If I sell garden gnomes wearing knitted hats, but I only make three a year and sell to only people who drive yellow cars, I doubt I could earn a decent living off this
The sub-text is that doctors are slightly corrupt and wish to be payed more, and therefore are incetivized to reduce the total number of doctors.
After reading the travails of what this doctor is going through, that seems like a very callous take, insulting even.
What's more, it seems that this article has triggered a reflexive anti-union stance, when it's more a hallmark of a place where capitalism does not work well. Why doesn't that hospital have more doctors? Surely, they could have found someone additional if they wanted. The hospital did not have to schedule every surgery as if they all required the average procedure time. The hospital could invest in better IT infrastructure and have software that was not a drag to use. Surely the hospital could have someone help the doctor not make 70+ calls over the course of a shift in addition to everything else they do. This blog post is not about a general scarcity of doctors; there's lots that could be done by the hospital investing in its staff and outcomes without hiring a single additional doctor.
Many hospitals are run by non profit organizations to help reduce this problem. However even they cannot run at a loss overall for long. Bankruptcy doesn’t help anyone actually provide services, after all.
Gov’t has different incentives - but then care is strongly controlled and limited by public policy, for better or worse.
And an organization that is able to optimize to produce more value than they consume (aka is more profitable) can take more risks, expand better, have more capital to invest in training, equipment, etc, be more competitive in who they hire, and have better and more comfortable facilities if they want.
And being a Dr. can be really miserable sometimes, and the training is also really hard and miserable.
Some (surgeons, esp. plastic surgery) optimize for maximum $$ for misery, usually. Others (pediatrics) optimize for maximum ‘feel goods’ for misery, usually. Most others are somewhere in between.
Either way, if they didn’t want/need the money, they’d be going to medicine sans frontiers or working in rural medicine eh?
Eg, businesses that cheat and get caught. Businesses that over consume and can no longer produce.Also, that optimization can have the opposite effect. Eg, optimize revenue by showing max ads, with max ads users start to flee. A hospital could optimize for patientoutcomes, and then do better because the patients stay around.
This overall though assumes that free market principles work in healthcare. Those principles tend to assume consumer choice.
That doesn't make any sense. And not everyone has the capital or capacity to make their own business
Further, you assume a surgeon could just become a GP. They are different fields.
https://www.quora.com/Can-a-surgeon-also-practice-as-a-prima...
"Can a surgeon become a regular doctor?"
> They can try. But they would have no idea what they are doing. But legally, they could certainly practice as a primary care doctor. They would not be board certified, and could not sit for the ABIM exam, and would not be able to pass it if they did.
> The professions are also very different, primary care is more allied to the work of a physician, whilst a surgeon is trained to do serious surgery, not the kind a primary care doctor would do. So not sure even if you could be legally certified in both specialties you wouldn't loose your surgical skills if you spend a lot of time in primary care.
> Knowing what I know about the medical world in general I would advice against such a combination, a surgical residency is such a taxing one that you wouldn't have time to do anything else beside surgery, furthermore the required mental approach to do the work well as a surgeon or a primary care physician is also quite different.
I'm seconding 'viraptor here - this isn't a good enough explanation. It doesn't stand up to scrutiny, and doesn't mesh well with day-to-day experience. Individual doctors I know seem to have very little influence over anything, and they're first in line to the protests about working conditions and pay.
1. Doctors have a lot of political influence because they are popular. This means they can get away with things that other industries mostly can't.
2. State provision of medical care corrupts the system, as I describe sidethread: https://news.ycombinator.com/item?id=40030452
One way to drive "medical costs" down is to ensure that the supply of medical care is low. This also drives prices up. This means that the incentives of the regulatory body are directly contrary to the incentives of the people supposedly benefiting from the regulation.
(And doctors and hospitals are happy with this, because such a system boils down to telling them "we want you to do less work, but for more money".)
3. (Tangentially, note that the general model of "restrict supply, subsidize demand" is incredibly common. It's popular both ways; the first part helps a small but politically active and highly motivated group, and the second part pretends to help the populace in general.)
How is this at play (from the article we are commenting on)?
The article does not mention once: "medicare", "medicaid", "regulation", "law", "government" - once.
If anything, it's the inverse. You have it bass-ackwards, the private hospital, the for-profit system is driving things like:
> I delivered my third child with my own hands because the obstetrician was stuck in a traffic jam. The following morning I went to work because if I didn’t 12 patients have to miss their surgeries, 2 anaesthetists and about 8 nurses will miss out on their day’s income. More importantly, admin would not be happy because a cancelled operating list is a huge financial loss to the hospital.
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> 1. Doctors have a lot of political influence because they are popular. This means they can get away with things that other industries mostly can't.
Can you clarify how this doctor exerts any type of political influence? They have a sleeping bag in their car they sleep at their job so often and are lamenting they barely get to see their family. I don't see your point at all being illustrated in this article, at all.
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> "And doctors and hospitals are happy with this, because such a system boils down to telling them "we want you to do less work, but for more money".
I get the feeling this doctor is on the verge of suicide from being over-worked. Do you think the person that wrote this article would agree with your statement?
The culprit is the AMA.
> In the 20th century, the AMA has frequently lobbied to restrict the supply of physicians, contributing to a doctor shortage in the United States.[10][11][12] The organization has also lobbied against allowing physician assistants and other health care providers to perform basic forms of health care. The organization has historically lobbied against various of government-run health insurance.
The doctors are simply wrong; the state is correct from a pernicious point of view.
Because the state is responsible for buying so much of the total supply of medical care, they generally view things from the perspective of "how much are we spending on the category 'medical care'?", rather than the perspective of how much any given treatment costs.
Increasing the number of doctors lowers the cost of all treatments and is unambiguously good.
However, it does raise the total amount of medical spending, which, in the eyes of the state, is bad.
That’s the view of the government?
Or induced demand.
That said, likely individual medical outcomes would be better.
Large scale systems tend to produce… odd behaviors.
Prestige is, of course, not a function of income alone. Plenty of software developers get paid at least as much as respected professors or top military brass. That doesn't mean they have equivalent prestige.
One reason you could imagine is that the health trusts determine roughly how many student doctors they are able to train and then the government limits graduation rates based on this. But I don’t know if that’s the actual reason, and it could be a half-reason, eg the number was set a long time ago and not updated.
The fact is it’s extremely expensive and time consuming to train physicians. There isn’t enough space. Third and fourth year med students are going to far-flung hospitals to have hands-on experience because staying in the larger cities means they’re competing for access to training with residents.
All of this factors in to the cost and limited space of med school classes. It’s sad, but we would have to reinvent how we train physicians to address the limitations.
I don’t even know what argument you’re trying to make here? It’ll take time to solve? Yeah, obviously. That’s why we should start ASAP and given that we don’t have a time machine, that’d mean right now.
Does the federal government set the national number of teachers who can be trained each year?
The underlying fact that the AMA is directly responsible for the doctor shortage in the USA is historically accurate. 20 years ago the AMA believes we were heading towards a doctor surplus and heavily lobbied and for fewer medical schools, caps on federal funding for residencies and big cuts to the available residencies.
The AMA has reversed course and no longer supports these positions but the damage has been done, both to our supply of doctors and to their own reputation. However, even today the AMA supports many policies that keep taks that other professionals could perform the sole purview of doctors (which excacerbates the suppoy problem they helped create.)
That is indeed the AMA the talking point to justify their stance. However my problem with the AMA here isn't that they support some scope restrictions (clearly many decisions do require full training) but that they strongly support ALL scope restrictions without data to support such a rigid hardline stance. They do this even when the loosening scope restrictions would decrease cost and increase availability without any harm to patient outcomes. This absolutely exacerbates the physician supply problem that the AMA created. If the AMA actually care about the physician supply issues in the country, it would work with state and federal regulators to identify which scope restrictions can safely be loosened.
The answer to a physician supply problem is increasing the supply of physicians, not having nurses do physicians' jobs.
When an organization with a clear history of a specific agenda has a talking point, it is good to take the context of their agenda into account. I would point out that this particular agenda is one that has been largely achieved, which is why doctors in the USA make so much more than any other country and part of why our healthcare costs are so much higher.
In this case, we have a problem that the AMA deliberately worked to create for 20 years. Now that their "oversupply of doctors" myth is no longer remotely tenable, the AMA argues that the ONLY way to solve the supply problem they created is a solution that takes 10+ years to take effect.
We absolutely need to increase the number of doctors we have, but we also need to look at other ways we can safely increase patient access and decrease patient costs while we wait for new doctors to be trained.
The problem with increasing the supply of physicians it takes 10+ years for policy changes to have effects.
Yes. What’s difficult to believe about this? People respond to incentives. The incentive for every physician is to maintain a shortage of physicians, therefore improving the job security and earning potential of every physician. The only way this could be done is if the physicians formed some sort of cartel that could control how many people were allowed to become physicians. This is what the AMA is and what it verifiably does.
Politicians "trust the experts" and the American Medical Association says...
The flaw is the AMA is just a union for doctors not a body that represents patients in any way.
https://www.deborahgutmanmd.com/blog/new-medical-schools-upd...
The immediate bottleneck really is in residency programs. Every year, some students graduate with an MD/DO degree but are unable to practice medicine because they don't get matched to a residency program.
https://blog.petrieflom.law.harvard.edu/2022/03/15/ama-scope...
> The flaw is the AMA is just a union for doctors not a body that represents patients in any way.
Ergo, AMA is not a union, hence that cannot be a flaw in the AMA. Chastising the AMA for not representing patients because it is too busy being a doctors union is a straw-man argument.
I think there is unstated subtext perhaps in your criticism. To one extent, a unions job is to care about its members. It is _not_ the unions job to care about anyone else. If the union acts in the interest of anyone other than its members, it is not doing its job. I think that criticism is more of a definition almost. The seamstress union was not created to care about the CEO and managers, but seamstresses.
It's hard to say a bit whether union benefits always do come at everyone else's expense. I'm reminded of the argument against $15 minimum wage. According to one third of business owners in 2021, it was going to cause layoffs. [1] That did not happen in Seattle where that was tried, instead the data shows: “Seattle’s minimum wage ordinance appears to have delivered higher pay to experienced workers at the cost of reduced opportunity for the inexperienced,” [2] Despite the data, there is still the claim that mass layoffs would be necessary.
I think this perhaps dovetails into the debates of trickle-down (AKA supply side economics) vs bottom-up economics. Be what it may, not everything union is good, yet you can still thank them anytime you have a weekend. [3][4][5] I'm just saying, be cautious when painting with a broad brush. The idea a union helping its members will always be at everyone else's expense strikes me as an anti-union talking point rather than something grounded in firm data. Could be true, but without citation showing that to actually be extensively true, I do not take that statement at face value.
To be sure, the _only_ claim I'm making here is that a union and professional union are not the same thing. I'm super skeptical of all these other claims/statements being made and am not really willing to accept anything on face value here without evidence, particularly broad generalizations. The points I raise I think bring some refutation to those generalization, which does not mean the inverse is true, but simply that those generalizations are neither helpful nor informative.
[1] https://www.cnbc.com/2021/02/10/one-third-of-small-businesse...
[2] https://fox59.com/news/heres-what-happened-when-seattle-rais...
[3] https://www.politifact.com/factchecks/2015/sep/09/viral-imag...
[4] https://www.unionplus.org/blog/union-made/eight-reasons-than... (this source is very biased)
[5] https://www.pbs.org/livelyhood/workday/weekend/8hourday.html
edit fixed citation links, one was missing. Added more citations in support of claim that unions are to thank for the weekend (please correct my history if wrong, my point is that historically, in the concrete, unions have done some really good things [assuming you believe not working an average of 102 hours per week is a good thing as was the case for building tradesman in 1890 [5])
Doctors's simply have the strongest association/union to preserve their privilege. No wonder why they easily earn way more than your average senior software engineer, lawyer or whatever around here. After the first few years from graduation, many of them go work in private sector where there's generally less stress, and 3-4 day workweeks are pretty common too, as they can afford it. Not a bad deal at all.
Here it has got to the point where young Finns pay money to go study in poorer countries like Latvia and Romania, because it's too hard to get in medical school here.