient, have no long-term relationship, ship them off to a specialist that has even less context of their overall health, and ultimately just prescribe them meds to treat a symptom, that person does not get healthier. Over thousands of patients that starts to challenge any sense of moral obligation you originally had when entering the field. Then you become disillusioned and burn out.
The irony is the part about everyone becoming less healthy. That creates more demand for medical services. Rinse, repeat. We truly have the worst system imaginable in the US. It evolved over time. It's nobody's fault. It's everybody's fault. It needs to be burned down and rebuilt. It seemed like we had a chance with the ACA but it was pretty clear early on that it wouldn't fix the root causes and it hasn't.
The irony is the part about everyone becoming less healthy. That creates more demand for medical services. Rinse, repeat. We truly have the worst system imaginable in the US. It evolved over time. It's nobody's fault. It's everybody's fault. It needs to be burned down and rebuilt. It seemed like we had a chance with the ACA but it was pretty clear early on that it wouldn't fix the root causes and it hasn't.
There’s a few doctors in my city who charge a $50 a month fee for a 30-39 year old and you can call and see them whenever. Insurance doesn’t cover it at all. I’d also imagine if you tried to really abuse the relationship and show up constantly for no reason the doctor might fire you. I feel like it’d encourage a relationship of respect both ways.
I interviewed a couple of them and one talked to me for an hour about health and diet and exercise, just a friendly chat to see if I wanted to use him. He said he was getting ready to retire from medicine after years of ER work when his doctor friend encouraged him to try direct primary care. It was so different than the regular medical system, cutting out all the middle men.
I interviewed a couple of them and one talked to me for an hour about health and diet and exercise, just a friendly chat to see if I wanted to use him. He said he was getting ready to retire from medicine after years of ER work when his doctor friend encouraged him to try direct primary care. It was so different than the regular medical system, cutting out all the middle men.
My parents have a concierge medicine relationship with their physician. It's fantastic. He is a complete professional who cares deeply about all of his patients (he works nights and weekends, does research outside of business hours, works around insurance and exploits every legal loophole possible to help them) but holy crap is it expensive. They are paying for their normal insurance plus this service ($3000 annually). This is what it's come to in the US---to be able to have a semblance of a relationship with your physician you need to pay a premium on top of the gouging that your "insurance" already charges you.
Note: My parents are not* rich, they scrape by on social security and my dads part time work fixing sprinkler systems.
Note: My parents are not* rich, they scrape by on social security and my dads part time work fixing sprinkler systems.
"I’d also imagine if you tried to really abuse the relationship and show up constantly for no reason the doctor might fire you." My worry with something like this would be the doctor firing me as a patient as soon as I became unprofitable for any reason. Sure if the doctor is good you'll be fine, but how can you really know until you need to know?
Is this in the US? I would think that US malpractice laws, and the corresponding malpractice insurance costs, make this impractical.
I have a friend here in U.S. who runs their practice like this. They don't make any money at all at this kind of price. They should be charing each patient more like USD 200 per month.
> When you have 10 minutes with a patient, have no long-term relationship, ship them off to a specialist that has even less context of their overall health[...]
If you see the same primary care physician and the same specialists (or is it just a random specialist in the US?), wouldn't that establish a long-term relationship with each? Plus your medical file should give any of them more context on your preconditions, history and general health.
(That's the case here in Israel and -- after googling -- the US too, but feel free to correct me)
If you see the same primary care physician and the same specialists (or is it just a random specialist in the US?), wouldn't that establish a long-term relationship with each? Plus your medical file should give any of them more context on your preconditions, history and general health.
(That's the case here in Israel and -- after googling -- the US too, but feel free to correct me)
Physician practices get absorbed by large national corporations and patient care gets reduced to metrics that administrators can tweak to extract more revenue and profit. The benefits get paid to administrators as bonuses, while physicians see their salaries stagnate.
The corporitization of physician practices is destroying the profession.
The corporitization of physician practices is destroying the profession.
The country also wants more supply of healthcare, at lower prices, while the supply of doctors remains constrained via the restriction on number of residency training spots each year. This is the root cause, insufficient supply in the face of demand, and it is manifesting itself in these various side effects.
This is incorrect. There is no supply/demand relationship for pricing services. Doubling the number of trained physicians will not decrease healthcare costs, it will simply drive down physician annual income.
The main driver of inflated healthcare costs is administrative waste: hospital management, insurance management, government management.
The main driver of inflated healthcare costs is administrative waste: hospital management, insurance management, government management.
> patient care gets reduced to metrics that administrators can tweak
So they’re applying “agile project management” then?
So they’re applying “agile project management” then?
The takeover of real jobs by bullshit jobs
Does this indicate that more physicians are needed in the market, or that current system/workflow is unsustainable?
Remember the AMA successfully lobbied to reduce the number of residencies and thus the number of doctors in the 90s.
We need to open up the medical profession to competition and allow the # of doctors to meet the demand.
We need to open up the medical profession to competition and allow the # of doctors to meet the demand.
This! It's crazy how infrequently the stranglehold the AMA has on limiting the number of doctors is mentioned when we talk about the cost of medical care in the US. It's like we allow a single institution to create an artificial shortage of something and then act surprised when the cost of that thing goes through the roof.
Well, here's a couple of points. Ultimately, the decision of how many residency slots to fund comes down to Congress. Here's an older article that discuss how the cost of residency slots is covered, but it's essentially covered by Medicare:
https://economix.blogs.nytimes.com/2013/12/17/how-medicare-s...
Now, hospitals could just fund additional slots directly, but they don't. That's a problem as well. Over the years, there have been several bills introduced to increase this number. Here's an article about efforts in 2013 and 2015:
https://www.the-hospitalist.org/hospitalist/article/122261/h...
Here's another one for this year:
https://www.aha.org/news/headline/2019-03-14-bill-add-15000-...
Generally speaking, they don't pass for a variety of reasons of which the AMA is only one.
I think it helps to understand that there's a large, complicated system that depends on this artificial supply limit and dismantling only a single section would not fix the rest. Universities make a huge amount of money with the tuition they charge medical students, which is much higher than for other degrees. They can charge this knowing that these students can absorb the debt using their future earnings, which are dependent on this limited supply. Mortgage companies have special home loans for physicians because they know this artificial supply and nature of physician contracts means that their money is nearly guaranteed. I could go on, but there many, many industries that depend on this system.
Again, I don't agree with this, but I think it helps to understand that it's not just the AMA who has a vested interest in keeping the status quo. Every industry who benefits from this system has interest in keeping it the same and actively lobby for it. Further, fixing this shortage problem necessarily means finding fixes for all of the other industries that depend on this money.
On top of this, even if we eliminate the soft cap on residency slots, it's not necessarily going to fix the problem with supply. The primary issue isn't lack of physicians, it's lack of family medicine physicians who want to work outside of large markets. While it depends on specialty, big markets like D.C., Seattle, and Denver can be very, very difficult for a physician to find a job. In fact, I know many physicians who live in these cities and then work remotely a week or two a month in a small town in a different state doing locums. They're paid a premium for such work and they enjoy it, but they'd never want to live in these places. Unless you want to force physicians to work in these markets, that problem doesn't change.
https://economix.blogs.nytimes.com/2013/12/17/how-medicare-s...
Now, hospitals could just fund additional slots directly, but they don't. That's a problem as well. Over the years, there have been several bills introduced to increase this number. Here's an article about efforts in 2013 and 2015:
https://www.the-hospitalist.org/hospitalist/article/122261/h...
Here's another one for this year:
https://www.aha.org/news/headline/2019-03-14-bill-add-15000-...
Generally speaking, they don't pass for a variety of reasons of which the AMA is only one.
I think it helps to understand that there's a large, complicated system that depends on this artificial supply limit and dismantling only a single section would not fix the rest. Universities make a huge amount of money with the tuition they charge medical students, which is much higher than for other degrees. They can charge this knowing that these students can absorb the debt using their future earnings, which are dependent on this limited supply. Mortgage companies have special home loans for physicians because they know this artificial supply and nature of physician contracts means that their money is nearly guaranteed. I could go on, but there many, many industries that depend on this system.
Again, I don't agree with this, but I think it helps to understand that it's not just the AMA who has a vested interest in keeping the status quo. Every industry who benefits from this system has interest in keeping it the same and actively lobby for it. Further, fixing this shortage problem necessarily means finding fixes for all of the other industries that depend on this money.
On top of this, even if we eliminate the soft cap on residency slots, it's not necessarily going to fix the problem with supply. The primary issue isn't lack of physicians, it's lack of family medicine physicians who want to work outside of large markets. While it depends on specialty, big markets like D.C., Seattle, and Denver can be very, very difficult for a physician to find a job. In fact, I know many physicians who live in these cities and then work remotely a week or two a month in a small town in a different state doing locums. They're paid a premium for such work and they enjoy it, but they'd never want to live in these places. Unless you want to force physicians to work in these markets, that problem doesn't change.
To be fair to the AMA, they submitted a support letter for the 2019 bill - https://www.ama-assn.org/education/gme-funding/how-gme-fundi... . Do you have evidence of them arguing against the 2013, 2015, or 2017 versions?
I'm sorry. I am incorrect and it was more a comment based on the lobbying efforts during the 1990s when the AMA lobbied for the cap. Thanks for the clarification.
I think this is the key, so much of of the problems physicians face were created by physician and their own lobbying. American Physicians are paid more then other countries by a lot [1] in large part because of high educational requirements that were supported by physicians. Resident burn out is awful, but the people pushing them to work insane hours aren't the hospital administrators, but older physicians who have the attitude that they went through it too. It's really hard for a physician from another country to immigrate to the US and practice, restrictions supported by, you guessed it, physicians!
If you really want to lower physician burn out and decrease health costs we need to increase the supply of physicians in this country, and you'll have to fight the existing physicians to do it.
[1] https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2010....
If you really want to lower physician burn out and decrease health costs we need to increase the supply of physicians in this country, and you'll have to fight the existing physicians to do it.
[1] https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2010....
American software developers also get paid multiples of their non-us counterparts. Same with many other professions.
As mentioned it's way easier for software developers to immigrate to the US, and there is no organization limiting the number of software engineers trained into the profession every year. There is an additional confounder in that the biggest and highest paying software companies are all located in the US and exporting products throughout the world, which is not how it works with physicians.
Except there is no organization limiting the number of software developers. In fact, I can't think of another field out there with so many free resources for one to educate and prove themselves a capable programmer.
Nurses make more in the us, then most doctors outside the us. There is a shortage of people in general in the usa, and we have the INS artificially limiting immigration for everyone.
Also don’t forget about resistance to becoming employees, but then complaining about the protections/advantages afforded to employees.
While the AMA is guilty of limiting the number of doctors before, they have reversed their position are are now actively lobbying for more funding of residency slots.
https://www.ama-assn.org/press-center/press-releases/ama-fun...
https://www.ama-assn.org/press-center/press-releases/ama-fun...
Yep, everyone seems to ignore that the AMA operates like a cartel. Hippocratic Oath my ass.
An analysis of the Hippocratic Oath and its application in the modern day will turn up the same results as any other ethical standard. Selectively applied on criteria that would rarely be tolerated if openly stated, requiring unstated assumptions to avoid internal contradiction, and powerless to change human behavior as those who commit to upholding it will do so only for interpretations in their own image. While I do admit my view of ethics as a whole is quite cynical, I think one only needs to consider how many ethically bound actors have caused significant harm with unquestionably wrong actions to see that such cynicism has solid foundations.
In short, we should treat doctors no different than any other human in regards to how they operate and how to protect society from bad actors. One practical example is that doctors should follow the same rules and others with regards to child safety such as ensure a child is always accompanied by two unrelated adults and that patients and their parents should be willing to seek second opinions on anything a doctor does that they do not feel comfortable with.
As for the issue at hand, we should not assume doctors will behave more benevolently than any other industry with regards to self regulation and rent seeking(-esque) behavior.
Also to clarify, there are many selfish doctors who do their best to help others. I'm not questioning our doubting that. I'm speaking of groups in general and not of every single member.
In short, we should treat doctors no different than any other human in regards to how they operate and how to protect society from bad actors. One practical example is that doctors should follow the same rules and others with regards to child safety such as ensure a child is always accompanied by two unrelated adults and that patients and their parents should be willing to seek second opinions on anything a doctor does that they do not feel comfortable with.
As for the issue at hand, we should not assume doctors will behave more benevolently than any other industry with regards to self regulation and rent seeking(-esque) behavior.
Also to clarify, there are many selfish doctors who do their best to help others. I'm not questioning our doubting that. I'm speaking of groups in general and not of every single member.
I've been working in the field (software side) for a while and it is a little bit complicated. Some medical procedures absolutely require constant practice to maintain a very high level of quality and safety. Others don't. If you grow the number of residents by 10x, the total number of cases won't follow and you can end up with a more dangerous situation overall as every physician will be less qualified by virtue of practising less. That varies by specialty.
There is also the money. Sure you can train 10-100x physicians, but total compensation won't grow as fast, and so you should see lower overall wages (supply and demand). But it's still more complicated than that, because some people choose not to undergo X or Y procedure for various reasons, insurers don't cover or whatever. So even if you could train enough doctors to fulfil the whole population's needs, that doesn't mean you will have: 1. enough equipment, material, operating rooms, etc to do the procedures 2. enough supporting staff, and on and on.
The most common reason I hear from MDs against training much more doctors is the first one I gave you: less practice means a more dangerous practice.
My own opinion is relatively simple. Medical schools should stop screening applicants as much and let students join freely.
Medical schools are all about getting well-rounded individuals who did extra-curriculars etc. They usually view it as a good thing that you have life experiences outside of medicine, like working or studying an entirely different subject. However it works one-way: you can't (generally) just go to med school, learn the subject matter and then move on to another field, enriching _that_ one with your experience. I have come to believe that if we are to see any improvement, med school will have to open up just like every other discipline. The current system of stressing out students for a few years before even being allowed in the classroom is, IMO, partly responsible for the job dissatisfaction that you see.
Now freeing up med school admissions does not mean allowing everybody to _practice_ medicine. Prospective students would actually get a chance to learn the material for a few years before having to interview for internships. So instead of filtering _before_ med school and forcing a huge sunk cost psychological barrier to students, you can let the students figure out by themselves if they actually enjoy the subject matter. It's not a perfect solution but I am quite certain that society as a whole would benefit. It is entirely unfair that medical knowledge (not practice) is restricted to a lucky few.
There is also the money. Sure you can train 10-100x physicians, but total compensation won't grow as fast, and so you should see lower overall wages (supply and demand). But it's still more complicated than that, because some people choose not to undergo X or Y procedure for various reasons, insurers don't cover or whatever. So even if you could train enough doctors to fulfil the whole population's needs, that doesn't mean you will have: 1. enough equipment, material, operating rooms, etc to do the procedures 2. enough supporting staff, and on and on.
The most common reason I hear from MDs against training much more doctors is the first one I gave you: less practice means a more dangerous practice.
My own opinion is relatively simple. Medical schools should stop screening applicants as much and let students join freely.
Medical schools are all about getting well-rounded individuals who did extra-curriculars etc. They usually view it as a good thing that you have life experiences outside of medicine, like working or studying an entirely different subject. However it works one-way: you can't (generally) just go to med school, learn the subject matter and then move on to another field, enriching _that_ one with your experience. I have come to believe that if we are to see any improvement, med school will have to open up just like every other discipline. The current system of stressing out students for a few years before even being allowed in the classroom is, IMO, partly responsible for the job dissatisfaction that you see.
Now freeing up med school admissions does not mean allowing everybody to _practice_ medicine. Prospective students would actually get a chance to learn the material for a few years before having to interview for internships. So instead of filtering _before_ med school and forcing a huge sunk cost psychological barrier to students, you can let the students figure out by themselves if they actually enjoy the subject matter. It's not a perfect solution but I am quite certain that society as a whole would benefit. It is entirely unfair that medical knowledge (not practice) is restricted to a lucky few.
I am also from the field (POLST management for hospitals). Do you think it would be useful to sort the type of medical procedures by difficulty to make that more known to the market?
Not really IMO as that has a certain level of subjectivity that could lead to endless argumentation. What's truly needed from my limited perspective is democratization of medical schooling. I've met MDs who are trying to make it with their startup who only went through medical school because of other people's expectations and an immensely stressful sense of sunk cost that had to be avoided at all cost. If they could have studied 2-3 years and then made the change to programming, for example, that would have made much more sense to them.
I take issue with the closed entrance door policy. I'd rather see selective internships than selective pre-screening.
I take issue with the closed entrance door policy. I'd rather see selective internships than selective pre-screening.
Some of both: https://jakeseliger.com/2012/10/20/why-you-should-become-a-n....
But, from what I understand, the number of residencies is the big choke point.
But, from what I understand, the number of residencies is the big choke point.
I'd guess both.
Yes.
Residency is the choke point right now.
Less than 80% of candidates match into a residency. That means 1 in 5 doctors are blocked from practicing.
Less than 80% of candidates match into a residency. That means 1 in 5 doctors are blocked from practicing.
I do not believe this is correct:
https://www.mdmag.com/physicians-money-digest/contributor/he...
From the article, "And, it turns out that most (more than 95 percent) U.S. graduates did match in a residency program." Generally speaking, the U.S. residency program prioritizes and favors physicians graduating from U.S. medical schools.
https://www.mdmag.com/physicians-money-digest/contributor/he...
From the article, "And, it turns out that most (more than 95 percent) U.S. graduates did match in a residency program." Generally speaking, the U.S. residency program prioritizes and favors physicians graduating from U.S. medical schools.
http://www.nrmp.org/main-residency-match-data/
79.5% match rate for PGY-1 positions.
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That does include US and IMG candidates.
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The 95% number comes when you only look at US med school based candidates. That suggests a much smaller gap between demand and supply.
The rate for an intentional candidate matching into an American program is in the 50% to 60% range. Lots of doctors want to come work in the US, but residency programs simply do not have the capacity to accept them.
79.5% match rate for PGY-1 positions.
-----
That does include US and IMG candidates.
-----
The 95% number comes when you only look at US med school based candidates. That suggests a much smaller gap between demand and supply.
The rate for an intentional candidate matching into an American program is in the 50% to 60% range. Lots of doctors want to come work in the US, but residency programs simply do not have the capacity to accept them.
Yes. The residency programs are heavily weighted toward and really designed to ensure that every graduate from an American medical school has the ability to enter the residency program. Those to who attend the Caribbean schools or who are trained at a variety of other institutions abroad are given what is left over.
Personally, I have mixed feelings about this. I don't really mind the federal government giving priority to graduates from American schools. Frankly, the federal government likely gave them the loans to attend, so it helps to get that money paid back, which will only happen if these graduates become attending physicians and residency is a requirement for this to happen. On the other hand, the U.S. denies reciprocity from virtually all physicians from abroad outside of Canada. In order to practice in the U.S., physicians need to repeat their residency in an American program and it can be difficult for them to get a residency in a specialty in which they already practice. This is wasteful and I'd like to see a process to expedite this process as long as we can ensure these incoming physicians understand the American standard of care, which is differs between countries, for better or for worse.
All that said, the U.S. doesn't need more physicians in general. They need more physicians in certain specialties like family practice who want to live in small markets. Simply flooding the market with more physicians won't guarantee that this will happen.
Personally, I have mixed feelings about this. I don't really mind the federal government giving priority to graduates from American schools. Frankly, the federal government likely gave them the loans to attend, so it helps to get that money paid back, which will only happen if these graduates become attending physicians and residency is a requirement for this to happen. On the other hand, the U.S. denies reciprocity from virtually all physicians from abroad outside of Canada. In order to practice in the U.S., physicians need to repeat their residency in an American program and it can be difficult for them to get a residency in a specialty in which they already practice. This is wasteful and I'd like to see a process to expedite this process as long as we can ensure these incoming physicians understand the American standard of care, which is differs between countries, for better or for worse.
All that said, the U.S. doesn't need more physicians in general. They need more physicians in certain specialties like family practice who want to live in small markets. Simply flooding the market with more physicians won't guarantee that this will happen.
That's a complicated question. Let's say you're working on a software project that's running late. Does that indicate you should through more software developers at it?
The problem with medicine is that you have a culture of perfectionism in a field where random bad shit naturally happens all the time, and there's a great amount of human suffering. On top of that, perfectionism helps a lot, in the short run, even though it may be toxic in the long run.
The problem with medicine is that you have a culture of perfectionism in a field where random bad shit naturally happens all the time, and there's a great amount of human suffering. On top of that, perfectionism helps a lot, in the short run, even though it may be toxic in the long run.
Adding more doctors isn't like adding more developers to a software project. Additional doctors can treat new patients in parallel without affecting the work that other doctors are doing.
Right, do you guys know if there is a bird's eye view platform on the net that talks about which region in US is under staffed in terms of physicians? People may be migrating to the cities for jobs and end up in under staffed areas. That could be good information for migrants.
(I am not from Beijing, but something like this: https://www.pri.org/stories/2016-04-11/want-see-doctor-china... and https://www.registerednursing.org/specialty/flight-nurse/)
(I am not from Beijing, but something like this: https://www.pri.org/stories/2016-04-11/want-see-doctor-china... and https://www.registerednursing.org/specialty/flight-nurse/)
No, the correct analogy would be that you're working on millions of independent software projects and are having trouble handling them all. In which case it would obviously help to add engineers.
What is the baseline of burnout for all mid-career professionals? I'm a mid-career guy and most of my friends/peers are a little burnt out no matter what they are doing. Balancing any serious career with kids on one side and aging parents on the other is tough.
Anecdotal but my gen prac warned me on this 10 years ago, that obgyns were being driven out by high malpractice insurance. He suspected this would ultimately lead to consolidation of doctors under health organizations to limit personal liability.
Sure enough you have conglomerate health services corporations absorbing small practices, cheaper prices for consumers with added bureaucratic noise & volume thresholds for practitioners.
Sure enough you have conglomerate health services corporations absorbing small practices, cheaper prices for consumers with added bureaucratic noise & volume thresholds for practitioners.
I've seen this with my own doctor. They said another reason besides the insurance was the increased demand for paperwork and electronic backups or something like that. So it's much easier and cheaper to have a single team manage the digital side for 20 doctors instead of just 1 or 2 doctors.
From the consumer end I like this more because their new group has a wide variety of specialties so you don't need to keep filling out the same paperwork and they also can afford to maintain an electronic system so you receive text notifications for appointments and can make appointments online and such.
From the consumer end I like this more because their new group has a wide variety of specialties so you don't need to keep filling out the same paperwork and they also can afford to maintain an electronic system so you receive text notifications for appointments and can make appointments online and such.
As a consumer, I'm coming to dislike it. In theory, that consolidation of redundant efforts should improve my care and reduce my costs.
In practice, I've seen the opposite happen. My local health care market has consolidated down into a single large corporate entity that, like any good monopoly, has every reason to reduce quality of service while increasing prices.
I guess I fill out less paperwork, but that isn't saving me enough time to justify all the little routine visits that used to cost me $50 out of pocket suddenly costing $300 out of pocket.
In practice, I've seen the opposite happen. My local health care market has consolidated down into a single large corporate entity that, like any good monopoly, has every reason to reduce quality of service while increasing prices.
I guess I fill out less paperwork, but that isn't saving me enough time to justify all the little routine visits that used to cost me $50 out of pocket suddenly costing $300 out of pocket.
“cheaper prices for consumers”
Has this ever materialized? I thought it was the other way.
Has this ever materialized? I thought it was the other way.
The article is paywalled, so maybe the title doesn't provide a good description, but what does malpractice insurance have to do with burnout?
I'm an attorney, not a doctor, but from my perspective, rising malpractice rates are connected to burnout because they indicate a working environment that feels hostile. Doctors generally become doctors because they want to help people, and they do all of their work in good faith, and it creates a lot of anxiety to constantly worry about being sued, and it creates even more when your take home pay is materially impacted by malpractice insurance. For competent doctors, this may be misplaced anxiety, but it exists nonetheless. This anxiety might cause the doctors to seek a work set up that limits their personal liability to relieve their own anxiety, but it creates other anxieties, like those that come with working for a giant company and lead to burnout.
Lawyers, it may surprise some people to hear, also enter the legal profession wanting to help people, and the same mechanisms are at work. I may want to be a solo-practitioner for the flexibility and the ability to charge lower rates to help a broader part of the community, but feel pressured into joining a much larger firm just to protect myself from some crazy, one-off, life-destroying legal event.
Like I said, it may be an irrational fear, but that, combined with a giant amount of student loan debt and an already rather stressful profession is a recipe for burnout.
Lawyers, it may surprise some people to hear, also enter the legal profession wanting to help people, and the same mechanisms are at work. I may want to be a solo-practitioner for the flexibility and the ability to charge lower rates to help a broader part of the community, but feel pressured into joining a much larger firm just to protect myself from some crazy, one-off, life-destroying legal event.
Like I said, it may be an irrational fear, but that, combined with a giant amount of student loan debt and an already rather stressful profession is a recipe for burnout.
> protect myself from some crazy, one-off, life-destroying legal event
It's funny, it's this exact type of thing that the recommendation "don't talk to the police" comes from. Most cops are wonderful people that do want to help. Then there's the one bad apple that ruins your life.
I guess "don't talk to the police" isn't exactly solid career advice for a lawyer ;)
It's funny, it's this exact type of thing that the recommendation "don't talk to the police" comes from. Most cops are wonderful people that do want to help. Then there's the one bad apple that ruins your life.
I guess "don't talk to the police" isn't exactly solid career advice for a lawyer ;)
Haha yeah exactly. I think this dynamic exists in a lot of places.
I feel like there should be a phrase that communicates something like "I know you're acting in good faith, but I'm just trying to be cautious." Because it's easy to misinterpret that reticence to talk as some sort of hostility or distrust (though the best cops won't interpret it that way).
I have a similar experience when someone is trying to sell me something, I don't bear them any ill will for doing their job, but also it's a waste of both our time for them to continue with the sales pitch. But it's hard to communicate that without implying that I think they're doing something untrustworthy.
And from what I've read, there are a lot of cons that rely on people not wanting to be rude and not questioning something they don't think is right.
I feel like there should be a phrase that communicates something like "I know you're acting in good faith, but I'm just trying to be cautious." Because it's easy to misinterpret that reticence to talk as some sort of hostility or distrust (though the best cops won't interpret it that way).
I have a similar experience when someone is trying to sell me something, I don't bear them any ill will for doing their job, but also it's a waste of both our time for them to continue with the sales pitch. But it's hard to communicate that without implying that I think they're doing something untrustworthy.
And from what I've read, there are a lot of cons that rely on people not wanting to be rude and not questioning something they don't think is right.
"Trust but verify" is the standard term, scientific papers and so forth.
> He suspected this would ultimately lead to consolidation of doctors under health organizations to limit personal liability.
That's not necessarily a bad thing. Safety in herds and shared risk pools work to limit individual risk for physicians.
This can take the form of larger private practice groups like Kaiser Permanente's physician group (a distinct entity contracted with the Kaiser Permanente hospital/managed care corporation).
It can also take the form of NHS in the UK which employs the vast majority of physicians there and represents them in malpractice cases.
The risk inherent in medicine is real and has to be borne somewhere. Better by shared risk pools, however they are organized, than by individual patients or doctors.
That's not necessarily a bad thing. Safety in herds and shared risk pools work to limit individual risk for physicians.
This can take the form of larger private practice groups like Kaiser Permanente's physician group (a distinct entity contracted with the Kaiser Permanente hospital/managed care corporation).
It can also take the form of NHS in the UK which employs the vast majority of physicians there and represents them in malpractice cases.
The risk inherent in medicine is real and has to be borne somewhere. Better by shared risk pools, however they are organized, than by individual patients or doctors.
I can see the burnout starting in medical school and I would not be surprised if this trend continues to get worse.
The physicians that I know talk about this a lot. From what I gather, part of the problem is that medical school is really expensive, so they take these really massive loans to get through school, which is generally on top of their debt from their bachelors and masters. Then, many of them discover that they're not in love with the field as much as they originally thought. The problem is that it's very difficult to back out at this point; they're hundreds of thousands of dollars in debt and dropping out leaves many of them with a degree that will not allow them to pay this debt down. As such, they power through. Then, they enter a profession were the hours are truly and utterly terrible. People don't get sick on a 9-5 schedule and unless you're working in something like dermatology, you're going to work nights and you're probably going to work shifts that range from 14-24 hours even as an attending. Yes, this depends on specialty, but hospitalists, emergency medicine, any surgical specialty, and most people doing procedures will end up with long night shifts at least a few times a month. And, this must be done for several years even after residency in order to clear the debt even if you just want to quit the profession entirely. Every physician I know of talks about an exit plan as soon as they enter the profession, which is generally not a good sign. Though, probably a smart one.
Now, does this differ from any other profession where we take on debt to get a degree in a profession that we don't like just to work that profession to pay off the loan? For the most part, no. I think the distinguishing feature for physicians is the debt is higher and it takes more years to get into a position to pay off that debt, so the exit point is farther away. I do think physician hours suck far more than most professions. I also think the profession is far more abusive than most white collar professions, but that's debatable.
Now, does this differ from any other profession where we take on debt to get a degree in a profession that we don't like just to work that profession to pay off the loan? For the most part, no. I think the distinguishing feature for physicians is the debt is higher and it takes more years to get into a position to pay off that debt, so the exit point is farther away. I do think physician hours suck far more than most professions. I also think the profession is far more abusive than most white collar professions, but that's debatable.
The Doctor's guild does this to themselves by restricting supply to obtain their grotesque salaries. Zero sympathy.
There are a lot of misconceptions and misinformation coming out in this thread. I'm going to try and shed some light on them. (HN says my post is too big, so I'll have to split up a bit).
There are four major groups of physicians:
-Residents. These are the folks that just completed medical school, and are doing four-plus years of training in a hospital setting to become independently practicing physicians. In year one they are called interns. By year three or four they have various amounts of independence: in internal medicine, family medicine, etc. they are basically practicing as full physicians, with some light supervision (the heavy supervision is years one and two). They are one of the hospitals most valuable employees: taking into account supervision costs, they are producing about 80-90% of the revenue of a "real" physician, for less than 1/4 the cost. These are the guys who work 80+ hours per week without exception, do all the scut, etc. These are not "mid career physicians". This is where "old physicians had to go through it, so young physicians have to go through it."
--Resident Training: the AMA has been pushing to expand resident training spots for years. The funding is part of Medicare legislation, and no one has been willing to back expanding medicare spending in the name of training physicians. I know the AMA has been backing this because I've attended the Region 7 and national meetings where the resolution to push for it has been passed, repeatedly. Literally, hit DDG and enter "AMA restricted residency training funding" and your entire page of results is the opposite. They may have done so more than a generation ago, but... let's move onto things that were done by, and affect, people not currently retired, eh?
-Hospitalists. These guys have completed their residency training, and elected to work for a hospital, doing in-hospital medicine. Their specialty is "hospital medicine." They have no private clinic, no private patients, and are paid a salary by the hospital. Whether this is an integrated system like Kaiser, or ... every other hospital in the market, they're very common. Their practice patterns are heavily dictated by the hospital, which is heavily dictated by the Centers for Medicare/Medicaid Services and the major insurers. Their work is increasingly focused strictly on documentation, since documentation is the way that CMS and insurers (a) find excuses to refuse reimbursement, and (b) the way that CMS and insurers outsource collection of "quality" information, by forcing docs to structure their input in very discrete ways. These physicians don't have to deal with billing directly, but they are constantly being pulled into trainings for the ways documentation requirements are constantly evolving, the ways in which payors want them order tests and in what order, etc. They constantly get phone calls from "helpful billing people" raking them over the coals whenever there's a mistake. THe hospital keeps running tallies and reports on doctors' mistakes in this arena, aiming for public pillorying and, ultimately, withheld wages. (Docs don't generally get bonuses, they get withheld wages - except for high-revenue services like procedures, where they may get a bonus for very high productivity.) These are "mid career physicians." They tend to work an official 10-12 hour day, ten days on, ten days off. In reality, due to documentation requirements, and the fact that they get more patients than anyone could ever see and document in 10-12 hours, they tend to work 14+.
-Private Practice. These guys completed their residency and either opened their own private practice (almost no one can do that these days, with the complexity of the documentation and EMRs required by CMS and insurers, and attendant overhead costs) or have become employed by such a practice with the medium-term goal of buying in as a partner. They are likewise having their arms heavily twisted by insurers and CMS, without any sort of leverage to fight back and negotiate better terms. These guys are going out of business left and right. These are "mid career physicians." Hours worked here are highly variable, depending on the specific practice pattern, number of employees and partners, etc.
-"Private Practice." Because of the complexities and overhead that are now required to stay open, many practices... can't. They sell to a local hospital - often at cost - and become hospital employees. The hospital offers solid salaries for the first couple of years, and then drives them out, replacing them with younger employees. Many of the "private practices" you go to are thus actually practices run by the hospital, with an employee acting as the physician. These are "mid career physicians." These tend to work 9-5 with one evening hour a week, or none. The spread of this is why no one can find a doctor to see in the evenings anymore.
Key to Understanding Medical Reimbursement:
This is not a free market. It is fee for service. You get a patient visit, it is coded as a particular service (usually a Level 3 Evaluation & Management), and a fixed amount of reimbursed, assuming you meet various documentation requirements. If you do not, the amount is decreased or denied altogether. Private insurers peg their fee schedules to CMS, so CMS - directly or indirectly - drives all physician reimbursement. If you own a geographic area (such as part of a sweeping hospital network), that network will negotiate better reimbursement (e.g., "112% of Medicare"), but that is not passed along to employee physicians. Total revenue for a physician is amount of work-time per year divided by time-per-average-service, times reimbursement-per-average-service.
That's it; that's your cap.
Thus, most services patients want are strictly cost centers. The sort of things that other businesses compete on - e.g., ambiance, good front desk staff - are problematic for physicians, because you can't pass that along to patients in moderately higher prices. The only way you can compete on service, and be free to set your prices accordingly, is to refuse all insurance and only take cash patients. There are vanishingly few such patients, largely due to a cultural expectation that insurance = healthcare. Actually paying cash for a primary care physician, at least, isn't that expensive, but since that doesn't cover all of your other healthcare costs, who can afford to pay that extra premium? Only upper-middle-class and up.
There are four major groups of physicians:
-Residents. These are the folks that just completed medical school, and are doing four-plus years of training in a hospital setting to become independently practicing physicians. In year one they are called interns. By year three or four they have various amounts of independence: in internal medicine, family medicine, etc. they are basically practicing as full physicians, with some light supervision (the heavy supervision is years one and two). They are one of the hospitals most valuable employees: taking into account supervision costs, they are producing about 80-90% of the revenue of a "real" physician, for less than 1/4 the cost. These are the guys who work 80+ hours per week without exception, do all the scut, etc. These are not "mid career physicians". This is where "old physicians had to go through it, so young physicians have to go through it."
--Resident Training: the AMA has been pushing to expand resident training spots for years. The funding is part of Medicare legislation, and no one has been willing to back expanding medicare spending in the name of training physicians. I know the AMA has been backing this because I've attended the Region 7 and national meetings where the resolution to push for it has been passed, repeatedly. Literally, hit DDG and enter "AMA restricted residency training funding" and your entire page of results is the opposite. They may have done so more than a generation ago, but... let's move onto things that were done by, and affect, people not currently retired, eh?
-Hospitalists. These guys have completed their residency training, and elected to work for a hospital, doing in-hospital medicine. Their specialty is "hospital medicine." They have no private clinic, no private patients, and are paid a salary by the hospital. Whether this is an integrated system like Kaiser, or ... every other hospital in the market, they're very common. Their practice patterns are heavily dictated by the hospital, which is heavily dictated by the Centers for Medicare/Medicaid Services and the major insurers. Their work is increasingly focused strictly on documentation, since documentation is the way that CMS and insurers (a) find excuses to refuse reimbursement, and (b) the way that CMS and insurers outsource collection of "quality" information, by forcing docs to structure their input in very discrete ways. These physicians don't have to deal with billing directly, but they are constantly being pulled into trainings for the ways documentation requirements are constantly evolving, the ways in which payors want them order tests and in what order, etc. They constantly get phone calls from "helpful billing people" raking them over the coals whenever there's a mistake. THe hospital keeps running tallies and reports on doctors' mistakes in this arena, aiming for public pillorying and, ultimately, withheld wages. (Docs don't generally get bonuses, they get withheld wages - except for high-revenue services like procedures, where they may get a bonus for very high productivity.) These are "mid career physicians." They tend to work an official 10-12 hour day, ten days on, ten days off. In reality, due to documentation requirements, and the fact that they get more patients than anyone could ever see and document in 10-12 hours, they tend to work 14+.
-Private Practice. These guys completed their residency and either opened their own private practice (almost no one can do that these days, with the complexity of the documentation and EMRs required by CMS and insurers, and attendant overhead costs) or have become employed by such a practice with the medium-term goal of buying in as a partner. They are likewise having their arms heavily twisted by insurers and CMS, without any sort of leverage to fight back and negotiate better terms. These guys are going out of business left and right. These are "mid career physicians." Hours worked here are highly variable, depending on the specific practice pattern, number of employees and partners, etc.
-"Private Practice." Because of the complexities and overhead that are now required to stay open, many practices... can't. They sell to a local hospital - often at cost - and become hospital employees. The hospital offers solid salaries for the first couple of years, and then drives them out, replacing them with younger employees. Many of the "private practices" you go to are thus actually practices run by the hospital, with an employee acting as the physician. These are "mid career physicians." These tend to work 9-5 with one evening hour a week, or none. The spread of this is why no one can find a doctor to see in the evenings anymore.
Key to Understanding Medical Reimbursement:
This is not a free market. It is fee for service. You get a patient visit, it is coded as a particular service (usually a Level 3 Evaluation & Management), and a fixed amount of reimbursed, assuming you meet various documentation requirements. If you do not, the amount is decreased or denied altogether. Private insurers peg their fee schedules to CMS, so CMS - directly or indirectly - drives all physician reimbursement. If you own a geographic area (such as part of a sweeping hospital network), that network will negotiate better reimbursement (e.g., "112% of Medicare"), but that is not passed along to employee physicians. Total revenue for a physician is amount of work-time per year divided by time-per-average-service, times reimbursement-per-average-service.
That's it; that's your cap.
Thus, most services patients want are strictly cost centers. The sort of things that other businesses compete on - e.g., ambiance, good front desk staff - are problematic for physicians, because you can't pass that along to patients in moderately higher prices. The only way you can compete on service, and be free to set your prices accordingly, is to refuse all insurance and only take cash patients. There are vanishingly few such patients, largely due to a cultural expectation that insurance = healthcare. Actually paying cash for a primary care physician, at least, isn't that expensive, but since that doesn't cover all of your other healthcare costs, who can afford to pay that extra premium? Only upper-middle-class and up.
This has been manipulated since roughly the eighties to increase HMO profit. There was a thesis that most physicians are not trying to maximize revenue, but trying to hit a target upper middle class lifestyle. If you cut FFS reimbursement down by 20%, they'd increase the amount of patients they pack into a waiting room by 20% (rather than taking a 20% pay-cut by seeing the same number of patients, or saying "fuck you" and no longer accepting patients from that insurer). And that's precisely what happened. That has driven the ongoing trend since in which revenue falls, number of patients per hour increases, and the result is physician income that hasn't kept up with cost in education or changes in purchasing power. You, too, would be very upset if you were being asked to work more and make less.
This also makes physicians a target for every spending adjustment measure. Physicians are not the primary driver of cost growth in america: new procedures and changes in drug prices are (when was the last time an internist raised his prices 5000%? Never, because his reimbursement is set by Medicare). But they do write the prescriptions and orders and referrals. This means that the entire system converges on controlling physician activity.
This plays directly into government willingness to expand on training positions. The government has a budget to hit; in fact, CMS is required to do studies showing that any changes they make will ultimately be budget-neutral, because they're legally obligated to protect the Medicare Trust Fund. As you see above, healthcare costs for the nation scale linearly with the number of physicians: if a doctor's total revenue for the year is capped at available time * service unit revenue/time, well, CMS' costs are that plus the cost of whatever service or drug he prescribes in that unit time. Double the docs, you double manpower costs, and double the opportunities for prescribing, in the context of trying to minimize healthcare cost.
So why are physicians burning out? Why are fewer and fewer "best and brightest" applying to medical school?
- Increased accountability with decreased authority. As the centerpoint for changes in documentation and prescription patterns, everyone is twisting physicians' arms to act in very precise ways, whether or not those ways are what the physician believe is good for the patient. Physicians get the scoldings, the pay decreases, the public scrutiny -"why don't doctors X?!" "why are doctors doing Y?!" - and none of the power to actually decide any of this.
- Decreased authority in the hospital. Hospitals are suffering the invasion of the MBAs (and MPHs, and MHAs), and have more and more people with zero clinical knowledge setting policy. The big trend has been in nurses getting MBAs (and MHAs and MPHs) and going into administration, combining "I saw what doctors do from the side, I must totally know what's going on in their heads, right?" with MBA acumen. It's deeply problematic. "This patient has depression, and you didn't give them an SSRI! Malpractice! What's wrong with you?"
"This patient has multiple comorbidities that are more serious than their depression. I have them on medications for those comorbidities, and those drugs are all second-line therapies for depression. Time has shown that this combination has been effective for controlling their depression, and as a bonus, I avoided risking the side-effects of putting this patient on a third medication."
You cannot imagine the absolute pleasure of being regularly second-guessed by someone with a tiny fraction of your training. I imagine it's rather like a senior engineer having their code regularly criticized by someone that just finished "learn python in one week!". And they will then go to the EMR folks and have them add an alert, so that I can never place an order w/o SSRIs for a patient w/ depression without going through a whole Alert! rigamarole. There are so, so many alerts that alert fatigue is ubiquitous.
Additionally, in (fair) response to bad behavior of physicians in the past, nursing and other auxiliary services have moved into parallel reporting structures.
So, when patients are mad at something that has happened in the hospital, they call the doctor and yell at them! How could the hospital have done such a thing! I have no authority over the nurses that did it, or the nurse MBAs that made the policy, but I will get to take the scolding, the risk of malpractice suit (because patients don't sue over errors - they don't know enough medicine to identify errors - they sue over breakdowns in relationships with physicians), have zero authority to change or fix anything, and if I say a word, it's outside of my operational stovepipe and I will be both ignored and ultimately ignored by nurses. The latter means that my future care orders will be ignored or given low priority, and I can rely on that ultimately affecting my patients. So I have to keep my mouth shut over anything less than egregious problems.
- Increased time doing things unrelated to patient care. There's a myth that somehow all this new documentation is meant to improve patient care. It does not. The three major reasons have absolutely nothing to do with patient care:
---Many of the increases in documentation have to do with increasing specificity that strictly increases opportunities for error, and thus reimbursement denials.
---CMS wants increasing information on practice patterns, and wants to extract this from EMRs. Because they can't spend any money to collect this information (as I said above, they are required to be budget neutral), they shift this cost onto hospitals, which shift it onto physicians (it's worthwhile for hospitals to comply, because otherwise CMS brings out the reimbursement stick.)
---EMRs make billing more reliable, and reporting data to CMS more easy, and are required now as part of the ACA. EMRs are slow as fuck, because the end-user is not the customer. Their UIs are just fucking atrocious. There aren't words enough to relate how bad they are. Most can't even present lab results in a decent way.
The result is more documentation, done more slowly, for reasons unrelated to taking care of the patient in front of me - but that none the less take time away from seeing the patient in front of me.
And there is a constant media barrage about how terrible physicians are, which studiously ignores that 99% of the things they are describing and criticizing are systems-level issues physicians have no control over.
On top of all this, I have only rarely met a physician without a real sense of professional pride. That we are ordering tests we don't want to order, creating delays we don't want to create, hiring shitty front desk staff we don't want to hire, creating massively packed waiting rooms we'd rather not have, while patients are being bled dry by their pharmaceutical companies, all while working our asses off, getting scolded for it, and having trouble paying off our ever-growing student loans is... it's fucking heart-breaking.
It's heart breaking.
You have no idea what a tide of idealism enters medical school, and what a shambling army of heart-broken zombies is left by "mid-career." If anyone was willing to pay me my current salary to see a dozen patients a day rather than thirty, to give every single one of them the extended visit to collect a rigorous history and give them the scrutiny they deserve, I'd take it in a heartbeat.
You want me to be that doctor. I want to be that doctor. The delta between that, and what the system allows me to be, hurts us both.
This also makes physicians a target for every spending adjustment measure. Physicians are not the primary driver of cost growth in america: new procedures and changes in drug prices are (when was the last time an internist raised his prices 5000%? Never, because his reimbursement is set by Medicare). But they do write the prescriptions and orders and referrals. This means that the entire system converges on controlling physician activity.
This plays directly into government willingness to expand on training positions. The government has a budget to hit; in fact, CMS is required to do studies showing that any changes they make will ultimately be budget-neutral, because they're legally obligated to protect the Medicare Trust Fund. As you see above, healthcare costs for the nation scale linearly with the number of physicians: if a doctor's total revenue for the year is capped at available time * service unit revenue/time, well, CMS' costs are that plus the cost of whatever service or drug he prescribes in that unit time. Double the docs, you double manpower costs, and double the opportunities for prescribing, in the context of trying to minimize healthcare cost.
So why are physicians burning out? Why are fewer and fewer "best and brightest" applying to medical school?
- Increased accountability with decreased authority. As the centerpoint for changes in documentation and prescription patterns, everyone is twisting physicians' arms to act in very precise ways, whether or not those ways are what the physician believe is good for the patient. Physicians get the scoldings, the pay decreases, the public scrutiny -"why don't doctors X?!" "why are doctors doing Y?!" - and none of the power to actually decide any of this.
- Decreased authority in the hospital. Hospitals are suffering the invasion of the MBAs (and MPHs, and MHAs), and have more and more people with zero clinical knowledge setting policy. The big trend has been in nurses getting MBAs (and MHAs and MPHs) and going into administration, combining "I saw what doctors do from the side, I must totally know what's going on in their heads, right?" with MBA acumen. It's deeply problematic. "This patient has depression, and you didn't give them an SSRI! Malpractice! What's wrong with you?"
"This patient has multiple comorbidities that are more serious than their depression. I have them on medications for those comorbidities, and those drugs are all second-line therapies for depression. Time has shown that this combination has been effective for controlling their depression, and as a bonus, I avoided risking the side-effects of putting this patient on a third medication."
You cannot imagine the absolute pleasure of being regularly second-guessed by someone with a tiny fraction of your training. I imagine it's rather like a senior engineer having their code regularly criticized by someone that just finished "learn python in one week!". And they will then go to the EMR folks and have them add an alert, so that I can never place an order w/o SSRIs for a patient w/ depression without going through a whole Alert! rigamarole. There are so, so many alerts that alert fatigue is ubiquitous.
Additionally, in (fair) response to bad behavior of physicians in the past, nursing and other auxiliary services have moved into parallel reporting structures.
So, when patients are mad at something that has happened in the hospital, they call the doctor and yell at them! How could the hospital have done such a thing! I have no authority over the nurses that did it, or the nurse MBAs that made the policy, but I will get to take the scolding, the risk of malpractice suit (because patients don't sue over errors - they don't know enough medicine to identify errors - they sue over breakdowns in relationships with physicians), have zero authority to change or fix anything, and if I say a word, it's outside of my operational stovepipe and I will be both ignored and ultimately ignored by nurses. The latter means that my future care orders will be ignored or given low priority, and I can rely on that ultimately affecting my patients. So I have to keep my mouth shut over anything less than egregious problems.
- Increased time doing things unrelated to patient care. There's a myth that somehow all this new documentation is meant to improve patient care. It does not. The three major reasons have absolutely nothing to do with patient care:
---Many of the increases in documentation have to do with increasing specificity that strictly increases opportunities for error, and thus reimbursement denials.
---CMS wants increasing information on practice patterns, and wants to extract this from EMRs. Because they can't spend any money to collect this information (as I said above, they are required to be budget neutral), they shift this cost onto hospitals, which shift it onto physicians (it's worthwhile for hospitals to comply, because otherwise CMS brings out the reimbursement stick.)
---EMRs make billing more reliable, and reporting data to CMS more easy, and are required now as part of the ACA. EMRs are slow as fuck, because the end-user is not the customer. Their UIs are just fucking atrocious. There aren't words enough to relate how bad they are. Most can't even present lab results in a decent way.
The result is more documentation, done more slowly, for reasons unrelated to taking care of the patient in front of me - but that none the less take time away from seeing the patient in front of me.
And there is a constant media barrage about how terrible physicians are, which studiously ignores that 99% of the things they are describing and criticizing are systems-level issues physicians have no control over.
On top of all this, I have only rarely met a physician without a real sense of professional pride. That we are ordering tests we don't want to order, creating delays we don't want to create, hiring shitty front desk staff we don't want to hire, creating massively packed waiting rooms we'd rather not have, while patients are being bled dry by their pharmaceutical companies, all while working our asses off, getting scolded for it, and having trouble paying off our ever-growing student loans is... it's fucking heart-breaking.
It's heart breaking.
You have no idea what a tide of idealism enters medical school, and what a shambling army of heart-broken zombies is left by "mid-career." If anyone was willing to pay me my current salary to see a dozen patients a day rather than thirty, to give every single one of them the extended visit to collect a rigorous history and give them the scrutiny they deserve, I'd take it in a heartbeat.
You want me to be that doctor. I want to be that doctor. The delta between that, and what the system allows me to be, hurts us both.
Because your post is quite far down, I'm not sure it'll get many views/replies. Just wanted to say that I read it all and it's both informative, interesting, and (regrettably) demoralizing.
In my first year of college I wanted to be a doctor and landed an absurd position - in hindsight - over my freshman summer where I was in the operating room with my surgeon nearly everyday (he led the residents). I tagged along through all the rounds, operations, and (of course) the tedious paperwork and billings.
By the end of the summer I was entirely jaded and switched programs. I still often think about whether or not I should have stuck it out.
However, what I ultimately saw (as you mentioned) were residents at this top, well-funded hospital who deeply loved medicine when they began medical school fall into a deeply jaded, pessimistic state. They made no money (while living in a high CoL city), were consistently overworked, and riddled with anxiety about where they would actually get a job post-residency.
Becoming a doctor - a surgeon in particular - struck me as a dozen year journey of constant make-or-break tests, quasi-lotteries with regards to residencies/fellowships, and then complete ambiguity as to where you would actually work when it was all done and you hit your mid-thirties. It also seemed increasingly devoid of any kind of professional autonomy and, most surprising to me, was how ungrateful and mean-spirited many patients were. Their lives would be saved, but they would yell at the surgeons over cosmetic concerns about the scars.
I often wonder whether my experience was not representative or simply too much to absorb as an 18-year-old at the time. However, the only folks I've talked to who seem to be truly satisfied and content with their careers are family doctors operating (largely) on their own terms and making 200-300k a year.
EDIT: I should say, I wish you the best moving forward and hope you find a level of contentment and happiness in a bruising - to put it mildly - system.
In my first year of college I wanted to be a doctor and landed an absurd position - in hindsight - over my freshman summer where I was in the operating room with my surgeon nearly everyday (he led the residents). I tagged along through all the rounds, operations, and (of course) the tedious paperwork and billings.
By the end of the summer I was entirely jaded and switched programs. I still often think about whether or not I should have stuck it out.
However, what I ultimately saw (as you mentioned) were residents at this top, well-funded hospital who deeply loved medicine when they began medical school fall into a deeply jaded, pessimistic state. They made no money (while living in a high CoL city), were consistently overworked, and riddled with anxiety about where they would actually get a job post-residency.
Becoming a doctor - a surgeon in particular - struck me as a dozen year journey of constant make-or-break tests, quasi-lotteries with regards to residencies/fellowships, and then complete ambiguity as to where you would actually work when it was all done and you hit your mid-thirties. It also seemed increasingly devoid of any kind of professional autonomy and, most surprising to me, was how ungrateful and mean-spirited many patients were. Their lives would be saved, but they would yell at the surgeons over cosmetic concerns about the scars.
I often wonder whether my experience was not representative or simply too much to absorb as an 18-year-old at the time. However, the only folks I've talked to who seem to be truly satisfied and content with their careers are family doctors operating (largely) on their own terms and making 200-300k a year.
EDIT: I should say, I wish you the best moving forward and hope you find a level of contentment and happiness in a bruising - to put it mildly - system.
> I often wonder whether my experience was not representative
Everything you described is concordant with what I saw on my surgery rotations in medical school, and everything I've seen of surgeons in the hospital since then. Especially the mean-spirited and ungrateful patients. The ones that hurt, though, are the ones that come into the hospital hostile and confrontational from the outset.
"I know exactly what I need, and exactly what you need to do, and you're going to do it, or I'm going to have your balls!" I mean, that might be true. Sometimes it is. Sometimes it isn't. But nothing about talking to me like a rabid dog is going to make the process any better. And honestly, if you know your health, that's great - that will be very helpful. But ignoring other things it can be that masquerade as what you've got would be tragically irresponsible, so please don't bite my head off when I address the other conditions on my differential. I'm not ignoring you, I'm just trying not to be negligent.
Some patients will understand that, if we're given time to talk to them like human beings. But we basically never are, which makes things terrible for everyone.
The constant make-or-break tests and quasi-lotteries are a particularly apt description of medical school, and why - IIRC - the most recent stats put medical student rates of anxiety disorders at almost 50% of med students, and depression at approximately 30%. We absolutely destroy young physicians right at the outset. Studies of physician compassion have found that med students' compassion drives into the ground somewhere in third year - not with their first "your entire career relies on this" exam, but with their first exposure of what medicine has become, and how patients will be treating them.
Everything you described is concordant with what I saw on my surgery rotations in medical school, and everything I've seen of surgeons in the hospital since then. Especially the mean-spirited and ungrateful patients. The ones that hurt, though, are the ones that come into the hospital hostile and confrontational from the outset.
"I know exactly what I need, and exactly what you need to do, and you're going to do it, or I'm going to have your balls!" I mean, that might be true. Sometimes it is. Sometimes it isn't. But nothing about talking to me like a rabid dog is going to make the process any better. And honestly, if you know your health, that's great - that will be very helpful. But ignoring other things it can be that masquerade as what you've got would be tragically irresponsible, so please don't bite my head off when I address the other conditions on my differential. I'm not ignoring you, I'm just trying not to be negligent.
Some patients will understand that, if we're given time to talk to them like human beings. But we basically never are, which makes things terrible for everyone.
The constant make-or-break tests and quasi-lotteries are a particularly apt description of medical school, and why - IIRC - the most recent stats put medical student rates of anxiety disorders at almost 50% of med students, and depression at approximately 30%. We absolutely destroy young physicians right at the outset. Studies of physician compassion have found that med students' compassion drives into the ground somewhere in third year - not with their first "your entire career relies on this" exam, but with their first exposure of what medicine has become, and how patients will be treating them.
'You have no idea what a tide of idealism enters medical school, and what a shambling army of heart-broken zombies is left by "mid-career."
Are you me and my MD friends?
I'd add, from the clinic setting, that the amount of micromanaging of care and the amount of cost shifting back onto the patient by insurers is appalling. Want to prescribe an inhaler? good luck trying to figure out which one the patient's insurance will cover, and once you do they'll change it to a different one in 6 months without warning you or the patient. Want your patient to take insulin? good luck trying to find anything for less than $100/month, often much more. I hear about "copays" of $3-400/month for patients for insulin. This is with insurance. Its a joke. And yet the insurers, and my employer, would like to grade me on the % of patients with diabetes under 'good control'.
I fantasize about various alternate careers on my commute home.
Are you me and my MD friends?
I'd add, from the clinic setting, that the amount of micromanaging of care and the amount of cost shifting back onto the patient by insurers is appalling. Want to prescribe an inhaler? good luck trying to figure out which one the patient's insurance will cover, and once you do they'll change it to a different one in 6 months without warning you or the patient. Want your patient to take insulin? good luck trying to find anything for less than $100/month, often much more. I hear about "copays" of $3-400/month for patients for insulin. This is with insurance. Its a joke. And yet the insurers, and my employer, would like to grade me on the % of patients with diabetes under 'good control'.
I fantasize about various alternate careers on my commute home.
Thanks for writing that, my heart breaks too. My girlfriend is a second year resident in Germany, which is different in many details but, for doctors if not for patients, surprisingly similar. I'm watching her passion, ethics, social life, and physical and mental health slowly crumble. I know she's probably thinking the same thing that I am: practicing her hard earned craft will cost her her happiness, and by extension that of those who love her. There is no light at the end of the tunnel, other than leaving. I know she knows it but so far I haven't had the heart to say it to her.
I'm really sorry to hear that. I've seen so many people crumble in residency and fellowship. I'm unfamiliar with the details of how Germany structures its medical training; for her, does residency imply she's already selected a specialty?
What I'd recommend is that she get in touch with a healthcare professional. So, so many docs I know are afraid of getting help for the (fucking inevitable) depression because they're afraid of the stigma, despite it being so common in our field. I was one of them. Keeping a good, discrete psychiatrist in your corner can be incredibly valuable for getting through that time in one's life.
What I'd recommend is that she get in touch with a healthcare professional. So, so many docs I know are afraid of getting help for the (fucking inevitable) depression because they're afraid of the stigma, despite it being so common in our field. I was one of them. Keeping a good, discrete psychiatrist in your corner can be incredibly valuable for getting through that time in one's life.
Thanks, it's nice to hear from people who know.
In Germany - once you finish medical school (6 years) you can practice medicine and be paid for it but you're not yet specialized. Specialization is achieved via a 5-year hospital residency. During that time you're considered an "Assistenzarzt" (assistant doctor), which is hilarious. She was handed her own station 2 months into her residency - a station with a capacity of 15 patients that's very often at 20, with extra beds crammed into what used to be 3 person rooms. That residency rewards you with a lower middle class salary for days that consist of 8 hours of frantic clinical work and 4 hours of clerical work. There's a serious overall doctor shortage, especially of senior doctors, so on-the-job training and guidance is very thin. Never enough time and always too much responsibility is the name of the game.
My girlfriend has a therapist who supports her and isn't afraid of any stigma. That part is easier here because the system is so desperate for doctors that no one has reason to fear for their job. But, I just don't understand what any therapist can do to help anyone survive 60-80 hour underpaid weeks with occasional night duty, in a context where serious medical mistakes are simply inevitable. She knows she's doing her best and she knows she's being set up to fail, but in her mind, understandably, none of that negates that in the end, it was her that made that mistake.
Where did you land? Did you find a sustainable way to practice?
In Germany - once you finish medical school (6 years) you can practice medicine and be paid for it but you're not yet specialized. Specialization is achieved via a 5-year hospital residency. During that time you're considered an "Assistenzarzt" (assistant doctor), which is hilarious. She was handed her own station 2 months into her residency - a station with a capacity of 15 patients that's very often at 20, with extra beds crammed into what used to be 3 person rooms. That residency rewards you with a lower middle class salary for days that consist of 8 hours of frantic clinical work and 4 hours of clerical work. There's a serious overall doctor shortage, especially of senior doctors, so on-the-job training and guidance is very thin. Never enough time and always too much responsibility is the name of the game.
My girlfriend has a therapist who supports her and isn't afraid of any stigma. That part is easier here because the system is so desperate for doctors that no one has reason to fear for their job. But, I just don't understand what any therapist can do to help anyone survive 60-80 hour underpaid weeks with occasional night duty, in a context where serious medical mistakes are simply inevitable. She knows she's doing her best and she knows she's being set up to fail, but in her mind, understandably, none of that negates that in the end, it was her that made that mistake.
Where did you land? Did you find a sustainable way to practice?
I'm so sorry to hear that. I know that scenario too well, and I know the pain is unbearable. You learn to keep an impersonal distance with 90% of your patients, just put on a good show, but once in a while you connect, and you see it all over again with fresh eyes and it's so painful.
My interest is in chronic pain management, by way of psychiatry. I have very strong feelings about the way chronic pain is handled, or mishandled. The american approach to pain is incredibly ... uncomfortable with pain. There's an underlying guilt and discomfort that makes physicians very, very uncomfortable, in a way I think very few are willing to honestly admit or engage with. They turn their brains off when it comes to pain, the better to salve their hearts. When the drug companies pushed hard to market "pain as a vital sign," it gave physicians permission to just throw painkillers at patients to shut them up. Now the addiction crisis gives physicians license to just not throw painkillers at anyone. Either way, it's mindless, and patients suffer for it. Heck, even when physicians are thinking about it, the question is always about addiction, malingering, etc. This isn't helped by the fact that addiction and malingering are common, and addicts and malingerers also get sick and also have pain that requires training.
I don't have a good answer for that one. It's just another survival thing. We aren't robots; we can only do so much to retain our sanity in the face of pain. But I am more bothered by pain treated poorly than I am by the mere existence of pain itself. It helps that I'm chronically ill myself, have been in shoes few patients have ever been in, and can meet them heart-to-heart on the topic.
Psychiatry residency in the states is pretty merciful compared to others, either because psychiatrists better appreciate psychological distress in general, or because we're the ones our colleagues come to for help and we're loathe to inflict the same suffering on our trainees. It comes with a decent hit to your bottom line - you give up a fair chunk of income in exchange for retaining your sanity - but I am happy to be able to see my loved ones and remain a human being. I used to think I'd want to do critical care, but seeing how critcare fellowships ate alive people far more resilient than I am... thank goodness I didn't do that.
My interest is in chronic pain management, by way of psychiatry. I have very strong feelings about the way chronic pain is handled, or mishandled. The american approach to pain is incredibly ... uncomfortable with pain. There's an underlying guilt and discomfort that makes physicians very, very uncomfortable, in a way I think very few are willing to honestly admit or engage with. They turn their brains off when it comes to pain, the better to salve their hearts. When the drug companies pushed hard to market "pain as a vital sign," it gave physicians permission to just throw painkillers at patients to shut them up. Now the addiction crisis gives physicians license to just not throw painkillers at anyone. Either way, it's mindless, and patients suffer for it. Heck, even when physicians are thinking about it, the question is always about addiction, malingering, etc. This isn't helped by the fact that addiction and malingering are common, and addicts and malingerers also get sick and also have pain that requires training.
I don't have a good answer for that one. It's just another survival thing. We aren't robots; we can only do so much to retain our sanity in the face of pain. But I am more bothered by pain treated poorly than I am by the mere existence of pain itself. It helps that I'm chronically ill myself, have been in shoes few patients have ever been in, and can meet them heart-to-heart on the topic.
Psychiatry residency in the states is pretty merciful compared to others, either because psychiatrists better appreciate psychological distress in general, or because we're the ones our colleagues come to for help and we're loathe to inflict the same suffering on our trainees. It comes with a decent hit to your bottom line - you give up a fair chunk of income in exchange for retaining your sanity - but I am happy to be able to see my loved ones and remain a human being. I used to think I'd want to do critical care, but seeing how critcare fellowships ate alive people far more resilient than I am... thank goodness I didn't do that.
So I'll be a little bit of a counterpoint. I am in my sixth year now of being a Hospitalist so I can talk from the other side rather than what you've seen as a medical student. I've got my kids crawling on me so I'm not going to type nearly as much but basically, I think the general sentiment you lay out is true but it's not as bad as it seems. Sure, I get annoyed by administrators asking me to reconsider how I coded something, but that doesn't happen daily nor have I ever worked somewhere where people are scolded or shamed. I think the biggest frustration with my job is that a lot of things are out of my control because medicine/healthcare is a very complicated beast, and when things go wrong, I am the frontline at the bedside.
I think the concept of burnout in medicine is not something unique to medicine. Everyone I know, whether they are family members or friends in computer science, architecture, law (big time), or even being a stay at home parent exhibits burnout to the same degree I see in my colleagues. I think doctors are just more likely to talk about it and publish it because (cynic in me), it's a way to write papers and pad the resume, career advancement.
I think the concept of burnout in medicine is not something unique to medicine. Everyone I know, whether they are family members or friends in computer science, architecture, law (big time), or even being a stay at home parent exhibits burnout to the same degree I see in my colleagues. I think doctors are just more likely to talk about it and publish it because (cynic in me), it's a way to write papers and pad the resume, career advancement.
Thanks much for writing this. One point that confuses me:
> This plays directly into government willingness to expand on training positions. The government has a budget to hit; in fact, CMS is required to do studies showing that any changes they make will ultimately be budget-neutral, because they're legally obligated to protect the Medicare Trust Fund. As you see above, healthcare costs for the nation scale linearly with the number of physicians: if a doctor's total revenue for the year is capped at available time * service unit revenue/time, well, CMS' costs are that plus the cost of whatever service or drug he prescribes in that unit time. Double the docs, you double manpower costs, and double the opportunities for prescribing, in the context of trying to minimize healthcare cost.
If I understand your first comment correctly, you're saying that the effect of increasing residency slots will be to employ more doctors working fewer hours, but since expenditures for services are more a function of # doctors than # services performed, this will increase medical expenditures overall, which is a non-starter for CMS due to its budget-neutral requirement?
> This plays directly into government willingness to expand on training positions. The government has a budget to hit; in fact, CMS is required to do studies showing that any changes they make will ultimately be budget-neutral, because they're legally obligated to protect the Medicare Trust Fund. As you see above, healthcare costs for the nation scale linearly with the number of physicians: if a doctor's total revenue for the year is capped at available time * service unit revenue/time, well, CMS' costs are that plus the cost of whatever service or drug he prescribes in that unit time. Double the docs, you double manpower costs, and double the opportunities for prescribing, in the context of trying to minimize healthcare cost.
If I understand your first comment correctly, you're saying that the effect of increasing residency slots will be to employ more doctors working fewer hours, but since expenditures for services are more a function of # doctors than # services performed, this will increase medical expenditures overall, which is a non-starter for CMS due to its budget-neutral requirement?
Excellent question! It addresses a point I didn't explicitly state.
There's more demand than supply for physician services.
The result of increasing residency training spots has two phases:
Phase 1, which I skipped discussing:
A given hospital, in the short term, has only so much infrastructure - i.e., 6 ORs. Adding residents does not address those bottle-necks. Or, if we're looking at internal medicine, I only have so many internal medicine beds to host patients, and only so much faculty to supervise those residents. This won't directly rack up medical costs, because the bottleneck on services provided isn't the number of residents. There are other knock-on effects, of course: if I have a surgical residency staffed such that my ratio of residents to current surgeries is approximately 1:1, that's solid training. If I go to 1.5:1, I now have an inadequate number of surgeries for training my residents, and I produce worse docs. Also, the american council on graduate medical education has requirements for how many procedures my surgical residents do, and if I can't meet those requirements they don't get to become surgeons. So, in this phase, if Medicare funds more spots, what we get is more Medicare expenditures without increasing supply of medical care.
But the primary issue is phase 2, which is what I discussed in my original post:
Those residents complete their training, and enter a market where demand >> supply. They go work for hospitals with under-utilized infrastructure, or they open their own clinics. Now they'll soon be working at capacity. Rather than diminishing the average workload across all physicians, they've simply shortened the backlog of unmet medical need somewhat. That's not a bad thing, but it's an increase in healthcare expenditures.
There's more demand than supply for physician services.
The result of increasing residency training spots has two phases:
Phase 1, which I skipped discussing:
A given hospital, in the short term, has only so much infrastructure - i.e., 6 ORs. Adding residents does not address those bottle-necks. Or, if we're looking at internal medicine, I only have so many internal medicine beds to host patients, and only so much faculty to supervise those residents. This won't directly rack up medical costs, because the bottleneck on services provided isn't the number of residents. There are other knock-on effects, of course: if I have a surgical residency staffed such that my ratio of residents to current surgeries is approximately 1:1, that's solid training. If I go to 1.5:1, I now have an inadequate number of surgeries for training my residents, and I produce worse docs. Also, the american council on graduate medical education has requirements for how many procedures my surgical residents do, and if I can't meet those requirements they don't get to become surgeons. So, in this phase, if Medicare funds more spots, what we get is more Medicare expenditures without increasing supply of medical care.
But the primary issue is phase 2, which is what I discussed in my original post:
Those residents complete their training, and enter a market where demand >> supply. They go work for hospitals with under-utilized infrastructure, or they open their own clinics. Now they'll soon be working at capacity. Rather than diminishing the average workload across all physicians, they've simply shortened the backlog of unmet medical need somewhat. That's not a bad thing, but it's an increase in healthcare expenditures.
Thanks again. Another question, just to figure out how medicine is an odd industry: how inelastic is doctors’ preference for an upper middle class lifestyle, especially at the cost of 70-hour workweeks?
I can see why hospital administration would drive doctors with that inelastic preference to work long hours. But if there is a sizable pool of doctors who’d rather get paid less to work less, that suggests some firm can come along, make such a hospital, hire those people and do ok, maybe even better since their doctors are not as overworked.
What prevents that?
I can see why hospital administration would drive doctors with that inelastic preference to work long hours. But if there is a sizable pool of doctors who’d rather get paid less to work less, that suggests some firm can come along, make such a hospital, hire those people and do ok, maybe even better since their doctors are not as overworked.
What prevents that?
It's fairly inelastic. You're in training into your thirties, you've given up your entire twenties, and your average social cohort aimed at things like finance and big law, and has been making for several years what you won't be making for several years more.
Try telling that person "you know, you could have a reasonable middle class life if you just give up on the idea that all that work and sacrifice should have had any ROI."
Administration also prefers docs to work those hours for the fact that the entire hospital is built around these shifts, operationally, and a good deal rides on a doc carrying all his patients in his head for their entire course of stay. Hand-overs are disruptive and inefficient. If you offer a hospital "I don't want to work 10 on and 10 off, how about I work 10 days on, 20 days off, and you prorate my salary accordingly?" the hospital might agree, but they'll get rid of you in favor of a full-timer as quickly as they can.
Try telling that person "you know, you could have a reasonable middle class life if you just give up on the idea that all that work and sacrifice should have had any ROI."
Administration also prefers docs to work those hours for the fact that the entire hospital is built around these shifts, operationally, and a good deal rides on a doc carrying all his patients in his head for their entire course of stay. Hand-overs are disruptive and inefficient. If you offer a hospital "I don't want to work 10 on and 10 off, how about I work 10 days on, 20 days off, and you prorate my salary accordingly?" the hospital might agree, but they'll get rid of you in favor of a full-timer as quickly as they can.
Student loans prevent that.
Even once a doctor is 35 or 40? They shouldn’t be paying off these loans for decades?
The cost of medical school is over 200k (mine was a blessed ~250), at an interest rate generally about 6.8%. This doesn't account for loans generally needed to pay for living expenses (assume another 50k for four years' rent), mandatory licensing exams (5k), study materials, etc. Medical school highly favors people that went to private undergraduate educations - add some number of thousands here. And on average, about 50% of medical school applicants these days have some sort of Master's degree - again, favoring private education.
When I went to school, a few people had wealthy parents that made the debt issue disappear. Most were about 300k in debt when they graduated. I had a cheap undergraduate, but a private master's, so I came out of school at about 350k, with my interest rates ranging from low-6's to high-6's, with one "small" loan (~80k) at 7.8%.
By the time you hit residency, some folks are still single, but most have at least a serious partner, or are married, plus or minus a kid. When I hit residency I had a wife and a kid; my buddies were all married, getting ready to have a kid. They'd all have one by their second year of residency.
So, at this point, you're making about 50k a year, your spouse is probably making something similar or less, while effectively being a single parent. They probably still have school loans of their own, never mind carrying the cost of supporting the entire household. They are not servicing your debt. Kids are expensive, and the childcare you have to pay for as effectively-a-single-parent is even more expensive.
If you're single, depending on cost of living in your area, you're either putting off all your repayments (taking income-based repayment schedule) and living with a few roommates, or you're actually taking more loans to make it through.
Your training program will pay for your licensing exams in residency, and cover a decent portion of the cost of attending academic conferences. You won't spend a lot in this category unless you're aggressively academic.
It is not uncommon at this point to finish your residency training with more debt than you started - if you went in with 350k, it would not at all be surprising to be >500k at this point.
Now you go into practice. Fresh out of residency, general internal medicine, depending on your region, expect to make 180-220k. You're also at this point in your 30s, you've got a kid or two, your debt, likely a good chunk of your spouse's debt. Most available jobs are in reasonably high CoL areas, or they're out in the middle of nowhere. CoL isn't entirely up to you - most residencies are in high population density, high CoL areas. Residency is where you form all your professional connections; it's very hard to land a job outside of the zone of your residency, unless you're willing to go to an extremely poor backwater that just can't attract a physician at all.
Some docs at this point are willing to continue living like they're paupers, keep their family penned up inside a tiny apartment, driving their old beater. If that's the case, you take your 220+60 = 280k/yr household income, call it 200k after taxes, and devote 100k of it to debt servicing. You can pay off your loans in six years.
The truth is, though, that after you've lived like a pauper for your entire twenties and into your early thirties, and you've got kids, and a spouse that has supported you through all this garbage, and all of your non-medical friends have long ago vastly outpaced you, and you haven't had a decent vacation in ages...
Some new docs go overboard and start spending like mad.
Most don't. All the folks I went to school with came out and got reasonably nice apartments, so that at least their kids could each have a bedroom, got a slightly-better-than-entry level sedan (Nissan Sentra or Nissan Altima was de rigeur), bought a few suits so that patients would stop confusing them for students, took their spouse on vacation, and started servicing their debt - most taking a 30-year plan, and adding pre-payments. Some folk could pay it off by the time they were 50. Most couldn't - once they realized they also had to start putting money into their kid's college funds, and hopefully build something like a retirement fund, well...
I entered residency with 380k of loans (I paid off undergrad by attending a cheap public institution and working it off, but I got a Master's in a private school, though they gave me a solid merit scholarship, and then... med school.) My wife had about 80k of her own loans remaining; luckily, her parents paid off her private undergraduate debt, but she had grad loans to pay. We had one child, and were planning on two - financially timing a kid is hard, because the counterpoint is the rapidly increasing chance of birth defects with maternal age. I was 32. (I worked for a bit between Master's and Med school). We lived in a 2br as far from our intensely-high CoL area as we could tolerate commuting to. Want to picture commuting an hour in each direction when you need to be in by 5:30a and (hopefully) leave by 6:30pm? Fuck. We drove a Nissan Altima, because the area we lived in (that far from the city center) was not public transport friendly. I was lucky, though, because my wife was a high-earner. We still managed to burn through her income on a monthly basis, but it meant that she was able to service her debt on a 10-year repayment plan, and when she got bonuses from work they were put towards my loans.
We were moderately disciplined. I wasn't a martyr; we bought organic fancy groceries for our kid (not for ourselves; we had "organic strawberries for baby and whatever random berry was reasonably cheap this week for mom and dad"), we went on a cheap vacation once a year; we went out once a month.
I got into residency commuting distance from a low-compared-to-where-we-were-before CoL area. We rented a 3br apartment for less than we were paying for our 2br before. My wife had to switch to a lower paying job, because she couldn't keep her old one remotely. Much lower. Our QoL went into the shit, and by the time I graduated, our collective debt had barely budged. Childcare expenses reigned.
I expect I'll be paid off by 45. Hopefully in time to start a retirement fund for my wife and I, and a college fund for the kid. In exchange, we will continue living in a cramped apartment and driving the same car I see college undergraduates driving. Or I could lease a nicer car, and mortgage a house, and I'll be paying off my loans well into my 50s or 60s. And of course this assumes I work crazy hours. If I work half as much, I don't pay off my loans in twice as much time - interest will be compounding. If I work half-time, I'll never pay off my loans, never mind put anything away for retirement.
When I went to school, a few people had wealthy parents that made the debt issue disappear. Most were about 300k in debt when they graduated. I had a cheap undergraduate, but a private master's, so I came out of school at about 350k, with my interest rates ranging from low-6's to high-6's, with one "small" loan (~80k) at 7.8%.
By the time you hit residency, some folks are still single, but most have at least a serious partner, or are married, plus or minus a kid. When I hit residency I had a wife and a kid; my buddies were all married, getting ready to have a kid. They'd all have one by their second year of residency.
So, at this point, you're making about 50k a year, your spouse is probably making something similar or less, while effectively being a single parent. They probably still have school loans of their own, never mind carrying the cost of supporting the entire household. They are not servicing your debt. Kids are expensive, and the childcare you have to pay for as effectively-a-single-parent is even more expensive.
If you're single, depending on cost of living in your area, you're either putting off all your repayments (taking income-based repayment schedule) and living with a few roommates, or you're actually taking more loans to make it through.
Your training program will pay for your licensing exams in residency, and cover a decent portion of the cost of attending academic conferences. You won't spend a lot in this category unless you're aggressively academic.
It is not uncommon at this point to finish your residency training with more debt than you started - if you went in with 350k, it would not at all be surprising to be >500k at this point.
Now you go into practice. Fresh out of residency, general internal medicine, depending on your region, expect to make 180-220k. You're also at this point in your 30s, you've got a kid or two, your debt, likely a good chunk of your spouse's debt. Most available jobs are in reasonably high CoL areas, or they're out in the middle of nowhere. CoL isn't entirely up to you - most residencies are in high population density, high CoL areas. Residency is where you form all your professional connections; it's very hard to land a job outside of the zone of your residency, unless you're willing to go to an extremely poor backwater that just can't attract a physician at all.
Some docs at this point are willing to continue living like they're paupers, keep their family penned up inside a tiny apartment, driving their old beater. If that's the case, you take your 220+60 = 280k/yr household income, call it 200k after taxes, and devote 100k of it to debt servicing. You can pay off your loans in six years.
The truth is, though, that after you've lived like a pauper for your entire twenties and into your early thirties, and you've got kids, and a spouse that has supported you through all this garbage, and all of your non-medical friends have long ago vastly outpaced you, and you haven't had a decent vacation in ages...
Some new docs go overboard and start spending like mad.
Most don't. All the folks I went to school with came out and got reasonably nice apartments, so that at least their kids could each have a bedroom, got a slightly-better-than-entry level sedan (Nissan Sentra or Nissan Altima was de rigeur), bought a few suits so that patients would stop confusing them for students, took their spouse on vacation, and started servicing their debt - most taking a 30-year plan, and adding pre-payments. Some folk could pay it off by the time they were 50. Most couldn't - once they realized they also had to start putting money into their kid's college funds, and hopefully build something like a retirement fund, well...
I entered residency with 380k of loans (I paid off undergrad by attending a cheap public institution and working it off, but I got a Master's in a private school, though they gave me a solid merit scholarship, and then... med school.) My wife had about 80k of her own loans remaining; luckily, her parents paid off her private undergraduate debt, but she had grad loans to pay. We had one child, and were planning on two - financially timing a kid is hard, because the counterpoint is the rapidly increasing chance of birth defects with maternal age. I was 32. (I worked for a bit between Master's and Med school). We lived in a 2br as far from our intensely-high CoL area as we could tolerate commuting to. Want to picture commuting an hour in each direction when you need to be in by 5:30a and (hopefully) leave by 6:30pm? Fuck. We drove a Nissan Altima, because the area we lived in (that far from the city center) was not public transport friendly. I was lucky, though, because my wife was a high-earner. We still managed to burn through her income on a monthly basis, but it meant that she was able to service her debt on a 10-year repayment plan, and when she got bonuses from work they were put towards my loans.
We were moderately disciplined. I wasn't a martyr; we bought organic fancy groceries for our kid (not for ourselves; we had "organic strawberries for baby and whatever random berry was reasonably cheap this week for mom and dad"), we went on a cheap vacation once a year; we went out once a month.
I got into residency commuting distance from a low-compared-to-where-we-were-before CoL area. We rented a 3br apartment for less than we were paying for our 2br before. My wife had to switch to a lower paying job, because she couldn't keep her old one remotely. Much lower. Our QoL went into the shit, and by the time I graduated, our collective debt had barely budged. Childcare expenses reigned.
I expect I'll be paid off by 45. Hopefully in time to start a retirement fund for my wife and I, and a college fund for the kid. In exchange, we will continue living in a cramped apartment and driving the same car I see college undergraduates driving. Or I could lease a nicer car, and mortgage a house, and I'll be paying off my loans well into my 50s or 60s. And of course this assumes I work crazy hours. If I work half as much, I don't pay off my loans in twice as much time - interest will be compounding. If I work half-time, I'll never pay off my loans, never mind put anything away for retirement.
Thank you for taking the time to type all of that out!
While I was having a vasectomy late last year I had a conversation with the doctor performing the surgery. It started with a quip about "It's not your first time, right?" or something to that effect, and went into the general process of developing new techniques which he claims is non-existent in the US right now, what with liability and the threat of malpractice squashing any incentive for innovation.
He gave a specific Urological example of a technique that was developed at MIT and took 6 hours, impractical for all purposes. European doctors have since come over and trained US doctors on a means of the same outcome that takes 1 hour.
My first thought was that the stagnancy of the field would contribute to burnout, but thinking about it more, I think just living under the imminent threat of malpractice lawsuits is probably enough.
He gave a specific Urological example of a technique that was developed at MIT and took 6 hours, impractical for all purposes. European doctors have since come over and trained US doctors on a means of the same outcome that takes 1 hour.
My first thought was that the stagnancy of the field would contribute to burnout, but thinking about it more, I think just living under the imminent threat of malpractice lawsuits is probably enough.
Mandated electronic medical records is the problem, not some constrained supply of doctors. (Not the concept of electronic records, but the implementation. Scanned paper records probably would have been fine. Epic and competing software solutions are not.) It means the same supply of doctors has less time for the same (or increased) demand.
Forcing doctors into a workflow dictated by software is what's causing 12 hour days to turn into 16-18 hour days, with no additional pay, and no reduced hours to compensate.
Also results in doctors focusing on the computer instead of the patient.
You didn't see burnout levels increase until electronic charts were forced.
Forcing doctors into a workflow dictated by software is what's causing 12 hour days to turn into 16-18 hour days, with no additional pay, and no reduced hours to compensate.
Also results in doctors focusing on the computer instead of the patient.
You didn't see burnout levels increase until electronic charts were forced.
Stuff like this make me question how those in the medical field can put up with this stuff. All that hard work, all that debt, all that lost time, and for what? Meanwhile there's a bunch of people in a handful of cities who make comparable if not greater salaries for writing software to freaking deliver ads to sell people shit they don't need (I'm exaggerating a little). And all while living a much more comfortable life! Time ain't free.
I cannot find the studies now, but I have seen multiple times numbers to the effect that medical interventions/treatments are responsible for 10% of health outcomes. The remaining 90% is determined by diet, exercise, and genetics.
Genetics is out of everyone's control. But the fact that 1/6 of the American economy is focused on that 10% is mind blowing.
The best ways to improve your health are to eat less, eat better, and exercise more.
Genetics is out of everyone's control. But the fact that 1/6 of the American economy is focused on that 10% is mind blowing.
The best ways to improve your health are to eat less, eat better, and exercise more.
I have seen this happen as a chronically ill patient for the past 30 years. There is a wave of poorly understood chronic illness and doctors are powerless to treat it. It must be exhausting to tell so many people that there is nothing they can do. I say this with 100% sincerity. It must be a nightmare to work so hard without the reward and satisfaction of significantly improving people's lives.
I think specialization is making labor markets more exploitative.
If the market expects you to do things that aren't worth the wage, but you spend a decade and half a million dollars on training and switching to something comparable would take a ton more time and money, well, then you probably won't switch careers. And if too few people switch then there's little market pressure to adapt.
If the market expects you to do things that aren't worth the wage, but you spend a decade and half a million dollars on training and switching to something comparable would take a ton more time and money, well, then you probably won't switch careers. And if too few people switch then there's little market pressure to adapt.
It's even worse in Pediatric ICU. They're one of the lowest paid doctors due to ICU not being profitable. They have the mental/emotional stress of really sick and dead kids. They have to work 24+ hour calls with little to no sleep. I know one who worked 36 hours last weekend and got 2 hours of sleep. That can't be good for outcomes, but they can't hire more because again, the ICU loses money. They don't get big salaries from drugs like anesthesiologists.
It's almost like healthcare shouldn't be run like a normal capitalistic business.
I imagine burnout is much lower around the world and would love to see the data on that.
It's almost like healthcare shouldn't be run like a normal capitalistic business.
I imagine burnout is much lower around the world and would love to see the data on that.
The root cause is the people receiving the healthcare in a pediatric ICU don't have the ability to pay for it, and based on the lack of votes for taxpayer funded healthcare, voters also don't want to pay for it.
Notice how people 65 and over have no issues getting their healthcare paid for. That group of voters has a very high voter participation rate.
Notice how people 65 and over have no issues getting their healthcare paid for. That group of voters has a very high voter participation rate.
IMO medicine is currently in a pre-germ theory of disease state when it comes to sleep. The importance of sleep is completely disregarded for residents, as well as for patients. There really isn't much that's more important than sleep.
And it's a well known fact that the extreme residency model was pioneered by a cocaine addict [1], but yet no progress has been made. It's fucking absurd.
1: https://en.wikipedia.org/wiki/William_Stewart_Halsted
And it's a well known fact that the extreme residency model was pioneered by a cocaine addict [1], but yet no progress has been made. It's fucking absurd.
1: https://en.wikipedia.org/wiki/William_Stewart_Halsted
hasn't this always been widely known? same with big law lawyers
I went back to undergrad to finish med school prereqs, after the mcat I decided to go back to coding and am so thankful that I did. I did it because of the earning potential, not passion, and I don’t think it’s possible to be happy in that career path if you’re just trying to get money out of it
Medicine burned me to the ground
Wouldn't a good solution be to pay doctors less and train more doctors? We pay our doctors really well by international standards, but we are also really good at burning them out.
We need doctors. This is a serious problem.
I wonder how this compares to countries with nationalized healthcare.
I wonder how this compares to countries with nationalized healthcare.
It seems reported healthcare quality is highly correlated with physicians per capita, in developed countries. Notable exceptions are Japan and Singapore, but these countries tend to have more efficient infrastructure and populations with predilections toward above average health. Socialized healthcare countries like the UK and Canada, known for their absurd wait times, have comparable physicians per capita to the US [0]. Most of the other European countries with touted healthcare systems also tend to have significantly more doctors than the US.
[0] https://data.worldbank.org/indicator/SH.MED.PHYS.ZS
[0] https://data.worldbank.org/indicator/SH.MED.PHYS.ZS
maybe we shouldn't saddle new grads with $1M in debt if we want to incentivize more people to go into the field
It's not so much the profession itself, but not finding one's true "Ikigai". Too many smart people getting medicine for the money and prestige. Unless you truely enjoy helping sick people, you will get burned out at some point..
There's burnout in every field because capitalism places a higher reward on burning people out and finding fresh replacements instead of keeping your existing employees happy and balanced in their lives. The structural market forces inevitably lead to this outcome in the insatiable quest for efficiency and profits. You can't fix burnout without fixing the underlying structural cause.
Physicians spend hundreds of millions of dollars making competing with them illegal.
Now they can't handle the demand.
But hey physicians make 300k/yr...
Now they can't handle the demand.
But hey physicians make 300k/yr...
Well well, I think most people have financial problems nowadays, it's not a secret that the human world is on the descending slope.
Almost all burnout in the medical profession stems from state intervention and the extremely complex lobby relationships between different actors in the market. Classical liberal policies would change everything in the market.
In particular, there are a few things that crush doctors:
Problem: Cost of education: You require licenses per-state, and a license can be gotten only after a very grueling and expensive educational process in the half a million dollars range or more in student debt.
Solution: Make it legal to practice medicine with foreign education licenses. Doctors can study in countries where the education is free or nearly-free.
----
Problem: Too few people go into the medical profession per-capita in the US. Currently a 20-year in practice specialist doctor from any other country has to go through a lowly paid residency in the US to be able to exercise, plus compete in the very narrow H1B visa space.
Solution: Make a special purpose visa for medical professionals (Nurses & Doctors) and allow them to practice medicine.
----
Problem: Malpractice insurance is extremely expensive due to the high levels of litigation in the medical profession, that far outstrip the typical responsibility of a professional. Some specializations require insurance of thousands of dollars a month!
Solution: Allow for malpractice waivers that let doctors practice at a cheaper rate, and let patients decide what kind of risk they are willing to get or not.
----
Problem: US has the lowest level of Primary Care doctors per capita of developed nations in great part because they are the least protected specialization by the AMA which is mostly compromised by specialty doctors. One rule made here is that PCP's cannot collect 'kickbacks' or revenue by referring patients to a speciality doctor, and thus the PCP works for free to provide referrals to specialists.
Solution: Allow for transparent processes of verticalization and monetization, which will bring PCP's to a more natural rate count.
----
Problem: The government subsidizes medical insurance by making it tax exempt. This makes it so everyone gets insurance through their employer which in turn makes it impossible for a doctor to compete with the insurance model that is tax exempt by being all-cash. The tax benefit allows insurance companies an oligopoly against small practices.
Solution: Eliminate insurance through employer and/or get rid of the tax exemption.
----
Problem: The government pays a higher revenue rate if the medical practice is digitalized. This has pushed the entire industry into using electronic records to get that revenue boost long before its time, producing terrible technical solutions. (The biggest player in the space, Epic, collections millions of dollars a year per hospital and its made in Visual Basic)
Solution: Get rid of all electronic record requirement laws, subsidies, programs, etc.
----
I can keep going. In the health industry market literally every single player has a legal advantage over every single other. Its everyone screwing everyone.
In particular, there are a few things that crush doctors:
Problem: Cost of education: You require licenses per-state, and a license can be gotten only after a very grueling and expensive educational process in the half a million dollars range or more in student debt.
Solution: Make it legal to practice medicine with foreign education licenses. Doctors can study in countries where the education is free or nearly-free.
----
Problem: Too few people go into the medical profession per-capita in the US. Currently a 20-year in practice specialist doctor from any other country has to go through a lowly paid residency in the US to be able to exercise, plus compete in the very narrow H1B visa space.
Solution: Make a special purpose visa for medical professionals (Nurses & Doctors) and allow them to practice medicine.
----
Problem: Malpractice insurance is extremely expensive due to the high levels of litigation in the medical profession, that far outstrip the typical responsibility of a professional. Some specializations require insurance of thousands of dollars a month!
Solution: Allow for malpractice waivers that let doctors practice at a cheaper rate, and let patients decide what kind of risk they are willing to get or not.
----
Problem: US has the lowest level of Primary Care doctors per capita of developed nations in great part because they are the least protected specialization by the AMA which is mostly compromised by specialty doctors. One rule made here is that PCP's cannot collect 'kickbacks' or revenue by referring patients to a speciality doctor, and thus the PCP works for free to provide referrals to specialists.
Solution: Allow for transparent processes of verticalization and monetization, which will bring PCP's to a more natural rate count.
----
Problem: The government subsidizes medical insurance by making it tax exempt. This makes it so everyone gets insurance through their employer which in turn makes it impossible for a doctor to compete with the insurance model that is tax exempt by being all-cash. The tax benefit allows insurance companies an oligopoly against small practices.
Solution: Eliminate insurance through employer and/or get rid of the tax exemption.
----
Problem: The government pays a higher revenue rate if the medical practice is digitalized. This has pushed the entire industry into using electronic records to get that revenue boost long before its time, producing terrible technical solutions. (The biggest player in the space, Epic, collections millions of dollars a year per hospital and its made in Visual Basic)
Solution: Get rid of all electronic record requirement laws, subsidies, programs, etc.
----
I can keep going. In the health industry market literally every single player has a legal advantage over every single other. Its everyone screwing everyone.
It is definitely not state intervention alone that explains the culture within the medical profession overemphasizing hierarchical relationships and deemphasizing direct patient care
You would be surprised! That is exacty the history of american medicine, depicted in the seminal work “the social transformation of rhe americam physician”
Jr year I interned at Amazon after that experience I knew I made the right decision. It is a really, really hard sell for this current generation to do another 5 years of school with residency and then specialization when you can quickly make 100k+ at a tech company. All of my friends who went into medical school are working hours like 6am-6pm or 8pm-8am. They get like two days off every two weeks. I think there are a bunch of possible solutions but the easiest one is making 5 year medical programs (2 years undergrad, 3 graduate) more common in the US.