You need to consider the economic cost of delayed earnings, which is massive for the physician, and the higher pay later typically doesn’t make up for the massive debt and low pay early on. It’s not just about a point in time salary sizing contest. Earning little to nothing early in one’s career creates a massive net worth void to fill.

I think the problem is that physicians are self-selected to be highly intelligent and driven individuals. Med school is not at all a walk in the park, and is very competitive.

You cannot compare the median physician who endured the years of grueling med school and residency to an average developer. FAANG is probably a more apt comparison.

Yea; not even close in the USA. There are exceptions like SV high-salaried tech jobs compared to pediatrician, but generally MDs make much more than software engineers and similar.

I agree, but it’s amazing how many times I’ve heard variations of this repeated as truth.

Developer compensation talk always gets biased toward top companies and high cost areas. The median developer or even top 10% developer isn’t living in the Bay Area working at FAANG, but that’s what gets talked about.

It is unfortunately true. Sr/Staff making a tech salary outearns all but the most specialized doctors. Even if you exclude FAANG that's true (other companies have to offer FAANG salaries to get FAANG talent).

You have to be living in a VHCOL to get that, but if you make >$300k TC you are outearning most doctors.

Also, people are not aware of their skill sets. A lot of doctors I know think, just because they were "smart" in school, that if they had gone into, for example, tech or finance, they would have become a CEO. But you can tell they don't have the skill set for business. I mean, they can't even run a medical office with 8 employees well, and they think they could run a business with 100K people. The office is a mess, the records are sloppy, the appointments are 2 hrs. behind, they don't pay the staff well, the receptionist is rude, the photocopied forms are barely readable. Yet they think they would be inovating like Jeff Bezos.

The unemployment rate for licensed physicians is ~0.

Yes, poorly worded on my part. Wasn’t intending to suggest it was ok to do that to a warehouse workers either, just that this is how physicians are being treated today (but neither is OK).

Thank you.

AMA lobbying hasn't been very effective. The rates that Medicare pays physicians have declined in inflation-adjusted terms.

To what end though? Safer meaning you have line of sight on employment? What kind of life is it where you have work but no life? I ask these as the husband of an internist who has been practicing for over 10 years. It’s a fucking grind. We’re 40 now and both of us are looking at her job and asking is it really all worth it?

Yes anyone who thinks engineers (HW or SW) are all paid amazingly needs to start taking in the wages of contractors too when calculating averages. Even many engineers working at FAANG HQs are lowly paid, abused contractors, making $50k-$80k.

I know personally of one big famous tech firm that has QA devs making literal minimum wage, because they are contracted from an outsourced firm. But 100% of those people's work is directed by and exclusively for the big tech firm so like all contracting it is an obvious paperwork scam to just mistreat their workers.

It’s hilarious to me that, according to Marxists, we’ve now been in ‘late-stage capitalism’ for longer than Communism even managed to exist, but they still keep hawking a 200 year old book as the answer to everything.

"Are you sure you can find that many more doctors? That they'll be any good? Speaking from Romania: ..."

The prior post was specifically talking about the US. (I assure you, arrogant dismissive doctors are also a thing in the US)

In the US, there are a number of things that artificially increase the barriers to becoming a doctor.

1) You typically need a four year college degree to apply to medical school

2) Medical schools are accredited by the AMA, which is controlled by doctors. The AMA makes it very difficult to start a new MD-granting medical school.

3) Medical school in the US is very competitive to get in. They are likely turning away a lot of people who could complete the degree.

4) Since 1997, the federal government has a fixed number of Medicare (Medicare is a federal health insurance program for people over 65) supported residency positions. That number was basically flat for 25 years. We lost about 20% per capita of doctors being trained with support from this program. The caveat to this is that the total number of residents per capita has increased over time, particularly the past 15 years or so. My understanding is that they are less likely to be fully funded, so they spend more money getting trained, and then have higher students loans (on average graduating with debt above 200k going back to the late 2000s) that they need to pay off, so they charge more.

And you can add to this that it can be very difficult to be a doctor in another country and come to the US to practice here.

I'd like not to have to wait for three months to see a doctor to prescribe me the routine treatment for my routine illness, so yes, more mediocre doctors would be good for me. It would also unburden the doctors who are "really into medicine" so that they could spend their time on more difficult cases.

Hate to be cynical, but going by the stories a doctor in my personal circles tells me, "talked to me for an hour, ordered a ton of tests" could be more about billing the national healthcare fund for many tests, that may not be most useful, but carry best margins for the facility.

In my country, there's a big feud between cardiologists and radiologists right now, big enough to be a regular topic in national media. Inside sources tell me it has nothing to do with quality of care, and is entirely about the march of technology allowing radiologists to perform some diagnostics that previously required cardiological procedures, and those procedures happened to be the major funding source for the cardiology departments.

So you're saying limiting the number of doctors work better?

Speaking from Poland, we see the same outcome: doctors rushing patients out after 5 minutes. The reasons may be different, though: since COVID, many doctors here have, in my view, become more arrogant and focused on money. Over the past few months, an uproar over doctors’ pay has swept through Polish social media.

Reports have emerged of doctors billing for overlapping work under multiple contracts. In one case, a doctor’s records showed 72 hours of work in a single day!

Meanwhile, the Polish Chamber of Physicians and Dentists (NIL) continues to defend caps on medical school admissions, adding fuel to the national debate.

You get the same problems in the US with the attitudes of doctors.

In the US, medical school is extremely expensive (like $400,000 expensive). There are many people who are excellent doctors who are just priced out of the profession. If we could make medical school less expensive (by subsidizing it and by reducing the amount of instruction), we would probably get many more excellent doctors.

> Would it help if we get a lot more of the first kind of doctors?

Depends? Did the tests actually find anything, or did they just make you feel better?

I had a talk with my GP about this at some point, and he more or less told me that he can just say "Go home, rest, come back in two weeks if it doesn't get better.", and 95% of the time that'll be exactly what is necessary. The hard part of his job is figuring out which of the visits are those 5%.

> Would it help if we get a lot more of the first kind of doctors?

Hard to tell when you don't let us know which of those doctors ended up solving the issues that made you seek a doctor.

Dismissive doctors are bad but so are those that waste your time and risk complications from unnecessary invasive tests.

We do have qualified people to do the work of doctors, and they're called nurses. But arbitrary lines are drawn between what they can do and what doctors can do, just to maintain the existing salary structure.

This is another one of those "kids these days" thing based on nothing but vibes. https://www.science.org/doi/10.1126/sciadv.aav5916

I'll give you some N=1 sample on older doctors since I'm also from Romania: a lot of these older doctors haven't opened a book in a very long time and are still using older practices instead of providing their patients with the latest and most effective treatments available because they're too lazy and/or prestigious to go and learn new things. Would you say that they "into medicine"?

> Would it help if we get a lot more of the first kind of doctors?

It would certainly help hypochondriacs a lot. Ordering "a ton of tests" needs to have some basis behind it, and doing it just to make the patient "feel seen" is not a great way to do your profession. People being dismissed quickly also happens in the US quite a lot, sometimes with disastrous results though it's not incredibly common, it's typically labeled under "diagnostic error" https://qualitysafety.bmj.com/content/23/9/727.long

Maybe I would rather be treated by such a doctor with time on their hands than a burned out brilliant doctor?

Yea, that is what is going to happen.

Earlier you just need to find a doctor and they were probably good. Now you have to take your luck with many till you find a good one (if you are still alive by then)..

I don't know why people think that they can mass produce competence..

Ah yes and when doctors give everyone expensive tests because the patients are a bunch of drama queens who think they know better because they have a doctorate in Google the costs go up.

Exactly! I suspect the parent commenter does not interact much with the US healthcare system.

The bottleneck is funding for residents and the AMA has been lobbying for more resident slots for nearly 30 years.

sooner or later whole world(west) is going to hire more doc at lower(not as high as it is right now) salary from East(asia). they might lower the barrier to entry. same would happen in medicine the causes are inflation, economic conditions and poor health system.

This is the bottleneck, right?

I hear people say "we need more doctors" all the time. It would seem to me, the people deciding how many new doctors we train per year, are doctors. Their pay is proportionate to their scarcity, if we had 5x as many doctors, existing doctors would make far less.

Imagine if existing software engineers got to decide how many juniors entered our profession each year. I think things would look very, very different.

Most countries get good results with shorter training and much lower salaries. And, just like most other US university degrees, the majority of the filtering is done on entrance, not on training. So it's not that we are evaluating the best doctor, but the best diligent people that get great scores in the MCAT. Whether that actually lines up well with being a good doctor is not all that clear.

It's low because there's no competition. MDs are like medieval guild: once you're in, you're set for life. Restrictive regulations are lobbied by MD associations, which limit competition.

If there are more doctors, it would require less of each one's time though.

It does not require more than your standard 8-17. Know tons of doctors that work the same hours as I do and spend their free time the way I do.

Yes, that's true to an extent. Some administrative tasks can really only be done by the attending physician. Ultimately they're the ones taking legal accountability. But other tasks can be automated or shifted to cheaper employees or not done at all. The problem is that many health system managers and administrators treat physician time as an unlimited free resource and impose all sorts of extra burdens on them. This is one of the factors driving physicians to burn out and leave the profession, further exacerbating the shortage.

Re-engineer the entire US system or train more doctors…

> Remove the bureaucracy and you instantly have 5x as many doctors, effectively. Add more doctors to the machine and the machine will only find more creative ways to waste their time and talents.

That’s a huge leap and not at all evidenced by your comment.

I’m all for simplifying all these administrative stuff. But no, that will not solve the fact that we have way more people who are way sicker and fewer doctors for them.

It’s 8%.

Of course people need to take some responsibility, but reality is most people live in a society and do as the society does. You can minimally change people with some financial intensives but the effect of that is pretty limited and its hard to implement.

You have to create a healthy system, that takes social engineering and government cooperating on a general plan. And in the US such a thing is basically not possible, even if they wanted to do it.

Ideally your transportation, agricultural, educational policies should all work together to produce healthy population. But this simply isn't the case.

But it will not 'reduce pressure' in a practical way, because such changes purely private or public take decades to work themselves threw the population.

Well let’s start with insurance actually acknowledging preventative care as a worthwhile investment. We have a system that incentivizes waiting until emergency care is necessary and that comes with massive cons.

I can’t even get basic foot stuff covered, they won’t care until my feet and knees land me under “disability,” so people like me - but unlike me they can’t afford to spend hundreds more a year on special inserts and shoes - just keep doing what they’re doing until they’re hurt.

People go to the grocery store and marketing teams are trying to sell them “vitamin water” which is neither of those things, so they have to do tons of research and pay constant attention to literally every food they buy. Then when they get hurt they can’t afford to go to a doctor and the insurance that is sucking up huge amount amounts of their annual pay doesn’t pay for it either.

Meanwhile we have a US administration that is telling everybody, a population that is incredibly predisposed to heart disease already, to go eat more red meat. Also, they have spent a decade telling people that vaccines are shady and maybe they shouldn’t get them. How much damage have we done to preventative care with that one?

I could go on and on, I’m barely covering the breadth and depth of this problem. We can’t just call it “personal responsibility” or whatever

Then you end up with students from places like Nepal and Pakistan, where cheating is so rampant that you can't really evaluate the quality of your medical student or applicant. Even standardized exams like the USMLE/STEP series have been gamed. You also end up with significant cultural mismatch. I don't believe this is a good solution.

It might not work for the other countries.

anecdote alert: had a family member treated by a foreign doctor last year, and received advice from that doc that was both 1) highly dangerous, 2) bare minimum 20 years out of date.

Inconceivable that a domestically-trained doc would have made the same mistake.

In most countries that do this training is longer which that total training time is only 1-2 years shorter.

So you’re doing a few things.

1. Moving more training from cheaper colleges to more expensive medical schools.

2. Moving the filter from undergrad to medical school

3. There is no national curriculum in US high schools, so essentially the first 2 years is getting everyone on the same footing. Removing this without changing high school, puts students at poor high schools at an even greater disadvantage.

This is so hilariously false and completely inverted that it shocks me that people not in medicine can believe it.

Out of respect for you as a fellow intelligent HN commenter — you are deeply misinformed, and I would urge you to reconsider your perspectives on this.

Every study shows that utilization of APPs and nurse practitioners Leads to decreased quality of care and a significant increase in utilization of other healthcare resources, like the emergency department and imaging, that better-trained physicians don't need.

Less-trained providers misdiagnose cancers, refer patients to the wrong specialists, overprescribe antibiotics, and generally cost the system significantly more in overall health load than if we had better-paid general practitioners.

There is an argument that not enough physicians go into general practice, which is true, but it's because subspecialties are in such high demand that they're generally better paid. The unfortunate fix is that we need to find a way to better compensate primary care, even though Medicare physician reimbursement rates continually decline and our health insurance system is not well structured to support this kind of primary care model.

I've left a few links below if you'd like to read them:

General burden of NPs higher than physicians even with lower appointment cost: https://static1.squarespace.com/static/615326dd2c363f1e2a5c8...

Skin cancer misdiagnosis: https://www.ovid.com/journals/jaderm/abstract/10.1001/jamade...

Antibiotics overprescribed: https://pmc.ncbi.nlm.nih.gov/articles/PMC5047413/

Speculating, but it could be a spiral where the shortage places more responsibilities on existing doctors, making the field less appealing to potential doctors. For too many people no amount of income compensates for a difficult lifestyle (we see this with air traffic control). If this were the case it would be productive to redesign medical systems to unburden doctors, but the current for-profit, scarcity-oriented system (in the US anyway) seems calibrated to squeeze everyone.

I think you’re not sufficiently taking into account the demographic trajectory of age distribution [0], and the lag induced by the length of the human lifespan on health improvements. For the next few decades, more doctors will be needed.

[0] https://www.calculatedriskblog.com/2013/08/us-population-dis...

While you're at it why not no crime so there's no police. Nothing dangerous so no firemen. Nobody throws anything away, so no need for factories. Peace on earth, so no soldiers.

We don't need firemen. Just don't start fires.

> From a more practical angle, I don’t know how you could possibly find more doctors by lowering their earning potential.

You certainly could if you were willing to accept people who are terrible at being a physician.

The notion that you can just throw more warm bodies at the problem is ludicrous

General practitioners make more like 250k on average. 150k for general practitioners working in academics, but not overall.

Widespread use of GLP-1 agonist drugs will prove to be the most effective prevention layer. I absolutely support people living healthier lifestyles in order to delay the onset of the chronic diseases that drive the majority of medical care demand. But on a population basis, attempts at lifestyle interventions have been broadly ineffective. A lot of the chronic disease burden including type-2 diabetes, hypertension, heart failure, MSK, etc is downstream of obesity so if GLP-1 drugs can cause a lot of people to lose weight then we might see some real improvements within a decade.

To be clear I'm not suggesting that everyone should be on GLP-1 drugs, and it's obviously better to maintain a healthy lifestyle and body composition without those drugs. But for people who can't or won't do that on their own the drugs seem to work pretty well. There's also promising evidence that they cause reduction in alcoholism and other substance abuse disorders.

Do you have a plan on preventing the effects of aging, such as mutations in DNA and wear and tear?

> I think general ability is way way way more important than the specialisation. I don't think the speciality that doctors spend money and time on add that much value..

And why do you think that? I'm a doctor and I disagree completely - the medicine nowadays is so advanced, that it's impossible to keep up with advances without specialising yourself in narrow area.

> I wonder if "Dcotor" ought not be a short career—one where you transition out after, say, two decades

In the US if a doctor is remotely competent with money then this is very achievable.

Same with politicians.

I'm sorry to hear that... this thing really took away a lot of good people...

Covid kills people even today! We should have a lockdows every winter!

Those nurses saved many people! It was worth it!

Not exactly. The Australian system is mixed public/private and many physicians work at for-profit organizations. While Australia does have some level of universal coverage it's a two-tier system where people who can afford it pay for private insurance to obtain better care.

> By that logic all food production and distribution should not be privatized because is should be for the public good rather then the profit of the few.

Sounds like good logic to me, at least for essentials!

The government already subsidizes private overproduction on US farmland. USAID was, at its heart, a farm subsidy.

And it should be said that most 'small' farmers in the US are millionaire scions and shouldn't need subsidies to make a profit in most parts of the US (we have abundant natural resources).

More than half of all calories produced in the US are not even for human consumption. And globally enough calories to feed every human on earth are lost to inefficiency each year.

We can all benefit from a better system of distribution and production without getting lost in the magical thinking of a public/private false dichotomy.

I mean the US gives enormous subsidies to farmers for food production, and Walmart receives somewhere around $27 billion a year in SNAP from customers. So in that sense, both of these are essentially public to some degree

This is terrible reasoning.

Food is, in general, very accessible, cheap, and elastic (People's food decisions are easily changed depending on the price).

Healthcare in America is not accessible, extremely expensive, and inelastic.

We have not had a famine in the developed world in quite a long time, but the healthcare crises continues.

The fact remains clear: The number one cause of bankruptcy is medical debt.

Healthcare is the only service that is life and death, where the money paid by the patient is completely inelastic.

I'm not saying doctors shouldn't be paid well. But what is really clear is that while the rich pay for premium concierge VIP treatment, the poor are regularly turned away for treatment they can't afford. You health insurance here is tied to your job. Lose your job? Pay $2000/month for COBRA or you don't deserve to have healthcare.

Don't act like public healthcare, expanding access to primary care physicians, and reducing medical administrative bloat is some economic degeneration headed for the sickle and hammer. I'm tired of pretending Ayn Rand style libertarianism capitalism is the perfect solution that has worked for everything including healthcare.

Er, do you mean miles? Like they use in Great Britain?

Really? This funny limbo seems pretty specific to American healthcare, which is a fairly unique and admittedly fascinating study in the intersection of politics and capitalism.

You don't perceive that system to be different from grocery stores, auto manufacturing, Nvidia, or lemonade stands? They're all very different in my mind, I'm surprised you see them as identical.

The article appears to be written by an Australian in Australia, FWIW.