Doctors are part of a guild. They artificially limit the number of doctors available by capping the number of medical schools, which also allows the existing schools to crank costs to astronomical levels (“don’t worry, you’ll make enough to pay it back”).
One thing that would help is letting non-MD’s, such as nurses or physicians assistants, do more “doctor” things. Dentists, a similar profession, is going apeshit that states are trying to let specially licensed assistants (but non-DMDs) do slightly more advanced work like fill cavities.[0]
The entire health system from top to bottom would benefit immensely from free market forces.
> Doctors are part of a guild. They artificially limit the number of doctors available by capping the number of medical schools
They do not. You may be confusing the AMA (which less than 25% of doctors even belong to) with the AAMC. The latter does cap the number of medical school positions nationwide, but they've also made a concerted effort over the last ten years to increase that number steadily.
But even if they eliminated that cap entirely, it wouldn't matter, because the number of medical school slots isn't a bottleneck for the number of practicing physicians. The number of residency slots is, and the funding gap for that comes from Medicare, which is responsible for funding them.
Unless more residency programs are funded, increasing the number of medical school positions would simply increase the number of people who have medical school debt and aren't licensed or trained to practice medicine, which would be even worse,
> which also allows the existing schools to crank costs to astronomical levels (“don’t worry, you’ll make enough to pay it back”).
Hardly - in fact, there's already been significant downward pressure on these, because the debt level is already at the tipping point. Today, the typical person who enters medical school can expect to pay off their medical school debt in their 40s. That level of debt load is already having a negative impact on qualifications for medical school applicants (who wants to be past child-bearing age by the time they've paid off their debt, when they can just go into another better-paying field without any of that)?
> In recent years, the number of medical residents has become so restricted that even the American Medical Association is pushing to have the number of slots increased. The major obstacle at this point is funding. It costs a teaching hospital roughly $150,000 a year for a residency slot. Most of the money comes from Medicare, with a lesser amount from Medicaid and other government sources. The number of slots supported by Medicare has been frozen for two decades after Congress lowered it in 1997 at the request of the American Medical Association and other doctors’ organizations.
I was confused by that part too because the article goes on to say teaching colleges "have an incentive to offer residencies in specialties from which they can get the most revenue per resident."
My guess is the 150K number ignores the revenue contribution of the residents (which must be significant because they carry out a significant amount of the work that requires a doctor at a hospital)
I did a google search and found one article that seems to confirm this: "Whether the programs are ultimately costs or moneymakers for hospitals is mostly unknown. Expenses tied directly to the programs are tracked, but overall cost-benefit accounting that would take into account such things as savings or lower medical bills for patients from the use of lower-paid residents instead of practicing physicians isn't done." http://www.modernhealthcare.com/article/20150719/news/307199...
The argument that federal funding is the only way to create more educational "seats" for doctors seems strange since the article claims they are paid much more than other fields, and is not really laid out well in the article.
> but overall cost-benefit accounting that would take into account such things as savings or lower medical bills for patients from the use of lower-paid residents instead of practicing physicians isn't done
This is talking about the cost-benefit from a societal perspective, not from the accounting perspective of the hospital. From an accounting or business perspective, it's pretty clear that residency programs don't make money for hospitals.
An easy way to reason about this is to remember that nothing's stopping hospitals from opening up residency slots that they self-fund. If residency programs predictably broke even, you'd expect them to do that. Except, almost no hospital does this, because the programs don't predictably break even - in fact, they pretty predictably lose money.
It's not that strange. Medicare has a physician fee schedule (PFS). Hospitals don't receive a PFS payment for services provided by a resident, unless a teaching physician is physically present during the key portions of the service, or under certain primary care exceptions. I'm not sure how private insurance companies do it, but I wouldn't be surprised if their rules weren't similar.
A similar thing is happening in the legal field. Clients wont pay for work done by first or second year lawyers, so large firms are cutting back entry level hiring and many smaller firms have stopped hiring entry level lawyers entirely. Thus you have a bizarre situation where there is a huge oversupply of JDs, but private-practice associate salaries continue to go up because there is a limited supply of experienced attorneys.
They don't receive the PFS payment, but they certainly do for room fees, imaging, labs and other diagnostics, not to mention medications.
And the patient is still tended to by nurses, who do absolutely generate revenue for the hospital.
While they don't get a PFS payment, we also can't provide that Medicare pays for the residency and then everything else is a charity case for the hospital.
That argument doesn't respond to whether it's "strange" that residents are unprofitable. It's just the unsupported assertion that certain unquantified ancillary payments will exceed the unquantified costs of employing and supervising a resident. But clearly they don't, or else hospitals would create more resident positions.
The charge is that hospitals are not creating more residencies in order to collude to drive up doctor salaries. Even if residents were profitable, but less profitable than experienced physicians, it would still be a rational business decision—rather than improper collusion—to hire physicians instead of residents.
That explanation makes sense (except partially for the sibling comment's point) but there is still something strange there.
In market terms, this is clients saying entry-level workers with lots of education provide zero value, or the risk outweighs the benefits. If that's true, it means that people need training until 30-somethings before they are valuable to society. Or our education system is broken.
Or it's not true and it's market manipulation. Given the choice between "no service" and "pay a fair entry-level price", many people will pay something.
And if/when they cann't get a job, the state then revokes their credentials. Hilarity ensues.. Oh did I say hilarity? I meant the spiral of loss of job/homelessness/garnishment/destitution. And it's then illegal to use the credential to try to make money to recover from.
Talk about being sold a bill of goods - Come get a degree from here, and if you can't find a job, we'll garnish you and remove your ability to use the degree you're being garnished for.
Not if the government already pays for it. Why open up self-funded slots and show that the government doesn't need to pay for it? If you make a small profit, you are just putting the other pure profit slots at risk...
> Not if the government already pays for it. Why open up self-funded slots and show that the government doesn't need to pay for it? If you make a small profit, you are just putting the other pure profit slots at risk...
I somehow doubt Hospital A, which has zero residency slots and receives zero residency funding from Medicare, cares if Hospital B down the road somehow loses their subsidies.
There is no "pure profit slot". Residency programs do not make money for the hospital. If they did, hospitals that do not have residency programs would open self-funded residency programs, and/or hospitals that already do have residency programs would expand theirs.
It is possible that if the AMA or others is intentionally restricting the supply then any hospital that started its own residency could have trouble hiring regular doctors. I am not claiming this is the case, but it is one reason that hospitals might avoid something that the free market would indicate.
Hospitals do not do their accounting in a normal way. When you or your insurance gets a bill, the doctors are often listed separately. In other words, patients pay for them directly for services, they are not paid as employees of the hospital. That means for residents, someone's got to pay for them. They are not seen as lower cost labor because doctors are not accounted for as high cost labor. I'm not sure how it's done, but it's not the same as interns in engineering.
> Are you sure it's not just a case of Hollywood style accounting?
Yes, for the reason I said:
> An easy way to reason about this is to remember that nothing's stopping hospitals from opening up residency slots that they self-fund. If residency programs predictably broke even, you'd expect them to do that. Except, almost no hospital does this, because the programs don't predictably break even - in fact, they pretty predictably lose money.
Even if you don't trust the accounting numbers, you have to trust the overall (lack of) incentive for hospitals to create self-funded programs.
I agree with this logic about "if residency programs predictably broke even" but I don't see any concrete support for that in the article. They don't have an accounting of revenue per doctor or at least the article has not shown one.
Saying the benefit is social benefit doesn't help here, obviously it is it's a hospital, there needs to be revenue numbers in the mix to talk about breaking even.
re-reading your comment "This is talking about the cost-benefit from a societal perspective, not from the accounting perspective of the hospital." I think perhaps you do not understand what residents do. Residents handle a portion of the patient workload. They provide direct economic benefit to the hospital by handling patient workload at a lower salary than more senior doctors. There is a hierarchical system by which work is reviewed by more senior doctors but this is used in all hospitals regardless of whether there are residents. The economic benefit to the hospital is that residents do the work for lower salary than doctors. Putting that into dollar terms is what this article has failed to do, likely because the data to do so is not there.
> I think perhaps you do not understand what residents do.
Given my background, I understand exactly what residents do.
My point still stands. Even if you don't trust the accounting numbers, you have to look at the end result.
Let's assume that residency programs are, at the margin, profitable for hospitals. Let's also assume that hospitals like profit.
- The statement "residency programs are profitable (at the margin) for the hospital" is logically equivalent to "increasing the number of residency slots (or programs) would be profitable for the hospital".
- If increasing the number of residency slots (or programs) would be profitable for the hospital, there would be more of them.
- However, there aren't - the number of self-funded residency programs has been (essentially) zero for decades.
Therefore, one of our two assumptions must be wrong. Either residency programs are not, at the margin, profitable hospitals, or hospitals just like turning down profit.
"residency programs are profitable (at the margin) for the hospital"
No, there are many options between 'profit' and 150k costs.
The question is can Medicare increase the number of residency's without increasing Medicare's costs. And because of the excessive number of specialists with higher associated costs the answer to that is clearly 'Yes'.
Thus, the cost of a residency slot is not inherently negative 150,000$/year. It's very possible for residency's to break even without hospitals to have any incentive to implement them, further that 150k/year provides profit even with the current mix.
> No, there are many options between 'profit' and 150k costs.
Why are you bringing $150,000 into this? That's the median debt load of a resident - it has nothing to do with what a hospital makes.
> The question is can Medicare increase the number of residency's without increasing Medicare's costs. And because of the excessive number of specialists with higher associated costs the answer to that is clearly 'Yes'.
I... don't even understand what point you're trying to make here. The point is that hospitals cannot generally provide self-funded residency programs, because they lose money on those programs.
Yeas, it's true that not all residency programs cost the same amount - some fields are more expensive than others. But it's not like we're trying to optimize for the total number of residents in the system at any time; the reason we have more expensive programs like neurology is because we need neurologists. Yeah, we could "save money" by training them in EM instead, but then that'd just mean an even greater shortage of neurologists (and even higher market wages for neurologists).
Because 150k/year is the current subsidy per resident. People may reasonably not want to spend more money on this, but it's hard to argue with spending money more efficiently.
You're demonstrating that hospitals do not consider residency programs to be worth funding, but you aren't helping us understand why, which is the far more interesting question.
There are multiple factors at work, only one of which is funding.
Residents are required to handle a minimum number of a large variety of cases by the time they graduate, in order to guarantee that they've seen a representative sample of cases in their field and have knowledge of all of them. E.g. a neurosurgery resident might need to do (completely fabricated numbers) 30 open vascular cases, 50 spine fusions, 40 tumors, etc. This is probably the primary limiting factor for specialist surgery residencies; these residents are profitable (they can handle the bulk of most simple cases fairly autonomously once they're a couple years into their training, and they stick around for 5-7 years), so many hospitals would like to hire more of them, but there are simply not enough patients with the necessary conditions for them to add more trainees.
For non-surgical residencies, the residencies are much shorter (so you have less time from highly-skilled residents), and the residents are less profitable, so funding is a significant limitation.
It's also important to note that residents are competing with mid-levels in the "less expensive practitioners" category, and mid-levels are a far better deal for the hospital in most specialties. They're somewhat more expensive in terms of raw salary, but they remain mid-levels, which means they have the time to develop near-perfect competence at the things they do handle, and they don't leave just when you've trained them up. A few good mid-levels make all the difference in keeping a department running smoothly.
> You're demonstrating that hospitals do not consider residency programs to be worth funding, but you aren't helping us understand why, which is the far more interesting question.
Because they... don't make money if they do?
I don't know how to make it any clearer. The costs of providing additional residency slots (paying resident salaries, paying additional attending salaries, paying taxes, paying insurance, etc.) don't bring in enough additional revenue or offset enough other costs to be worthwhile.
It's not particularly complicated math - it's the same arithmetic a McDonald's franchise owner has to do to decide whether to hire another person to flip patties, just with bigger numbers attached to it.
The way to make it clearer would be to discuss specifically why the services rendered by residents are not valuable enough to cover their costs.
A concrete example: I've had a resident do a checkup while I was in the hospital. If they hadn't done it, a fully trained doctor making a lot more per hour would have needed to. Did the hospital lose money on that checkup? If so, wouldn't they have lost more money if the fully trained doctor would have done it? If they make money on that sort of thing, what kinds of things are the opposite?
I don't know how it works, I've only ever been a patient. It seems like you might know, so I'm asking you how it works. Do you see how "they don't make money" is really not an answer?
> A concrete example: I've had a resident do a checkup while I was in the hospital. If they hadn't done it, a fully trained doctor making a lot more per hour would have needed to.
You're assuming that, in the absence of the resident, they'd be hiring an additional attending physician. In reality, they'd just have a smaller staff, and you'd have to wait longer, the doctor would have to work longer/harder/faster, etc to cover the same patient load.
Hiring a resident doesn't bring in additional revenue. Insurers don't reimburse more per patient just because an additional physician was involved. Hiring a resident doesn't bring more patients in the door, because that's not the bottleneck for hospitals anyway. It does increase costs, because it's an additional person on staff - they have to pay them an extra $51,000/year, plus 25% of the cost of an additional attending physician to supervise them (and three other residents), plus taxes, plus health insurance, plus insurance to practice medicine, plus licensing fees, and so on.
> Did the hospital lose money on that checkup?
Probably not, unless you're on Medicare or Medicaid - in which case, yes, they do lose money on you on a per-patient, per-service basis.
Great point about how it isn't a question of the same service at a different price but of avoiding poor service which would otherwise have to be accepted because of the distorted market for health care that makes it hard to effectively punish poor service.
Are residents that much less effective? Do they require so much supervision?
If residents are just cheaper doctors, then hospitals would optimize for a high resident:attending ratio.
So what is it? As far as I know, in hospitals residents are really cost effective doctors. Yes, sure, they don't do the big fancy operations, but they are very capable.
It might be that hospitals have other parameters to factor in. Maybe if there would be too many residents compared to regular doctors, people would flock to other hospitals. And so on.
Oh nice! This is what I'm interested in! What kinds of things can they and can't they do without supervision? What is common in practice? Is there a good place to read about how this all works?
Then ... that means the supervision of residents is not working. That basically means, it's useless. (Since it'd make sense to apply the maximum amount of supervision when a resident is new and as the resident gains trust, decrease it.)
Or of course it means, that attending doctors do a constant amount of (insufficient) supervision, or they ramp up supervision after someone screws up... :|
Residents are cheaper doctors, but they are cheaper because they are less trained, less experienced doctors. They aren't equally-capable doctors with lower salary demands.
Sure, but lots of real problems require more than the skill level expected of residents, if nothing else to have reasonably justified confidence that the problem isn't one which requires more specialized attention.
Some hospitals especially teaching hospitals are non-profits. So I don't think the profit motive is sufficient justification. I think it is more likely a capacity problem.
> Some hospitals especially teaching hospitals are non-profits. So I don't think the profit motive is sufficient justification. I think it is more likely a capacity problem.
Once again, "non-profit" or "government agency" doesn't mean "no profit motive". The profit motive affects all players.
This is not-even-wrong levels of reasoning here. Personally, your comments on this subthread, and the confidence with which you've delivered them, will stay with me for a long time, and whenever I find myself nodding along with something that is facilely convincing and authoritatively stated, I'll think back to your posts and remember to be a bit more skeptical, a bit more discerning. For that, I thank you.
For the rest, well, I can't be as laudatory.
>This is talking about the cost-benefit from a societal perspective, not from the accounting perspective of the hospital. From an accounting or business perspective, it's pretty clear that residency programs don't make money for hospitals.
"Medicare pays for services furnished in teaching settings through the Medicare Physician Fee
Schedule (PFS) if the services meet one of these criteria:
1 They are personally furnished by a physician who is not a resident
2 They are furnished by a resident when a teaching physician is physically present during the critical
or key portions of the service
3 They are furnished by a resident under a primary care exception within an approved Graduate
Medical Education (GME) Program"
Crucially, there is no distinction between how much a hospital can charge for services an attending working alone has delivered (1), and how much it can charge for services a resident has delivered, as long as the attending signs off on it (2). You might naively suppose that the "physically present" part of (2) means that both attending and resident are in the room for the dx differential, and through a Socratic back and forth they jointly treat the patient, and you'd be mistaken. And of course, if you're in your final year of residency, or you're a Chief Resident, the oversight an attending will choose to exercise will be perfunctory. Read more about just how much (or little) it take to technically comply with these rules: http://www.hcpro.com/HIM-283624-8160/Coding-billing-and-docu....
Then reread this short, moving piece published in the NYT mag for an illustration: https://www.nytimes.com/2017/10/24/magazine/the-rules-of-the.... As a resident in his third year out of medical school, how was it that the author was able to essentially run his own service if residents are really just stumps of malformed medical errata, all but useless unless they have their hands held by an attending?
Or just ask yourself: how is it that you can give a hospital a senior resident in radiology, or anesthesiology, or dermatology, who is just months away from demanding 350k+ on the job market, cap the resident's salary at 60k or less, and have the ability to work them for up to 80 hours, how is it that a hospital fails to make money here?
Sure, you can go through all the malpractice costs that have to be priced in, the free cafeteria food, the upkeep of the residents lounges. Sure, and Google spends a ton on the great insurance and fun perks it offers too. Somehow they manage to make sure they don't lose money on their employees.
>An easy way to reason about this is to remember that nothing's stopping hospitals from opening up residency slots that they self-fund. If residency programs predictably broke even, you'd expect them to do that. Except, almost no hospital does this, because the programs don't predictably break even - in fact, they pretty predictably lose money.
An even easier way to see you're making things up is to realize that medical residents can earn up to $100+/hr by moonlighting[0], all while they're apparently causing their home institutions to "predictably lose money" while earning an 10% hourly rate.
[0] https://www.staffcare.com/medical-moonlighting-for-residents... and the doctors discussed in this article aren't getting these opportunities after some long rigorous period. One of them was in his second year of residency once he decided to start moonlighting, literally a year out of med school. Again, this goes to show residents are pretty valuable right off the bat, are (overall, generally speaking) a bargain for their home institutions, and only get more financially profitable as time goes on.
> This is not-even-wrong levels of reasoning here. Personally, your comments on this subthread, and the confidence with which you've delivered them, will stay with me for a long time, and whenever I find myself nodding along with something that is facilely convincing and authoritatively stated, I'll think back to your posts and remember to be a bit more skeptical, a bit more discerning. For that, I thank you. For the rest, well, I can't be as laudatory.
Look, I could respond to each of the points you bring up in turn, and explain how it's actually quite easy for those individual statements to be true but still impossible for most residency programs to turn a profit.
But I've been on Hacker News long enough to know that, when someone begins a lengthy comment with an insult that underhanded and that personal, there's no way that they're in the mood for a good-faith discussion, and attempting to engage further in a reasoned debate is a recipe for frustration.
I see you're a relatively new commenter here, so I'll just say: on the off-chance that this interpretation is wrong, and you were looking to have a good-faith discussion on the topic, I'd recommend next time leaving off the personal insults.
Hmm I don't read the quoted text as a personal attack (snarky, okay fine) and I certainly don't see anything "underhanded" about what I posted, but if you think I'm posting in bad faith (all too endemic online, unfortunately), I don't think you can be faulted for not wanting to engage. That's certainly fair. And honestly, if you felt it was personal, I can apologize. Sorry.
That being said, you've made ~15 comments itt, in which you're variously appealed to your own authority ("Given my background, I understand exactly what residents do". Actually, I don't know any medical resident who could make such a statement, given how broad and diverse the fields that postgraduate medical training encompasses are, but sure.), and made repeated statements about what residents are and aren't capable of, all seemingly without citation or reference.
All of which is to say, I think if you could have made the case that the facts and figures posted above, and in this thread, are perfectly compatible with your contention about medical residents being a net financial drain for hospitals and academic centers, you would have done it by now. In that sense, I agree further debate would probably not be very productive.
I was confused by that part too because the article goes on to say teaching colleges "have an incentive to offer residencies in specialties from which they can get the most revenue per resident."
One way this makes sense is how Medicare pays teaching hospitals. A hospital gets $X for a procedure code. If they are a teaching hospital, they get $X+2% (can't remember the exact bump but it's relatively small).
The more expensive the procedure, the bigger the bump for being a teaching hospital. That's the incentive to get residents practicing expensive specialties.
Does it cost $150k/yr of actual concrete costs or does it cost $150k/yr because that's what they're used to receiving and they want the gravy train to continue?
> Does it cost $150k/yr of actual concrete costs or does it cost $150k/yr because that's what they're used to receiving and they want the gravy train to continue?
There's no "gravy train" - residency programs are not self-sufficient without this money from Medicare. It costs a lot to train a doctor, and that's even paying doctors less than minimum wage in many areas[0].
If they were, hospitals would be free to open as many residency programs as they wanted without Medicare's subsidies, except they generally don't. There are very few non-Medicare funded residency positions, and they tend to be very special cases in obscure regions.
[0] The average resident salary comes out to $12.25/hour, which is literally less than minimum wage in some areas.
The fact that residents aren't paid much by the hospitals doesn't mean that the hospitals aren't making a net profit, it would normally be evidence that it is profitable for the hospitals. Even working 100 hour weeks all year that salary would only come to $65k leaving another $85k to be accounted for. Some of that is benefits and some is the time used by doctors to train the residents and by hospital administrators to oversee them. But the residents also do work for the hospital that would otherwise have to be done by doctors or nurses. So I'd expect that they are profit centers for the hospital but I'm willing to be convinced otherwise if someone can come up with numbers.
The hospital doesn't directly receive money for work done. In many cases they get paid for a procedure done by a doctor, but don't get paid for the exact same procedure done by a resident, so it matters who does the work because that directly affects revenue.
They still bill a healthy profit on the procedure done by the resident by way of room fees, equipment fees, lab fees, imaging fees, diagnostic fees, nursing care fees, PT fees, and so forth.
> You have too much faith in the free market. There are all kinds of things that could cause hospitals to not hire more residents.
So far, in this entire thread, nobody has been able to offer one explanation that doesn't ultimately boil down to either "hospitals don't actually want to increase their profit".
Here's a purely economic argument: if there is an expected profit from self-funding but it is less than that from receiving the Medicare funding, and there is a perception that the Medicare funding only exists because the argument has successfully been made that self-funding is not profitable, then making the smaller profit from self funding would put at risk the possibility of receiving the larger profit through Medicare funding, and administrators might determine it is not worth the risk.
Here's a practical argument: perhaps combined with the uncertainty of the above calculation, administrators are humans, for whom the inertia of the status quo "this is just how it's done" is powerful.
That's all speculation, just like your purely economic argument is just speculation. What would provide actual insight would be some understanding of why residencies are unprofitable, if it's true that they are.
> Here's a purely economic argument: if there is an expected profit from self-funding but it is less than that from receiving the Medicare funding, and there is a perception that the Medicare funding only exists because the argument has successfully been made that self-funding is not profitable, then making the smaller profit from self funding would put at risk the possibility of receiving the larger profit through Medicare funding, and administrators might determine it is not worth the risk.
No, that doesn't add up. Hospitals only receive $80,000 per resident from Medicare. If residency programs were profitable at level P, they could increase them from N residents to M residents, where (80000 + P)N < P M[0].
Furthermore, hospitals that currently don't receive any money from Medicare would simply expand self-funded programs, because they wouldn't be losing anything by doing so[1].
There's also no way that hospitals would be doing so much to preserve a mere $80,000 stipend, because increasing the number of physicians is in their best interest - it allows them to decrease their expenses (physician salaries) in the long run.
> That's all speculation, just like your purely economic argument is just speculation.
No, it's not speculation; it's exactly what hospitals, government employees, elected officials, and industry analysts have pretty much all been saying for decades. And it's supported by the actual evidence at hand, including all of the financial figures that they publish.
[0] Of course this doesn't work if P is a decreasing function of either N or M, which is the entire point - it is decreasing, and in fact, is already negative for the current value of N.
[1] Except, of course, if P is negative - which it is.
As we've gone on in this thread, you've provided an increasing amount of actual details on how this works (thanks!) and now express knowledge of external sources that back this up (though citations to those would be useful). Your initial claim read to me as just, "it's simple free market incentives", which is not the same as the more full picture we've gotten as we've gone on, which now includes more analysis of how the Medicare incentive might play out for different decision makers. I feel like that was peoples' point (at least it was mine): an indirect "follow the money and don't worry about why it works the way it does" argument was not sufficient. So thanks for taking the time to fill in a bunch of gaps!
I still think you may be downplaying the impact of the risk calculation hospitals have to make regarding their ability to receive the stipend now or in the future. It may be only 80k, but clearly that 80k is enough to incentive many hospitals to have residents, so it must be material to them to some extent.
Your point about increasing supply of doctors being in hospitals' interest in the long run is interesting, but this is the same training conundrum everyone has: it is often difficult to make the decision to invest in the near term when the payoff is not realized until much later.
I'm sure you're right about all this in general - training people is a tricky and expensive problem for every industry.
Not really, it's just that most people here are simply relying on the very good heuristic that most markets, government (mis-)managed or free, are chock-full of perverse incentives.
In this case, the likely culprit is that accepting residents for less than $150k/yr in sponsorship sabotages their ability to claim that the fair market value of residency training is $150k/yr, and they've calculated that the marginal benefit from accepting a single resident at a lower cost does not outweigh the risk of being forced to provide the same discount to their existing residency positions.
> In this case, the likely culprit is that accepting residents for less than $150k/yr in sponsorship sabotages their ability to claim that the fair market value of residency training is $150k/yr, and they've calculated that the marginal benefit from accepting a single resident at a lower cost does not outweigh the risk of being forced to provide the same discount to their existing residency positions.
So you're saying that hospitals which receive no funding from Medicare eschew this potential profit center (a residency program) so that their rival hospitals can keep receiving funding from Medicare and make an even larger profit?
This makes even less sense than the other theory being proposed, which is that hospitals are eschewing short-term profit in order to increase the expenses they have to pay in the long-term.
> they've calculated that the marginal benefit from accepting a single resident at a lower cost does not outweigh the risk of being forced to provide the same discount to their existing residency positions.
only holds up for schools with existing residency positions, which there are many without. If a residency were profitable without the subsidies, one would expect to see those non-teaching hospitals launching residency programs. Especially so because they don’t have to worry about threatening the subsidies which they aren’t receiving.
> So far, in this entire thread, nobody has been able to offer one explanation that doesn't ultimately boil down to either "hospitals don't actually want to increase their profit".
My wife is in med school, here's my argument based on what I see in her education.
Training doctors is fucking hard.
Profits and business and all of that jazz plays a part, sure.
What I've seen is none of that really matters because hospitals can't even get enough qualified staff to support more residency positions. It takes a lot of work for a senior physician to include a medical student or resident in their daily activities. On top of already having a stressful job, dealing with naivety and inexperience of young doctors makes it very unattractive for doctors to want to participate in the process.
> Training doctors is fucking hard. What I've seen is none of that really matters because hospitals can't even get enough qualified staff to support more residency positions.
Yes, and I don't mean to discount the challenges in finding and compensating enough physicians properly for even agreeing to do this in the first place!
Put another way, what I was saying before is that, even if the costs were linear, hospitals couldn't pay for it (without external funding). But as you point out, the costs aren't linear, which makes it even harder.
Or put yet another way, we can't easily increase the number of residents we train to practice medicine, because we don't have enough people trained to practice medicine in order to train them.
This isn't unique to medicine; we have the same problem with law too[0]. Heck, I even know startups that have complained that they don't have the bandwidth they need to hire and train more people.
In other words, doctors salaries are so extreme because it saves the state government a few bucks when training doctors.
This is pretty common knowledge among doctors of course, who starting at least a decade ago, have started clamoring for more and cheaper places in education programs. These it's tough finding any doctors at all who aren't asking for more doctors in training.
But systematic decisions to defund education, starting a long time ago (like 30 years ago or so) and have continued under every government since. That is the root cause here.
Or you know, hospitals with residency programs could just use of the massive insurance money they make to fund residency positions. It's not like the residents aren't employees or something.. Even the medicaid/medicare procedures are reimbursable.
Medical stuff is incredibly complex. Hospitals aren't making massive amounts of money -- overall the situation is that there are too many hospital beds as insurers push more and more procedures into outpatient settings with better outcomes and lower shared cost.
That's why medical networks are forming -- they put the GPs on a salary, cram in more nurse practitioners and PAs, avoid union contracts that are more common in hospital settings and extract more money from those settings.
So you have lots of implicit and explicit subsidy. Hospitals lose money on Medicare and some medicaid patients, and on no-pay patients who lack insurance. When my wife had my son, the unplanned c-section cost over $40k, largely because of those insane overheads that require subsidy.
i think one of the most interesting things about healthcare is how local it is. Most hospitals around the country are struggling, but there is a subset of large powerful hospitals that are making money hand over fist. They are basically buying physician networks so that 1) they can charge more for the same services by getting facility fees and higher negotiated rates and 2) they can control patient flow from primary care all the way to the hospital. And often that means treating a patient in the most profitable setting to the health system
Sutter is a shining example of this type of health system -- get huge regional scale, vertically and horizontally integrate, control patient flow, and crush payers at the negotiating table. Their prize is having some very profitable hospitals, including the second most profitable in the nation (almost $300M / year in profit at one hospital). And this profit is after paying their execs handsomely
Hospital spending is the biggest driver of cost, in no small part because of practices like the above
Oh totally. These networks engage in all sorts of unethical and self-dealing practices as well.
The Catholic hospital and medical network in my region was swallowed up with Trinity Health, which is a national medical network. Your interaction with a doctor or hospital is entering a sales funnel, where each additional interaction is engineered to generate more revenue for the network.
A family member had a stroke, which was debilitating and had a bunch of after affects. Prior to hospital discharge, the social worker (aka salesperson) drops a packet of nursing homes in the room and demands that it gets filled out by the end of that day. (which is illegal) That packet doesn't include acute rehab facilities, which is contrary to their physician's guidance. The list is sorted by available beds and exclusively consists of nursing homes owned by the medical network.
> Their prize is having some very profitable hospitals, including the second most profitable in the nation (almost $300M / year in profit at one hospital).
Yea, but this is on over $12 billion in revenue. That's less than 2.5% margin.
the article i saw said that the $270M profit was for a single hospital, sutter memorial hospital in sacramento, which does revenue of $3B per a separate article i found.
it is interesting that sutter's overall system-level profit is $370M. i think they have a few other very profitable hospitals as well. they must spend a lot on corporate sg&A and executive salaries (their CEO has a $7-10M salary IIRC)
I think sutters CEO is in the top 3 or so highest paid non profit CEOs, and sutter may be the biggest / second biggest non profit health system in the country, so I don't know that there are many industry comparables
I'd love to see a breakout of corporate g&a vs provider level g&a at sutter vs a set of comparable systems. All that "non-profit" profit has to go somewhere
> Even the medicaid/medicare procedures are reimbursable.
Medicare reimburses rates below-cost. About 7% below COGS, which means they lose money per-patient, even before they have to pay doctors, nurses, janitorial staff, etc.
> Or you know, hospitals with residency programs could just use of the massive insurance money they make to fund residency positions.
The "massive insurance money" is used to subsidize the losses that hospitals make on Medicare patients.
> It's not like the residents aren't employees or something
Great point. And that's why companies generally don't hire employees unless they work they do is profitable for the company. As it turns out, residents are not profitable for hospitals, which is why hospitals don't "just hire more of them".
> As it turns out, residents are not profitable for hospitals, which is why hospitals don't "just hire more of them".
This isn't quite in line with reality. If you familiarize yourself with specific hospital system figures, you find gems like this: Of Beaumont Hospital's 395 residents, 91 are not covered by Medicare and so are paid for by Beaumont. The $57 million for GME represents 4.73% of Beaumont's net patient revenue in 2013, or about $189,368 per resident. [0]
> The 91 residents that are trained within the hospital system without medicaid funding speaks to the fact that residents are in fact employees
...nobody ever said that residents weren't employees? The point is that they are and hospitals aren't going to go out and hire more unless it's profitable for them to do so. (Which it isn't, or else they would have done so, and that article even says as much).
For profit hospitals and doctors do not have to accept medicare or medicaid patients. Non-profits are required to to get non-profit tax exempt status. Some providers are more efficient then others so a statement that medicare reimburses below cost is not accurate. Maybe some procedures reimburse below cost but not all do. It is also not rational for these profit seeking doctors/hospitals to accept medicare patients but they do which directly conflicts with your statement that hospitals only do profitable things. One could argue that medicaid and medicare patients are sicker and there are more of them than most so they provide a larger revenue stream than private insurance covered patients (and they also require more procedures). If you didn't have these patients then your utilization would be lower and therefore your COGs would be higher as well. Also you might not be able to scale your hospital to take on the profitable procedures. Residents are also lower paid which give the hospital greater incentive to have them treat the medicaid/medicare patients as well. So logically it is better to employ more residents if you have sufficient patient load since it would reduce COGs.
> Some providers are more efficient then others so a statement that medicare reimburses below cost is not accurate. Maybe some procedures reimburse below cost but not all do.
I never said all do - I said that in aggregate, Medicare reimbursements are 7% less than COGS. "Efficiency" doesn't really enter the
picture, because COGS isn't driven by efficiency (ie, overhead); it's driven by upstream costs.
> So logically it is better to employ more residents if you have sufficient patient load since it would reduce COGs.
Nope, none of the stuff you mentioned falls under COGS.
> One could argue that medicaid and medicare patients are sicker and there are more of them than most so they provide a larger revenue stream than private insurance covered patients (and they also require more procedures)
This is the classic "we'll lose money per customer, but make it up in volume" argument.
You keep giving me the sense (like with your "7% below COGS" statistic) that you do actually know why residencies aren't profitable, but you keep making an indirect economic argument instead of talking about that directly.
All anyone in this thread is trying to figure out is why folks getting paid poorly to do work that we know costs tons of money (because we see the bills) would incur net negative profit.
> All anyone in this thread is trying to figure out is why folks getting paid poorly to do work that we know costs tons of money (because we see the bills) would incur net negative profit.
Because hospitals have to pay:
- residents' salaries
- attendings' salaries
- health insurance
- residents' insurance (for practicing)
- licensing fees
- taxes
It turns out, that all comes out to a lot of money. And hiring additional residents doesn't really save them much money, or bring in much additional revenue. The costs are greater than the revenue or savings. So, it's not profitable.
> to do work that we know costs tons of money (because we see the bills)
That's a question of medical billing, which is a whole other separate topic. In short: hospitals don't receive anywhere near the sticker amount for those bills, and a massive chunk of reimbursements from privately-insured patients goes towards recouping the losses that Medicare and Medicaid patients incur (as explained elsewhere, hospitals lose money on a per-patient basis for publicly-insured patients).
It seems to me that all of that (both the fully loaded costs of an employee, and the complexity of medical billing) applies equally to any other doctor, with a single exception. The exception is the portion of the attendings' costs that can be "charged" to each resident.
Is it that the additional cost in attendings' time, along with the reduced ability to earn larger sums for complex unsupervised procedures, outweighs the lower salary?
> Or allow people to do internships with normal, non-ER doctors.
Huh? What does that even mean? The only people who do their residency training with EM physicians are residents training in... EM.
> Or eliminate the residency requirement completely.
So... have people who aren't qualified to practice medicine be allowed to practice medicine?
Residency isn't just some arbitrary requirement - it's how neurosurgeons actually train in neurosurgery[0], and so on.
[0] Well, to be pedantic, neurosurgery also requires a post-residency fellowship. But you'd be hard-pressed to make the argument that neurosurgery fellowships could somehow eschew the residency requirement - it's a prerequisite for a reason.
> Well, to be pedantic, neurosurgery requires a post-residency fellowship.
Doubly pedantic: further specialization within neurosurgery (complex spine, vascular, tumor, peripheral ...) is done via fellowship, but plenty of practicing general neurosurgeons ended their training with residency. Source: wife is in her final year of neurosurgery residency. Of the folks in her program who have graduated while she's been around, about 1/2 did a fellowship, the other half went straight into practice.
(I hesitate to post this extremely minor correction, because everything you've said in this thread is absolutely spot-on and a very welcome dose of facts.)
Now that we are discussing facts... please tell us how many doctors you have personally visited that have been required to perform neurosurgery on you? I can't think of a single incident where that has been necessary in my own experience, and yet every doctor I have seen has been required to have residency experience. Rather counterintuitively, most of the time that has seemed unnecessary, and the work was done by a low-paid nurse or technical staff with the doctor waltzing-in at the end to "sign-off" on the results in order to fulfill the requirements of the insurance companies and ensure the hourly-billing rate was well-above what it would have cost to pay a private clinic staffed by the same nurses to do the same work.
So please enlighten me instead of just slamming what seems a fairly obvious point without adding anything of actual substance to the discussion. Because from the perspective of an actual patient it seems rather silly that a nurse can't take a blood test, and a paediatrician-in-training can't study with a family doctor or another paediatrician in a private practice. And it seems absurd that extensive state funding is now accepted as necessary simply to certify someone to oversee tasks like prescribing antibiotics, or signing-off on STD tests, or allowing patients to get blood test results.
No-one is suggesting that neurosurgery should be done by people without specialized training (I would actually think that "residency" is a poor way of measuring competence in that field as well, fwiw). And by reducing the complaints to this rather silly level all you are really suggesting you have no practical answer to the question of why "residency" is a reasonable bottleneck blocking the certification of doctors and keeping the costs of general medical care far above what is actually needed to deliver the vast majority of it that doesn't involve cutting into people's brains.
EDIT: I love the downvotes people, but you would be better off answering the question since I have karma to burn and enough experience with the US medical system to know that "residency" hasn't been necessary for almost any of the medical care I have received.
Residency at an ER isn't necessary for someone to become a pediatrician. Pediatricians do a pediatric residency. You seem to be very, very confused.
> Why have you elevated some bottleneck guild requirement into a general license to write prescriptions? Or sign-off on an STD test? Or allow patients to get blood tests? Or to inform them of said test results?
Literally everything you listed here can be done by a mid-level (i.e. non-MD), and commonly is (though the scope of prescriptions they can write is limited by states, IIRC).
> by reducing the argument to this level you are only suggesting you have no adequate response to the actual problem
I have no idea what you're talking about; I posted a minor factual correction to someone else that has nothing to do with this point. Again, you seem to be very, very confused.
----
In your edit you say:
> I would actually think that "residency" is a poor way of measuring competence in that field as well
Residency is not a tool for measuring competence. It is the means by which that competence is acquired[1]. You demonstrate competence by passing the written and oral boards in your specialty.
> "residency" hasn't been necessary for almost any of the medical care I have received.
May this continue to be true. If everyone were so lucky, the medical system would be much, much simpler.
[1] Foreign doctors who may already be competent are required to go through residency in the US as well; there probably should be a way to short-circuit that and allow them to demonstrate competence.
> Residency at an ER isn't necessary for someone to become a pediatrician.
You may simply be talking past each other here. All of my (now doctor) friends who went through residency pulled at least one, and usually more than that, rotations through ED. I can't imagine all 3 hospitals had wildly different residency programs than the rest of the nation, so I imagine 3-6mo of ED rotation is quite common during residency.
Yes, a 3-6 mo ED rotation is quite common for medicine docs (so is an ICU rotation for surgeons), but that's wildly different from an actual emergency medicine residency.
> In recent years, the number of medical residents has become so restricted that even the American Medical Association is pushing to have the number of slots increased.
This does not sound like a system where students can fulfill their residency requirements working at general care facilities with trained doctors who have years of experience.
> The major obstacle at this point is funding. It costs a teaching hospital roughly $150,000 a year for a residency slot.
So why exactly is there a slot shortage if people can literally fulfill their residency requirements pretty much anywhere? There are plenty of hospitals that could easily use the labor.
Scroll up, Stephen. These quotes are in the thread at the heart of this discussion, and they are pulled directly from the article.
I mean... I appreciate getting downvoted for reading the article and addressing it directly, but if there are indeed adequate residency spots then you are disagreeing with the article and would be better served to focus on what it gets wrong instead of attacking me for making rather rudimentary observations that follow from its core premise.
Right, but I never said there were adequate residency spots. In fact, I think that there aren't[1]. So again, why are you replying to this thread in particular?
[1] however, from what I've seen it isn't a critical issue for US healthcare; we need more mid-levels and to expand their scope of practice more than we need residents. For residents, it would be far more effective to reduce the span of pre-residency training somehow, so that people aren't starting residency with $300k in debt.
I think it is correct. They pushed for a cap, but are now pushing for an increase. ...the AAMC is now calling for an annual increase of 3000 Medicare-funded slots.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4978854/
According to the above article, new programs are not capped. However, the bureaucracy hurdles you are required to jump to establish such a residency program is huge.
Restricting access to medical education (certification) is only one way to restrict supply.
Another way is to require certification for more kinds of activities in the first place.
If Americans want access to less expensive healthcare, why not make it so that some kinds of medical treatment are available from people with ~2 years of education instead of 10? (Yes, the treatment would be inferior, but also much less expensive.)
Also, when IBM's Watson becomes the world's best diagnostician (Any Day Now), what will its legal status be? Probably IBM would be happy with a special exception to the law that makes it hard for other computer companies to enter the market?
> If Americans want access to less expensive healthcare, why not make it so that some kinds of medical treatment are available from people with ~2 years of education instead of 10? (Yes, the treatment would be inferior, but also much less expensive.)
We already have. It turns out that patients generally don't want this. When given the choice, they generally opt for the practitioner with more training (the physician) over the one with less (an NP or PA).
Sure, we can (and do) pass these costs on to the patient, or (in some cases) force them to use the cheaper option, but at that point, you're literally talking about either:
(A) forcing patients to assume the costs of their care directly, either entirely or in proportion; or
(B) forcing patients to use the lower-cost, lower-quality option
Politically, people don't like (A) because it means patients' access to quality medicine is restricted by their ability to pay. And people don't like (B) because nobody likes to be told that they can't have access to the top level of quality (whether or not they're expected to pay for it themselves).
Man, pro tip- always go with a PA over an actual doctor for most general purpose visits. Doctors are waaaaaaaaay harried and checked out of the process. PA all the way. Honestly, even for hard problems I'm half inclined to go with a PA first, just because getting through to a doctor is so difficult, and there's always an easier solution they're going to try to make you prove won't work (to save themselves a little trouble).
> We already have. It turns out that patients generally don't want this. When given the choice, they generally opt for the practitioner with more training (the physician) over the one with less (an NP or PA).
That's because there's no price consequence for the majority of people in that circumstance. If the doctor costs $500 to see, the 2 year example costs $50, and the person actually has to feel that cost, it's very obvious which one they will choose.
Most working Americans get heavily subsidized insurance from their employer; most of the rest get almost entirely subsidized coverage from the government. Accordingly, very few Americans ever directly touch the cost of care. The majority of all Americans never get anywhere near that in fact. That's one of the big reasons why we're spending a trillion dollars per year beyond what we should be.
> Hardly - in fact, there's already been significant downward pressure on these, because the debt level is already at the tipping point.
Yeah, by my calculations, my SO is currently taking home around $-1 per hour in residency. Some reasons: ~50k/year, expensive area, ~400k in loans, 8% interest rate.
I took a slightly more comfy route, career-wise (Ph.D.). Her bank account will likely surpass mine when she's ready to retire (around 55-60).
A bit offtopic, but 8% interest rate on a loan you can't default on sounds bonkers. I'd rather expect something like 0.5 percentage points over the current interbank offered rate.
At the time she's licensed, she'll be over a million dollars behind where she would have been if she went straight into industry. Break even is something like 25 years down the road - even with "high doctor salaries"
I based it on her Biochem degree. Many of her peers who decided against medical school went into medical related fields like pharma and medical engineering.
Every time the topic comes up, you bring up the Medicare funding issue. Every time I explain why that doesn't seem to make sense:
If there are more aspiring doctors than can fill the subsidized slots (there are), you can balance demand and supply by passing some of the costs on to the resident[1]; many will still gladly accept this because of the extreme returns to becoming a doctor.
The fact that they don't allow that happen is not a funding issue.
You can further massively increase the supply at little cost to doctor quality by getting rid of the pointless four-year degree pre-requisite. (vindicating the blame placed on the AMA)
More generally, if demand vastly exceeds supply (as it does here), subsidies can't be the bottleneck. To reiterate the analogy (from the past copies of this exchange), it would be like saying the musical Hamilton can't come to LA because the TSA won't pay for the plane tickets to get the cast down there. No: there is enough demand to cover the cost of airfare. And there is enough demand to cover the shortfalls in resident subsides.
[1] Concretely: instead of funding 100,000 slots at 100%, fund 120,000 at 80% or something like that.
> Every time the topic comes up, you bring up the Medicare funding issue. Every time I explain why that doesn't seem to make sense: you can balance demand and supply by passing some of the costs on to the resident[1]; many will still gladly accept this because of the extreme returns to becoming a doctor.
And every time, I've explained that there aren't "extreme returns" to becoming a doctor. After accounting for all the expenses that physicians are required to pay out-of-pocket (which are not tax-deductible, due to AMT), the expected take-home pay is lower than what a mid-career engineer at Google or Microsoft makes, And the debt load is already high enough that it's discouraging people from entering the field[0][1][2], due to both the size and the risk..
Making medicine an even riskier bet (by taking on an even larger debt load with a longer time horizon) isn't going to solve any of that; it'll just lower the overall quality. At that point, it's more efficient to talk about NPs and PAs than piling on more debt to physicians.
You're citing marginal[1] cases of people that got disincentivized away. That doesn't change the fact that the demand vastly exceeds the supply and has a well-trod solution.
Also, the returns aren't simply monetary, but the fact that you have much higher social status in general that outweighs a lower net salary, even if it got to that point.
>Making medicine an even riskier bet (by taking on an even larger debt load with a longer time horizon) isn't going to solve any of that; it'll just lower the overall quality.
They still have to meet the med school and residency requirements.
>the expected take-home pay is lower than what a mid-career engineer at Google
The typical doctor would not qualify to work at Google.
>At that point, it's more efficient to talk about NPs and PAs than piling on more debt to physicians.
Or, as I said before, lifting the pointless requirement to have an unrelated four year degree. Or applying a whole host of QA feedback loops to the process. That doesn't change the fact that Medicare funding cannot reasonably be called the bottleneck here, for the same reason a subsidy can never be called a bottleneck when there is excess demand.
[1] marginal in the economic sense; not saying they are rare just that they're not common enough to affect the logic
> The typical doctor would not qualify to work at Google.
The top ones absolutely would. In fact, math and statistics (which includes CS, in their categorization) is the second-highest performing undergraduate major for medical school matriculants.
You're kidding yourself if you think that the top students aren't making career decisions between medical school or finance and STEM and factoring in the massive difference in both risk and reward in the process.
> Or, as I said before, lifting the pointless requirement to have an unrelated four year degree.
There is no requirement to have an unrelated four-year degree - or any degree at all. Medical schools could accept someone straight out of high school. Except they don't, because the top-performing matriculants are those with a degree in the humanities, followed by those with a degree in the social sciences. Pre-med, amusingly, comes in dead last.
> the fact that you have much higher social status in general that outweighs a lower net salary
This may be the funniest thing I've read in this thread. No, compared to the other options available for a bright, qualified college student, going into medicine is probably the worst option if you want to optimize for either wealth or social status.
But sure, if you want to propose an incredibly convoluted process for filtering away the top prospective doctors (incentivizing them towards finance and STEM instead, for the better pay and respect), replacing them instead with less-qualified, middle-of-the-pack, independently-wealthy people who are willing to take on an extremely large and risky debt load because they can afford to and they don't have any other well-paying options... fine, go ahead, I won't stop you. If you think that that's the answer, then that means there's no policy solution needed. Nothing's stopping you from finding those people and going to them and encouraging them to take on that debt load themselves and apply to medical school today. They can take out those loans themselves, or use their own money to pay their own way.
But then please stop derailing these conversations by talking about lifting non-existent requirements, or making rather pedantic quibbles about terminology. When we're talking institutional policy, it's perfectly fine to say that an existing subsidy is "the bottleneck", in the sense that, ceteris paribus, increasing it would alleviate the problem and decreasing it would exacerbate it.
>> The typical doctor would not qualify to work at Google.
>The top ones absolutely would.
I was referring to the typical one.
>Medical schools could accept someone straight out of high school. Except they don't, because the top-performing matriculants are those with a degree in the humanities, followed by those with a degree in the social sciences. Pre-med, amusingly, comes in dead last.
But they're not even considering those without a four-year -- that's another cause of low supply.
>This may be the funniest thing I've read in this thread. No, compared to the other options available for a bright, qualified college student, going into medicine is probably the worst option if you want to optimize for either wealth or social status.
You're saying the typical doctor has lower social status than the typical CS job or finance?
>But sure, if you want to propose an incredibly convoluted process for filtering away the top prospective doctors (incentivizing them towards finance and STEM instead, for the better pay and respect), replacing them instead with less-qualified, middle-of-the-pack, independently-wealthy people who are willing to take on an extremely large and risky debt load because they can afford to and they don't have any other well-paying options...
That's a strawman -- the comparison was to doing e.g. 10% more residencies by having them 10% less funded. Still no requirement for independent wealth.
>But then please stop derailing these conversations by talking about lifting non-existent requirements, or making rather pedantic quibbles about terminology. When we're talking institutional policy, it's perfectly fine to say that an existing subsidy is "the bottleneck", in the sense that, ceteris paribus, increasing it would alleviate the problem and decreasing it would exacerbate it.
When you talk about "the bottleneck", has a precise meaning: "this is the limiting factor that must be relaxed for any growth". If that criterion doesn't hold, it's just one of many factors and one of many options to consider.
When you say that Medicare subsides are "the" bottleneck, you're claiming it's literally impossible to have more doctors unless a government agency spends more tax money on it. That's every bit as false as the equivalent claim about Hamilton in LA and the TSA: if the private market is already willing to pay, and to be paid, enough for it to happen, the problem can't be insufficient subsidies, but a refusal to implement well-trod solutions (or the regulations that prevent that well-trod solution).
That is definitely not a pedantic quibble, but the difference between "this needs more money" and "this only needs more money because they're adhering to harmful practices" (like rejecting qualified students who don't yet have a four year degree, which they're apparently doing even if not required).
Iirc residents are a profit center for hospitals, meaning that if they really wanted to, residency slots could be self funded by the host institution without federal funding. That line of reasoning sounds like an attempt at obfuscation (not necessarily by you, but by the hospitals and medical profession in general).
> Iirc residents are a profit center for hospitals, meaning that if they really wanted to, residency slots could be self funded by the host institution without federal funding. That line of reasoning sounds like an attempt at obfuscation (not necessarily by you, but by the hospitals and medical profession in general).
They're not. If they were a profit center, there would be more of them, unless you think that hospitals would willingly refuse to do something that's clearly profitable for them.
There are plenty of reasons to eschew short term profitability for long term profitability and prevent flooding the market. Fwiw my information is gleaned from "An American Sickness" where the Harvard MD writer claims that a resident costs something like 180k but makes the hospital 300k.
If it is the case that the author has intentionally neglected to mention other factors that contribute to a resident being a cost center, I would sincerely be interested to learn about this.
> There are plenty of reasons to eschew short term profitability for long term profitability and prevent flooding the market.
That's not what we're talking about.
What people are proposing here is literally that hospitals are eschewing short-term profit in order to increase the expenses they have to pay in the long-term (physician salaries).
> There are plenty of reasons to eschew short term profitability for long term profitability and prevent flooding the market.
Pretty much in any industry, participants could collude to reduce supply to keep up prices. In practice, such arrangements are highly unstable, because individual participants have huge incentives to break rank and seek short-term profitability. What makes you think hospitals are different?
> Pretty much in any industry, participants could collude to reduce supply to keep up prices. In practice, such arrangements are highly unstable, because individual participants have huge incentives to break rank and seek short-term profitability.
In addition to everything you said (which is true), in this case, the hospitals and doctors have opposing incentives. I can't imagine why hospital administrators would collude to increase their expenses (ie, their employees' salaries).
When Apple, Google, etc. were found to be fixing wages, they were trying to keep salaries down, not bring them up.
> unless you think that hospitals would willingly refuse to do something that's clearly profitable for them.
The original claim you were responding to was that a doctors guild artificially limits the number of doctors available by capping the number of medical schools, the implication being that it leads to higher a demand for doctors and thus higher prices.
Granted that it's a lack of residencies and not medical schools that creates the demand, is creating artificial demand not a reason why hospitals might willingly refuse to do something that's clearly profitable for them?
Are you disagreeing with the OP only on who is creating the artificial demand?
> The original claim you were responding to was that a doctors guild artificially limits the number of doctors available by capping the number of medical schools, the implication being that it leads to higher a demand for doctors and thus higher prices.
That's a pretty fundamental misunderstanding of economics, then. Capping the number of medical schools can't cause higher demand for doctors. It can restrict the supply, which means that the prices will be higher, but it doesn't affect demand at all.
> Granted that it's a lack of residencies and not medical schools that creates the demand, is creating artificial demand not a reason why hospitals might willingly refuse to do something that's clearly profitable for them?
Even if this premise were correct: why would hospitals refuse to do something that's profitable for them, just so that they could pay more in expenses (salaries) in the long run?
> That's a pretty fundamental misunderstanding of economics, then. Capping the number of medical schools can't cause higher demand for doctors. It can restrict the supply, which means that the prices will be higher, but it doesn't affect demand at all.
My lord, that clearly means an excess of demand over supply.
> Even if this premise were correct: why would hospitals refuse to do something that's profitable for them, just so that they could pay more in expenses (salaries) in the long run?
Because they expect revenues to outpace those expenses??
> Well the alternate is capacity. They only have so many doctors on staff to supervise which limits the slots. Think of it as a management problem.
First: residents are doctors.
Second: Yes, they ratio of residents to attendings is fixed, by law, as is the number of hours that they're allowed to work per week. Both of those were fixed because we found that working residents 100-120 hours/week and without enough attendings resulted in mistakes and people dying.
Since this ratio is fixed, it means that hiring 4 more residents also means hiring an additional attending, and you only get an additional 320 resident-hours/week from them. It turns out that this isn't profitable, because if it were, more hospitals would do it.
Yes, obviously, residents are doctors. By "doctors on staff" I meant supervising doctor. The phrase "on staff" usually means permanent staff vs the residents who are temporary.
> the typical person who enters medical school can expect to pay off their medical school debt in their 40s. That level of debt load
Does how long it takes someone to pay a debt off say anything at all about how big the debt load was? You've juxtaposed these sentences as if it does.
Many people pay off their student loans last, as they're usually very low interest. You could have a student debt into your 40s but not because you can't pay it off - rather because it's cheaper than your mortgage.
Why pay off a cheap debt to buy a new expensive one?
People probably pay off their student debts in their 40s as they part of pay off the last of the mortgages and look to finally get rid of other debts.
> Many people pay off their student loans last, as they're usually very low interest. You could have a student debt into your 40s but not because you can't pay it off - rather because it's cheaper than your mortgage.
As explained below, no, the debt load that doctors hold is not very low interest. It's in the line of 8-10%. For contrast, I have credit cards that have APRs within striking distance of those rates, and that's consumer debt.
You seem to be thinking of undergraduate student loan debt, which is heavily subsidized.
Yea, I'm 37 and have about $2,500 of student loan debt left. I could pretty much pay off the balance whenever, but the interest is low, the monthly payment is low, so meh.
> Doctors are part of a guild. They artificially limit the number of doctors available by capping the number of medical schools
>> They do not. You may be confusing the AMA (which less than 25% of doctors even belong to) with the AAMC.
Actually the AMA is the problem. They lobby to uphold the incredibly strict licensing requirements that doctors use to maintain the exclusivity of their job.
Doctor licensure requirements are stricter in America than most of Europe. For instance, why do doctors NEED to do a 4-year undergrad degree before medical school? Why do they NEED to go to a 2+ year residency after medical school? In Europe, students can go straight to medical school from high school.
Each additional licensure requirement to become a doctor decreases the supply of new doctors, increases the salary of current doctors, and increases the cost to consumers.
> For instance, why do doctors NEED to do a 4-year undergrad degree before medical school?
They don't. Medical schools can accept students straight out of high school, as long as they've completed the required pre-medical coursework. They don't, however, because those students drastically underperform their peers who received an undergraduate degree in a different field.
> Why do they NEED to go to a 2+ year residency after medical school?
Because without it, they literally have never been trained to practice medicine. Where do you get the idea that Europe is somehow different? Residency is required (and comparably long) in the UK, Germany, etc.
> Medical schools can accept students straight out of high school, as long as they've completed the required pre-medical coursework. They don't, however, because those students drastically underperform their peers who received an undergraduate degree in a different field.
I guess all those Australian medical schools will be interested in hearing how their graduates "drastically underperform" all these American doctors who did a postgraduate medical school.
Seems to work well enough, to me, as someone who has used physicians extensively in both countries, and worked in healthcare in both. "drastically underperforming" doesn't really fit that picture.
This. Residency is the bottleneck and is funded mostly by the Govt. I'm not a doctor but have worked in healthcare the majority of my career and have family members who are doctors. Doctors deserve what they are paid. Period.
What does "deserve" have to do with it? People who work at Walmart deserve a living wage and a financially secure retirement, too.
If there's an artificial restriction in the supply of doctors (because the government sets an arbitrary limit on the number of residency slots it will fund), then doctor salaries are inflated by government fiat. If we increase the number of residency slots to reduce the price of medical care --- which everyone seems to agree we badly need to do --- then doctor compensation will decrease. You seem to believe that's a bad thing.
Everyone deserves to be paid fairly. There is a difference between a doctor and someone who works at Walmart. You seem to discount the fact that there is infinite demand for doctors in specific and healthcare in general.
why aren't there more residency spots? Why can't people who need to do residency be forced to go to a (more) far away city that has a lack of doctors and be trained there?
Because residency programs are very difficult to operate and require a level of staff that not all hospitals have access to.
The issue isn't with the supply of graduating students, it's with the number of residency spots.
This year 95.3%[0] of graduating students matched to a residency program. Out of 18.5k applicants, only 17.5k matched to an available residency program.
That's an interesting theory. It seems to parallel the situation in the legal field. Unlike in medicine, there's no shortage of JD graduates--there are about twice as many graduates as there are legal jobs for them. But the bottleneck for the supply of trained lawyers is the number of opportunities to get real-world experience, which is limited by the underlying economy (the number of trials, the number of mergers, etc.).
> who wants to be past child-bearing age by the time they've paid off their debt, when they can just go into another better-paying field without any of that)?
doesn't matter if the non-debt income is substantially higher.. most would rather take 500k a year with 100k of debt repayment over 100k a year with none..
> One thing that would help is letting non-MD’s, such as nurses or physicians assistants, do more “doctor” things.
An alternative scenario is to train doctors more quickly and effectively for primary care positions. Currently, to become a family practice doctor, you need 4 years of undergrad, 4 years of medical school (much of it not geared towards primary care), and then 3 years of residency. Instead, students could be started earlier, with immediate exposure to primary care (working internships) and education focused towards practical medical aspects of primary care. It would take far less than 11 years and arguably give them much more exposure and training that's directly applicable. I'd wager you'd get both higher quality care and lower costs.
I can't agree more with this, especially with respect to undergrad. I've taught hundreds of undergrads about ohm's law so that they could go on to become doctors. And that was one of the more useful skills they learned. They also took classes on western legal theory and renaissance art and modern Russian literature.
Don't get me wrong: some doctors need hard science skills, but while I want my neurologist to understand ion channels I don't need that from my orthopedic surgeon.
As for the liberal arts base, personally I'd rather have a doctor who entered medical school 4 years earlier, and had a chance realize that med school wasn't for them 4 years earlier. With our current system, acing the MCAT means that you will be a doctor if you want to be one. And once you're in medical school you've sunk too much into education to back out and try something else.
It still makes sense to have a hierarchy of capabilities. You see this in many places in medicine, e.g. EMT, EMT-I, paramedic, with the RN-MD divide being one of the more notable gaps.
IMO the fact that RN's wind up with tacit approval to perform certain proceedures and make certain decisions that the MD is nominally supposed to, is a clue it would indeed be suitable.
I don't understand the requirement for the initial 4 years of undergrad before you enter medical school here. All it seems to do is increase the debt burden for doctors & their time it takes to get into actually practicing medicine.
My wife is a doctor. She is just over a year out of residency. She makes around $300,000 per year. It's a lot of money. She has to make that much money because the U.S. has stupidly decided to burden doctors with massive med school debt. Her debt is $400,000.
When she pays off her debt her salary won't go down. People expect to make more in successive years. Hence large salaries are going to be normative unless there is drastic change in the system. It would be much better for the country, and for my wife, if her debt were wiped out and she made a lot less money. We'd be happy for that.
Whatever system is going to be in place will require some form of rationing. Prior to Obamacare that rationing was done on the basis of money, and whether or not a person was lucky enough to have a job that had health benefits. Obamacare is an attempt at free market forces whilst providing care for most people. It's somewhat better now than in the past but not ideal. I think universal, government funded healthcare is the most moral and economical option.
Taxes and whatnot account for 50% of her salary. She does need to save for retirement and one must include more than just the federal income tax rate to calculate how much is taken out in taxes. There's FICA, state taxes, and state sales taxes and property taxes. There is also rent, food. She can not save put 50% of her salary toward her student loans. That said, she can pay it off relatively quickly.
However, after 4 years undergrad, 4 years med school, and 4 years of residency it's time to live, no? What's the point of it all if you don't actually make enough to live a little until you are 40? A way better system would be to just provide for higher education and not burden people with debt. Instead a large salary is needed to pay the large debt but the large salary is permanent and the debt is not. Save a lot more money buy just properly funding higher education.
Well, debt free at 40 leaves still 25-30 years of a pretty good career, no?
The downside of govt just paying for it is you'll get a lot more people who really aren't committed to the profession and it taxes everyone else - it's not free, it's done through higher taxes on everyone else.
It doesn't have to involve higher taxes on everyone else. We spend well over a trillion dollars a year on national defense/spying. Also, we spend way higher per capita on healthcare than any national healthcare system and those systems generally include paying for medical school. Thus the evidence is that it will involve less money spent. Perhaps there would be a tax reduction as a result.
I used to be a big believer in freer markets in these areas, but all the places that are cheaper appear to use monopsomy power to drive down costs which is kind of the opposite. Even if there is a widely competitive market you don't get to make informed choices, negotiate and leave for elsewhere when you have a bad hospital or surgeon in a priority case. It's also far easier for people to make irrational choices when dealing with their health. As far as filling cavities, many fillings literally amount to cutting a tooth open inserting a material and reattaching the piece that was cut. Common complications include hitting nerves. Allowing assistants to do this on fairly limited training seems to be a very poor idea -- I've changed dentists because of complications from a filing and the inability to fix it, and I wouldn't wish the complications on someone.
> The entire health system from top to bottom would benefit immensely from free market forces.
lolnope. Free market sooner or later ends up screwed because humans are inherently greedy and will cut corners to make more profit. The corner cutting is bad enough in IT security, I do not want to see this in any health related stuff.
The free market may be fine for most stuff in a society - but the corner stones of society must be regulated as hell: transportation infrastructure, water, electricity, telecommunication, medicine and education.
> Doctors are part of a guild. They artificially limit the number of doctors available by capping the number of medical schools, which also allows the existing schools to crank costs to astronomical levels
Your thesis is that a cabal operated by doctors is limiting more doctors from getting acceptance into med school as well as intentionally preventing more medical schools from opening, with the goal of inflating their student loans to such astronomical levels so they can have the privilege of graduating with ridiculous debt loads they'll be lucky to pay off by the time they're 50 years old? That's.... fascinating.
> One thing that would help is letting non-MD’s, such as nurses or physicians assistants, do more “doctor” things.
They do, are you in the USA? It's actually quite challenging to see an MD without direct pay or concierge, or without seeing a specialist (in which case be prepared to wait 2-5 months, depending on their specialty). When was the last time you went to a primary care office, urgent care, or similar clinic in the USA, and had a visit with an actual doctor (MD) and not a PA, NP, RN, or similar non-MD? Doctors are so rationed in much of the USA that many obstetric or surgical followups are handled entirely by a completely unrelated RN or PA instead of the very doctor who performed the actual procedure on that patient. And the boomers haven't even retired and reached medicare age yet, imagine what the doctor shortage will look like in another 5, 10, 15 years.
My pet theory is that the long-term reasoning for artificially limiting the number of residencies/medical school spots is to avoid an oversupply of healthcare professionals after the baby-boomers die off in 15-20 years.
Sure, there is tremendous strain (and consequently profit to be made) in the system now, at the expense of overworked doctors with limited interaction with their patients. But if the supply of doctors met market demand _right now_, in 20 years there would be an over supply. An over supply of doctors would introduce a new set of problems associated with lower salaries and eventually lower quality of care (see Soviet Union). So in a way, this artificial market manipulation of the supply of doctors is forcing innovation and timing the population market, and betting on medical advances that will eliminate many doctor visits through preventative medicine or computer asssisted diagnostics.
Essentially the AMA is lobbying to prevent a scenario that created the artificial STEM shortage myth in the 1990's that new career scientists have still not recovered from.
How did having too many doctors cause an decrease in quality of care in the Soviet Union?
And the AMA is lobbying for decreased slots because it increases their salary. American doctor's pay is way out of line with the rest of the developed world.
> They artificially limit the number of doctors available by capping the number of medical schools, which also allows the existing schools to crank costs to astronomical levels
This is such bullshit. Nobody is artificially limiting the numbers. Schools are accepting and graduating more doctors than available residency programs.
Right now the biggest bottleneck in the process is the number of residency spots. There simply isn't enough bandwidth for hospitals to teach graduating medical students to become independently licensed doctors. Medical schools will happily push as many students as possible through (and they are with new schools opening).
The problem is training a resident is extremely expensive and comes with a lot of overhead. The government pays hospitals about $110k to per residency position. While this incentivizes some hospitals, many are facing issues with finding willing and qualified staff to come teach at their hospitals. It's hard to convince an established doctor to take a pay cut and take on more work to train students.
As it stands right now, I have to disagree with letting nurses or PAs do more "doctor things". Their training isn't anywhere close to what it needs to be. Also, the term nurse is very loaded to your average patient. You could be talking about a CNA with 16 weeks of training, or a DNP with 8 years of schooling.
>ROSALSKY: The main argument against allowing NPs to practice independently is that they have less training than physicians. But there’s a mountain of empirical evidence from randomized trials, case studies, systematic reviews, and analyses of malpractice claims in states where similar legislation has already passed that all points to the same thing: when it comes to primary care, NPs are just as safe and effective as doctors.
I saw a nurse practitioner at a drug store who prescribed some antibiotics for an ear infection I had. It went well, it was a simple problem, and it didn’t require being examined by an MD. There are definitely things they can do.
It was a pretty common case of swimmer’s ear. Oral and ear anti biotics were prescribed, along with advice not to swim for awhile and later to wear ear plugs. It was all very standard.
Believe it or not, most infections will clear up with anti biotics. I get a painful infection every 3 or 4 years that require them (less often when I was younger), hardly someone you would consider abusing them.
> As it stands right now, I have to disagree with letting nurses or PAs do more "doctor things". Their training isn't anywhere close to what it needs to be.
Sort of. What people in this thread refer to when they say nurses should do more "doctor things" is a nurse practitioner:
(think of an MD as a commissioned officer in the military, whereas a nurse practitioner is a non-commissioned office who rose through the ranks but is still slightly below a commissioned office in ranking)
Source: Mother was a registered nurse
TL;DR Leveling up nurses around the country to "nurse practitioner" and having them take on more traditional doctor responsibilities is a solid path to success versus churning out more doctors overloaded with debt
That works great... until there’s a subtle reason to think that it’s not streptococcus for reasons ABC or that’s not the proper treatment for reasons XYZ and you have a mild case of death.
Physicians that you see in the office won't detect those reasons ABC and save you from death. The expert diagnosticians often work in hospitals and are only used when other PAs/Physicians tell them "I ruled out all of the common explanations for these symptoms, what could it be?"
> Physicians that you see in the office won't detect those reasons ABC and save you from death.
Any hard research showing this? Something that addresses confounding factors, overburdened doctors, etc.? Is there a study showing that spending 30 minutes with a physician is equivalent to 30 minutes with an RN or PA for all outcomes (not just death)? I have a feeling we're all acting like medical experts in this thread even though very few of us are. It's like when we see research about programming methodologies and are able to poke so many holes in the study it becomes swiss cheese.
Probably not. Or, better stated, not that I am aware of.
Let's think. Seeing a doctor instead of a PA is associated with better outcomes if, and only if, your condition can benefit from the doctor's specialized knowledge. That means it requires treatment, the treatment is time-sensitive (i.e. worse outcomes if there's a delay), and there are significant adverse effects in case of a lack of appropriate treatment.
The problem is, these conditions are either too rare to be studied in any meaningful way, or the patients' very obviously sick and taken directly to the hospital, where he is obviously seeing a doctor and not a PA.
A lot of people go to the doctor for pretty benign ailments which don't really require a treatment, or for conditions that any intelligent, motivated patient is theoretically able manage himself without a doctor. Examples : virus infections, sprains, acid reflux, chronic conditions like hypertension, diabetes, and so on. E.g. : someone has type I diabetes, understands how and when to give himself insulin, checks his feet for infection and so on. In a case like this, the doctor can barely bring any plus value apart from ordering the regular blood work.
Another frequent scenario is when the patient does have a time-sensitive, treatment-required condition, but does not follow the treatment. Again, him seeing a doctor is unlikely to result in any appreciable benefit.
No, just intuition. 70% of the primary care medicine appointments are "eh, it's a virus, come back if symptoms persist." [1] 10% is casts/sutures/I&D/debridement. 15% are "I'm telling you, these symptoms are all due to your diabetes and your diet will kill you if you don't take it seriously." Maybe 4-5% are really diagnosing serious chronic issues. And generally it's just referral to a specialist who makes the official diagnosis. A missed diagnosis here can be a serious consequence in some cases, but symptoms that can indicate those diagnoses are big red flags.
Well, as someone who has a mildly life-threatening condition that manifested "off-book", and only one of several doctors I saw was able to identify it, I'm probably a bit more skeptical than average. But, it's worth noting that my symptoms were severe enough each time I had it that a PA would've certainly referred me to a doctor (I called an "advice nurse" each time who told me to see a doctor). So maybe that's a point in favor of PAs doing initial screens.
With respect to that comic, I would've gladly paid $4k out of pocket for a diagnosis. I still think fondly of the doctor who quickly figured out the puzzle that tricked a couple other specialists, my PCP, an urgent care doctor, and an emergency medical doctor. The same doctor who quickly sent me to the hospital in an ambulance with a note on my chart that said "this is serious, don't send him home until you confirm my diagnosis."
Agreed! The whole system is in need of an overhaul. Why don't students start off medical school right away in undergrad? Who the F* wants to wait until they are 30 years old before they finish school?
So? Those extra four years of education for people who want to be doctors are mostly waste, an elaborate hazing ritual. Make undergraduate entry to medical school a five or six year programme, like in Europe. The increase in physician career years will swamp any plausible decline in incoming student quality, even if they just admit students straight from high school to the current US med school system.
That's kind of my point. How would an 18 year old know what they actually want to do without having spent some time studying it and other things? I went into school with intention of becoming a doctor and had changed my mind 2 years in. That's an expensive mistake if I hadn't been at a liberal arts school.
Importantly, the costs of our medical system relative to other systems will never be fixed until we fix this problem. But this is the hardest problem to fix, because nobody wants to talk about it. It's political suicide.
Doctors are a guild everywhere so this isn’t the big difference. They always want to limit the number of new doctors. Perhaps in the US they wield more power?
Public medical schools should just educate more doctors and make it cheaper and lower risk to become one. Add a few thousand more spots in state universities and fill them via
full scholarships.
A simple solution to the management of doctors’ time is to hire secretaries to do administrative tasks that otherwise take a lot of time. We have that here now (a recent invention) with a 2 year education.
"Doctors are part of a guild. They artificially limit the number of doctors available by capping the number of medical schools, which also allows the existing schools to crank costs to astronomical levels (“don’t worry, you’ll make enough to pay it back”)."
- True (in principle). But even with so much filtering, I have encountered not so bright doctors practicing and it is not a pretty sight... Plus you have to consider the time investment, apart from money, there is lost time and opportunities. Take a typical cardiologist for example: 4 years undergrad + 1 year research or something else to beef up CV + 4 years medical school + 3 years of internal medicine + consider 1 year chief residency to beef up CV + 3 years cardiology fellowship. That's 14-16 years either getting in debt or being underpaid.
"One thing that would help is letting non-MD’s, such as nurses or physicians assistants, do more “doctor” things. Dentists, a similar profession, is going apeshit that states are trying to let specially licensed assistants (but non-DMDs) do slightly more advanced work like fill cavities.[0]"
- That's were market forces are driving us anyway, it is happening. As long as you are OK with everyone being seen by a PA or NP... Most people though that support what you said kind of feel like this is "for the other people" but for themselves they "demand" to be seen by a doctor when they are seen by a PA or an NP. Don't get me wrong PAs and NPs are fine for 95% of everything that needs to be done but they simply lack the knowledge and the training to troubleshoot complicated problems and what makes it worse is that many times they cannot even detect that it is beyond them.
"The entire health system from top to bottom would benefit immensely from free market forces."
- There is a free market for medical services in the upper bracket and doctors are making even more there.
> They artificially limit the number of doctors available by capping the number of medical schools,
Also not accepting qualifications from other countries. UK has tons of Indian doctors. Lets get them here too, I don't get why we dont already do this.
We do. In fact we make them redo their 3-4 residencies and following that, dangle the promise of a Green Card after seven years and send them to the god forsaken underpaid rural shitholes American trained doctors have fled because of the inadequacy of the cash salaries(taxed at reg brackets unlike our execs and bankers) relative to student debt and medical practice overhead. How do I know this? Because this is how I came to America.
People do not do a strict cost benefit analysis when deciding their line of work. See: English majors.
The market is being distorted by lack of residencies. This could possibly also distort the cost of medical school. It is not an undersupply problem of people wanting to be a doctor.
It's always good to remember that D.D.S. stands for Doctor of Dental Surgery. Filling cavities is a lot more advanced than taking x-rays, scraping plaque and polishing enamel.
Amen to this. Like every other government regulation, government interference in the medical field simply limits competition and protects entrenched interests, it does not keep people safe (and that is not the real intention.)
> Let psychologists prescribe common, low-risk psych drugs (instead of scarcer psychiatrists),
What the hell? No, there's no way you want a psychologist to be prescribing medication. They receive absolutely no medical training whatsoever.
If you want psychiatric drugs without going to a psychiatrist, find a GP or NP. They're at least trained to practice medicine, even if they're not specifically trained in psychiatry.
You probably should not get psychiatric drugs from a GP or NP without first being assessed by a psychologist. While GPs have meds training, they aren’t trained in how medication fits into a larger psychological treatment plan to actually address the underlying issue. This is equivalent to demanding OxyContin from your GP for a recurring knee problem, rather than seeing an orthopedist to find out what’s actually wrong.
> You probably should not get psychiatric drugs from a GP or NP without first being assessed by a psychologist. While GPs have meds training, they aren’t trained in how medication fits into a larger psychological treatment plan to actually address the underlying issue.
I'm not telling anyone to do anything, but the idea of going to a psychologist for prescription drugs is beyond ridiculous.
> This is equivalent to demanding OxyContin from your GP for a recurring knee problem
It's worse - it's like demanding Oxycontin from your personal trainer at the gym. At least your GP went to medical school and did residency training.
I think you missed my point. I’m not saying psychologists should prescribe meds. I’m saying that medicating psychological problems should not be done in the absence of an appropriate diagnosis of those problems. This can be done only by a psychiatrist or psychologist (edit: and most psychiatrists aren’t trained in testing either, and will generally refer you to a testing psychologist if they think your problems are complex in nature). GPs and NPs do not have appropriate training in diagnosis.
My wife is a psychiatrist. She doesn't prescribe drugs to people with psychological problems. She prescribes drugs to people with psychiatric problems. She's been trained to know the difference. The PA that works under her has been similarly trained. But he doesn't understand the non-psychiatric medicine part that patients often times have.
What is the difference between a psychological and psychiatric problem? I've never seen these terms used in the same context you used them anywhere in medicine.
Hallucinations are generally a pyschiatric problem. Being manic/depressive is a pyschiatric problem. Being a jerk isn't. Having a hard time saying saying no isn't. There are gray areas. As a rough approximation, where drugs can help it's psychiatric, where they can't it's psychological.
5-HT1A stimulation results in decreased aggression, increased sociability, and decreased impulsivity. Sounds like a lack of 5-ht1a activity might make you a jerk, and it's stimulation might cure it.
I’m not a psychiatrist, my wife is. I don’t know hat 5-HT1A is or what your point is. The brain is an organ. It’s the only organ that can be harmed by non-physical means. My understanding is that behavior problems resulting from lack of certain “chemicals” or over abundance of them are psychiatric problems. Problems that don’t arise from such brain defects aren’t. When other organs are defective and don’t produce the right stuff to function properly people take drugs in order to function properly. The brain is no different except there are times the damage is not medical. There are gray areas.
5HT1A is a serotonin receptor generally thought to be responsible for the majority of SSRI effects.
Sorry I guess I wasn't very clear. My point is that there are some conditions that are just "medical". Things like parkinsons or ms. You usually see a neurologist for these conditions.
I'm arguing that any behavior a psychiatrist treats, has some neurological component. And many can be treated with therapy or drugs. So seems weird to use two categories where almost everything is falls into both categories
Think "bottom-up/biological" (psychiatric) vs. "top-down/behavioral" (psychological). Many behavioral disorders have components of both, which means that you either need a psychiatrist doing both med management and behavioral work (e.g. therapy) OR a psychiatrist + psychologist working together to address the problem. The second option can be quite a bit cheaper, since the behavioral treatment is usually far more time-intensive, and psychologists' time is generally less expensive.
>"What is the difference between a psychological and psychiatric problem? I've never seen these terms used in the same context you used them anywhere in medicine"
You really ought to stop pushing your uneducated opinions and do more research.
One this is a completely unhelpful comment. Similar to name calling. A much more helpful one would be showing that medical researches clearly divide problems into psychological and psychiatric.
And no one I know in research, or the psychiatrists I know would say there are many problems that fall into one category or the other. The vast majority of problems you'd see a psychiatrist for fall into both camps.
Mood disorders, and anxiety. The two most common categories of disorders are at least partially treatable by both therapy, and medication.
There are Mental Health Nurse Practitioners, who can and do prescribe psych meds.
I agree that letting psychologists prescribe meds is problematic due to lack of medical training, even though clinical psychologists have a PhDs or PsyD.
You need a prescription to buy contacts? Weird. In 3 European countries I’m familiar with they are a supermarket item (literally) or anyway simply an over the counter item from pharmacies and opticians’ shops
You can get the same brands of contacts from UK websites shipped to the US very easily (and cheaply). I know a few people who do this and they haven't had any problems yet.
People who have no idea about an industry saying how that industry should be regulated.
The reason we have different professions withing the medical industry is because of the years of training it takes to specialise in that area and get to a level of competency in that field.
Optometrists in the UK already prescribe glasses and contact lenses, I'm not familiar with the US system for glasses prescriptions but having to see more than one person seems... Illogical and expensive.
Nurses already push meds. After a suitably qualified and experienced doctor has assessed the patients records, seen or read a history and decided on a course of treatment. A nurse is not capable and should not be expected to know that level of detail about drug interactions and treatment pathways, that is literally what the doctor is for. Not everyone has the capacity / interest to know all this stuff, but we still need staff to tend to and care for our patients. Hence we have nurses.
Not to be disrespectful to nurses because they do incredible work and are essential to the medical industry and patient care but I happen to know quite a few nurses and doctors through friends and what I've come to realise is that anyone who can follow an instruction can become a nurse. And there are a lot of bad nurses. Thankfully not just anyone can become a doctor in the western world, because we have stringent regulations and laws.
The major contributing factor that adds cost to medicine are patents. Companies artificially inflating the prices of drugs and medical devices, not wages on the front line.
The thing that goes through my mind when I hear people talk about delegating more procedures to less qualified staff is... What happens when the dental nurse slips up and causes bleeding or hits a nerve and causes loss of feeling / facial paralysis. Does she run and grab a suitably qualified dentist and pull him away from the procedure they are currently performing?
People don't seem to realise that the reason we entrust certain people with certain jobs is not because that highly qualified person has done x procedure x numbers of times, it's because they have a very deep and thorough understanding of any complications and what to do when things go wrong.
Not just in medicine but in engineering and many other critical professions where decisions cost lives.
What you're talking about when you say deregulating is vastly increasing risk. There's a reason why current regulations exist and were created in the first place, because at one time they didn't exist and people died or became seriously ill.
I'd be genuinely interested to know what medical procedures people here would be happy to have a nurse perform rather than a doctor.
One thing that would help is letting non-MD’s, such as nurses or physicians assistants, do more “doctor” things. Dentists, a similar profession, is going apeshit that states are trying to let specially licensed assistants (but non-DMDs) do slightly more advanced work like fill cavities.[0]
The entire health system from top to bottom would benefit immensely from free market forces.
[0] http://www.mercurynews.com/2017/07/01/dental-lobby-bares-tee...