There is absolutely a shortage of doctors. AMA is unwilling to fix this and instead rely on a system that drives many to suicide.
My wife is a doctor. I’m a software engineer. While she now makes more than I do, it took nearly 10 years. That whole time, we were racking up tuition/debt on tuition. Residency was demanding and severely underpaid.
Based on our math, we’ll be 25 to 30 years into our careers before her medical education with have a better ROI than my career choice. I didn’t even push for top-dollar jobs.
In other word, medical training had a huge opportunity cost. Even if you solve the bottleneck of residency placement, salaries need to offset the insane burden of training.
Similarly, my husband is a commercial pilot and is now starting to make more money than me in tech after his 10+ years of underpaid work and a high student loan debt load.
But, here's the deal: he's basically going to make top dollar until he's 65. Meanwhile, I'll likely be seen as a dinosaur in tech by that age and will be lucky to find work at all.
I imagine your wife will be seen the same way. She can comfortably work until retirement age, in an profession that sees experience as a positive thing, while you might be a pariah before you know it.
Yes, we make good money when we're young in tech. But we age out much more quickly due to the bias common in our industry.
Maybe I am naïve but I don't get this age vibe really. I do backend java distributed system stuff for a large company. A lot of my peers and managers are "older" 40s and 50s with kids. A lot of the work is high collaborative and design focused. Maybe I am just in a bubble of an aging tech stack but it does seem like we are always using "new" (at least different) databases, caching, and network layers to stay somewhat current.
Its hard to imagine that 5,10,15 years of distributed systems and system design experience and knowledge along with domain knowledge and social skills will be all of a sudden be so irrelevant that it is worth phasing all of us "old guys" out for someone who happened to learn the newest programming language straight out of school.
We are constantly expected to learn the new stuff and will just a project assigned with a mandate "okay this is to be done in spring boot, using this DB, this HTTP layer, etc...
I’m 41 and I totally understand this sentiment. A silver lining is that the tech industry is just so much larger now than it was when we started, a trend I think will continue, and there are now tons of jobs where it’s really helpful to also be a developer. Some examples:
Developer and marketer/technical writer
- selling to other devs is a giant business now and it often takes devs to make that content.
Developer and SRE
- we live in the world of huge scaled our saas businesses where there are always support issues too advanced to be handled by non-devs
Developer and project manager
- everybody has worked with non-dev project managers and it’s usually terrible.
Developer and people manager
- there are so many more eng manager roles than there used to be, and moving to the management side is a well worn path now.
Developer and product manager
- you have to develop a lot of new skills but in this role a past life as a developer can give you super powers.
That said, I moved first into people management and then into running a small software company which sort of demands a little bit of all of those skills
> But, here's the deal: he's basically going to make top dollar until he's 65. Meanwhile, I'll likely be seen as a dinosaur in tech by that age and will be lucky to find work at all.
Errr, I'm 64, generally get a title like "senior programmer", and have switched jobs a few times recently and didn't have a day out of work. I expect to be going for a few years yet - in fact I expect your husband will be forced into retirement, whereas I will chose my time.
Moreover, I have quite a few software engineering friends or about the same age. It's the same for them. Some are still working, some not. But in every case it's been their choice, they weren't forced into it by the industry.
I question the aging out aspect of software dev on a career level. Yes you might get agism at trendy companies started by and heavily employing young people, but there are many software companies out there with many industries now employing software divisions, and the heavy demand I always see is for senior developers with experience.
One “problem” in software: it’s really difficult to coast for a long period of time without training up new skills. You can certainly do it, but eventually the industry shifts underneath you. So the cushy senior Java dev position in a particular service might be able to last you for a decade or more at some companies, but I think most developers agree that if you want to keep getting better salaries you need to stay on top of trends and keep reeducating yourself.
And I don’t really see this as a problem as much as a feature of tech, but if you’re looking for predictability in a career I think it’s a tough thing to get in tech.
> Meanwhile, I'll likely be seen as a dinosaur in tech by that age and will be lucky to find work at all.
I disagree. Go to some technical meetups.
At practically all of them I have seen people offering jobs to both juniors and greybeards. The biggest problem everybody is having right now is connecting. The garbage in the middle is clogging everything up. So, everybody is going back to the old tried and true, the weak social network of in-person acquaintances.
Yeah, you have to not suck and you have to keep your skills up-to-date. But, that's true whether you are 20 or 60.
> Meanwhile, I'll likely be seen as a dinosaur in tech by that age and will be lucky to find work at all
My dad is in his 60s and is still doing cutting edge work on Kubernetes, Golang, eBPF, etc in a big tech company in the Bay Area. It honestly isn't that hard to keep yourself up to date with technology looking at his experience.
If you can't get yourself interested in upskilling or learning the next new paradigm you're in the wrong field.
I think the ageism thing is not as big of an issue anymore. Yes, you will see it in startups that are run by 20somethings but I'm in my early 50s and haven't had any problem staying employed or getting offers.
If you stagnate skills wise or stop trying to grow/evolve your abilities then you definitely will have issues but that's true in many industries, not just ours.
I mean, mathematically speaking, having your high-income years happen earlier in life is significantly better because of the way compound interest works.
Not to sound like a naive optimist, but the average age of somebody working in tech is going up over time, and that is likely going to make tech less exceptional in its ageism.
Tech is also slowing down in how much it is changing, which makes it easier to do the work while older, which again takes the edge off of ageism.
Your husband is also in the position where any mental issue and a lot of physical health issues will force an early retirement.
And if he wants to make the big bucks, there are not that many companies to work for (~10 mainline carriers in the US at the moment), and the seniority rules suck.
I think if you actually take the time to talk to some older dev people you will find that you are wrong, and when you actually get older you will find out how wrong. We are doing great - financially and professionally, despite having to face a small number of people with this attitude.
I hope you’re correct but the very realistic possibility of
SPO (single Pilot Operations) is what pushed myself - and many others like me - away from the career. The current pilot shortage was by design, as the airlines were well aware of the issue and had many ways to avoid it. I’m still of the mind the current shortage (and short term plans to mitigate it) are just to hold them over long enough to end the current 2-pilot system and bring the standard to single pilot operations
> But, here's the deal: he's basically going to make top dollar until he's 65. Meanwhile, I'll likely be seen as a dinosaur in tech by that age and will be lucky to find work at all.
My grandfather made good money fixing systems for y2k in the 1990s and retired shortly after.
There's plenty of work for dinosaurs. Plenty of systems quickly hacked together today will be around for much longer than planned for.
>But, here's the deal: he's basically going to make top dollar until he's 65. Meanwhile, I'll likely be seen as a dinosaur in tech by that age and will be lucky to find work at all.
People used to believe this, but it's not true at all in my experience.
It's not a matter of the goodness of the deal that a doctor has versus that of a software engineer. It's that the deal doctors get is emotionally scaring to them and it produces horrific social dysfunction.
> I'll likely be seen as a dinosaur in tech by that age and will be lucky to find work at all.
Can confirm, but it’s more like around 50. That is why you tend to not see a lot of senior folks wanting to bounce gigs every three years like the younger folk do. I hope to ride out another 7 years at my current gig and retire. Hopefully they won’t have other plans because at that point I’ll likely have to shift to WalMart greeter.
> Yes, we make good money when we're young in tech. But we age out much more quickly due to the bias common in our industry.
52. Gimme 10 more years, I won't care. I don't want to be working any job after that even though I love programming and it's all I ever wanted to do (for a living).
> But we age out much more quickly due to the bias common in our industry.
Just prove you lost a job or weren't hired due to age, and you'll have a lawsuit that results in a large enough settlement you will once again be paid more than your spouse and won't even need to work.
I wouldnt be so sure. aviation is ripe for automation (and planes can even land on its own now.). I can see airline companies pushing for only 1 pilot in the cockpit.
> Based on our math, we’ll be 25 to 30 years into our careers before her medical education with have a better ROI than my career choice. I didn’t even push for top-dollar jobs.
I just want to point out that - you landed (probably more random than intentional) into arguably the best career in the history of labor.
Compare a doctor to almost anything beside an engineer - and it won't seem so terrible.
Most people that have been in engineering for >10 years got into it because it's what they liked doing - and then it just so happened to be ridiculously lucrative and not require you to go into hundreds of thousands of debt to get trained to do the job (medical, lawyer, etc).
Even most trades (electrical, plumping, beauty, the taxi medallion system, etc) are designed similar to the medical industry - and require ever more schooling (debt, opportunity cost) to get the job - to artificially reduce the work force to benefit current workers at the cost of future workers and everybody who uses those services.
I think the particular problem with the medical industry is... it's particular detrimental to society to be overworking doctors to the bone and it not really paying off for them until they're in their 50s.
We're all gonna need medical help some day...
Maybe we can do our own plumping and cut our own hair and be good law abiding citizens and not need a lawyer. But we're all going to have severe medical problems at some point.
While that is the result I think emphasizing that it isn't made easier is important.
Electricians need to install high voltage wires that are safe in the home for untrained individuals for potentially a century.
Plumbers need to install water tight pipes that can withstand significant pressure without leaking (which can be difficult to detect and very quickly devastating damage wise)
Doctors are expected to be able to catch nearly any disease in their specialty based on an honest consultation.
Lawyers need to know a phenomenal amount of information to meaningfully know what o research when it comes to prepping for court cases.
All of these jobs are hard to prepare for and their is value to everyone else that you can prove you actually prepared.
The problem is the incentives for encouraging more people to prepare are backwards (those supporting the newbies benefit from fewer of them) which causes no real help to be given and the labor shortages.
But it isn't made up boundaries just to benefit existing members.
There can be more schooling and training in engineering.
After undergrad, master’s, PhD, a postdoc or two, one would still make low income. After that, there is a never ending path where one has to constantly chase ever changing technologies. The older you get, the harder it will be to keep up and remain employed.
In medical science, you finish the residency (roughly equivalent to 1-2 postdoc in engineering), and you start to practice. Already, income is OK in residency. The older you get, the better!
> I just want to point out that - you landed (probably more random than intentional) into arguably the best career in the history of labor.
I don't disagree. However, I certainly am not a top earner in the industry. Much of my career has been remote. My income is not out of line with most STEM fields. The main benefit for me was the ability to work remotely, moving with my wife to various small towns/cities.
Keep in mind, my wife had almost 10 years of med school and residency to start her career. I was making income the whole time. That's essentially a $1M difference 10 years into careers. It takes a while to overcome that gap.
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> I think the particular problem with the medical industry is... it's particular detrimental to society to be overworking doctors to the bone and it not really paying off for them until they're in their 50s.
Yep. There's also a huge personal burden of carrying that non-dischargable debt. If residency doesn't work out for some reason, you're in a huge hole.
We know many physicians who say they wouldn't do it again if they had know how shitty the journey would be.
Problems are doctors are unlikely to "help" with, and are highly likely to make matters much, much worse.
Also, contrary to popular opinion, there's little stigma or awareness of "bad doctoring", for a number of systemic reasons.
So you have someone who doesn't give a fuck about anything, certainly not your situation, not listening to you, and trying to prevent you from receiving medical treatment.
This doesn't look so necessary to me. I know there will still be medical experts and surgeons and so forth, but much of this medical infrastructure doesn't benefit the average citizen (I know there's an argument that it does or for a change in perspective, but that's a whole different can of worms.
Similar to policing, if you think of the typical way you interact with the medical system, you start to realize there's very little in there to help you. 99.99% of the infrastructure is built to benefit powerful people with tons of money; helping you is an after thought.
What happens when you're a victim of crime? Turns out there's very little in place to help. Oh, someone is actively trying to murder you? well give us a call after it happens and maybe we'll investigate.
How many of us have experienced something like this? I'm not saying there's no reason for the arrangement, but we should stop trying to pretend these people are looking out for the public.
I know people may be tempted to chime in regarding some situation a police officer or doctor helped you. I'm not saying you're wrong, just explaining why some people are asking questions; if you honestly think about it, your naive assumptions about safety and health will be shattered.
A doctor, in many ways, arguably has a patients WORST interests at heart, in a similar manor to a police officer, in it's interaction with the public. They have, as their most important responsibilities, to detect certain things, and take actions to hurt the person.
This is priority #1, virtually everything else comes after. This is an important observation, is not obvious, and should cause us to reconsider these institutions.
Same here. I am a programmer with a wife who is a doctor. It took her about 12 years after she started her practice before her total earnings surpassed mine.
One thing that rarely discussed in this kind of conversation is taxes. A doctor spends 12 years earning next to nothing and going into debt for training costs. Then the second they start making a real doctor salary, the IRS thinks they are 'rich'. They are taxed at the highest tax bracket even though it might take them another 10 years to surpass someone who was earning barely a six-figure salary the whole time.
If you spend 9 years earning nothing and then make $1M in your tenth year, you will pay much more taxes than someone earning $100K for 10 years (even though both earned a total of $1M over those 10 years).
Not to mention that most retirement accounts have yearly maximums, if you where making 401k for 10 years at 100k you will have significantly lower effective taxes than a person who made nothing and then sees high earnings trying to put into retirement.
Who knows if software engineers will be paid the same in the future but doctors will most likely have a strong "moat" till the day they die. Software engineers lucked out in this era not because they are smarter / harder working than people like mechanical engineers but they just chose a profession that naturally scales, and scaling is really how you can make a lot money.
I'm actually expecting doctor's moat to break in our life time. We're already seeing the beginnings of it.
Essentially, physicians have been so bottlenecked for so long that a bunch of states has simply said "screw it" and started paving the way for mid-levels (NPs and PAs) to operate in certain roles physicians have previously covered. The physician lobbies seem unwilling to address this, so I expect that mid-levels will continue to move up the chain. They know the market is desperate for a solution and physician interest groups are completely unwilling to provide that.
> [...] harder working than people like mechanical engineers but they just chose a profession that naturally scales
The product of mechanical engineering also naturally scales. Once you design a machine, you can build it an infinite number of times. However, in neither case does the labour scale. One engineer, whether their focus be on software or mechanical, can only do so much in a day.
Software engineers lucked out in this era because it is a new, relative to other industries, field that saw a rapid rise in demand for labour, with comparatively few people able to fulfill the need for that labour. By virtue of supply and demand, incomes had to run high to attract workers.
> and scaling is really how you can make a lot money.
That is true, but engineering doesn't scale. It is highly doubtful that engineers will continue to benefit into the long future. The owners of the software built by engineers will be able to continue to reap the benefits of scalability, but the labourer – who does not scale – will undoubtedly start to get squeezed as the industry matures and demand is no longer growing exponentially.
> they just chose a profession that naturally scales, and scaling is really how you can make a lot money.
They chose a profession that appears to scale to investors. When software _actually_ scales rather than being a subpar substitute for an existing mechanism is when the people involved were indeed smarter and worked much harder (typically).
> salaries need to offset the insane burden of training
A cycle here is that student loans rise with expected earnings and banks are fairly open ended about it, institutions happy to justify the use of the cash.
Salaries wouldn't need to be nearly as high if you didn't walk out of residency with 200k+ [medical school ] debt at a point that is effectively mid-career. As a society we'd probably be better off if the both the median salary and median debt was much lower. I've also seen the "guarantee" of a high salary later lead many young doctors and med students to be foolish with money, as "eh, what's a little more debt" is easy to fall into.
It's also part of the driver to overspecialization, more available GP's and fewer people reliant on emergency visits would obviously improve the system, but the economics and QOL for a general practice keep getting harder.
Residency bottleneck and the high barrier for foreign trained mid-career people are the two other areas for potentially major impact.
Why are you expecting the AMA to fix this? The primary bottleneck on producing more physicians today is lack of residency program slots. Every year some doctors graduate from medical school but are unable to practice medicine because they can't get matched to a residency program. The AMA has been lobbying Congress to increase Medicare funding for those programs.
Why on earth would medicare have anything to do with residency spots to start with? Why wouldn't the hospitals use this as an apprenticeship program and pay the residents and charge appropriately for their services?
Residency slots are the bottle neck because the AMA requires residency to be the bottleneck.
There is literally no path to becoming a physician other than the blessed med school + residency path. By contrast, you can become a lawyer simply by passing the bar exam.
Some states are starting to allow physicians to practice without residency and the AMA is vehemently against it.
The general impression is that AMA is basically giving lip service to that goal. In public, that may be their goal. In private, it's certainly not happening.
Most states are begging for more qualified providers. Many are looking to mid-levels to fill the gaps. If the AMA were serious, they'd be working with all of these states to fill those gaps with physicians.
Medical schools absolutely want to expand, they make tons of money and have many applicants who are qualified and willing to pay. The problem is there aren't enough residency seats. If there were more med school grads without expanding residences many competent graduates would go unmatched.
I have no source for it, but I read once that (GP) doctors make less than software devs on average, simply because devs get that decade head-start with much less debt. It makes sense.
This is such a hard problem to fix. I doubt anyone is interested in hearing any solutions that involve worse-trained doctors, or longer training schedules, or massive pay increases for what are viewed as some of the highest-paid people in the nation. There is a lot of talk about opening up medical care for more people - which, naturally, means there will be a surge in demand. I can only imagine this would exacerbate the problem. It feels like we're running out of time to fix this.
Based on the workload of medical students and residents, I do not believe that even if the AMA relaxed the standards for entry that unless they relaxed the standards for exit we would have more doctors.
And by workload, I don't mean just hours on the job, I mean amount of material to learn. It is overwhelming to most
Is it all really necessary? As an outsider it looks like letting the perfect be the enemy of the good. That, or it's just tradition / an elaborate hazing ritual.
I don't see how the ability to work long hours is necessary to heal the sick. They don't train airline pilots like this, or nuclear plant operators. What's so special about doctors?
I know a guy who accrued $400k+ of med school debt and dropped out last quarter. Insane system. I didn't even consider medicine, despite being a top science student, because of the stress.
And god forbid you think you can handle it at 18 years old and then being stuck on the medical track for... decades.
There is a reason why most med schools have like a 5% acceptance rate. They have a much bigger moat than most software engineers. They are guaranteed a lot of money even if they aren't that good. They don't have to worry about leet code grinding and learning the newest random framework either.
On the other hand, you want doctors to be well rewarded because it's a high stress, high work hours, high responsibility, high liability, high effort and high opportunity cost profession. If it doesn't pay well, very few people are going to bust ass in medical school and residency for 10 years to do it.
In my country the government flooded the market with doctors and the results weren't pretty to say the least.
And not to mention that doctors usually have no work life balance. I have many doctors in my family/friends here in the US and most of them have no time for anything including weeknights and weekends. It is crazy.
Most of my friends who became doctors have rich parents. The ones without rich parents funnily enough dated software engineers who were the main breadwinners during their med school/residency.
> Based on our math, we’ll be 25 to 30 years into our careers before her medical education with have a better ROI than my career choice. I didn’t even push for top-dollar jobs.
This has quite frankly zero relevance to anything. The analysis depends on what you her husband does (I mean seriously how does that prove a point at all) and your choice and abilities (totally arbitrary based on a host of factors especially given the tech scene over the last decade.
I mean ROI? So someone makes a career decision by comparing to what their partner makes or what ROI is?
> AMA is unwilling to fix this
This has to do with residency slots and residency slots are determined by how many hospitals can accept residents. Now you can say AMA is a roadblock to that but there are a slew of other roadblocks in addition (if true not sure it is) to having more residency slots.
You can think idealistically that you can re-imagine the whole system but massive change in something entrenched like that (where lives matter) most likely is not practical.
Ageism in tech is based on the premise if you aren’t already a multimillionaire dabbling in angel investing by 30, you don’t have the “it” (ambition, skill, etc) to really contribute at a high level, and a young programmer can do similar work but be more familiar with latest tools and langs
>Based on our math, we’ll be 25 to 30 years into our careers before her medical education with have a better ROI than my career choice. I didn’t even push for top-dollar jobs.
Depending on if you're married or brought a home, her education and status already paid off with special rates for doctors/lawyers/high earners/professional mortgages:
On some quick googling the mean debt at graduation from medical school is about 250,000 (this includes undergrad). This number is trending upward. There is also the opportunity cost of 4 years additional school and 3-7 years of getting paid 60-70k.
Most doctors end up making between 265k and 382k per year, this varies wildly (from pediatrician on the low end to brain surgeon on the high end).
It varies wildly depending on the medical school (state school in Texas is affordable for example), scholarships, program (MD/PhD programs, MD only, MD/JD programs), and terminal specialization.
The difference being a doctor is a lifestyle business requiring performance of service while a software developer can potentially make passive income. There is, however, a lack of essentialism to being a software developer that AI can replace, whereas caregivers will be the last to be automated away. It is likely software development incomes have peaked and will decline long term.
Hmm, are you turning both your wages into hourly rates and then comparing? My wife is a physician (me a SWE) and at face value she makes more but after considering hours worked it’s not even close.
She is regularly pulling 65-90 hrs/wk with little flexibility in her schedule.
I'd say that the law of one price applies here. Doctors need to be making this much to compensate for living in debt their whole youth and early adulthood. Also having money is probably more enjoyable when you're younger.
Yeah, for real, the whole residency/shifts they are submitted into are borderline abusive, and I don't think any other profession accepts their professionals going though this
America needs tuition-free state universities and trade schools. Full-stop. We're encountering endless problems, sending our entire economy (and living standards) out of whack, because we don't.
And career longevity. A 40 year old developer is "old". At 50 you're ancient.
A 40 year old doctor is insanely young. A doctor in his late 60s can easily be in their prime, especially in some practice areas or research. Provided they are okay health-wise, even an 80 year old doctor can still be working, especially if they have a strong team. They'll probably be in a mentorship role or a more laid-back practice, but they'll still be earning a meaningful income and having a very real impact on their patients.
And generally speaking, doctors in the West live longer than the general population, so that longevity is better as well.
So far, that really hasn't been a factor for us. It is worth noting that job security becomes much less important as you build wealth. It's a lot easier to build wealth when you're not racking up debt and being underpaid in your 20's.
Just want to expand on that "tuition/debt/time" bit.
TL;DR: Becoming a physician requires sacrificing an additional 6-10 years of your life to education and training beyond what you'd expect for most careers, and assuming something like $250K in additional debt. It'll take the average physician about 16-years out of college before they start to out-earn the average engineer.
Details:
Let's imagine that two smart people start college in the United States. One goes into engineering, the other into med school.
The day they graduate, on average the engineer will get job that pays them $74k their first year.
Year 4, the engineer is likely making $84k/yr, and they have earned a total of about $315k in their career.
Meanwhile, our doctor friend has so far accrued about $250k in debt. A delta of about $560k in just 4 years, but it's gonna' get worse before it gets better.
For the next ~3-5-years (for most specialties, there are outliers), our doctor friend is gonna make about $50k/yr . (Yay, positive cashflow!) We'll generously assume their debt doesn't accrue interest in this period.
Assuming our engineer friend assumes an average career path, he's gonna be up to $92k/yr at the end of this period, with a lifetime total earnings of $669k, while our doctor friend has clawed their lifetime earnings all the way back up to -$52k.
This is also the biggest delta between the two careers. At year 8, our engineer friend has out-earned our doctor friend by a delta of $720k.
Now, on average, our doctor friend starts making $202k/yr. Good money, right!
To make the math easy, we'll assume that their debt still doesn't accrue interest.
With all that, it's not until 16-years out of college that the average American physician will start to out-earn the average American engineer.
So if they both graduated at 23, our Engineer friend is gonna out-earn our doctor friend until they both hit just about 40.
Of course, if our doctor friend has to pay some interest on their med school debt, and our engineer friend is able to invest a chunk of their salary in those early years, the magic of compound interest will be on their side as well.
And that says nothing of the fact that our doctor friend probably had to sacrifice about 4-years of mandatory 80+ hour work weeks. It also assumes that our doctor friend doesn't drop out/fail out of med school and manages to match to and complete a residency. None of which are givens.
Which is a very long way of saying: physician compensation is wonky because it's a career where you sacrifice a ton and take a ton of career risk very early on, for the promise of higher compensation and quite high job security later on in your career.
"In 1997 federal funding for residencies was capped, forcing hospitals to either limit programmes or shoulder some of the financial burden of training their doctors. Some spots have been added back, but not nearly enough. Many potential doctors are being left behind. “Not everyone who would be willing to go through that training and could do it successfully is being allowed to,” says Professor Gottlieb, the economist."
I regularly hear it is the AMA that is creating an artificial shortage, but this seems to indicate that the logjam is at the level of residency funding.
Does anyone have a good insight or data about this?
The AMA has lobbied to limit federal funding for medical residency. This is the bottleneck.
The fundamental problem is that the US government should not be in the business of funding residencies to begin with. That should the on the hospitals.
Right now the problem is that no hospitals want pay the 150k cost for residency when there is the option for the federal government or another hospital to pay it. It basically leads to a tragedy of the commons/prisoners dilemma, where all the hospitals defect and try to fight for limited grants.
Do you have evidence of this lobbying? It does not stand to reason, since care provided by residents is quite cheap to hospitals from the perspective of labor.
Hospitals have no obligation to hire the residents they produce, so an optimal behavior would seem to be training many residents and not hiring them.
My understanding is that at least at one point in the past the AMA lobbied either for the cap or to not fix the problem. Also inversely speaking, you don't really hear much about the AMA lobbying to -fix- the problem and given the frequency of this theory, you would think they would publicise it more.
There is also the weird thing where, my understanding is that the hospitals can 'sell' the slots to each other and strangely they can fetch more than the funding in question.
But really, so much of the medical residency industrial complex reminds me of a hazing ritual in and of itself.
The program was started by a guy hopped up on cocaine the whole time, that's why the hours alone suck:
"William Stewart Halsted developed a novel residency training program at Johns Hopkins Hospital that, with some modifications, became the model for surgical and medical residency training in North America. While performing anesthesia research early in his career, Halsted became addicted to cocaine and morphine" https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7828946/#:~:tex....
It's absolutely abusive and I cannot believe there's never been more of a push around patient advocacy. It's bad enough for the residents working 100 hours a week and getting fits of sleep in a shitty spare hospital room they share with multiple other residents. It's even worse for the patients receiving care from a tired, overworked resident.
Residency funding, and the fact that even fully trained foreign doctors have to redo residency to practice here.
An American can marry a foreign doctor with 10 years experience, get their spouse a green card and everything, and they still can't work as a doctor without redoing residency like a fresh graduate.
You are precisely correct - this is not an AMA issue. Funding for this is tied to Medicare/Medicaid and thus a political issue that does not turn based on what the AMA may request. In searching for the below table, it seems that there is some effort to use funds from other sources to pay for targeted slots[1]
A former roommate of mine was a doctor in residency. They were paying him peanuts and grinding as much work out of him as they could. I think this was maybe 5 years ago and he was at 65k or so in a major metro in the US.
So if you're a hospital, and you can get cheap doctors in residency who basically need to work whatever workload you give them, why wouldn't they hire as many of them as they could? I figure the limiting factor should be their ability to manage them, not federal funding. They are paying pennies on the dollar for doctor labor that they are NOT giving patients a discount on.
Residencies all lose money. That's why they're subsidized. My family member is a chair of a residency and the business analysts are constantly trying to close it because it takes time away from the doctors and doesn't provide anything to the bottom line.
You figure wrong. Hospitals require residents to do a lot of work, but they can't bill Medicare/Medicaid or private insurers for much of that work. Hospitals can't afford to just hire more.
Residents are still doing work. The notion that they should be federally-funded, rather than just getting paid for doing that work directly through the proceeds of whatever patients get charged for that work, seems dubious to me. I'd also be skeptical of a claim that available slots are more of a limiter compared to the fact that propective physicians are looking at 4 years of post-graduate education followed by 3-9 years of working 100 hour weeks for $30-40k a year before they can get licensed.
I once considered becoming a doctor when I was still a teen, and I'm quite confident I could have gotten into medical school and qualified for a residency somewhere, but it was the decade of hazing while being paid like a ranch hand that dissuaded me.
This has led to is a rise in PAs and ARNPs for primary care, and scary things like CRNAs asking MDs for sign offs without a supervising anesthesiologist.
I'm a bit of a radical on this, but we should basically remove traditional college from the whole medical school pipeline. When I think of my friends that went to med school, they all took the MCAT after two years of school. That seems like a great indication that the last two years aren't important[1]. Two years of fundamental sciences, and then right into med school.
Also, we have some many people that want to be doctors. We should let them all start medical school, and let them get weeded out from there.
[1] the caveat here is research. But MD/PhD fits far better into the traditional college pipeline.
The US and Canada are globally unique in requiring a 4 year bachelors before 4 more years of med school. Every other OECD country has a single 5-6 year program available straight out of high school.
Other nations have longer post-graduate training requirements, sometimes including compulsory national service. For many specialties, a US high school grad will be fully qualified before her UK peer
A stupid amount of my wife's medical education was completely wasted for two reasons:
* "To make sure you know what career to go into". No. You don't need 2 years to see every possible option. Everyone has some idea before they even go to med school. Focus on the 2 to 6 that you care about.
* Residency application. 4th year was a complete joke. Most of it was consumed with travel/distractions while applying to residency. Maybe 2 or 3 months of actual learning fit in their.
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The med school my wife's residency is associated with is actually a 3 year program. They skip summers and condense a lot of information.
Wow, that seems so short then. In Europe medical school is 6 years, with a 7th year spent on preparing for residency. At least in Spain. And it doesn't start off easy. All student are required to have spent the last 2 years of high school in a science-focused baccalaureate program, which in my experience is similar to early American undergraduate in terms of academic rigour.
I strongly agree. That's what the European system is like, as others have mentioned. Even the 2 years of fundamental science preparation. In Spain, what I would say is the academic equivalent of high-school ends at 16. 16-18 is then spent in "baccalaureate", an optional university preparation program, which is more rigorous and ends in nationally-administered university preparedness exam. A prospective medical student would need to do the science-based variant of this program.
I agree, and I also think it would be OK if there are different “levels” of doctors. I also think that diagnostic tests will have to carry more of the load as opposed to relying on the doctors judgment. This could mean more imaging processed by AI.
We think of doctors as healers because that’s the traditional role they grew out of. But with the institutionalization of medicine in the 20th century, they became accessory bureaucrats. Their job is to approve or deny access to institutional services, per institutional policy, and they go through many years of learning how to do that. Their pay is scaled with the cost of the institutional services they safeguard, those costs in some markets being obscene and arguably corrupt.
But people still need genuine healers for everyday ills, and so we see the institution move towards restoring that role to those with a less critical role in the institution, like nurses, pharmacists, physical therapists, etc
From my experience as both a patient and a spouse to a general practitioner the opposite is generally true. Doctors are grossly unaware of both costs to patients and insurance eligibility of procedures. They push for the solution that they believe will resolve the issue with the best health outcomes while minimizing their own risks of lawsuits without considering other factors. Next, a faceless bureaucracy on both the medical and medical insurance side of things (few of whom are medical doctors) will slowly spin into motion to maximize profit and minimize costs, all while you have very little recourse/leverage/knowledge to fight the outcome.
I will grant you that in some specialties and smaller private practices what you describing is probably true.
It's really an indictment of how far HN has fallen to Redditification* that you see this kind of low-brow ignorance so prevalently and so often.
Yes, the greedy doctors who are lucky to get a couple hours of medical coding training when they start practicing and get needled constantly by their billing department for underbilling actually have "years of learning" in how to screw over their patients.
Maybe they mean the man-years of time wasted arguing with insurance companies, shuffling around medications and care plans to please them, evenings and weekends spent in the EHR finishing up patient notes (because there's no time to get them done during the working day with 20 minute visits) and correcting and signing off on patient care for the PAs and NPs (cold-heartedly taking 100% of the malpractice risk burden for the nurses who actually care about "healing").
I'd encourage people this far gone on the deep end of visualizing physicians as hand-rubbing greed machines to spend a day actually shadowing one. Because you are very ignorant about how they spend their time and the amount of effort they put into caring for patients in spite of continual soul-crushing roadblocks put in their path.
* Yeah I know it's against site rules to say but I don't care it's true
Whenever I run into a doctor like this I just assume they're willfully ignorant because they don't want to rock the boat. How can you not be curious about such a large part of your profession?! It's a pretty negative signal in a person in my opinion.
I've spent considerable time tracking down why X costs Y, explaining it to a doctor, only to have the reply be "woah, you should tell people!" No, you should tell people, that's part of your job! Mind blown at some of these people.
Of course doctors are often committed to the wellness of their patients, but I'd argue that the point of their extensive training is to help them align "best health outcomes while minimizing their own risks" with very specific institutional understandings of what that looks like. And that's what their pay is ultimately based on. They need to make the correct decisions, per the AMA/government/etc, about very expensive things and with minimal supervision. And it needs to authentically feel like it's for a good reason.
But when it comes to the broad swath of everyday ills, someone with far less alignment training and who therefore hasn't been entrusted with the "MRI approved" stamp can often do a perfectly comparable job of taking care of people. That's what most practical medical care demands and it's what US doctors are now too overqualified and overpaid to provided.
There is bureaucracy surrounding what insurance companies and medicare will pay for, given specific diagnoses (medical necessity guidelines).
But the actual process of diagnosing a patient is not trivial and that function can not be described as that of a "bureaucrat".
Yes, you need a specific diagnosis X to justify procedure Y, and that can feel bureaucratic, but there is nothing bureaucratic about getting to diagnosis X in the first place.
I always find it funny when people say that we'd have less doctors under 'socialized medicine'. This article clearly shows that other countries have more doctors per capita. Not only that, but by and large those doctors are happier working under that system than our doctors are working under ours
My guess is that not dealing with a mercurial insurance industrial complex that tries to constantly deny medically necessary treatment to your patients makes your day to day work more enjoyable.
The AMA is a leading reason that we don't have socialized medicine, though. They were one of the largest bodies that opposed single-payer for Obamacare.
Cuba is a weird case though where doctors are essentially one of their most important exports where they send them to other countries, primarily in Latin America.
When I use the word 'socialized medicine' I'm referring to a system of universal healthcare, not communist authoritarianism. It irritates me to no end that the two are conflated.
One of the worst requirements is mandating that medical students spend four years getting their bachelor's degree before entering med school. Realistically, the essential prerequisites for med school could be covered in two years. This would allow graduates to start their careers younger and with less debt.
The "bachelor for everything even if it has no direct correlation with the work" mentality is a real plague. It's causing issues with airline pilots too. From what I understand the FAA does NOT mandate it, they "only" ask that you get a PPL and 1500 hours of flight to get your ATP and then you can work for an airline. But airlines want to hire college educated people for some reason...
The FAA has no such educational criteria requirements for being able to get your commercial license. In fact, a great deal of pilots often get a bachelors degree in an unrelated field just in case working as a pilot doesn't pan out for them for various reasons (poor pay, medical issues, etc).
Yes. Other countries don't do this - you go directly from HS to a 6 year medical school. It not just saves time, but increases your useful career length by over 10%, probably more if we weigh age-effectiveness.
Plus it would let many more people do MD-related jobs like medical researcher.
At the same time, a more holistic educational experience could help to reduce long-standing social biases. For example a significant portion of doctors, to this day, think that for some reason having more melanin in your skin increases your ability to tolerate/process pain. The two phenomena are entirely unrelated from a scientific standpoint, but are intertwined in the social fabric.
Yeah, but it makes a lot more sense to just incorporate that into the medical school curriculum than to make students sit through 4 years of Chemistry classes and hope that the dance class they took to fulfill the university core curriculum will erase all of their intrinsic biases
A bit orthogonal to the article, the answer to why someone makes "so much" or "so little" boils down to how badly people need that work done and how many people can do it. IE, supply and demand.
Consider a doctor or even a plumber. When you have a problem that needs one, that problem is usually important and urgent, and it's not a job you can "afford" to be poorly done by an amateur. So you end up paying a lot to get it done quickly by someone from a small pool of qualified providers.
On the flip side of that is something like a barista. My 3 year old has figured out how to operate the Keurig and while obviously a high-end barista can make a way better coffee, the second-best and "nearly free" option is totally acceptable, putting a hard ceiling on how much a barista can make. That option doesn't exist for doctors and plumbers so they make a lot.
There are insane controls on supply. It’s not a free market. Everyone has to choose a Ferrari treatment or not go to the doctor. There’s no budget option.
Note also the last line of the article: "This looks a lot like a labour market that has been rigged in favour of the insiders." That's exactly right. In the U.S., the medical profession is an AMA-led cartel.
The law of supply and demand is not dependent on a free market. It is merely observance of the social dynamic between humans (as well as other living creatures!) that plays out when scarcity is a factor.
Indeed, in this case the scarcity is, at least in part, artificial, but the cost still comes down to supply and demand at the end of the day.
I think the "how many people can do it" part is where things go astray. "Can" can mean "are capable of doing it" or it can mean "allowed to do it" and those are conflated under the current system.
Plumbing is maybe a good example, in the sense that if I own a home and feel comfortable with something, I can do whatever repairs I want. I could hire my friend John Smith to do it if I trusted him. The limit is the inherent risk I take, and knowing that if I screw something up, I could cause problems that cause problems to me. There are code issues, but that gets complicated and is orthogonal to the issue of who does the work that meets code.
In healthcare though, even if you are entirely capable of doing something yourself, you are not able to legally. If there's a medication that you have been taking your entire life, and has been deemed safe in the primary scientific literature, you are still not able to just go buy it from the pharmacy without a prescription. If you want help or advice with the medication, you also can't just go to a provider that you want. You can't take the drug yourself, under the advice of the pharmacist for example — even though the pharmacist often knows more about drugs than an average physician — and you can't take it from a different type of provider that you trust more, for whatever reason.
I mean yes... My point is that it's supply and demand, not that the friction to enter the profession is identical across plumbers and doctors.
The point still stands... the number of people who are willing to take plumbing matters into their own hands is pretty low. I am one of them sometimes but 99.9% of households are still competing for the handful of "capable and available when I need him" plumbers.
I've seen more than a few $100,000 bills for surgeries.
The fee paid to the surgeon is something like 2-4% on the ones I've seen. So, a few grand to save someone's life. I don't think they're paid so much at all. What they are paid seems more than earned to me. We might instead ask why so little of the money paid for procedures seems to be paid to the doctors, and so much to the medical bureaucracy.
Most of what people complain about isn't the plumber charging $500 to fix plumbing, so to speak, but why the Plumbing Center adds another $40,000 to the bill and itemizes things like "$50 Miscellaneous Paper Towels".
Often high pay is related to competition in hiring or demand/need by the employer, but not always. In my town like in many others they have lots of help wanted signs. All they need to do it pay more and they’d have a much better chance of hiring people. They just don’t want to pay that much. Starbucks apparently pays over $20/hr starting, and they have benefits if you work enough (something like >20hrs/week) but they seem to manipulate people’s work hours so they don’t work enough. And they are evil union busters, but that’s another issue.
The are significant structural reasons behind pay. Teachers can’t be paid more because they are govt jobs and the govt almost always doesn’t do that. So programmers in govt are underpaid too, and they can’t raise rates. Or they raise them a little but they don’t have anything like market rates.
The pay of real estate agents, where each side commonly gets 3% of the sale price (shared usually with your firm) is a rediculuous cartel that needs to be destroyed. In my city avg home price is over a million, so the seller/buyer each pay a 30k commission for a few hours work? That high pay comes from a cartel.
Some people are paid high amounts because that’s the expectation. Parity with other jobs might be a support for high pay, but maybe not. I’m skeptical of this argument applied to doctors. I had more years of college than a doctor plus medical school plus a year or two of hospital / internship. I used to be paid less than them by a large margin, probably I make more than most now. It’s market rates. Am I doing more important things for society than teachers in my town? (where they can’t find enough and now they recruit parents to be subs because they don’t pay enough for that either). What I’m doing is useful but probably not more important than public school teachers.
Hi, I am the person you replied to. I think all of your points go along my point that it all boils down to supply and demand.
// In my town like in many others they have lots of help wanted signs. All they need to do it pay more and they’d have a much better chance of hiring people.
Right... so apparently they don't "demand" that labor badly enough to pay "whatever it takes" - as you would with a doctor when you're sick or a plumber when your house is flooding.
// Teachers can’t be paid more because they are govt jobs and the govt almost always doesn’t do that. So programmers in govt are underpaid too, and they can’t raise rates.
But it seems like the "government rate" is sufficient to attract the kinds of people that become public school teachers and government programmers, right? Supply and demand...
// The pay of real estate agents... so the seller/buyer each pay a 30k commission for a few hours work
Yeah but how many agents are you competing with and how many houses are you moving a year? The top realtor in my town moved over 20M of property a few years ago, so she cleared 600K in commissions that year. The bottom bunch of realtors in my town sold $0 worth of house and got $0 worth of commission. The reason the first woman made that $600K is because there's a demand for her services... and the reason those other guys made $0 is because there isn't.
I get the point you're making about fixed fees, but these fees don't guarantee you any profit for just becoming a relator.
// Some people are paid high amounts because that’s the expectation
What is an example of that? To whom do you pay more than you have to in the market because of "expectations"
// I used to be paid less than them by a large margin, probably I make more than most now. It’s market rates.
Right, it's supply and demand as I am saying because someone needs you to do the thing you do whatever it is, and they can't find someone to do it for less.
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My wife is a doctor. I’m a software engineer. While she now makes more than I do, it took nearly 10 years. That whole time, we were racking up tuition/debt on tuition. Residency was demanding and severely underpaid.
Based on our math, we’ll be 25 to 30 years into our careers before her medical education with have a better ROI than my career choice. I didn’t even push for top-dollar jobs.
In other word, medical training had a huge opportunity cost. Even if you solve the bottleneck of residency placement, salaries need to offset the insane burden of training.
But, here's the deal: he's basically going to make top dollar until he's 65. Meanwhile, I'll likely be seen as a dinosaur in tech by that age and will be lucky to find work at all.
I imagine your wife will be seen the same way. She can comfortably work until retirement age, in an profession that sees experience as a positive thing, while you might be a pariah before you know it.
Yes, we make good money when we're young in tech. But we age out much more quickly due to the bias common in our industry.
Its hard to imagine that 5,10,15 years of distributed systems and system design experience and knowledge along with domain knowledge and social skills will be all of a sudden be so irrelevant that it is worth phasing all of us "old guys" out for someone who happened to learn the newest programming language straight out of school.
We are constantly expected to learn the new stuff and will just a project assigned with a mandate "okay this is to be done in spring boot, using this DB, this HTTP layer, etc...
Developer and marketer/technical writer - selling to other devs is a giant business now and it often takes devs to make that content.
Developer and SRE - we live in the world of huge scaled our saas businesses where there are always support issues too advanced to be handled by non-devs
Developer and project manager - everybody has worked with non-dev project managers and it’s usually terrible.
Developer and people manager - there are so many more eng manager roles than there used to be, and moving to the management side is a well worn path now.
Developer and product manager - you have to develop a lot of new skills but in this role a past life as a developer can give you super powers.
That said, I moved first into people management and then into running a small software company which sort of demands a little bit of all of those skills
Errr, I'm 64, generally get a title like "senior programmer", and have switched jobs a few times recently and didn't have a day out of work. I expect to be going for a few years yet - in fact I expect your husband will be forced into retirement, whereas I will chose my time.
Moreover, I have quite a few software engineering friends or about the same age. It's the same for them. Some are still working, some not. But in every case it's been their choice, they weren't forced into it by the industry.
One “problem” in software: it’s really difficult to coast for a long period of time without training up new skills. You can certainly do it, but eventually the industry shifts underneath you. So the cushy senior Java dev position in a particular service might be able to last you for a decade or more at some companies, but I think most developers agree that if you want to keep getting better salaries you need to stay on top of trends and keep reeducating yourself.
And I don’t really see this as a problem as much as a feature of tech, but if you’re looking for predictability in a career I think it’s a tough thing to get in tech.
I disagree. Go to some technical meetups.
At practically all of them I have seen people offering jobs to both juniors and greybeards. The biggest problem everybody is having right now is connecting. The garbage in the middle is clogging everything up. So, everybody is going back to the old tried and true, the weak social network of in-person acquaintances.
Yeah, you have to not suck and you have to keep your skills up-to-date. But, that's true whether you are 20 or 60.
My dad is in his 60s and is still doing cutting edge work on Kubernetes, Golang, eBPF, etc in a big tech company in the Bay Area. It honestly isn't that hard to keep yourself up to date with technology looking at his experience.
If you can't get yourself interested in upskilling or learning the next new paradigm you're in the wrong field.
If you stagnate skills wise or stop trying to grow/evolve your abilities then you definitely will have issues but that's true in many industries, not just ours.
Tech is also slowing down in how much it is changing, which makes it easier to do the work while older, which again takes the edge off of ageism.
And if he wants to make the big bucks, there are not that many companies to work for (~10 mainline carriers in the US at the moment), and the seniority rules suck.
My grandfather made good money fixing systems for y2k in the 1990s and retired shortly after.
There's plenty of work for dinosaurs. Plenty of systems quickly hacked together today will be around for much longer than planned for.
There's no such guarantee in any of the professions.
People used to believe this, but it's not true at all in my experience.
Can confirm, but it’s more like around 50. That is why you tend to not see a lot of senior folks wanting to bounce gigs every three years like the younger folk do. I hope to ride out another 7 years at my current gig and retire. Hopefully they won’t have other plans because at that point I’ll likely have to shift to WalMart greeter.
52. Gimme 10 more years, I won't care. I don't want to be working any job after that even though I love programming and it's all I ever wanted to do (for a living).
Just prove you lost a job or weren't hired due to age, and you'll have a lawsuit that results in a large enough settlement you will once again be paid more than your spouse and won't even need to work.
In fact any long term plans at this point seem silly. AI is going to make all human labor irrelevant.
I just want to point out that - you landed (probably more random than intentional) into arguably the best career in the history of labor.
Compare a doctor to almost anything beside an engineer - and it won't seem so terrible.
Most people that have been in engineering for >10 years got into it because it's what they liked doing - and then it just so happened to be ridiculously lucrative and not require you to go into hundreds of thousands of debt to get trained to do the job (medical, lawyer, etc).
Even most trades (electrical, plumping, beauty, the taxi medallion system, etc) are designed similar to the medical industry - and require ever more schooling (debt, opportunity cost) to get the job - to artificially reduce the work force to benefit current workers at the cost of future workers and everybody who uses those services.
I think the particular problem with the medical industry is... it's particular detrimental to society to be overworking doctors to the bone and it not really paying off for them until they're in their 50s.
We're all gonna need medical help some day...
Maybe we can do our own plumping and cut our own hair and be good law abiding citizens and not need a lawyer. But we're all going to have severe medical problems at some point.
While that is the result I think emphasizing that it isn't made easier is important.
Electricians need to install high voltage wires that are safe in the home for untrained individuals for potentially a century.
Plumbers need to install water tight pipes that can withstand significant pressure without leaking (which can be difficult to detect and very quickly devastating damage wise)
Doctors are expected to be able to catch nearly any disease in their specialty based on an honest consultation.
Lawyers need to know a phenomenal amount of information to meaningfully know what o research when it comes to prepping for court cases.
All of these jobs are hard to prepare for and their is value to everyone else that you can prove you actually prepared.
The problem is the incentives for encouraging more people to prepare are backwards (those supporting the newbies benefit from fewer of them) which causes no real help to be given and the labor shortages.
But it isn't made up boundaries just to benefit existing members.
After undergrad, master’s, PhD, a postdoc or two, one would still make low income. After that, there is a never ending path where one has to constantly chase ever changing technologies. The older you get, the harder it will be to keep up and remain employed.
In medical science, you finish the residency (roughly equivalent to 1-2 postdoc in engineering), and you start to practice. Already, income is OK in residency. The older you get, the better!
I don't disagree. However, I certainly am not a top earner in the industry. Much of my career has been remote. My income is not out of line with most STEM fields. The main benefit for me was the ability to work remotely, moving with my wife to various small towns/cities.
Keep in mind, my wife had almost 10 years of med school and residency to start her career. I was making income the whole time. That's essentially a $1M difference 10 years into careers. It takes a while to overcome that gap.
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> I think the particular problem with the medical industry is... it's particular detrimental to society to be overworking doctors to the bone and it not really paying off for them until they're in their 50s.
Yep. There's also a huge personal burden of carrying that non-dischargable debt. If residency doesn't work out for some reason, you're in a huge hole.
We know many physicians who say they wouldn't do it again if they had know how shitty the journey would be.
Also, contrary to popular opinion, there's little stigma or awareness of "bad doctoring", for a number of systemic reasons.
So you have someone who doesn't give a fuck about anything, certainly not your situation, not listening to you, and trying to prevent you from receiving medical treatment.
This doesn't look so necessary to me. I know there will still be medical experts and surgeons and so forth, but much of this medical infrastructure doesn't benefit the average citizen (I know there's an argument that it does or for a change in perspective, but that's a whole different can of worms.
Similar to policing, if you think of the typical way you interact with the medical system, you start to realize there's very little in there to help you. 99.99% of the infrastructure is built to benefit powerful people with tons of money; helping you is an after thought.
What happens when you're a victim of crime? Turns out there's very little in place to help. Oh, someone is actively trying to murder you? well give us a call after it happens and maybe we'll investigate.
How many of us have experienced something like this? I'm not saying there's no reason for the arrangement, but we should stop trying to pretend these people are looking out for the public.
I know people may be tempted to chime in regarding some situation a police officer or doctor helped you. I'm not saying you're wrong, just explaining why some people are asking questions; if you honestly think about it, your naive assumptions about safety and health will be shattered.
A doctor, in many ways, arguably has a patients WORST interests at heart, in a similar manor to a police officer, in it's interaction with the public. They have, as their most important responsibilities, to detect certain things, and take actions to hurt the person.
This is priority #1, virtually everything else comes after. This is an important observation, is not obvious, and should cause us to reconsider these institutions.
is that really the purpose? or is it that an entire industry has been built on top of the trades, and that industry does whatever to continue to grow?
95% of health is being proactive about your health: food, fitness, sleep, dentist, etcetera.
I wonder how much doctoring is due to negligence of a healthy lifestyle, or perhaps chronic choices (addictive substances like alcohol, shift-work).
> But we're all going to have severe medical problems at some point.
Which often are untreatable - and the doctoring is regularly prophylactic. Hip-replacements are an obvious outlier.
One thing that rarely discussed in this kind of conversation is taxes. A doctor spends 12 years earning next to nothing and going into debt for training costs. Then the second they start making a real doctor salary, the IRS thinks they are 'rich'. They are taxed at the highest tax bracket even though it might take them another 10 years to surpass someone who was earning barely a six-figure salary the whole time.
If you spend 9 years earning nothing and then make $1M in your tenth year, you will pay much more taxes than someone earning $100K for 10 years (even though both earned a total of $1M over those 10 years).
Essentially, physicians have been so bottlenecked for so long that a bunch of states has simply said "screw it" and started paving the way for mid-levels (NPs and PAs) to operate in certain roles physicians have previously covered. The physician lobbies seem unwilling to address this, so I expect that mid-levels will continue to move up the chain. They know the market is desperate for a solution and physician interest groups are completely unwilling to provide that.
The product of mechanical engineering also naturally scales. Once you design a machine, you can build it an infinite number of times. However, in neither case does the labour scale. One engineer, whether their focus be on software or mechanical, can only do so much in a day.
Software engineers lucked out in this era because it is a new, relative to other industries, field that saw a rapid rise in demand for labour, with comparatively few people able to fulfill the need for that labour. By virtue of supply and demand, incomes had to run high to attract workers.
> and scaling is really how you can make a lot money.
That is true, but engineering doesn't scale. It is highly doubtful that engineers will continue to benefit into the long future. The owners of the software built by engineers will be able to continue to reap the benefits of scalability, but the labourer – who does not scale – will undoubtedly start to get squeezed as the industry matures and demand is no longer growing exponentially.
do you believe this is the case now?
They chose a profession that appears to scale to investors. When software _actually_ scales rather than being a subpar substitute for an existing mechanism is when the people involved were indeed smarter and worked much harder (typically).
A cycle here is that student loans rise with expected earnings and banks are fairly open ended about it, institutions happy to justify the use of the cash.
Salaries wouldn't need to be nearly as high if you didn't walk out of residency with 200k+ [medical school ] debt at a point that is effectively mid-career. As a society we'd probably be better off if the both the median salary and median debt was much lower. I've also seen the "guarantee" of a high salary later lead many young doctors and med students to be foolish with money, as "eh, what's a little more debt" is easy to fall into.
It's also part of the driver to overspecialization, more available GP's and fewer people reliant on emergency visits would obviously improve the system, but the economics and QOL for a general practice keep getting harder.
Residency bottleneck and the high barrier for foreign trained mid-career people are the two other areas for potentially major impact.
https://savegme.org/
There is literally no path to becoming a physician other than the blessed med school + residency path. By contrast, you can become a lawyer simply by passing the bar exam.
Some states are starting to allow physicians to practice without residency and the AMA is vehemently against it.
Most states are begging for more qualified providers. Many are looking to mid-levels to fill the gaps. If the AMA were serious, they'd be working with all of these states to fill those gaps with physicians.
Who is lobbying for this system to be improved? Because almost certainly loan companies and universities are lobbying against that.
It's pretty foolish to take out private loans for medical school. Most people avoid it unless they need to cover living costs.
Federal loans have the chance of being forgiven with PSLF.
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This is such a hard problem to fix. I doubt anyone is interested in hearing any solutions that involve worse-trained doctors, or longer training schedules, or massive pay increases for what are viewed as some of the highest-paid people in the nation. There is a lot of talk about opening up medical care for more people - which, naturally, means there will be a surge in demand. I can only imagine this would exacerbate the problem. It feels like we're running out of time to fix this.
And by workload, I don't mean just hours on the job, I mean amount of material to learn. It is overwhelming to most
I don't see how the ability to work long hours is necessary to heal the sick. They don't train airline pilots like this, or nuclear plant operators. What's so special about doctors?
And god forbid you think you can handle it at 18 years old and then being stuck on the medical track for... decades.
Life will always get you. There’s no way around work if you are a well paid professional. Maybe nepotism or fraud can get you there.
I’m not sure what leet code entails but these tests required a lot of preparation:
MCAT (hundreds of hours, thousands of questions, 10 practice exams)
USMLE Step 1 (hundreds of hours, 5,000 questions, 1 practice test)
USMLE Step 2 (maybe 40-60 hours, probably less than 2,000 questions)
USMLE Step 2 CS (4 hours a few dozen practice clinical scenarios. this thing doesn’t exist anymore)
USMLE Step 3 (30 hours, less than a 1,000 questions
Radiology CORE 1st board licensing exam (hundreds of hours, 5,000+questions)
Radiology Certifying 2nd board licensing exam (8 hours, 2,500 questions)
My next one is the CAQ and I haven’t started grinding for that yet. I do wake up every morning and do practice q’s though.
I still have a deeply negative networth and hate my job. Maybe others don’t, good for them.
In my country the government flooded the market with doctors and the results weren't pretty to say the least.
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This has quite frankly zero relevance to anything. The analysis depends on what you her husband does (I mean seriously how does that prove a point at all) and your choice and abilities (totally arbitrary based on a host of factors especially given the tech scene over the last decade.
I mean ROI? So someone makes a career decision by comparing to what their partner makes or what ROI is?
> AMA is unwilling to fix this
This has to do with residency slots and residency slots are determined by how many hospitals can accept residents. Now you can say AMA is a roadblock to that but there are a slew of other roadblocks in addition (if true not sure it is) to having more residency slots.
You can think idealistically that you can re-imagine the whole system but massive change in something entrenched like that (where lives matter) most likely is not practical.
At every company I've been at, the most senior people are the ones with the most pull, with the strongest direction and advice.
I've worked with a few people 60+ who suck. I bet they sucked at age 30, though.
Depending on if you're married or brought a home, her education and status already paid off with special rates for doctors/lawyers/high earners/professional mortgages:
https://www.studentloanplanner.com/professional-mortgage-loa...
I have a child I’m encouraging to become a doctor, and it’d be great to know some actual economics before I push too hard this profession.
Most doctors end up making between 265k and 382k per year, this varies wildly (from pediatrician on the low end to brain surgeon on the high end).
Here is a good article: https://www.whitecoatinvestor.com/how-much-do-doctors-make/
My teenager wants to be a radiologist but I have no idea if it’s even possible to do that in a way that isn’t a path to depression and burnout
She is regularly pulling 65-90 hrs/wk with little flexibility in her schedule.
I ask because I didn’t know 65-90 hrs/week (13 hr days / 7 days per week) was typical for non-residents.
The law of one price requires free market competition.
It's basically a firm of hazing
America needs to stop letting their University systems bloat everything unrelated to actual education and research.
A 40 year old doctor is insanely young. A doctor in his late 60s can easily be in their prime, especially in some practice areas or research. Provided they are okay health-wise, even an 80 year old doctor can still be working, especially if they have a strong team. They'll probably be in a mentorship role or a more laid-back practice, but they'll still be earning a meaningful income and having a very real impact on their patients.
And generally speaking, doctors in the West live longer than the general population, so that longevity is better as well.
So far, that really hasn't been a factor for us. It is worth noting that job security becomes much less important as you build wealth. It's a lot easier to build wealth when you're not racking up debt and being underpaid in your 20's.
Wait, you're getting paid?
TL;DR: Becoming a physician requires sacrificing an additional 6-10 years of your life to education and training beyond what you'd expect for most careers, and assuming something like $250K in additional debt. It'll take the average physician about 16-years out of college before they start to out-earn the average engineer.
Details:
Let's imagine that two smart people start college in the United States. One goes into engineering, the other into med school.
The day they graduate, on average the engineer will get job that pays them $74k their first year.
Year 4, the engineer is likely making $84k/yr, and they have earned a total of about $315k in their career.
Meanwhile, our doctor friend has so far accrued about $250k in debt. A delta of about $560k in just 4 years, but it's gonna' get worse before it gets better.
For the next ~3-5-years (for most specialties, there are outliers), our doctor friend is gonna make about $50k/yr . (Yay, positive cashflow!) We'll generously assume their debt doesn't accrue interest in this period.
Assuming our engineer friend assumes an average career path, he's gonna be up to $92k/yr at the end of this period, with a lifetime total earnings of $669k, while our doctor friend has clawed their lifetime earnings all the way back up to -$52k.
This is also the biggest delta between the two careers. At year 8, our engineer friend has out-earned our doctor friend by a delta of $720k.
Now, on average, our doctor friend starts making $202k/yr. Good money, right!
To make the math easy, we'll assume that their debt still doesn't accrue interest.
With all that, it's not until 16-years out of college that the average American physician will start to out-earn the average American engineer.
So if they both graduated at 23, our Engineer friend is gonna out-earn our doctor friend until they both hit just about 40.
Of course, if our doctor friend has to pay some interest on their med school debt, and our engineer friend is able to invest a chunk of their salary in those early years, the magic of compound interest will be on their side as well.
And that says nothing of the fact that our doctor friend probably had to sacrifice about 4-years of mandatory 80+ hour work weeks. It also assumes that our doctor friend doesn't drop out/fail out of med school and manages to match to and complete a residency. None of which are givens.
Which is a very long way of saying: physician compensation is wonky because it's a career where you sacrifice a ton and take a ton of career risk very early on, for the promise of higher compensation and quite high job security later on in your career.
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it's that simple.
I regularly hear it is the AMA that is creating an artificial shortage, but this seems to indicate that the logjam is at the level of residency funding.
Does anyone have a good insight or data about this?
The AMA has lobbied to limit federal funding for medical residency. This is the bottleneck.
The fundamental problem is that the US government should not be in the business of funding residencies to begin with. That should the on the hospitals.
Right now the problem is that no hospitals want pay the 150k cost for residency when there is the option for the federal government or another hospital to pay it. It basically leads to a tragedy of the commons/prisoners dilemma, where all the hospitals defect and try to fight for limited grants.
This article has some general details: https://thesheriffofsodium.com/2022/02/04/how-much-are-resid....
Hospitals have no obligation to hire the residents they produce, so an optimal behavior would seem to be training many residents and not hiring them.
There is also the weird thing where, my understanding is that the hospitals can 'sell' the slots to each other and strangely they can fetch more than the funding in question.
But really, so much of the medical residency industrial complex reminds me of a hazing ritual in and of itself.
"William Stewart Halsted developed a novel residency training program at Johns Hopkins Hospital that, with some modifications, became the model for surgical and medical residency training in North America. While performing anesthesia research early in his career, Halsted became addicted to cocaine and morphine" https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7828946/#:~:tex....
It's absolutely abusive and I cannot believe there's never been more of a push around patient advocacy. It's bad enough for the residents working 100 hours a week and getting fits of sleep in a shitty spare hospital room they share with multiple other residents. It's even worse for the patients receiving care from a tired, overworked resident.
An American can marry a foreign doctor with 10 years experience, get their spouse a green card and everything, and they still can't work as a doctor without redoing residency like a fresh graduate.
https://www.medscape.com/viewarticle/993693
1. https://www.aha.org/news/headline/2023-07-27-hhs-awards-15-g...
Here's a breakdown for funding for one year in the recent past: https://www.ncbi.nlm.nih.gov/books/NBK248024/table/tab_3-1/?...
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So if you're a hospital, and you can get cheap doctors in residency who basically need to work whatever workload you give them, why wouldn't they hire as many of them as they could? I figure the limiting factor should be their ability to manage them, not federal funding. They are paying pennies on the dollar for doctor labor that they are NOT giving patients a discount on.
I once considered becoming a doctor when I was still a teen, and I'm quite confident I could have gotten into medical school and qualified for a residency somewhere, but it was the decade of hazing while being paid like a ranch hand that dissuaded me.
Also, we have some many people that want to be doctors. We should let them all start medical school, and let them get weeded out from there.
[1] the caveat here is research. But MD/PhD fits far better into the traditional college pipeline.
The US and Canada are globally unique in requiring a 4 year bachelors before 4 more years of med school. Every other OECD country has a single 5-6 year program available straight out of high school.
https://www.niskanencenter.org/the-case-for-shortening-medic...
A stupid amount of my wife's medical education was completely wasted for two reasons:
* "To make sure you know what career to go into". No. You don't need 2 years to see every possible option. Everyone has some idea before they even go to med school. Focus on the 2 to 6 that you care about.
* Residency application. 4th year was a complete joke. Most of it was consumed with travel/distractions while applying to residency. Maybe 2 or 3 months of actual learning fit in their.
----
The med school my wife's residency is associated with is actually a 3 year program. They skip summers and condense a lot of information.
But people still need genuine healers for everyday ills, and so we see the institution move towards restoring that role to those with a less critical role in the institution, like nurses, pharmacists, physical therapists, etc
I will grant you that in some specialties and smaller private practices what you describing is probably true.
Yes, the greedy doctors who are lucky to get a couple hours of medical coding training when they start practicing and get needled constantly by their billing department for underbilling actually have "years of learning" in how to screw over their patients.
Maybe they mean the man-years of time wasted arguing with insurance companies, shuffling around medications and care plans to please them, evenings and weekends spent in the EHR finishing up patient notes (because there's no time to get them done during the working day with 20 minute visits) and correcting and signing off on patient care for the PAs and NPs (cold-heartedly taking 100% of the malpractice risk burden for the nurses who actually care about "healing").
I'd encourage people this far gone on the deep end of visualizing physicians as hand-rubbing greed machines to spend a day actually shadowing one. Because you are very ignorant about how they spend their time and the amount of effort they put into caring for patients in spite of continual soul-crushing roadblocks put in their path.
* Yeah I know it's against site rules to say but I don't care it's true
I've spent considerable time tracking down why X costs Y, explaining it to a doctor, only to have the reply be "woah, you should tell people!" No, you should tell people, that's part of your job! Mind blown at some of these people.
But when it comes to the broad swath of everyday ills, someone with far less alignment training and who therefore hasn't been entrusted with the "MRI approved" stamp can often do a perfectly comparable job of taking care of people. That's what most practical medical care demands and it's what US doctors are now too overqualified and overpaid to provided.
There is bureaucracy surrounding what insurance companies and medicare will pay for, given specific diagnoses (medical necessity guidelines).
But the actual process of diagnosing a patient is not trivial and that function can not be described as that of a "bureaucrat".
Yes, you need a specific diagnosis X to justify procedure Y, and that can feel bureaucratic, but there is nothing bureaucratic about getting to diagnosis X in the first place.
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https://image.slideserve.com/488686/physician-satisfaction-w...
My guess is that not dealing with a mercurial insurance industrial complex that tries to constantly deny medically necessary treatment to your patients makes your day to day work more enjoyable.
You can squarely place the blame on the AMA who (proudly) lobbied for years to cap Federal funding for medical Dr education and residency.
https://www.aamc.org/news/combined-bachelor-s-and-md-program...
Plus it would let many more people do MD-related jobs like medical researcher.
Consider a doctor or even a plumber. When you have a problem that needs one, that problem is usually important and urgent, and it's not a job you can "afford" to be poorly done by an amateur. So you end up paying a lot to get it done quickly by someone from a small pool of qualified providers.
On the flip side of that is something like a barista. My 3 year old has figured out how to operate the Keurig and while obviously a high-end barista can make a way better coffee, the second-best and "nearly free" option is totally acceptable, putting a hard ceiling on how much a barista can make. That option doesn't exist for doctors and plumbers so they make a lot.
What do you say to things like shopping around using newly-transparented prices, telehealth, minute/community clinic visits, and nurse help lines?
Indeed, in this case the scarcity is, at least in part, artificial, but the cost still comes down to supply and demand at the end of the day.
Plumbing is maybe a good example, in the sense that if I own a home and feel comfortable with something, I can do whatever repairs I want. I could hire my friend John Smith to do it if I trusted him. The limit is the inherent risk I take, and knowing that if I screw something up, I could cause problems that cause problems to me. There are code issues, but that gets complicated and is orthogonal to the issue of who does the work that meets code.
In healthcare though, even if you are entirely capable of doing something yourself, you are not able to legally. If there's a medication that you have been taking your entire life, and has been deemed safe in the primary scientific literature, you are still not able to just go buy it from the pharmacy without a prescription. If you want help or advice with the medication, you also can't just go to a provider that you want. You can't take the drug yourself, under the advice of the pharmacist for example — even though the pharmacist often knows more about drugs than an average physician — and you can't take it from a different type of provider that you trust more, for whatever reason.
The point still stands... the number of people who are willing to take plumbing matters into their own hands is pretty low. I am one of them sometimes but 99.9% of households are still competing for the handful of "capable and available when I need him" plumbers.
The fee paid to the surgeon is something like 2-4% on the ones I've seen. So, a few grand to save someone's life. I don't think they're paid so much at all. What they are paid seems more than earned to me. We might instead ask why so little of the money paid for procedures seems to be paid to the doctors, and so much to the medical bureaucracy.
Most of what people complain about isn't the plumber charging $500 to fix plumbing, so to speak, but why the Plumbing Center adds another $40,000 to the bill and itemizes things like "$50 Miscellaneous Paper Towels".
The are significant structural reasons behind pay. Teachers can’t be paid more because they are govt jobs and the govt almost always doesn’t do that. So programmers in govt are underpaid too, and they can’t raise rates. Or they raise them a little but they don’t have anything like market rates.
The pay of real estate agents, where each side commonly gets 3% of the sale price (shared usually with your firm) is a rediculuous cartel that needs to be destroyed. In my city avg home price is over a million, so the seller/buyer each pay a 30k commission for a few hours work? That high pay comes from a cartel.
Some people are paid high amounts because that’s the expectation. Parity with other jobs might be a support for high pay, but maybe not. I’m skeptical of this argument applied to doctors. I had more years of college than a doctor plus medical school plus a year or two of hospital / internship. I used to be paid less than them by a large margin, probably I make more than most now. It’s market rates. Am I doing more important things for society than teachers in my town? (where they can’t find enough and now they recruit parents to be subs because they don’t pay enough for that either). What I’m doing is useful but probably not more important than public school teachers.
// In my town like in many others they have lots of help wanted signs. All they need to do it pay more and they’d have a much better chance of hiring people.
Right... so apparently they don't "demand" that labor badly enough to pay "whatever it takes" - as you would with a doctor when you're sick or a plumber when your house is flooding.
// Teachers can’t be paid more because they are govt jobs and the govt almost always doesn’t do that. So programmers in govt are underpaid too, and they can’t raise rates.
But it seems like the "government rate" is sufficient to attract the kinds of people that become public school teachers and government programmers, right? Supply and demand...
// The pay of real estate agents... so the seller/buyer each pay a 30k commission for a few hours work
Yeah but how many agents are you competing with and how many houses are you moving a year? The top realtor in my town moved over 20M of property a few years ago, so she cleared 600K in commissions that year. The bottom bunch of realtors in my town sold $0 worth of house and got $0 worth of commission. The reason the first woman made that $600K is because there's a demand for her services... and the reason those other guys made $0 is because there isn't.
I get the point you're making about fixed fees, but these fees don't guarantee you any profit for just becoming a relator.
// Some people are paid high amounts because that’s the expectation
What is an example of that? To whom do you pay more than you have to in the market because of "expectations"
// I used to be paid less than them by a large margin, probably I make more than most now. It’s market rates.
Right, it's supply and demand as I am saying because someone needs you to do the thing you do whatever it is, and they can't find someone to do it for less.