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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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