Throwaway05
1hr ago
I have spent literally years here replying every time explaining that this is not how the doctor shortage works and this is not how the AMA works and that this information is easily discoverable. At this point it's embarrassing.
I guess I will now also have to explain that that is also not how AI in medicine will work and not how medicine works.
Throwaway05
16hr ago
This is conspiratorial thinking. Physicians pay for services which you can see public approximations of that show salaries, they then use these numbers in negotiations. They are off by a little, not millions of dollars.
Additionally something is horrifically off with your sample, ten homes and 25 million in brokerage accounts is a lot of fucking money. That's a lot of non-physician business, luck with investments, or fraud.
Also, you have to listen when I say that the 80s and 90s aren't what is happening now.
Tons of doctors in their 40s and 50s are still paying off loans. A saw a physician publishing data to other physicians showing that the average 40-50 year old physician is worth less than a million dollars.
Things change. Don't be like the woke people who refuse to acknowledge that you can turn of the affirmative action funnel because women started outnumbering men higher education in the 80s.
I've repeated a million times here that the AMA is not doing what people think it is doing, and none of what they are saying is how the physician supply line works. If you have doubts watch a Sheriff of Sodium video. Also that's not what the AMA is. People act like it's some mandatory guild instead of a much reviled in the field organization that lobbies for its own interests which are abstruse and not related to physician interests.
Throwaway05
16hr ago
Let me back up and reiterate - the culture in the vast majority of undergraduate and graduate programs and types of program in the U.S. is that they have a holistic admission process that requires candidates to do a variety of things beyond just take a test and excel at it.
It's water. We don't do that here. And importantly - wokeness has made this orders of magnitudes worse.
You want that to change you have to reorganize the way education is done in the U.S. top to bottom, that's a big change and med schools aren't going to lead it.
Students, parents, the government - everyone expects extracurriculars and other holistic admission processes to be the lay of the land.
You are saying "well stop playing basketball, just play football instead." That is a ....big project.
Now as an adjacent matter I do believe the holistic admission process is in many ways better, but that's a separate thing.
Throwaway05
17hr ago
I don't see any reason why med school in the US couldn't use a similar combination of SAT scores and a dedicated entrance exam if they wanted to. Move the exam date slightly later, have the high school graduation in May and there's really nothing that would prevent a similar entrance exam based system.
I mean other than that's not how we do it here?
The woke have just run through a multi decade mostly successful plan to get rid of the ACT/SAT for general undergrad admissions and it's only now starting to cool off. They even managed to kill one of the physician licensing exams (making Step 1 pass/fail - was the main way to discriminate amongst candidates prior, and now the situation is awful).
Even beyond that extracurriculars have been a core part of admissions of all kinds in the U.S. for over a hundred years. It started as a way to discriminate against Jews and is now a way to discriminate against Asians and for other minorities but it's part of the environment and making it go away is a total non-starter.
You won't be able to change it just for medical education.
Throwaway05
17hr ago
Medical pay is a bit unusual - the fancier the job (prestige work at an Ivy for instance) the less the pay. Sometimes literally to the tune of hundreds of thousands of dollars. Most desirable locations (that are also more expensive!) like NYC, Boston, Seattle... they all pay less. Again sometimes to the tune of hundreds of thousands of dollars.
It can take a significant carrot to get fancy specialists who make "enough" and sacrificed the entirety of their 20s and sometimes 30s to go to shitty locations.
I can believe 900 for like Vascular for instance. More for neurosurgery. Not really close to that for most others.
Throwaway05
18hr ago
I mean you are looking at end career people.
However they are absolutely not making 1-5 million per year unless they are department chairs at major institutions or own extremely large practices. Most executives at run of the mill mid sized businesses don't make that much in comp. 1-5 million is (per google) the amount that executives at KP (one of the largest and most important health systems in the country) are making.
They might have wealth that matches that pay range but that's through being boomers and having come up during boom times and making investments and getting paid in an environment that does not exist now.
A good example of this is ophthalmology - in the 90s they were filthy stinking rich. Then the government changed their compensation structure and while still well paid it's probably a fourth what it was in the 90s. But if you are friend's dad is a former 90s eye doctor, he got a bag.
The situation has changed though.
You can also just google salary averages for various specialities the numbers are off sometimes but they aren't off by millions of dollars.
That's just not what people are getting paid.
I'm not complaining about my compensation, I am stating that it isn't what you think it is.
Throwaway05
18hr ago
I did not say that it is impossible to change anything without making things worse.
Also large swathes of medical care do not follow the laws of supply and demand due to things like inelasticity.
And also - medical school and residency need to be two separate buckets with two separate applications. One without the other does not work and has the potential to be worse than useless. This differs from most professional training.
Throwaway05
18hr ago
In most countries with this model everyone takes one giant exam that determines what you are allowed to do based off of scores. That's pretty self-explanatory and enables placement very proximal to graduation.
In the U.S. everyone (even for regular undergrad) does this whole thing with letters, and exams, and grades, and extracurriculars and a whole bunch of shit. This takes time. For Medical School as is - you have a full application year, given that this other stuff would not go away (for all kinds of reasons - including wokeness, racism, and more).
So you need to apply in the 15-17 range and have interest before that (assuming graduation age is 17-19).
The U.S. doesn't really have a culture of time off between high school and college (which to my understanding much of Europe does).
Throwaway05
18hr ago
Yes practice owners in things like Derm, Plastics (especially if the latter is doing cash practice for fucking surgeries!!!) can make tons of money. The total percent of physicians doing that is a rounding error.
Likewise the highest paid public employee in most states is either the college football coach or the head of a surgical department. But executive pay has little to say about the average Joe.
Throwaway05
18hr ago
The amount of resource investment in a medical student (and later resident) is immense, like millions of dollars of physical stuff (like cadavers) and valuable time (not just lecture style teaching but academic physicians taken away from care provision to do education) and infrastructure. Not to mention the cost in tuition.
Once started you are locked in and if you leave at any time you leave with nothing. In the case of BS/MD programs if you drop out from difficulty you often end up without even an undergrad degree.
Even cutting undergrad out training time is 4+(3-7)+(0-???).
This isn't really comparable.
And all of that to say nothing of the Western values of general education and such that you get out of a regular degree.
Throwaway05
18hr ago
Not sure how old you are but if you are in your 30s or 40s then you are looking at an old problem, if you are younger I'm not sure what that's about very, very few doctors make 7 figures even in the U.S.
Physicians used to make considerably more relative to inflation, have much lower debt (which later snowballs into wealth) and had other options to bring in money - medical inventions, ownerships of practices and other stuff, less regulation of conflict of interest and advertisement, and so on. Loopholes have been patched, reimbursement has been adjusted, and wages have declined relative to inflation.
Neurosurgery is the only specialty (and maybe vaguer things like spine) that is making 7 figures without something weird happening like fraud, sketchy cash practice, charing a department, or ownership. But ownership is.....gone.
People who already had a bag are doing great but the young aren't catching up.
It is possible you are living in a good area with the most successful people, but up until recent a few specialties still had averages below 200k in the big metro areas.
Throwaway05
19hr ago
Don't overdo it! All of us shouting at each other saying the same things isn't good for the soul (and likely fixes beliefs and frustrations by repetition).
Throwaway05
20hr ago
Committing to being a doctor at age 20-28 is very different than age 16. At the latter people are mostly forced in by their parents, haven't explored their interests and haven't exhibited durable commitment. With how bad residency is, that's important.
Throwaway05
20hr ago
Okay I think I understand a little bit more about where you are coming from and importantly I think the way you wrote makes me thing you are more worried and fearful than certain which means I do think we can talk, especially because I don't think we are as far apart as you fear.
I think everyone needs to keep two things in mind:
-Trump (and Western values) have been the recipient of an immense smear campaign for years and years. This is coming from inside the house in the form of the media, academics and so on and outside the house as a specific way used by the enemies of the West (including Iran and Russia) to destabilize us. It works. If you are still posting here you are probably heterodox and free thinking and resistant to these tactics but being buried under lies, exaggeration, misrepresentation and fear mongering for decades is going to stick at least a little bit.
-The tremendous amount of recent success of American/Western culture recently has allowed us to have (as embarrassing as it is to say it) a children's view policy and politics. Of course importing an endless stream of foreigners is going to change a country. No, it's ridiculous that 6 dead servicemen is going be painted as a reason that the war should end. I've seen more dead people today at my day job.
Likewise dealing with Iran is going to suck but it's going to happen at some point. Yes something was always going to happen to fracture US/Euro alliance if they continued using the U.S. as a pay pig. The anti-Trump memeplex creates a really potent way for people to dismiss and ignore hard problems and conversations.
Two address two of your specifics: Greenland. We know how Trump talks and negotiates now, he's been around for years. It helps Euro politicians if they handle it in the way they did, but it's important for the free thinking public to recognize what Trump is and how he works and how their politicians are trying to use that.
America isn't a perfect hegemon, but it's so comically more in line with Western values that people reaching for China and Russia really need to stop and think about how much exaggeration is happening. People are out there saying that U.S. is worse than Iran because of Pretti. This is just not reality. Being pissed by Trump's low class presentation style doesn't justify this much of divorce from reality.
Throwaway05
22hr ago
It isn't quite as universal as all that, procedural skills and procedural specialties for sure need that, for medical specialties you can usually do a decent enough job with adequate extended length education and case simulation.
However the specific problem you are talking about kinda stems from improvements - as surgical technology and medical management improves you don't need to do certain kinds of things as often. This is great! But some things you simply cannot be allowed to do alone for the first time without decades of experience pecking at the margins to improve skills in aggregate.
This means that the number of surgical specialists needs to be restricted by supply of ill patients, and furthermore by supply of academic centers that can actually train them.
If you gave the SE federal funding for 2,000 extra general surgeons they just ....couldn't do a good job. The NE might be able to figure it out.
Throwaway05
22hr ago
This sounds good until you create more work by being incompetent. Psychiatric NPs are famous for doing this by putting patients on unsafe medication regimens that increase total burden to the system.
Throwaway05
22hr ago
It's complicated, multifactorial, and hard to convey quickly and clearly.
The population, amount of knowledge, complexity of patients, and demands on doctors have all increased sharply. This also means that training is harder and more burdensome, this can be partially fixed by increasing spots but not entirely. At the same time the positives of the profession have decreased (including respect and wages relative to inflation). It makes sense that less people would be interested, that they'd be of lower quality, and that they'd want to work less when they are in it. Back in the day you could hang your own shingle and become truly wealthy and some people did that, working 2-3 full time jobs worth of patients seen. People don't do that anymore nearly as much. Likewise we've adjusted who we choose to be doctors away from mercantile money types and hard working autists. We have more need, more complex work, less people doing to relevant to the population, and those each doing less work.
A bigger problem is the allocation one. Most of the types of work are not primary care but most of the volume of patient doctor interactions are primary care. You need to encourage people to do that, in the area that needs them, but the job is no fun, harder than other, and pays less - a solution of "pay more" does help with the problem but is gloriously unpopular for the obvious reasons.
Throwaway05
23hr ago
If you'd like to deep dive into the causes I recommend sheriff of sodium on YouTube.
Throwaway05
23hr ago
I will absolutely complain about affirmative action in medicine but the problem is a bit more complicated - for instance we've decided to push away the autists in favor of socially minded types. This is both good and bad.
Throwaway05
23hr ago
It's worth noting that PAs do get a somewhat condensed version of the physician curriculum, but NPs do not actually learn regular medicine.
That sounds ridiculous and it is. It should also stress you out and if it does, good.
Throwaway05
23hr ago
This an outdated meme, wrote a bit more about it elsewhere in the thread.
Throwaway05
23hr ago
Wrote a little about this in my general comment elsewhere in the thread.
Throwaway05
23hr ago
I'm sure you know this but it's worth reemphasizing that the amount of stuff a doctor has to know has absolutely exploded in recent decades.
Compare the size of First Aid for Step 1 between now and 2004.
Related: the us training model worked much better when most of patient care was hopes and prayers.
Throwaway05
23hr ago
Okay batching out my usual response to this:
-Most people don't have a good feel for what doctors actually do, your intuitions for your outpatient PCP are probably good, but outside of that something like The Pitt is more representative than general OP clinic life, and when you ARE in the hospital and you see your doctor for under five minutes it isn't because they are just chilling in an office somewhere doing nothing. This will be important for AI later.
-No the AMA is not conspiring to cause a doctor shortage. That's an outdated meme for the 70s and 80s. For the last few decades the AMA has been lobbying for an increase in supply via the production of midlevels (for senior doctors to supervise) and watching that genie get loose from the bottle. The AMA is also extremely unpopular with doctors, most doctors want more med schools and residencies, and we HAVE made more med schools and residencies. As it turns out what is actually happening with the shortage is (shocking!) highly complicated (ex: my rants about surgical modality changes making it so we can't really increase the number of surgical training slots anymore).
-The healthcare industry and government have been workshopping this problem for a long time. They've landed on midlevels as the solutions. As designed they work okay but they quickly metastasized beyond that and are a catastrophe. Putting aside the quality difference which yes is very real, they generate more shortages in some cases by over testing (which requires physician evaluation) and over consulting (ex: cardiologists are flooded with work that midlevels cant handle but is easily within PCP physician scope of practice).
-Decreasing training length by making undergrad medical school is a mixed bag. It works well in other countries with less economic opportunity and a less painful training period. In the U.S. you get lots of career changers into medicine (and you'd lose these) and drop out rates are reasonably high in med school/residency, this would worsen that problem. Think of all the Indian moms who would decide their 16 year old will be a doctor long before it becomes clear if that is reasonable. I don't know the drop out rates for BS/MD vs. traditional MD but I bet it's bad.
-AI is obviously coming but it's incredibly far from prime time. This is for a number of reasons. Risk: if we aren't allowed to have self-driving cars and it's taking forever but any accident is an unacceptable travesty...how much worse are people going to handle an AI getting things wrong? Lawsuits: people want to be able to see. You can't sue the computer. This is also one of the problems with midlevels, you cant sue them the way you can sue doctors. Hospitals like this. The actual work: most types of physician tasks aren't "I have x, y, z, how do I treat this?" Usually you are managing several comorbid conditions that overlap, trying to interrupt what the symptoms the patient tells you actually means "I am dizzy" means different things to every patient and will send you down different rabbit holes. Patient's who can't communicate well or have to be visually eyeballed and examined are a huge part of the work. That's not counting physician leadership roles (aka motivating the nurses) and so on. The types of ambiguities that exist in actual clinical practice are huge barriers to AI taking over. It will happen one day but by that point everyone has lost their jobs.
Let me add a little bit -
The constraint is fundamentally ensuring adequate training quality, you'll see people here saying that isn't necessary and maybe they believe it but shit that doesn't seem wise.
People with more knowledge than anyone here (including me) have been working this problem for a long time, the approach is two fold - yes they have been increasing the number of medical schools and residency slots, maybe not as much as required but they are trying. Every year a large tranche of students doesn't advance to the next level of training. We have room to optimize this and interest in doing so.
The other piece has been an explosions in mid-levels, they suck frankly, and have expanded beyond the intended use case while in some ways making the issue worst by overusing specialists. If a US doc wants to retrain to cardiology they need like 2-5 years training. A midlevel needs zero. Guess who makes a better cardiologist?
In most cases the issues are things like allocation problems (which mid levels don't fix, they don't want Gainesville either), a decline in work done by physicians (increasing administration burden, malpractice, and decline in compensation and people work less), a decrease in years worked (turns out women drop out more and faster) and other complicated things like that.
Stealing doctors from other countries is a popular solution and it has some ethical and practical problems (prior to recent political changes everyone wanted to come here, we cant steal from everybody! Additionally if you import enough to depress the wages the reason for coming dies off). However they do seriously need retraining, I don't have access to the private stats but best I can tell the two most common causes of residency termination are intractable substance use and terminal inability to survey the mandatory retraining.
With respect to AI, you can't rubber stamp every case needs actual review to make sure you aren't missing something or you'll be using the doctor as a liability sponge.
AI will come eventually but it isn't ready yet.
AI can't solve procedural work (that's robotics), inpatient work is as much coordination and other soft skills as medical knowledge, and outpatient work has a lot of social components (including the usual things, but also stuff like realizing what the patient means and says are different things).
AI is not ready for that level of ambiguity. It also can't be sued, which the American patient demands.
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