In the 19th and early 20th centuries there was in the US a proliferation of medical schools - many unaffiliated with Universities - with very few entrance requirements, extremely uneven quality of education and little standardization in curriculum. In fact many people became doctors through apprenticeship right up through the turn of the 20th century. Many states had extremely lax or nonexistent licensing requirements. It was quite chaotic and unregulated.

In light of this, Abraham Flexner was commissioned by the Carnegie Foundation to produce a report on the state of medical education and to make recommendations.

The Flexner Report was published in book form in 1910 and set forth a programme of reform for medical education and the broader healthcare system in America. The structure envisioned by Flexner largely remains with us to this day.

The crux of the problem is that in response to a very chaotic system, order was imposed in the form of strict licensing and educational requirements which made sense given the problems of the time but have contributed to new problems in our time. Outdated regulations, standard practices and conventions have artificially restricted supply of qualified medical personnel in America and it's time we address these structural issues.

Targeted reform of the system is the best solution for American healthcare.

The number of physicians per capita in the U.S. is greater than Canada or Japan, both of which have cheaper healthcare. Yes, apparently most European countries have a significantly higher ratio. But, interestingly, all the Anglo countries (UK/GB, US, AU, IE) seem to cluster together.

The issue seems more complex than something simple like number of physicians. A high ratio is unnecessary for cheaper, quality healthcare (e.g. Canada, Japan), and whatever dynamics control the ratio in the U.S. (schooling, licensing) probably also exist in other countries with similar legal systems, but with different outcomes.

Data: https://data.worldbank.org/indicator/SH.MED.PHYS.ZS?location...

EDIT: Looking at the ratio of GP to specialists for Canada (~1:1) and California (~1:2), it's more likely that the problem (such as it relates to numbers of physicians) is that we have too many specialists in the U.S. See https://www.cma.ca/sites/default/files/pdf/Physician%20Data/... and https://www.chcf.org/wp-content/uploads/2018/06/CAPhysicianS... And that probably has to do with 1) how we consume healthcare in this country and 2) the career expectations of medical students. And arguably this is a typical pattern of American culture more generally and in all our industries. Everybody wants to push the envelope and everybody expects the products and services they consume to be bleeding edge, both as a cultural expectation and in pursuit of higher profits--as consumers we tend to assume more costly services are more advanced.

The regulatory restrictions don't just apply to the doctors themselves, but have expanded to stifle innovation in every part of the system, from hospitals to equipment to drugs to administration. Each takes its toll.

“fully trained” has a different meaning in other countries. In the US the number of doctors that can be “fully trained” is artificially limited. Furthermore, many countries with cheaper healthcare have abbreviated training for doctors.

> abbreviated training for doctors

I mean do doctors really need to spend 4 years getting a bachelor's degree in "pre-med"? If you know you're going to be a doctor why not just start off with biology, anatomy, physiology, chemistry in year one and go on to cutting up bodies in year 2? It seems utterly ridiculous to spend 4 years majoring in humanities, or calculus[1] only to seek entrance to med school.

The UK doesn't feel the need to do this.[2]

1. https://prepexpert.com/pre-med-class-recommendations/

2. https://en.wikipedia.org/wiki/Medical_school_in_the_United_K...

You are speaking from a place of ignorance. The prerequisites needed to take the courses that you mention alone are >1 year, yet alone all of the material needed to become a doctor. Where I went to Uni, you didn't take biochem until you were a senior. The reason for this is because before you take biochem you need General Chemistry 1 & 2, Organic Chemistry 1 & 2, and some smattering of Biology. You have to take these courses sequentially, they build on each other. If you don't know what a nucleophile is then you simply can't pass biochem, and that's how it should be.

Granted, you could theoretically shorten the program by removing all the humanities courses; but shouldn't doctors-to-be take ethics courses?

> You are speaking from a place of ignorance

You're right, I hold my hands up. I don't have any medical training.

> Where I went to Uni, you didn't take biochem until you were a senior. The reason for this is because before you take biochem you need General Chemistry 1 & 2, Organic Chemistry 1 & 2, and some smattering of Biology. You have to take these courses sequentially, they build on each other.

You obviously know what you're talking about and I won't debate you on how this works. But again, does a prospective doctor need to spend 4 years on this? How does every country other than the US and Canada manage to train their doctors without making them get a Bachelor's along the way in something non-medical? Why can't doctors study 5 or 6 years and graduate with a medical degree, ready to become a general practitioner? That's how they do it in the UK. Are you saying their docs didn't pass biochem or don't know what a nucleophile is?

> shouldn't doctors-to-be take ethics courses?

Pretty sure med students have time to take ethics courses if they do a 5/6 year medical degree.

My apologies, I didn't mean to come off harshly, it's approx 3 am here so I'm not exactly a ball of sunshine.

Do doc's need to spend 4 years doing an undergrad before med school? Maybe. There are a lot of things that you need to learn before you can learn what you need to be a doctor. Do you need to know physics? Eh, only kind of.

I'm not terribly familiar with the system in the UK, but at least where I went to school, most of the folks who were planning on going to med school studied either Chem, Biochem or straight Biology. In fact, it was something of an issue because the Chemistry courses tended to be weed out courses, i.e. you had to pass Organic chem 1 & 2 with a (3.0+)/4.0, or you didn't have a ghost of a chance of getting in to med school. I, personally, didn't know anyone who was planning on going to med school who was studying anything outside the STEM umbrella.

>Pretty sure med students have time to take ethics courses if they do a 5/6 year medical degree. Reasonably. I was really only picking on this point because of, what I had thought was, a dismissal to the usage of the humanities as a doc.

If it's anything like CS there's maybe a couple of semesters of applicable material and a bunch of filler to extract money for the university.

Good news! It's not anything like CS.

Things you need to learn, not an inclusive list, before med school: Chemistry, drug interactions, A&P, Ethics, Statistics, Maths, and Biology.

That's (6, 2, 1, 2, 3, 4) 18 courses minimum. Remembering that they have to be done sequentially rather than concurrently and you're looking at, bare minimum, 2 years rather than 2 semesters.

This is as it should be. To bring it back to your CS example, if you are making a web app and you fail to secure your attack surface, the worst that happens is that folks get their info stolen. If you fail to do your drug interaction math correctly, people die.

In other countries banks don't make five+ figures on every doctor's education, and their doctors certainly don't make enough to service six figures in education debt.

Finance capitalists keep the vicious cycle going. Doctors' unions scratch and claw for high comp because without it their new entrants are screwed.

100% on the (fiat) money.

The 250k+/year US salary of the fully trained doctor setting bones could be a problem. Many doctors are paid significantly less in many of those other countries.

It's not, though. It takes under an hour to set a bone, so that doctor's time is not driving the expense.

Why do I need to see a doctor to get a mole or skin lesion checked? Why is it necessary for someone to go through 4 years of undergrad, med school, etc etc just to examine a mole and remove it with a scalpel?

Are you trolling? Are you legitimately asking why you need a doctor to check something that might be, amongst the million other possible complications, Cancer?

The mole-specific training is probably a couple of months, max (if that's all the person needs to do). Division of labor.

Go back a step further. Why do they need a big income? Because they took on lots of education debt. Why did they take on so much? Why is it so expensive? Because the usurers extend that much credit.

The free market in shampoo is okay, sort of. For a lot of other stuff "free market" + fiat looks like a mess.

We don’t have a free market in healthcare. We have a highly regulated one. Free market healthcare is lasik and boob jobs. Both have come down in price because they are not part of the insurance system. They’ve also gone up in quality due to competition and demand.

Dental care is also a 'free market' and I don't think I need to say how much of a disaster getting any sort of dental work can be in the US.

Why haven't dental costs fallen through the floor if it's a free market?

It's covered by most employer health plans, so patients don't see the true cost and don't shop around much. That's not the case for lasik or elective plastic surgery.

Of course since the latter are elective, customers have the luxury of shopping around and taking their time.

I'm not sure where you've been employed, but dental plans have always been separate from the actual health plans and generally cover nothing beyond giving a pittance per year that hardly rolls over. Once that's gone, you get to pay the full cost.

I've had to deal with the true cost of dental work and I can guarantee you anyone that's needed to deal with significant dental issues has had the same experience. So why hasn't the free market dropped down prices? Why are we still paying more for basic dental work compared to other countries?