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Yeah, this is the eternal threat, right? But ok, what are these people going to do? How many jobs in America are there that pay as much as medicine and aren’t ’top of the corporate pile after a 40 year career’ type jobs?
Very, very few.
A few jobs in big tech. A few jobs in front office high finance. A few jobs in big law. A relative handful in (other) professional services.
None of those professions have medicine-tier job security. All of them (save maybe big tech) have very long hours. All of them are ultra-competitive.
Doctors on the internet always seem to assume they could be investment bankers or deepmind engineers instead, but I don’t think they could. The truth is that medicine is a lot less competitive and more midwit than most of these jobs. Plus, most of these jobs have an extreme up-or-out career progression that medicine just doesn’t have. Of a thousand junior investment bankers at Goldman Sachs who already passed an application process with a 1% acceptance rate, how many become managing directors or seniors in PE? Maybe thirty or forty. Most end up failing out into comfortable PMC professions, often paid less than many medical specialties and again still with far, far less job security.
Plus, there’s status. Nobody in modern American society has higher status than doctors, not billionaires and certainly not bankers, lawyers or engineers. That also has value - socially and for one’s own ego - that can’t be measured solely in pecuniary terms.
Even if medicine paid half as much there would still be doctors. There are still huge numbers of bright eyed, intelligent college students with elite credentials who want to be journalists.
Journalism is a non-central case because there's a very large non-monetary compensation in the form of influence/power.
Most journalists even at the NYT don’t have very much influence/power.
It's highly nontrivial to get "very much" influence/power, and the main ways involve quite a bit of luck. Journalism reliably gets some, can get quite a bit, and while it's tricky to get "very much" strictly as a journalist, journalism -> politics isn't unheard of.
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I know you hate that argument so I very specifically didn't make it this time.
Based off your historical unwillingness to update your understanding of anesthesia compensation and work duties I don't think we are going to have a fruitful discussion on the doctor skills/role and work alternatives side of things.
By the way, and I truly am sorry if you’ve gotten that impression, I have a great deal of respect for doctors. I think you do a great job, and I think you should be well-paid for it. And and, I think doctors’ pay is only one part of the issue with the US system’s immense inefficiencies, of which a great deal can be laid at the feet of Congress, insurance companies (not out of ‘evil’ or even the profit motive, but just because of the perverse regulatory and incentive environment they’ve been out in), the way big pharma is funded and to some extent the tragedy of the commons.
My only real ‘thought’ on doctor pay is that we should have more doctors. Let’s train them, let’s import them (from native english-speaking countries with decent standards, like our peers in the anglosphere), let’s do whatever it takes to increase residency spaces. And let’s make residency easier, let’s limit medical liability to bring down the ridiculous cost of malpractice insurance, let’s make medicine an undergraduate course like it is elsewhere so doctors don’t have to waste four years and more money going into debt.
But yes, ultimately, let’s work to bring down some salary costs. Is that so unreasonable?
Do these people want to come? I'm not sure they do.
Usually when this conversation comes up what happens is that I say something like "sure increase supply just don't compromise quality" and then someone says "being a doctor is easy, there aren't really quality differences or problems" I recall this argument from you in the past but if you don't endorse it now no problem, but ultimately most supply increasing options involve compromising quality in some way. Americans are mostly uninterested in decreasing quality, but if we decide that's on the table then we have a lot more tools available to solve some of these problems without touching supply at all.
Also, right now we seem to be in a situation where shortages are pronounced enough that the market can absorb a much higher number of physicians without bringing salaries down. In fact we likely need to increase salaries (specifically: one of the biggest problems right now is that people will refuse to work in red states or rural areas, these jobs already offer higher salaries, sometimes as much as twice as much, but in some cases that's not enough).
We already have some evidence that salaries are too low for some needs, taking salaries down further is liable to make those issues first (and again does little to decrease the overall healthcare costs).
Paging @self_made_human
I believe he’s one doc who wants to come! And I would have him. Hell maybe I’ll even marry him to get him over here.
Heh, it's a dream alright. If you're willing to marry me, I'll promise to be the sub ;)
LOL you better. I couldn’t handle being with a doctor who’s also a dom. Sounds intense.
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Is this a ‘flyover’ issue that clears up for Miami, or is this progressive lying about Texas laws again?
A good half of it is medical people being hysterical idiots about "right wing legislation." Dumb shit for sure.
The other half is people refusing to work in rural Mississippi or whatever because they are educated, selected to be blue tribe, and want to actually have fun when they finally have the money and ability to actually choose where they live.
Stop being woke AF and this will self correct to some extent.
A lake house and a boat and a housekeeper(because getting paid $300k+ in Mississippi makes domestic labor cheap) isn't enough of a draw?
No, running theory is that the people in the pipeline currently are simply too culturally blue and want to avail themselves of big city resources when they finally have the ability to do so.
Given how many people leave residency single there is also the reality of finding a partner, and since most people want a class/wealth/intelligence equal and being a doctor isn't really a draw anymore, they go where the other young professionals are (and stay).
Totally get wanting a class-equal partner. But, uh, what are 'big city resources' in this context? You can travel(the usual blue tribe luxury AFAIK) from Atlanta or Houston or DFW about as easily as from NYC, and having to drive in or take a connecting flight doesn't seem like that big a deal? I can kind of grasp that the blue tribe doesn't want a lakehouse/cabin in the woods or a nice deer lease very much because they'd prefer to travel internationally, but everyone wants a nice big house with a housekeeper and a handyman, right? There's gyms and bars and decent restaurants and whatnot in flyover.
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I would be interested to hear @self_made_human respond to this, if willing.
Doctors from the Anglosphere?
Yes. At least some parts of it.
For example, British doctors are massively disgruntled, and a significant portion of them are trying to leave the country, though as always, the majority of people anywhere don't really want to emigrate. When Brits run, it's usually easier to go to Australia or New Zealand, where wages are markedly higher, work life balance is better, and their credentials are recognized as equivalent with little faffing around. Some opt for Canada.
Aus/NZ doctors are largely content, and only a small number want to move, and when they do the US is their goal most of the time.
If licensing regimes like the USMLE were relaxed for these specific countries, I doubt you wouldn't see a 2-5x efflux, comparable to the boost in salary they'd see, even if the working hours are worse.
Hell, I'd go if I could, I opted for the UK because I didn't have a better choice for long and painful reasons. Depending on how the job market looks in 3-6 years and if the barriers go, I could well be tempted in the future.
I'd say doctors from these countries are competent, especially native ones, I've certainly been nothing but impressed. They make do with shit wages and a QOL that is worse in many ways because of the UK being a stagnant country, but they're sticking around both because of inertia and because the US isn't easy to go to. They're seeing their own wages stagnate, and face stiff competition from international medical graduates (like yours truly, I have to look out for my own interests), training is unnecessarily long and painful, and many don't need more than a nudge to reconsider.
Thanks! I guess for context I considered you as "part of the Anglosphere", although there are different degrees of centrality to that concept. I remember you had a couple (interesting, IMHO) posts a while back about how difficult the US regime would have made transferring your education credentials.
I'd imagine most people here would consider the "Anglosphere" to be the Commonwealth countries plus the US, I doubt India would come to mind for them. While we have a gazillion English speakers, it's not strictly the language of the majority! I would hope that I qualify for honorary membership nonetheless haha.
I'm uniquely screwed when it comes to practising in the US, I won't elaborate since you seem to recall my moaning before, but even in an ideal world, I'd be looking at the USMLE and 3 years of residency. I haven't heard of anyone actually getting those requirements waived if they're a credentialed specialist elsewhere, but that could be my ignorance as opposed to me denying @Throwaway05 's claims. It's not a formalized route at any rate.
I suspect what's happening is that in general you have to redo residency but they keep it open as a possibility to get things waived in order to potentially steal somebody important. That resolves the tension between the anecdote (which I agree with) and the language on the website.
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IF the US wanted to poach British doctors, you could get about half of them (including some of the ones who are currently heading to Australia). Please don't. I love my family, and several of them are dependent on healthcare to stay alive.
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Same! When I see this online it's mostly people bitching about the U.S. being terrible but I'm sure that's not representative of how people actually feel.
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From my experience talking to Anglosphere doctors, you would instantly collapse British, Canadian, South African, and probably Australian/New Zealand healthcare if you opened up the American medical system. (Don't laugh about the South Africans, they turn out some incredible doctors.) The big issue I've heard from them is less about the objective difficulty of getting US certified, and more that you're sacrificing even more years of your youth on a particularly pointless altar.
I 100% believe they want to come here for South African (I actually had supervisor at one point who was South African, he was incredible). Australian, and NZ healthcare actually pays comparable to the U.S. to the point where we have people going there. I'm sure if you opened it up you'd get a mix in both directions. Canada is already pretty open to transfer with the U.S. is my understanding with some jobs making the same some making less, some making more.
Britain is the odd one. Granted redoing say IM/FM/Peds/EM residency here is only three years and be a huge life gain. They don't seem to sign up for it. Most of the time I see this online it's associated with a bunch of anti-Americanism.
It isn't just "three years" - it's "three years of hell", and if you are doing it for the second time to tick a bureaucratic box, it's unedifying hell. People who are already upper-middle class don't put themselves through just to double their salary. You either need to offer enough upside potential to take the winners out of the upper-middle class (startup founders, finance jobs) or something that speaks to the soul.
Also those are the specialties that are at the bottom of the food chain in the US in a way they are not in the UK, so they are the ones where the benefit of moving is least. NHS GPs who want to graft can make as much money as successful surgeons.
I was initially going to say something about this not being be that bad in those specialties and then realized my understanding of what is too much work is now pretty much forever broken.
And yeah it's bad, but it's instructive. I am amenable to the idea that every hour of US and UK training are roughly equivalent, but if US trained physicians are getting that many more hours of training it really does a decent amount to justify the need to retrain to US standards. Yes those hours rapidly have diminishing returns, but I find most foreign doctors are willing to admit that training is better and more thorough here (in part because of stupid oddities of our system, in part because we have more resources than everywhere else, or our population is less healthy, or just sheer weight of hours).
I wasn't claiming that US residency was worse than being a junior doctor in the NHS (I have no idea if it is or not) - I was saying that being an early-career medic is a crapsack lifestyle anywhere because of the intensity of the training plus the amount of medical scutwork you have to do to justify the senior doctors paying attention to you plus the hazing element of it all.
Three years of "hell" that gives you the power to heal the sick is worth it for both career and soul reasons. Doing it again for mere money when you already have a ticket to the upper-middle class - well I'm sure the dignity of a British doctor has a price, but it isn't cheap.
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From the UK? I assure you they do.
Why don't they then?
I wasn't able to find a good single source of truth but medical students can do it (which Scott did(ish)) if they are interested. It's harder than it would be a for a U.S. grad but likely much much easier than an Indian medical school grad.
The BMA website implies that some "adult" (saying it this way because I can never remember the British terms) doctors may be able to come over without any specific retraining but does not provide details.
Training is probably somewhat worse in the UK but not enough that I'd have any complaints about anyone coming over (although this would obviously be bad for the UK).
The one I'm married to wanted to in 2014/15. She passed the USMLE had her ECFMG certificate, recent clinical experience in a western European native English speaking country and didn't require visa sponsorship as the spouse of a US citizen, applied to a variety of programs and failed to match, not even any interviews. ☹️
I appreciate the N!
Most of the countries that seem to match into residency in the US seem to have pretty well developed infrastructure to help explain what to do, outside of that its hard to know what locations are programs are realistic. It's a brutal process even for US MD grads.
:/
She may want to try again. Any advice on trying following a ~10 year career break?
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You need to redo your residency if you want to become a US doctor even if you are a consultant with 15 years of experience in the UK. That is enough of a barrier that prevents people from coming over, never mind the extremely onerous visa requirements the US imposes on foreign professionals of every trade and type.
The official stance of the BMA per their website is:
"Doctors who are already on the UK specialist register may be able to apply for partial exemption from the residency programme requirement. To check if you are eligible, you should contact the relevant specialty board in the US."
My guess is that the answer is not yes or no but "it depends."
It happens a handful of times a year for people who are usually elite figures in surgical and clinical specialties, for example the surgical director of a top UK hospital trust hired to run a similarly-sized team in the US (who, for reputation’s sake, is still expected to do some surgery/clinical work on the side), or a renowned psychiatrist hired by a US university/teaching hospital whose application is obviously expedited for similar reasons.
For any normal senior doctor they will in 99% of cases have to redo residency unless they’re a global figure of import, presenting in top slots at the bigger international conferences in their field and have a lot of people on side in the US.
So sure, if you’re a towering figure in ophthalmology and are friends with half the people on the leadership committee of the American Board of Ophthalmology or whatever and get hired for a top position at a hospital in NYC or LA then you can probably skip it and they’ll wave you through. Otherwise, the possibility of an exemption is a myth.
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