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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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