As the other poster mentioned, med schools aren't actually the barrier to increasing the physician workforce. In order to be a practicing physician you need to go through residency training. However the number of residency spots has stayed fixed for the last 3 decades and is controlled by government funding.

If you want more doctors, lobby your government to increase residency training funding.

The number of residencies is set by a board which the AMA controls a majority of the seats on. They blame the lack of Medicare funding for additional residency spots, but that is such a preposterous excuse. American medicine is one of the most lucrative industries in the world, and American doctors some of the highest paid people in the world. They don't need the public to subsidize their training.

The AMA is a guild and the doctor shortage is their fault.

The doctor shortage is their intentional strategy. The fewer new doctors, the higher their pay.

They are a labor organization that's intentionally limiting supply.

Yes. One time I was (politely) arguing this with a MD acquaintance and I let him convince me it was an unfortunate, unintentional outcome rather than a successful hustle.

A few weeks later I read an article about a new cuneiform tablet that had just been translated. The oldest translated writing in the world, at the time. Evidently the brick-making guild hadn't been training enough young apprentices and the price of construction was becoming excessive. They wanted the king to step in. It was the same trick! This was literally the oldest trick in all of recorded history!

I am still somewhat adjacent to the biomedical scene and I've heard that the AMA has reversed course recently -- but I don't know the degree to which the new words correspond to actual actions. In any case, the sentiment is correct: if they don't become part of the solution, they will be seen as part of the problem when the eye of Sauron turns in their direction, and the terms imposed on them will be much worse than the terms that could otherwise have been arranged.

I’m less optimistic. It’s just too easy for the AMA to say “hey we are saving lives and we need to make sure we have the best of the best!”. I think a parallel system needs to happen which won’t be controlled by AMA. It will happen eventually but it will probably take a long time.

I think it's happening right now. There's a reason CVS and Walgreens are both trying to position themselves less as drugstores and more as walk-in clinics.

There's a huge opportunity in the market for providing low cost care that has fewer regulations and restrictions.

Honestly, I don't know if it will work or not, but I think it's interesting they're trying to take advantage of the (frankly ridiculous) medical situation in the US right now.

In the AMA’s case, physician pay was explicitly their objective. They said so.

Or to lower the requirements. Doctors with no experience but a medical school are still much better than no doctors. I don't need a doctor with a fancy license, I need a doctor who has a scientifically adequate (and up-to-date) idea of how does a human body work and what has a good chance to be a reasonable way to cure my sickness.

I agree with this comment. US medicine has setup a long and tortuous road, which might result in extremely well qualified people (or might not), but other developed countries seem to do just fine without the hazing ritual the US required doctors to go through.

Why would you ever choose to be a doctor over an employee at a FAANG? It would be worse for your mental and physical health, and now the pay isn’t even much higher for doctors.

I would guess the average pay is not higher at all. Even if you don't account for opportunity cost and the time value of money, I think it may be that top tech cos pay better for someone with similar levels of experience. Certainly I don't think many of my doctor friends my age are making as much as I do, and I was also earning for almost a decade before most of them were able to become attending physicians. And many of them went into family practice or other solidly middle class specialties, which certainly pay a good deal less. This is not even accounting for the fact I work like 36h a week with zero on call time (at least on the current project), and few doctors can swing that.

I left FANG for medicine. I think this is not a good argument for 2 main reasons.

1) People tend to compare FANG to family medicine. It wouldn't be more apt to compare the average tech worker making 100-200k to family medicine, or compare to some of the more competitive specialties.

2) Salaries are underestimated by many people. The best source is the MGMA is is often used to negotiate salaries by the hiring side. Unfortunately the data is expensive to access so few have it - there's an older screenshot someone took [1]. Further, these are biased lower since academic medicine and part time researchers tend to make less. You can also tailor you're career with more flexibility. Want to make $1M? Go for it. Want to work 2 weeks a year and still bring in 2-300k? Go for it.

Now if you want to live in NY or SF tech will pay more as medicine pays more as you get more rural.

[1] : https://imgur.com/gallery/ZQo6aKo

I think the last 40 years were golden years for doctors in the US. They made great money, but now the jig is up and there are 2 options for the next generation:

1) if US goes with taxpayer funded healthcare, expect pay to go down similar to other developed countries with taxpayer funded healthcare. Because there will be no negotiating power.

2) with the ACA framework, it’s a race for insurers, hospitals, and physicians groups to get as big as they can do they can gain as much negotiating power as they can. I can see it with all the M&A in the hospital and provider space, and the rule of thumb is “the closer you are to the money, the more you make”. In this case, insurers will hold the money, so it will be at their mercy that they approve or deny payments for certain procedures.

The American people themselves don’t have enough money to continue paying for this gravy train, and the government was picking up the slack, but I think that’s going to be over soon.

The CVS/Aetna vertical integration model is interesting too, as they are talking about adding doctors to their stores to make it a one stop shop. Insurance, provider, medicine all in one, similar to Kaiser.

And then there’s doctor groups who are able to pump out more work from one doctor by using physician assistances and nurse practitioners to actually see patients “supervised” by one doctor, but the doctor never actually sees the patient.

Pay may go down a bit. I don't have a source off hand but a huge portion of medical expense are due to administrator bloat, doc pay is much smaller. Ideally the regulations and billing gets simpler cutting that bloat. Regardless many docs advocate for better healthcare despite lower pay. I don't have data to say most, but my experience has been that in a conservative part of the US.

The NP/PA practice is also a growing concern amongst doctors. Those groups are advocating for independent practice despite reduced training.

I'll admit, I'm a fairly stereotypical introvert tech guy and tend to judge people more than I should. Talking to patients has a way of shifting your views. I used (and I suppose still do a bit) to judge alcoholics, drug users, and other preventable conditions. But you realize how they really are a result of social or medical circumstance and I think for that reason many doctors are willing to sacrifice some pay. Hell I went into medicine for the security and money (mostly, plus more academic stimulation than software), as taboo as that is, and I'd be ok with it.

That said I think specialty medicine pay is fairly safe. Fact is supply is limited, right thing or not.

I doubt there are many doctors that bring in 200-300k in two weeks a year of work. :) And are these numbers net of expenses or gross? E.g. is it net of malpractice insurance costs?

But yes it appears the median doctor gets paid somewhat more than I thought. Although only a few of the surgical specialties outstrip my personal compensation, I would guess I'm a good deal above the median for software engineers and the median engineer is probably only in the same neighborhood as the median doctor, not above.

I meant 2 weeks a month! I wish in a year :)

People also bring up malpractice but a good employment contract will include that with tail coverage.

What was the process you followed to get into medicine?

It was always on the radar for me so I just worked for a few years and applied.

I do know people who were engineers for a decade plus, and they had to do a year of coursework (special medicine program) before applying to med school.

If it's something you personally are interested in, happy to talk more.

Yeah, I'm interested in chatting with you on this because I'm curious about the process. I looked in your profile but couldn't find an email. Would you mind sending me a message at [email protected]

Because you want to help people and not hijack their reward systems to maximize ad revenue?

The inflated requirements are a result of restricting the supply of seats, not a cause.

Makes sense but how can you be sure?

Depends on the specialty, I would think. Pediatricians, general practice, etc. can probably have lower standards than other specialties since they are where people typically enter the medical system for treatment. If they haven't seen a malady before, they refer the patient.

However, for cardiologists, anesthesiologists, neurosurgeons, etc. you probably want a higher education standard.

I think what'll happen eventually is that the doctor situation will be sidestepped and the role doing stuff like looking at patients coming in to check on a generic cough or headache will go to physician assistants and nurse practitioners. To some extent I'm already seeing it happen.

They're already kind of doing that with Nurse Practitioners. I used to have asthma, and for years I always saw a doctor. Towards the end, I rarely saw a doctor but saw a nurse practitioner instead. I strongly doubt the difference in pay was reflected in my bill.

The theoretical person you’re describing sounds like a nurse practitioner.

The way Medicare funds residencies is also odd. What they do is add a pay bump to all reimbursement for a teaching hospital.

For example, for an appendectomy, a non-teaching hospital might be reimbursed $4,500. If you’re a teaching hospital you get an extra 1.3% (too lazy to look up exact number, but it’s quite small), so $4,559. And that’s for every procedure at the hospital, whether the resident was involved or not.

Seems like a more direct, “here is $80,000 for each residency spot” would make things a bit more transparent?

Maybe drop the requirement that only governments fund residency slots?

Such a requirement doesn't exist. 77% of residency slots are funded by the federal government. But there are slots that aren't funded by the federal government. And this makes sense because residents make residency programs money.

"Let private corporations do it." - America

In case this wasn't clear -

Maybe drop the requirement that "only" governments fund residency slots?

What do students who pass med school, but can't get a residency do? If the numbers are right, then there should a large pool of them.

So propublica isn’t being pro pubic and letting us know what the real issue is, but would rather present it as their own perceived issue?

They could say this is the quick fix but the long term solution is different.

We already have an excess of medical schools. We have a shortage of residency training spots; we have med students every year that are stuck as non-practicing physicians because of this.

Residency training spots are, while not a snap of the fingers to increase, not difficult - if congress was willing to actually legislate the increase in funding, as it comes through CMS.

There's no real reason for the government to be funding residency slots. Residents are profitable for hospitals and the slots are objectively valuable things. Hahnemann Hospital shut down and auctioned off their residency slots for 1 million per slot. In other words, the right to hire a resident and collect their subsidy is worth 1 million dollars.

The government is a convenient scapegoat to protect a system that restricts the supply of doctors to maintain their wages.

So a hospital has to pay a 1M per slot - sounds surprisingly similar to NYC medallions right before Uber. Artificial scarcity.

100% this. If the hospitals are desperate to increase the supply of doctors in the states (US), they can easily fund the residency spots themselves. They pay ~60-70K USD/year for each resident for three years anyway. Those residents do most of the grunt work that more senior doctors (like attendings and hospitalists) in the hospital don't want to do. In comparison, generalist attendings and hospitalists (full-blown doctors) at hospitals earn salaries in the range of 210-250K USD/year easily.

To become a full-blown doctor in the US, one has to jump too many hoops and hurdles including -- 1. maintaining 3.8+ GPA (out of 4.0 max) in undergrad while paying overpriced college tuition (which encourages students to take relatively easy course load other than the required ones like organic chemistry, biochem, a couple of basic math and physics classes, etc.); 2. pay yet another loads of money to attend med school, which is where you actually begin to learn something relatively useful; 3. volunteer unpaid at various research and/or healthcare institutions to beef up one's resume (which is only affordable/possible if you are well-connected and/or have money to volunteer); 4. pay exorbitant and unnecessary exams (each 8-9 hours long spanning sometimes 2 days for Step 3 USMLE: https://www.princetonreview.com/med-school-advice/usmle) that promotes rote learning (and you forget what you memorized ~2 months after the exam anyway); 5. pay a lot of money to apply for residency programs while footing the bill (hotels and air travels) yourself to go around the country for residency interviews; 6. spend 3 years (minimum) in residency while spending ~60+ hours per week in your first year doing the grunt work that no senior doctors want to do (e.g., night shifts/floats) 7. maybe spend another 2+ years in fellowships if you want to be a specialist

In contrast, one just need to do these in my home country to become a doctor (I know India has a very similar system to train their doctors): 1. get a high score in national standardized/matriculate exam (in my country, ~5% of top students have option to go to medical school) to get into public medical schools (there are four of them and three of them are definitely pretty good) 2. spend 5 years studying medicine (to be honest, they can cut out the first year if they want to, but it's still better than spending 4 years as undergrad in the US) 3. spend another 2 years as a rotational intern at major government hospitals (OBGYN, Surgery, Child, etc.) doing what the residents in the US system do [from what I've been told, those 2 years are certainly more demanding than the residency years in the US system] 4. take masters degree to specialize (takes ~3-4 years)

The quality of the doctors produced by these two aforementioned systems is not that different. How do I know this? My wife (foreign medical graduate) is a current medical resident at a US hospital and we have a lot of friends in the US residency programs, some of whom are foreign medical graduates. In order for them to get into these residencies as foreign graduates, they have to score on average better than their US counterparts (on top of having to work pretty hard to gain experience in the US because 99% of hospitals/medical institutions in the US don't allow volunteers/externs/interns unless one is trained from the US pipeline and is a citizen).

So the question is why is the path to becoming a doctor in the US needs to be paved with so much expenses and hurdles? Who established this path?

I'll close my long rant with what my wife recently told me after spending a year as a medical resident in the US, (I'm paraphrasing her a bit here) "I don't want to be a patient in the US hospital when I'm old. We need to go to somewhere like Singapore for treatment (she worked at a hospital in Singapore for a bit before coming to the US)."

Medical schools are biased towards wealthy students. Poor students don’t look at them as say, “huh, let’s make no money for a decade and get tons of debt”. Making the process longer and more expensive ensures that poor kids don’t have a chance, while also allowing universities and hospitals to milk the students for as much money as possible.

100% agree.

I have two college friends who are now full-blown specialist doctors (one orthopedic from UCSD and another psychiatrist graduated from JHU). Both of them came from well-off backgrounds (in fact, both of them have at least one parent who is a doctor). Their parents helped them connect with practicing doctors in famous hospitals (e.g., children hospital of Philly) when they were in college, and both of these friends already had a handful of internship/externship experiences at credible hospitals when they graduate from college.

The psychiatrist friend even took one year off to study for USMLE step 2 before she applied to med school. Who can afford this kind of luxury? It's simply because her parents are both doctors (one psychiatrist and one anesthesiologist) and make a total of easily 600K/year back in 2009.

In comparison, while she (my friend) was studying for USMLE step 2, I was frantically looking for a job in 2009 after graduating from college (the same class year as her).

If one does a bit of research on doctors, one may likely find a positive correlation with their parents being wealthy (and also being one of their parents being a doctor). To become a doctor, one has to be born in a truly middle-class family (like parents earning at least 200K/year total with nowadays dollar kind of middle class).

That highlights a fundamental difference between US vs other countries university education system. In most countries university is vocational training e.g. you learn very deeply what's needed for a relatively specialized job with few chance to retrain once enter the workplace. The US focuses on broad undergrad education system, thus students can/should be able to adapt in their long career, even retraining and switching career if necessary.

But let's say, for the sake of arguments, that US adopts the requirement of having highschoolers applying straight away to medical school. Then suddenly you need a very different selection criteria. High school grades are off. SAT is jokingly too easy, so you need a much more difficult national exam (and enforce that nationwide). Students either grind in high schools for high grade or they'd rather drop that early to go for "normal" universities. And finally, you need better schools across the board to provide students with such opportunity, because if left unchecked, you'll have 10-20 percent of students from California, and only a few spots from Tennessee, thus not ensuring rural area having enough doctors.

What do students who pass med school, but can't get a residency do? If the numbers are right, then there should a large pool of them.

I assume you are asking about the ones in the US system (because in the system like India and my country, everyone who finishes the med school are assigned rotational spots without exception). From what little I observed (almost all of the people I know get into residency in the 3-5 years of trying), some decide to become physician assistants, some medical scribes or some chose pharmacy school. After studying medicine for 4 years or more, one has sufficient knowledge about medicine to branch into similar professions like those.

Wait didn't you say the slots are worth a million dollars _because_ of the subsidy? But that it shouldn't be subsidized because it's profitable?

Little bit of both. The right to hire someone should be valued at 0 as it's an inherent right every company has. Going for one million per slot shows something is very wrong. Could be just the subsidy or it could be worth it to join the price fixing club.

Presumably most of the subsidy goes toward paying the resident, so most of the value to the hospital of the residency is the work done by the resident.

Some of it does, but most of it does not. I believe most residents make something like $50k-$60k/year, and work ~60-80 hour weeks.

https://www.reddit.com/r/Residency/comments/hdx3gw/no_laughi...

Can confirm this comment. Residents earn ~60-70K/year (usually close to 60K) and work ~60-65 hours/week (not 80 hours/week; there's a bit of exaggeration in that number). My wife is a current US medical resident and we have a lot of friends who are at various US residency programs.

Yes but how much is the subsidy and how much goes towards expenses the hospital only has due to the resident? For example the subsidy also covers the resident's malpractice insurance but the hospital isn't profiting from that. It also looks like there is the IME, a system where all Medicare payments are increased proportional to the number of residents intended to cover the extra work and expenses of training residents. So it's a rather thorny question and probably depends on the hospital (how many Medicare patients they have, etc). I imagine it's like NIH grants where the overhead is like 40% - substantial but I think the work done by the residents is likely to be a significant fraction of the value.

I believe residents need to have an attending sign off on everything they do, so while they could increase premiums indirectly, I don't know by how much. If anyone is named in a lawsuit, I think it would be the attending since the buck stops with them, and they should carry their own malpractice insurance in addition to the hospital's.

Based on what I've read, I suspect residents are very profitable for hospitals, even if they use a significant portion of the grant.

Nice to know there is someone out there willing to make all presumption

What is the system then? Do hospitals being made out of doctors not want to do it? Is the bottle neck actually at a different stage?

To put it in tech terms, imagine if the FAANGs + 20 other big software companies had universities. Along comes the government and says that the only way for you to be a programmer is to work at one of these companies for 3-7 years. Oh yeah, and the FAANGs et.al. have an anti-trust exemption that allows them to collude on wages/benefits.

Pretty clear why that system gets abused. The result is that doctors have to pay 50k+ tuition for 4 years and then get paid (relatively) crap wages for 3-7. After that, they make bank because of how hard it is to become a doctor.

Existing doctors have been all to happy to pull the ladder up behind them. They continue to make it harder and harder to become a doctor by extending the training time. As a recent example, to work in a pediatric hospital now requires an addition two years time as a fellow. Of course, no current pediatrician is going to be required to do more training. Just anyone that wants to enter the field and compete now has to accept an additional two years of lower wages.

The linchpin holding this all together is the government license requirements for doctors. Take that away and it all crumbles.

Big problem.

But speaking to the Australian experience: Between 2000-2010 we went from producing 1500 new doctors to 3000.

We have a different training pathway to the US (and there are many criticisms of both) but you have to complete at least one, usually 2, generally 3-4 years of generalist or semi-generalist Training before entering your chosen speciality. This results in a much older age of graduate. However it also results in people entering the speciality that they desire. On the other upside, we exit with little Med school debt (most Americans I met left with 250-300k in debt)

The persistent bottleneck is with medical education and training.

You can not, in the course of a handful of years, massively increase the number of trainees for speciality isotopes without adequately upskilling sown the line and making sure people have jobs to go into and that the existing power structures are there to facilitate integration and adequate skill set/not be overly disenfranchised by their own hold on things that they don’t let go.

Capability is evenly distributed, opportunity is not. We must all work to improve on this

Okay, but how is that going to get us more doctors now when we're short of hands for dealing with the coronavirus?

Why are people only discussing the long term changes necessary and not the fact that we need more people to treat the coronavirus now?