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A lot of things are going on here, some of which are a bit more complicated to get the full picture on like the historical issues with hierarchy and abuse.
Two simpler bits:
-You don't decide where you work and learn during training and if you leave, quit, or get fired you are done. Sometimes with upwards of 500k in debt. Programs know this and will mistreat trainees knowing they can't vote with their feet and their lives are pretty close to over if they don't suck it up. Suicides and deaths from things like sleep deprived car accidents aren't common per se but are frequent enough that we all know multiple people who went out those ways.
-Unlike most high education/high skill labor you need a lot of 24/7 coverage and physicians are very expensive and in high complexity specialties like surgery you have to do a FUCKING LOT of stuff to become independently proficient in a reasonable number of years. The solution is typically to rely on trainees and long hours. On paper Residents aren't allowed to work more than 80 hours a week, must get at least 4 days off in a month, and aren't allowed to work more than 24+4 hours in a row. On paper. Very common for people to violate one or more of those in an easy specialty at an easy program. In something harder like procedural specialties? You might work 80-100 hours a week with an average of four days off a month.
For 5 years.
Shockingly!!! Substance abuse, mental illness, and medically measurable premature aging (fun study that one) are rampant.
This breaks people down and I think could be reasonably considered torture.
Add on the fact that you can't leave, and many other aspects of the training can be considered abusive (said things that are a bit harder to explain)...
I can't believe we even have doctors, given this system. I wouldn't live like that for 5 years even if the payoff was a trillion dollar lump sum.
This is why you'll frequently see us claiming the ability to easily retrain into other jobs if healthcare collapses. Effort substitutes well for a lot of talent and getting through medical education is tremendously difficult and outright traumatic, but if you can do it you'll be able to do most things.
This year a U.S. medical student got two olympic gold medals. She had to pause training to do it but that is the kind of aspirational insanity you'll often see in the field.
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Wow I had no idea the state of medicine was so bad. Jesus.
So are you saying that the state of residency is sort of justified by the difficulty of the profession?
How would you do it differently if you had the magic wand of 'fix up the medical training system'?
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Plenty of other crap is going on and much of that presents easier targets - excess regulatory burden, administrative overreach, wellness modules, U.S. malpractice environment, etc.
A large swathe of the central problem is that Americans doctors are expensive (so hiring more staff for instance is...difficult) and at the same time Americans won't work in American healthcare without those salaries (because of things like the American patient population, malpractice and so on). It makes bigger fixes extremely hard.
Many kinds of surgeons are just fucked - medicine has improved, which means we do surgery less often and the types of surgeries we do are more complicated and harder to learn. It's an order of magnitude or more easier to learn how to remove something from an option approach (think just cutting someone open) than a laparoscopic approach but the latter is much much much better for the patient. Finding ways to make this not extend training time is a nearly intractable problem.
However, a sensible target is malpractice insurance. Doctors do fuck up and do fuck up in ways that should involve penalties but functionally these seems to be entirely separated from who actually pays and gets penalized in our current system. Malpractice insurance alone for OB can be over 150,000 dollars a year. That's insane.
Stronger unions for residents and attendings is probably also a good idea. Unions can absolutely be bad but we are far off from the point where that's an issue.
Likewise kill some various forms of rent seeking and other bad behavior like egregious non-competes, physician boards that costs of tens of thousands of dollars, substance abuse programs that also costs tens of thousands of dollars if you somehow manage to get caught smoking weed, etc.
On a structural level you can probably free up money that can be use to improve healthcare and reduce burden on doctors by targeting various middlemen and administrative horseshit. Fire the front desk staff to pay for an extra useless diversity or infection control administrative and the doctor just adds that job to the list of things they do.
Walk that back, the ratio of clinical to administrative staff is insane and grows worse every year.
I'll try not to blather too much but however bad you think it is it's a lot worse. A classic example is the fact that the population of people we've selected to be doctors might be offered the option of working in NYC or getting paid 300k more a year to work 2.5 hours to the northwest and they'll pick the city. Shit's fucked.
Sidebar: 24+ hour shifts were taken away and then brought back because most people (including residents) thought they were better than the alternative. Which sounds insane and is.
Do you know how the medical system ended up in this fucked state in the first place?
On the training end it's relatively easy, residents are called residents because they live in the hospital, attendings are called attendings because they attend rounds (and then go home). This was initially somewhat sustainable because the level of respect associated with being a doctor was very high (therefore allowing the whole thing to not be a total social catastrophe) and because work was small (because billing and admin requirements were low and we didn't.....have many meds or other shit we could actually do). The whole thing got started by a guy (William Stewart Halstead) who was a huge coke addict but we didn't realize until his training model became the thing). It stuck around because things like the U.S. is wealthy and this process sucks so salaries are high which means that hiring actual night staff to replace is hard. Add in U.S. pro business decisions (lots of our bodies have antitrust exemptions and so on) and it becomes sticky.
Larges swathes of this stuff exist elsewhere though, because being a doctor has several fundamental shitty elements. You deal with the worst parts of society. You are at physical risk in a variety of ways that does not apply to most high education labor. People die, that's traumatizing and so on and so on.
Lots of the other stuff is harder to explain.
Where did America's obsession with lawsuits come from? Not entirely sure, but it's possible to get sued and objectively done the right thing but to have your malpractice settle or end up in a ten year lawsuit that you eventually lose (or win with a lot of stress).
Ya got something specific you want to target and I'll try and comment.
Thanks for dropping Halsted’s name, it led me to these papers explaining how it spread across America:
How or when did this model become unsustainable?
I mean, is it unsustainable? It sucks but one of the reasons we let it go is because residency is temporary and when you are done with residency it's great. Not sure THIS PORTION of US healthcare is gonna collapse.
Ah ok, when you said “initially somewhat sustainable,” I interpreted that to mean that it’s no longer sustainable
I supposed tolerable would have been a better word choice in my initial post, as I'm not sure if it's truly unsustainable or not (you'd think it'd collapse, but you'd also think it would have collapsed a while ago at this point). Certainly it made more sense when it was first a thing, less so now.
The "everyone bitches about residency" while in residency (and it truly is profoundly awful) is well counterbalanced by "almost everyone shuts up when they are free of it."
The U.S. healthcare system as a whole? Fuck that's gonna need some changes or it will die. It's also doing very well in some ways (like quality of care) and everyone is going to be fucked when demographic crisis creates severe rationing on caregivers for the elderly.
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Do you think there's any value in weeding out the people who can't cut it? Or do you lose valuable people who'd actually make decent doctors?
I think it's somewhat difficult to tell, we lose the most people in preclinical years of Medical School (typically year 1 or 2, which is the drinking from a firehose traditional coursework) and in the transition to Residency. Both of those seem appropriate times for people to realize they can't hack it or don't want to.
Residency creates a trickle drain of people too burnt out to continue with some definitely being people who need to go. The former might be generated by the process as much as assessed by it however, which is tricky.
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Wait but you were saying earlier that it's hard to hire people and doctors need more support because it's expensive. Wouldn't the admin staff help with this??
Oh trust me I am pretty severely blackpilled on the Western medical institution, although I do admit that modern medicine has miracles aplenty. My mother's life has been saved on three different occasions by relatively recent medical inventions. So I'm grateful.
But I also wasted over $20k in my early twenties trying uselessly to figure out my chronic pain issues with TMJ, sciatica, RSI, and other various health stuff. Was told by multiple doctors I'd need surgery if I ever wanted to use a keyboard and mouse again. I'm pretty close to recovered now but... anyway that's a story for another day lol.
I didn't realize they were taken away! Ugh yeah it's so fucked. I've seen studies on like the efficacy of doctors based on how long they've been on shift and it's terrifying. Going to the hospital seems like such a crapshoot luck of the draw type situation in some respects.
Think admin like university admin - hospitals are laden with nursing executives, management and so on who at best ensure compliance with various regulations but often are just money drains. Admin in the sense of support staff would be great. Feminism has caused some of the pain here - support staff used to be competent women because it was women's work, now it is often people who can't get other forms of work (not saying I think the change is bad, just noting it).
says nothing about aggressive, trigger happy proceduralists
With respect to patient safety basically the research says that hand offs (to new doctors) are bad and sleepy doctors are bad. About as bad. It's cheaper to overwork the doctor so we go with that. If you've ever studied overnight or stayed up late gaming it is tempting to think of it as the same thing. It is not. Saving (or risking) a patient's life in a fugue state on hour 30 of no sleep and not realizing you'd done anything at all until 20 minutes after the fact is fucking horrifying.
In any case the specific thing with duty hours is that in the 16 hour max shift world you'd just be expected to stack 16 hour shifts indefinitely. With 24s you typically manage to get a "post-call day" meaning you'll do something like 8am-to 10am the next day, but have the rest of the day off "to live your life" aka pass the fuck out, which enables something resembling recovery.
These days the option is typically to take the sleep deprived resident/fellow or have a midlevel who works nights. I don't know a single doctor who'd ever take the midlevel over the physician, no matter how tired.
Ahhh I see. Ty for all the explanations.
Wow this sounds horrific. I can't imagine. No wonder doctors are emotionally repressed and not able to handle healing modalities that incorporate emotions. Brutal. I actually am gaining a lot more sympathy for doctors reading your responses.
Do you have any recommendations for like picking a good time to schedule a surgery for instance, as a patient? Or finding a good/competent doctor?
Being a physician (in general, not just the U.S.) is a very strange mix of job attributes, you need to be reasonably bright, hardworking, educated, dedicated, some baseline level of ability in connecting to others and it tends to generate what you'd expect from that description, reasonable amounts of prestige, good compensation, job security. However you also have the total opposite. Brutal scheduling you don't usually see in the white collar world, constant exposure to the worst segments of the population, incessant abuse and threats (sometimes physical) from patients and even other staff, lots of death and misery... Theirs a reason why bed side manner is often so limited, and why substance abuse and other bad outcomes are rampant in MDs and RNs.
That said people often feel it's worth it because of the good you can do. It's only within the last 10-15 years that the vibe really changed for the worse.
With respect to getting good care...it's extremely difficult. I can't tell most of the time if it's outside my areas of knowledge and social connections. The things that make patients feel like they are getting good care are very frequently orthogonal to actual quality. Classic examples are things like "oh yes I know my body and this needs an antibiotic" "yeah sure fine" "wow what a great doctor!" (that was a bad doctor).
Avoid the temptation to assume good bedside manner or vibes equals good doctor. Often it means people pleasing or good salesman (but not always, especially in disciplines like Psychiatry). Same with spending less time with you, could be because they are busy and over-scheduled and doing a lot of good, or could be because they are greedy and trying to do too much.
How do you protect yourself? Stick with academics, private practice has a higher ceiling but it's hard to tell who is actually good, in academics you tend to have multiple eyes on everything which is very helpful. Doesn't have to be the tippy top, just trainees in general means better care.
All kinds of lore exists for this, for instance an orthopedic surgeon might tell you that you want someone 5-10 years out of residency so that they've had time to develop and practice technical skills but they aren't so far out that they've gotten stuck in their ways and have fallen behind on advancements in the field. However individual ability variation and procedural expertise is so variable that I don't really think you can use this rule.
The gold standard would be things like finding a PT, and asking "which physicians in your area seem to have better outcomes when you follow their patients for outpatient therapy after the surgery."
That kind of stuff is nearly impossible for a lay person to suss out, and even if you have friends you can ask you run the risk of them having maligned incentives or poor insights into their own technical skills or judgement of others.
Do you know anything about healthcare systems in other parts of the world? Would you recommend medical tourism to anywhere?
Depends on what you mean. With respect to differences in the trainee experience, not as well as I'd like. Well enough to answer the question of "how do I get a good doctor in X country?" No.
For the question at hand, plenty. INCOMING RANT.
TLDR- No the U.S. has EASILY the best healthcare system in the world.
You'll note that for the most part the people who say we (the U.S.) have a deficient healthcare system are the same ones making all kinds of other claims we (as in the average Mottizen) have immense concern about.
If you can afford it (which is admittedly a big if) the U.S. still offers the best healthcare in the world. We often see people throw out outcome measures but they tend to be misleading. The U.S. is stuffed with obesity and other comorbid conditions and ....other forms of intractable problems that naturally lead to bad outcomes. Those same people would do worse elsewhere.
If you already have a rare genetic disease, an incurable condition, cancer, or DM2, CHF, and COPD - you'll get the best care here, should you be able to afford it. You may be more likely to end up with problems here, but you'll get better treatment.
That's because we are rich as fuck and have tons of resources and a huge chunk of global research is done here. Doctors also get paid more than elsewhere which means we drain everyone else's doctors and researchers, likewise we also work more than elsewhere which means more experience and faster care. Our training is also the best, often to a comical degree (which makes sense - we suffer through those hours and people are motivated by the pay). That's the carrot that goes along with the sticks I was whining about.
Wait times are a big difference with Canada, you may complain about waiting two-three months to see a neurologist in the U.S. but you'll wait two-three years north of the border.
Medical tourism does have a role, especially if you don't have unlimited money, but it's very easy to get grossly deficient care, end up with "customer service" care, or other problems (see: BBL complications). If you know the one hospital in Mexico or India that actually has good care that might turn out well, but it's still an actuarial game - if you have complications from anesthesia you are way more likely to die abroad, for example.
Also watch out for things like rationing and end of life care differences.
Other stuff adds some complexity here, as the U.S. does have some problems and while some European practice guidelines are inferior to our some are probably superior or more beneficial to such and such population of patients.
These tend to be very specific things though that don't alter the main point.
Scott would probably say something about the FDA, approval processes, cost disease and so on. Yeah people die because we take awhile to approve stuff but as far as I can tell we also make certain kinds of mistakes less frequently. It's complicated and individual patients can fall in or out of favor of those trends but ultimately it's likely the better structural approach.
Does that answer the question?
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Whew well that's both depressing and reassuring, knowing that there's not much I can do anyway hah.
Thanks again for all the detailed replies my friend.
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