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It would seem there are some things that benefit from a focus on hyperspecialization at an early age, and some things that don't.
Chess and gymnastics? Absolutely. Medicine or personal training? Not so much.
Totally agree. The practice of Medicine just isn't that deep. It's some pattern recognition (sick / not sick), extracting the right features from the patient (patient says "man my chest feels weird" and figuring out if they mean chest pain, shortness of breath, etc.), heuristics (this cluster of signs and symptoms matches this), and then a short decision tree (D-dimer --> CTA).
It turns out that at the end of that relatively shallow decision tree, if you can't figure it out, 99% of the time it's not because there's a Dr. House moment waiting on the other side, it's because nobody knows. Sometimes that's -- well we've discovered that you have stage IV pancreatic cancer. Here's a clinical trial but otherwise that's the end of human knowledge. Sometimes it's "well, I don't know why your chest feels weird, but we've ruled out the bad stuff so let us know if it gets worse!".
And obviously there's bad doctors who can't go through that without fucking something up along the way. Maybe there's even a lot of them? But outside of a small handful of surgical subspecialties (like you do open heart surgery on babies), I would guess that there's not much difference between an 90th percentile doctor and a 99th percentile doctor -- and almost certainly not between 99th percentile and 99.9th percentile.
I hope you're not a doctor.
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As is usual when this kinda thing comes up, time for me to jump in and defend the field.
Doing medicine isn't what people expect.
For most specialties the hard part isn't knowing what to do for any specific patient (outside of fields with technical skills like surgery, or fuzzier guidelines with broader knowledge bases like Psychiatry), it's balancing all of the tensions of medicine. Some things are complicated. Radiology needs to know everyone else's shit. Neurology involves tough, at times technically challenging physical exams that are actually meaningful for diagnosis.
However most patients really only interact with primary care or basic bitch outpatient medicine, and then they go "I can toss this shit into google and get myself the diagnosis and the management." Yeah you can, we get paid for knowing the situations where the first hit on google is wrong, but that doesn't seem to excite people so let's talk about the other shit.
The hard parts of medicine include the long training period, brutal hours even as an attending physician, working nights, weekends, holidays, and 24+ hours in a row. Managing multiple types of intensely dysfunctional bureaucracy (the government, insurance, the hospital system, medical records), dealing with constant death and bad outcomes, writing notes that need to be clear for whoever is coming on to replace you and will protect you from getting sued if you fuck up, or if you don't, and doing all of this an environment where people are screaming, constantly trying to get your attention, and with a chair and keyboard that a homeless shelter would reject for being too gross.
It's the summation of requirements, including empathy and related fatigue and burnout, and also the necessary customer service/patient interaction skills, and the need to be doing stuff other than your work constantly like basic research and the need to continue to study continuously every year for the rest of your career...
Most doctors are teachers, researchers, and all kinds of other shit in addition to the doctor.
Balancing all this stuff without becoming an alcoholic or killing is absolutely a challenge and well, we see high rates of both of those things in the MD population.
I can't really think of many jobs that combine reasonably high intelligence, massively high work ethic, significant administrative burden, massive hours, catastrophically poor resources and equally disruptive customer service needs.
Takes a lot to balance.
To put some context in, most jobs involve things like lunch breaks and misc. downtime during the day where you can shoot the shit, unwind, and refocus. It's extremely common for a physician to work 16+ hours with barely enough downtime to piss and shove a flaccid banana down your throat like a two dollar hooker.
That's absolutely foreign to most sectors of the economy (including nursing).
I'll note once again that the way to fix "My job is hard mostly because there are so few of us that we have to work long shifts with many patients and it is exhausting" is to lower standards and introduce more workers into the job, making it easier and reducing the standard of quality needed to perform the job, which would allow those lower standard workers to perform at the necessary level.
What you're describing is the inefficiency of a medieval guild system engaging in rent seeking.
No no, it's not simple like that. For one, patient handoffs are so dangerous that one of the reasons we work stupidly long shifts is because someone so sleep deprived they are drunk is safer than having someone else come in for a complicated patient.
For another, we've been part of a multi-decade long project to remove the "guild" and reduce training requirements to bring in replacements. When I first started complaining about this the jury was still out, it's back - and it doesn't work. NPs and PAs have much less exhaustive training requirements and have been in place and growing for years. They suck. They don't save any money because increased testing costs money (it's just a transfer from the doctor to the hospital) and the increased testing and consults create burdens any everyone else. NPs and PAs just consult everything, overloading the sub-specialists even more. Radiology is near breaking from unnecessary testing.
Train more doctors you say. Sure, fine. Except that that takes a long time, requires professors and other resources (we don't have enough cadavers for anatomy lab already) and things like surgery specialties don't have enough procedures to adequately train in a timely fashion. You need to see a variety of cases and patients and advancements in medical care have made this harder (which is mostly good but not for this specific issue).
Import foreign doctors you say. Okay better. Yes most foreign doctors are very much not as good. They are also mostly good enough, especially after retraining. But then you are stealing doctors from other countries, which you know, need them. You are also stealing jobs and wealth from Americans, which is sometimes justified but most of the people making this complaint don't like it when it happens to them or people they like.
In the longer term you'd kill Americans going into medicine, and Americans going into medicine and our absurd wealth is responsible for a huge amount of medical advancement.
Even if you fix the hours worked issue (which for most specialties is a problem during training more than anything), you won't remove the other major causes of burnout which include administrative burden, malpractice, American patients, fucking dealing with dying people, and so on.
Man, the goalposts are moving around so much that I can't even remember if this is a home or away game anymore. But let's chalk that up to exhaustion and address what you're saying point by point.
Our learned friend in argument @was started this discussion with the statement:
So sure, fine, we need a few hero-genius doctors willing to work insane hours for complicated patients. That doesn't really address the majority of patient needs, the majority of interactions that a typical individual has with a doctor and with the medical system, which typically are simple checkups and checkins and outpatient procedures and don't require constant observation. Why are we incapable of discriminating between those tasks and assigning appropriately?
That's fine, no one brought them up. The whole argument I'm making is that improving access to doctors will be a positive, even if the doctors that one has access to are not hero-geniuses.
All the more reason to start today. Not doing something because it takes a long time is setting us up for the same problem ten years from now. Pipeline problems require time to address, but you have to start. And what we're seeing today is downstream of what we did 40 years ago:
The physician shortage of today is the result of policies then. Do you think that the percentage of Americans who meet those rigorous hero-doctor requirements declined as a result of those changes in slot-availability, or do you think that fewer Americans who were capable of doing the job were being trained? So now we're downstream of those policies facing a shortage, we should give up? It will take institutional knowledge and years of training-the-trainers to come to fruition, so we should never start?
Also, RE: cadavers. Pay for them. Or make it opt-out rather than opt-in. We've got the dead bodies. Not having enough cadavers is a question of will, not some immutable law of the universe.
So, at this point, we get the whole story lined up directly: adding a large number of inferior doctors will be good enough to keep the system moving, but it would reduce the wealth of existing stakeholders. This is called rent-seeking. Look, if you want to work brutal hours in a hellscape because it will make you good money, that's mostly* your right. But then don't complain about it and attack the solutions to the brutal hours and the hellscape. Either this is a good deal you want to preserve, or it isn't.
Why would making more residency slots available for Americans kill Americans going into medicine? You know what increasing med-school spots and residency requirements would kill? Affirmative action. If every qualified applicant gets a spot, who cares who gets priority. And why would improving on a system which you say sucks kill applications? You say:
Ok, let's get you a piss break, and maybe even lunch and an afternoon smoke break. People aren't going to want that job?
*There is some point at which I'm uncomfortable with a job being done at all if it requires inhumane working conditions or incredibly low wages. But we're talking about different universes than medicine, like when I saw the illegal immigrant tree planting crews that a landscaper near us hired for an industrial job planting three inch caliper birch trees without any power equipment. Three Americans could have done the whole job in a day with a mini excavator you can rent at home depot, instead these guys were breaking their backs for days to put them in, paid piecework so ultimately a significantly sub-minimum wage. At minimum wage it wouldn't be profitable to have them do it, and you'd have to have somebody with a backhoe doing the work.
The average patient's average interaction with a doctor is not complicated. What patient's don't generally realize is that is a small fraction of the overall work done by doctors. This is true both because more complicated patient's and problems take up more time but also because they have more interactions, and more kinds of interactions. Family Medicine is bread and butter outpatient appointments, but nobody else is. Every single interaction Emergency Medicine starts complicated or can go from simple to complicated at the drop of a hat, and needs to be treated as complicated for that reason and for others like defensive medicine. Entire specialties like Radiology and Pathology never see a single patient or outpatient appointment, and complex surgical specialties will see someone for five minutes in the clinic but only after all the work is done. Even when the thinking part is simple other parts of the workflow or not. An anxious 20 year old comes in with chest pain. It's MSK or anxiety, not a heart attack. But if you have to rule out the heart attack just in case. Remembering to do that is not hard. Triaging when to do it when you are balancing everything else, knowing what level of intervention (EKG? Sure. Echo? Absolutely no. Trop? Maybe, but if we do serial trop the patient might leave) is hard, and communicating this to a stressed patient again while balancing all the other tensions in your job is hard. Non medical people, and even medical people underestimate the level of intellectual challenge in medicine, and yes it doesn't require as much horsepower as being NYC PE person, but it's not a small amount....but it's only one slice of the job.
NPs/PAs are important because society decided that you are right, and they came up with this plan. And it sucked. It was decided to be the best plan, and it made everything worse. Other solutions will have similar problems, otherwise we'd have done them.
All the billionaires get together and decide to donate a 100 billion dollars to improving U.S. medical education to increase supply of doctors. Some things can be fixed. Some things can't, even with infinite financial support. One of the biggest problems is that doctors want to go where the people and society are because they have to give up years of their lives in training and don't want to live in upstate NY or Arkansas. Fine. 100 billion. Offer them 3 million a year and they'll go to the places that need doctors. You can fix that problem with infinite money but we don't have infinite money and its extremely unpopular to raise doctor salaries so even if you increase the supply all you'll be doing is improving supply in a few geographic areas and depressing salaries in them. Not helpful.
Some things just can't be trained. Surgeons require a certain number of procedures to be proficient. If we don't do them often enough because we don't need to then you can't train them. Plenty of programs cannot handle more residents because not enough stuff is happening to adequately train more than we have. You can increase the numbers mildly in most specialties but somethings it just won't work. With 100 billion you could bribe people to get extra, unnecessary surgeries or to use outdated modalities that you only do in emergencies, but that would be grossly unethical.
Year after year going into medicine becomes less popular. People quite and burn out and it's not because of the hours its because of other stuff like lawsuits, lack of respect, administrative burden. None of what you are talking about addresses any of those. Cut salaries by further increasing supply and you'll get less Americans in it.
Foreign doctors aren't free and without issues. Patients complain about accented doctors all the time. Training is inferior in most countries. This is a real problem. Stealing them from other countries is an honest to god additional ethical issue you can't ignore. Often (like with other forms of importing) they become trapped and subjected to poor working conditions.
What's your job? If you are posting here, probably tech? How do you feel about outsourcing? Americans are losing job, the product is terrible quality, most workers hate it and most employers hate it because it sucks, but go with it because cheaper is king. I don't want your job to go away, and you don't either. That applies here also.
The typical model of rent seeking is something like NYC taxi cab medallions. You can more or less costly increase the supply with maybe some mild increase in traffic and a significant decrease in salaries. Again that is not the case here. Importing foreign doctors is vaguely possible if you are okay with decreasing the value of American healthcare (which is a massive segment of the economy) and reducing quality of care (which you don't believe is important) and reducing salaries (which you don't care about at all) but you can't do a lot to increase the total number of American medical grads because their isn't enough work to properly educate them.
You're putting a lot of words in my mouth, which I'll attribute to your repeatedly mentioned intellectual exhaustion.
Quality of care for the average patient will improve with increased access to doctors. Which can most easily be achieved by increasing the number of doctors.
I'm admittedly not in medicine, but growing up basically all my high school best friends wanted to go into medicine. Only one out of seven still wanted to go into medicine by junior year of college. These were all guys with SAT scores within a shout of mine in the mid 2200-2400 range. Why? Because they looked at the available slots and realized that if you have the misfortune to be white or Asian and interested in medicine, you face a series of gatekeeping processes that heavily limit your odds of making it. Return to the article I linked:
And that's after you get into med school.
I argue that much of the lack of interest from top students in going to med school is that 57% chance of not getting into med school at all, followed by extra gatekeeping and artificial systems that might still leave you without options and certainly leave you without prestige. Much of it tied up in racist affirmative action policies and destructive undergrad competition. Why not opt out and go into consulting or finance or tech, as many of them did, where you've got a comparatively high chance of making it into the industry and little gatekeeping to prevent your rise after you are employed?
Make it seem easier to become a doctor and more people will become doctors. Make being a doctor seem less horrendously awful, as you repeatedly claim it is, and more people will want to become doctors. Create more doctors and more of them will choose to move to Arkansas. These things are really economics 101 stuff.
Alternatively, I'm sure we're only a few days from Trump proposing that doctors shouldn't pay taxes.
As for foreign doctors, my general belief is that we should not restrict immigration of high human capital candidates. Every (legitimate) Masters degree should come with a green card stapled to it. If we need to do outside testing to insure quality, let's do it. But that's a technical issue not a strategic one. Regardless, that's not a solution I'm proposing.
It's possible, because I've had this conversation many, many times and nobody seems to learn or listen, but calling me "exhausted" is straight up ad hominem.
You won't catch me saying the affirmative action policies are good, but there still aren't a large number of minorities present in medicine, it's mostly the Whites and Asians involved in the rat race. People drop out/abandon because it doesn't seem worth the money and they can't hack it, which they will often not admit.
With the tensions present in medicine today we can't get doctors to work where we need them with salaries we have, but all of the suggested solutions to the problem reduce salaries...
You'll get worsening shortages, or more realistically the two tiered system we've started to develop.
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How do you handle this when you do eventually have to switch off? I'm imaging trying to hand off a tricky piece of software to a new team every 24 hours - I guess a short interview plus some notes? How complicated is a complicated patient?
As is usual for us there's a whole bunch of different ways this happens. I'm going to simplify some of this for ease of reading.
Surgical rounding team (ex: post-op patients). A team of 4 residents manages 80 post-op patients they know nothing about. Some of them are very complicated, but they are complicated in a relatively small number of ways that can be picked up and put down as needed. Someone prints out a hand out from the computer that tells the residents everything they should need to know, which is generated automatically. Some particularly weird situations get handed off verbally. Nobody remembers what was said. Every X amount of hours the team changes over or new people come on and off. Shift times are generally vague, they exist on paper but emergencies are constantly happening and surgeries run long. One intern (first year resident) who doesn't really know anything about anything is hypothetically in charge of making sure floor patients don't die, while everyone else hides in the OR as much as possible. Handoff risk: low-to medium.
Radiology. You finish your worklist and everything is done. No handover. Ish. Handoff risk: low.
Medical floors. During the day 12 residents manage 120 patients. 2 them stay overnight or two fresh people going on to work 16 hour nights for a week straight. If something happens overnight you hope it's someone you know, otherwise you look at the chart, the notes are good because it's medicine, ideally if something complicated is expected to happen the day team told you about it. Sometimes they don't or it's a new problem. Fuck. Also the nurse will call you at 10pm asking for an update on the discharge plan because the family asked. You don't know because you've never met this patient before and never will. Handoff risk: normally low-to medium, but sometimes high.
Surgery. You don't hand off, you can't. Handoff risk: incredibly high, but because the docs stay until they are done, low. If the surgery has NPs/PAs involved (most typically Anesthesia). Can be hugely problematic since they don't have responsibility and try to stick with shift times.
Surgical/Medical ICU. Patients have failures of multiple organ systems. Documentation is good and on paper tells you what is up. In real life you lose track of how often fluid or blood products went in. Complicated stuff happens constantly. You takeover a patient and have to tell their kids and their mom is going to die. You've never meet the mom. Actually that was the other patient. This person is a dad and is fine. Fuck. Okay now someone else is dying. How many units did the first person get again? You've worked 90 hours a week for the last two weeks. Handoff risk: fuck my life.
Obviously I'm making this sound more ridiculous than it is for the most part, but in real life we do endeavor to write good documentation that supposedly allows an oncoming doctor to pick up the patient, we have handoff reports with automatically summarized information, and a verbal signout (or written via computer for like a weekend daytime doc on a psych unit) happens. But the reality and complexity of the situation often gets in the way.
Lots of research has been done to get this as safe as possible, and it works to some extent, but you can't substitute for actually knowing the patient and being the one who did the surgery or admitted them last week.
Thank you very much for the explanation.
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This is exactly what I think every time I see the
argument. It seems pretty likely it's easier to select three people who can competently work 8 hour shifts than one person who can competently work after being awake for 24 hours.
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This is being a nurse, not a doctor. Doctors can triage, but also have to understand the intricacies of the body well enough to publish research or prescribe drugs.
What percentage of doctors publish research?
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