8 ms·

Doctors Unionize to Resist the Medical Machine

104 points by e15ctr0n 11y ago

jraines 11y ago
All of this rings true from what I've heard my dad, a GP, complain about for years. It's hard for him to watch other doctors game the system to increase their earnings -- not only seeing more patients with unaccountably short sessions, but also up-coding their maladies and ordering unnecessary tests. In addition to the pressure of seeing more patients per day, they have all this new administrative bullshit (ironically in the name of efficiency) preventing them from doing so. For example, doing charts went from dictation, to data entry in absurdly bad (understatement) EMR software on cheap, outdated hardware that they weren't properly trained to use. And oh yeah, you can have pay withheld if you fall behind on that, too. It's just sad, and many older doctors don't even recommend the profession to young people at this point.
- marshray 11y ago
  My doctors usually spend less than 5 minutes talking to me and 10 minutes hunting and pecking at the computer. Some offices will have other staff do much of the data entry, but it doesn't seem to result in the doctor any spending more time with me.
  - merqurio 11y ago
    Precisely we just created an start-up with a product that helps doctors making the EHR much faster and intuitively so they can focus on the patients.
    - marshray 11y ago
      I believe you, but when I worked in a medical office in 1993 vendors were saying that exact same thing.
      - merqurio 11y ago
        I know, I hope my Background as MD and CS plus the idea we had will make it different. We are working on something similar to an IDE :)
        marshray 11y ago
        Break a leg :-) And whatever you do, just don't let anyone deploy it on some overloaded Citrix server.
        knughit 11y ago
        Congratulations in advance for when EPIC buys your company and then ruins your product.
        gameshot911 11y ago
        Epic doesn't acquire.
        gmarx 11y ago
        You sound like me and this sounds like software I created more than a decade ago. Good luck. It is an incredibly difficult sale (yes, I am a little bitter :))
      - lucidrains 11y ago
        Cool, me too :) would be interested to hear more on what you are working on if you are in the city. (SF)
        gmarx 11y ago
        Me too and I am near SF. Would also be interested in talking
  - Mz 11y ago
    You could try looking for Direct Primary Care, another growing movement among doctors in reaction to how messed up the system is. I wrote a bit about it recently: Http://micheleincalifornia.blogspot.com/2015/12/how-to-fix-americas-financial.html
  - cglace 11y ago
    The hospital system my dad works for just got all the doctors scribes to take the data entry burden off of them.
- sghodas 11y ago
  Hell, I'm only in my second year of med school in the US, and I wouldn't recommend young people go into this profession.
  - merqurio 11y ago
    I'm in the last year and I would totally do it again. It's true college it's abusive(http://www.kevinmd.com/blog/2016/01/physicians-arent-burned-theyre-abused.html http://www.kevinmd.com/blog/2016/01/physicians-arent-burned-...), but I find it amazing as a career.
    - Lordarminius 11y ago
      (MD here...) With all due respect, wait until you have been in the profession for at least one decade. Then, I'd like to hear your opinion again.
    - Lordarminius 11y ago
      (MD here...) With all due respect, wait until you have been in the profession for at least one decade. Then, I'd like to hear your opinion again.
      - merqurio 11y ago
        I'm sure the work is super hard, and I will change my opinion, everybody said that to me, but at least academically, I found it amazing. :)
- acveilleux 11y ago
  Not having dictation is just dumb. Voice rec is quite capable these days and the doctor's time is too valuable to waste on their typing speed. One note though, the PC never really has to be any good because most of the EMR crap is accessed over Citrix... To make IT's life easier (in theory) and avoid having the need for fancy PCs on the wards.
- switch007 11y ago
  Similar story in the UK. My aunt, who works for the NHS (not a GP), has cried in the toilets a few times because she is forced to use bad software to the point of utter frustration, and she is not of the computer generation. There are ~10 people in her team in a simular situation. They should just have a dedicated person doing data entry in to the computer system.
- kamaal 11y ago
  >>It's hard for him to watch other doctors game the system to increase their earnings Make no mistakes this isn't just restricted to the US. This is quite common in India too. >>not only seeing more patients with unaccountably short sessions, but also up-coding their maladies and ordering unnecessary tests. In India there practices are almost in the fraud territory. Start from doctors having small testing labs in their clinics. Where they order unnecessary test for patients they don't need. Almost every clinic has a neighboring pharmacy, that sells medicines of brands only the doctor next to it prescribes. You won't be able to buy that medicine anywhere else, plus the doctor makes commission in the medicine sold in the pharmacy. Prolonging treatments to maximize per consultation fees is extremely common. Its very common for hospitals to indulge in advising patients with either incorrect treatments or prolonging treatments. Pointless tests, doctors cooking up stories to scare patients to spend more at hospitals is all common. >>It's just sad, and many older doctors don't even recommend the profession to young people at this point. I talked to many doctors(friends, relatives and acquaintances) actually many feel cheated opting to chose a career in medicine. They are told they are very smart people, and all. Told they are super smart hence they deserve to go to medical college. Hence they expect to be paid proportionally. Most watch their friends in engineering, who they think have it(apparently, that's how they perceive it) a lot easier. While they spend a lot of studying, piling up a good deal of student debt, plus on a average making the same money at the end anyway. Except that every thing in life happens decades later. They look at engineers, especially programmers as people who have a lot of opportunity to switch streams, learn and move on to new stuff, work at big companies, start companies. Especially programmers who are good investors come across as people who made far more sensible career decisions. Doctos at the end of the day are humans, and are driven by peer financial pressures.
nostromo 11y ago
For what it's worth, people have been calling the AMA a union by another name for several decades. http://www.forbes.com/sites/johngoodman/2014/09/03/the-doctors-union/ http://www.forbes.com/sites/johngoodman/2014/09/03/the-docto... They lobby, they control the supply of doctors, they restrict competition, and they even engage in price fixing: https://www.washingtonpost.com/business/economy/how-a-secretive-panel-uses-data-that-distorts-doctors-pay/2013/07/20/ee134e3a-eda8-11e2-9008-61e94a7ea20d_story.html https://www.washingtonpost.com/business/economy/how-a-secret... They shape a lot of medical legislation, for example killing the Affordable Care Act's "public option." http://www.nytimes.com/2009/06/11/us/politics/11health.html http://www.nytimes.com/2009/06/11/us/politics/11health.html This isn't a recent thing. The AMA was key in killing Truman's universal healthcare proposal starting in 1945. http://umhm.mededu.miami.edu/?p=394 http://umhm.mededu.miami.edu/?p=394
- Spooky23 11y ago
  The dynamics of medical practice are changing substantially. Regional medical organizations are consolidating and creating vertically integrated medical behemoths. As a result, MDs are losing their independence and becoming just another group of highly paid employees. Once big corporate entities take over, neutralizing noisy, highly paid employees is always part of the playbook.
- sayhar 11y ago
  > They lobby, they control the supply of doctors, they restrict competition, and they even engage in price fixing It saddens me that those are your go-to ideas of what a union is. > The AMA was key in killing Truman's universal healthcare proposal starting in 1945. Actual unions have been pushing for universal healthcare for much earlier than I was born. On this front AMA has been the enemy of real organized labor for decades. A real union is about workers banding together to stand up to a boss who says "fuck me or you're fired", or to resist management giving themselves millions while cutting pay for workers. Please don't dishonor the good name of organized labor by comparing them to the millionaire doctors who killed our chances for a sane healthcare system.
  - 11y ago
horsecaptin 11y ago
The more middle-men you have between the consumer and the provider - be it a product or a service - the more the middle-men will constantly fight for 1) higher prices, and 2) marginalizing both the service provider and the customer. This applies to education (universities, private schools), healthcare (large hospitals, insurance companies), social services, food, electronics...
potatote 11y ago
One thing that I never understood about the US medical education is the requirement of the bachelor's degree (pre-med) before applying for most med schools. In my home country and many others, you can directly apply to med school. Now that the college costs are quite considerably expensive, four-additional year of college studies simply adds to the cost of becoming a doctor and therefore, the newly minted doctors expect to make a lot of money. This pre-med education requirement adds unnecessary, in my opinion, burden not only to wannabe-doctors, but also to the medical system (create scarcity of doctors to say the least).
- andrewpi 11y ago
  I actually prefer the US system in that it potentially provides doctors with a more well-rounded education.
  - XorNot 11y ago
    Ah yes, the moral duty American colleges feel for ensuring a rounded education at the low low price of tens of thousands of dollars per year.
    - PhasmaFelis 11y ago
      My CS degree focused on a rounded education, which would have been okay if it had also taught me how to, say, write a useful program. I didn't realize 'til I'd graduated that I would have to teach myself if I wanted a career.
      - krisdol 11y ago
        To be fair it was never called a degree in programming.
        PhasmaFelis 11y ago
        When I signed up for classes, I said I wanted to be a programmer, and the advisor said "oh, you want Computer Science, then." That was just as much a lie as if they'd called it Programming outright.
c3534l 11y ago
Doctors are already paid absurd salaries in the US and the barriers to entry already high. As much as we all hate dealing with insurance companies, when I lost my insurance and had to pay for things out of pocket, the difference between what they charged me and what they would have charged an insurance company was obscene. Insurance companies actually do a pretty good job of reducing the costs of medical care, although some of the same power and information asymmetries still exist (that is, I'm saying that doesn't necessarily make the insurance companies the good guys). But the consumer has no bargaining power on his own and he doesn't know enough to challenge or negotiate. And the entire regulatory structure puts all the power in the hands of the doctor, not the patient. I don't see this as being a good trend for consumers. I find this to be very worrying. Edit: since this my "absurd salaries" remark seems like it might be the most controversial bit, I was thinking of I was referring more to information like this: http://www.motherjones.com/files/blog_physician_compensation_0.jpg http://www.motherjones.com/files/blog_physician_compensation... That's because it sidesteps many issues like how hard it is to become a doctor by simply comparing the pay of American doctors to the pay of doctors in countries with national healthcare. By "absurd salaries" what I really should have said was that American doctors are paid significantly more than other countries. Of course everyone, no matter what their job, thinks they work too hard for too little pay.
- pragone 11y ago
  > Doctors are already paid absurd salaries in the US To put it in context, when I finish all my training, I will owe over $600,000. It's not the doctors being "paid absurd salaries" that makes medical care in this country expensive. It's lawyers - malpractice insurance can take upwards of 25+% of your income - and it's insurance companies, who have shareholders they are responsible to, and it's hospital administration, whose positions keep multiplying.
  - Dr_tldr 11y ago
    And yet, when Texas put a cap on medical malpractice awards, the cost of medical care didn't go down at all. Surely you have a good explanation for that and you're not just repeating discredited talking points for personal gain.
parennoob 11y ago
With the whole "Everyone Should Learn to Code" movement taking on so much steam, I cannot help but wonder why there isn't a similar "More People Should Learn to Do Basic Diagnosis" movement. We need a shit ton more Nurse Practitioners and "basic" doctors to diagnose and treat minor ailments, so doctors who have gone to 6-year plus medical school can spend time on the more serious ailments.
- acveilleux 11y ago
  Some of it is a perception issue, no one wants anything but the very best for their loved ones. So nurse practitioners, while great in theory, are only acceptable for others... Of course if you live in the boonies, a nurse here is a heck of a lot better than a doctor 4h away.
  - veritas3241 11y ago
    Similar line of reasoning happens with anesthesiologists versus nurse anesthetists (CRNA). Most anesthesia is administered by a CRNA with a anesthesiologist overseeing most, but there's been pushback b/c it cuts into the salaries of the anesthesiologists.
induscreep 11y ago
I don't understand this about healthcare in the USA. Why not import a few thousand doctors from Asia through H1Bs, and drive down the cost of medical care? Remove artificial caps on licenses imposed by the AMA while at it.
- TDL 11y ago
  The AMA is a very powerful lobbying group in the U.S. They have been able to steer regulations/laws on the state & federal level to limit competition.
- objclxt 11y ago
  Because you have to spend years re-training and certifying to US standards, all the time without a job and earning money to pay for said training: http://www.npr.org/sections/money/2013/02/15/172108835/should-the-u-s-import-more-doctors http://www.npr.org/sections/money/2013/02/15/172108835/shoul... And that's putting aside the fact H1-Bs are not exactly easy to come by right now.
  - potatote 11y ago
    Not trying to undermine your point, but I believe it won't take much long to re-train those "imported" doctors. Only those who are ambitious and bright would come to the US and I have at least a handful of friends from the medical school in Myanmar, who were in the same class year as I was, already doing their residencies. Most of them took ~2-3 years of taking the USMLE and applying for hospitals in the US which sponsors H1B (mostly the rural ones). They seem to be liking what opportunity they've been given to as far as I can tell. I actually regret quitting med school there and leaving for college in the US after my 2nd year just because I want to be an aerospace engineer (turns out, I cannot because there's almost no company that would hire an H1B aerospace engineer, so I had to change my studies back to comp sci).
- douche 11y ago
  Culturally, I suspect this would not go over well. There are a shocking number of people that would be less than impressed to be served by a doctor with a non-Anglo-Saxon last name, even if they spoke perfect English. Especially older people, who are the largest consumers of healthcare.
lordnacho 11y ago
Why do people insist on having objective criteria for performance when it's inherently subjective whether your care was any good? I've seen this with the NHS in the UK. They have a bunch of numbers they have to make, but what do the numbers actually mean? What happens when people end up gaming the system, because the rules tell them to?
- DanBC 11y ago
  > objective [...] subjective They should be trying to capture the subjective stuff too. See, for example, the Friends and Family test which is everywhere. Service Use Experience Committees also try to capture the subjective stuff. Complaints department mostly deal with subjective stuff. Healthwatch independently deal with mostly subjective stuff too. There's a wide range of subjective stuff that's measured using things like PLACE (Patient Led Assessment of the Care Environment) or 15 Steps Challenge. But people paying the money tend to like things that are more directly measurable. They might have CQUINs (Commissioning Quality through Innovation (or something like that) to ask people to implement 15 steps challenge, without worrying too much about what the results are. > They have a bunch of numbers they have to make, but what do the numbers actually mean? What happens when people end up gaming the system, because the rules tell them to? I dislike the focus on numbers, but if you compare areas where they have strict numbers (4 hour A&E limit) and areas where they don't (access to talking therapy) you see that most (it was national scandal when it dropped to 85%) people who attend A&E are triaged and then treated + released or admitted into hospital within four hours versus, well, untold wait. Very recently (or maybe it's not in place yet) there's an 18 week limit for access to community based psychological therapies, so it'll be interesting to see if it makes a difference. > What happens when people end up gaming the system, because the rules tell them to? Various regulators and scrutineers hate that, and they have some power to drive change. Or NHS England / DoH force change. Some hospitals were transferring people to an observation ward from A&E, rather than treating them or admitting them into hospital. That got stopped pretty quick.
BingsF 11y ago
I first read this as "un-ionize". Poster's username probably helped prompt that.
marcoperaza 11y ago
Milton Friedman gave a lecture on the economics of the medical industry: https://www.youtube.com/watch?v=ss5PxPlnmFk https://www.youtube.com/watch?v=ss5PxPlnmFk . He discusses the AMA's guild-like tactics at one point (https://www.youtube.com/watch?v=MAjOryNaDkA https://www.youtube.com/watch?v=MAjOryNaDkA), but their folly is a theme throughout.
Shivetya 11y ago
Best of luck with that union, it might win you a little reprieve but that profession is now more susceptible to foreign trained Doctors coming here to take their place. Unions of professional workers are last resort actions. If you are at that point the chance has blown by to take corrective action, all they can do is slow it down. Plus, if the ACA doesn't get axed next year hospitals and management companies won't be the biggest threat to their pay or number of patients they will see. The government will set rates and if they want to eat they are going to have to see more patients, if they even get them as there will be nurses who will step into those roles too
stephenboyd 11y ago
> The basic accounting problem for hospitalists is that they are not a profit center. That is, when they treat patients, the amount a hospital can bill Medicare and insurance companies is typically less than what the hospital must pay them. The opposite is true for other specialists, like surgeons. The rest of the article focused on peoples' emotional reactions, but that paragraph is key. Medicare, Medicaid, and the insurance companies will pay more than enough for tests and surgeries, but not for the diagnoses and treatments that hospitalists and GP's perform themselves. So the folks running the hospital budgets are naturally trying to change the model so that the hospitalists quickly refer patients to the more profitable departments. The only actor able to change this model is the US Congress, which makes the legislation that sets the Medicare and Medicaid reimbursement rates. There were major improvements with the ACA/Obamacare, but it's a dysfunctional system that can only be fixed by an even more dysfunctional system.
- dmix 11y ago
  > it's a dysfunctional system that can only be fixed by an even more dysfunctional system Indeed, the health industry is probably one of the worst places for capitalism/markets to rule. Not that I believe unionization and a further regulated industry is the answer either. While I'll defend markets to death in most other areas, there are admittedly a few industries where it the corrective benefits of competition/market pricing just doesn't make sense. Healthcare is the perfect example of where abiding strictly by these incentives create perverse side-effects which ultimately create a net-negative environment for the industry and the consumers. Living in Canada has given me perspective on this matter, where our public health insurance system functions very well without markets. It's a shame politics drives everyone to think they should be purists on each matter. Sometimes the data and emotional experience will demonstrates otherwise. Or worse, politics often create a muddled middle-of-the-road compromise, easily manipulated by either-side's special interests. It takes quite a bit of self-delusion to believe a particular economic theory should be applied uniformly everywhere when results show otherwise.

104 points by e15ctr0n 11y ago

All of this rings true from what I've heard my dad, a GP, complain about for years. It's hard for him to watch other doctors game the system to increase their earnings -- not only seeing more patients with unaccountably short sessions, but also up-coding their maladies and ordering unnecessary tests. In addition to the pressure of seeing more patients per day, they have all this new administrative bullshit (ironically in the name of efficiency) preventing them from doing so. For example, doing charts went from dictation, to data entry in absurdly bad (understatement) EMR software on cheap, outdated hardware that they weren't properly trained to use. And oh yeah, you can have pay withheld if you fall behind on that, too. It's just sad, and many older doctors don't even recommend the profession to young people at this point.

marshray 11y ago
My doctors usually spend less than 5 minutes talking to me and 10 minutes hunting and pecking at the computer. Some offices will have other staff do much of the data entry, but it doesn't seem to result in the doctor any spending more time with me.
- merqurio 11y ago
  Precisely we just created an start-up with a product that helps doctors making the EHR much faster and intuitively so they can focus on the patients.
  - marshray 11y ago
    I believe you, but when I worked in a medical office in 1993 vendors were saying that exact same thing.
    - merqurio 11y ago
      I know, I hope my Background as MD and CS plus the idea we had will make it different. We are working on something similar to an IDE :)
      - marshray 11y ago
        Break a leg :-) And whatever you do, just don't let anyone deploy it on some overloaded Citrix server.
      - knughit 11y ago
        Congratulations in advance for when EPIC buys your company and then ruins your product.
        gameshot911 11y ago
        Epic doesn't acquire.
      - gmarx 11y ago
        You sound like me and this sounds like software I created more than a decade ago. Good luck. It is an incredibly difficult sale (yes, I am a little bitter :))
    - lucidrains 11y ago
      Cool, me too :) would be interested to hear more on what you are working on if you are in the city. (SF)
      - gmarx 11y ago
        Me too and I am near SF. Would also be interested in talking
- Mz 11y ago
  You could try looking for Direct Primary Care, another growing movement among doctors in reaction to how messed up the system is. I wrote a bit about it recently: Http://micheleincalifornia.blogspot.com/2015/12/how-to-fix-americas-financial.html
- cglace 11y ago
  The hospital system my dad works for just got all the doctors scribes to take the data entry burden off of them.
sghodas 11y ago
Hell, I'm only in my second year of med school in the US, and I wouldn't recommend young people go into this profession.
- merqurio 11y ago
  I'm in the last year and I would totally do it again. It's true college it's abusive(http://www.kevinmd.com/blog/2016/01/physicians-arent-burned-theyre-abused.html http://www.kevinmd.com/blog/2016/01/physicians-arent-burned-...), but I find it amazing as a career.
  - Lordarminius 11y ago
    (MD here...) With all due respect, wait until you have been in the profession for at least one decade. Then, I'd like to hear your opinion again.
  - Lordarminius 11y ago
    (MD here...) With all due respect, wait until you have been in the profession for at least one decade. Then, I'd like to hear your opinion again.
    - merqurio 11y ago
      I'm sure the work is super hard, and I will change my opinion, everybody said that to me, but at least academically, I found it amazing. :)
acveilleux 11y ago
Not having dictation is just dumb. Voice rec is quite capable these days and the doctor's time is too valuable to waste on their typing speed. One note though, the PC never really has to be any good because most of the EMR crap is accessed over Citrix... To make IT's life easier (in theory) and avoid having the need for fancy PCs on the wards.
switch007 11y ago
Similar story in the UK. My aunt, who works for the NHS (not a GP), has cried in the toilets a few times because she is forced to use bad software to the point of utter frustration, and she is not of the computer generation. There are ~10 people in her team in a simular situation. They should just have a dedicated person doing data entry in to the computer system.
kamaal 11y ago
>>It's hard for him to watch other doctors game the system to increase their earnings Make no mistakes this isn't just restricted to the US. This is quite common in India too. >>not only seeing more patients with unaccountably short sessions, but also up-coding their maladies and ordering unnecessary tests. In India there practices are almost in the fraud territory. Start from doctors having small testing labs in their clinics. Where they order unnecessary test for patients they don't need. Almost every clinic has a neighboring pharmacy, that sells medicines of brands only the doctor next to it prescribes. You won't be able to buy that medicine anywhere else, plus the doctor makes commission in the medicine sold in the pharmacy. Prolonging treatments to maximize per consultation fees is extremely common. Its very common for hospitals to indulge in advising patients with either incorrect treatments or prolonging treatments. Pointless tests, doctors cooking up stories to scare patients to spend more at hospitals is all common. >>It's just sad, and many older doctors don't even recommend the profession to young people at this point. I talked to many doctors(friends, relatives and acquaintances) actually many feel cheated opting to chose a career in medicine. They are told they are very smart people, and all. Told they are super smart hence they deserve to go to medical college. Hence they expect to be paid proportionally. Most watch their friends in engineering, who they think have it(apparently, that's how they perceive it) a lot easier. While they spend a lot of studying, piling up a good deal of student debt, plus on a average making the same money at the end anyway. Except that every thing in life happens decades later. They look at engineers, especially programmers as people who have a lot of opportunity to switch streams, learn and move on to new stuff, work at big companies, start companies. Especially programmers who are good investors come across as people who made far more sensible career decisions. Doctos at the end of the day are humans, and are driven by peer financial pressures.

nostromo 11y ago

For what it's worth, people have been calling the AMA a union by another name for several decades. http://www.forbes.com/sites/johngoodman/2014/09/03/the-doctors-union/ http://www.forbes.com/sites/johngoodman/2014/09/03/the-docto... They lobby, they control the supply of doctors, they restrict competition, and they even engage in price fixing: https://www.washingtonpost.com/business/economy/how-a-secretive-panel-uses-data-that-distorts-doctors-pay/2013/07/20/ee134e3a-eda8-11e2-9008-61e94a7ea20d_story.html https://www.washingtonpost.com/business/economy/how-a-secret... They shape a lot of medical legislation, for example killing the Affordable Care Act's "public option." http://www.nytimes.com/2009/06/11/us/politics/11health.html http://www.nytimes.com/2009/06/11/us/politics/11health.html This isn't a recent thing. The AMA was key in killing Truman's universal healthcare proposal starting in 1945. http://umhm.mededu.miami.edu/?p=394 http://umhm.mededu.miami.edu/?p=394

Spooky23 11y ago
The dynamics of medical practice are changing substantially. Regional medical organizations are consolidating and creating vertically integrated medical behemoths. As a result, MDs are losing their independence and becoming just another group of highly paid employees. Once big corporate entities take over, neutralizing noisy, highly paid employees is always part of the playbook.
sayhar 11y ago
> They lobby, they control the supply of doctors, they restrict competition, and they even engage in price fixing It saddens me that those are your go-to ideas of what a union is. > The AMA was key in killing Truman's universal healthcare proposal starting in 1945. Actual unions have been pushing for universal healthcare for much earlier than I was born. On this front AMA has been the enemy of real organized labor for decades. A real union is about workers banding together to stand up to a boss who says "fuck me or you're fired", or to resist management giving themselves millions while cutting pay for workers. Please don't dishonor the good name of organized labor by comparing them to the millionaire doctors who killed our chances for a sane healthcare system.
- 11y ago

horsecaptin 11y ago

The more middle-men you have between the consumer and the provider - be it a product or a service - the more the middle-men will constantly fight for 1) higher prices, and 2) marginalizing both the service provider and the customer. This applies to education (universities, private schools), healthcare (large hospitals, insurance companies), social services, food, electronics...

potatote 11y ago

One thing that I never understood about the US medical education is the requirement of the bachelor's degree (pre-med) before applying for most med schools. In my home country and many others, you can directly apply to med school. Now that the college costs are quite considerably expensive, four-additional year of college studies simply adds to the cost of becoming a doctor and therefore, the newly minted doctors expect to make a lot of money. This pre-med education requirement adds unnecessary, in my opinion, burden not only to wannabe-doctors, but also to the medical system (create scarcity of doctors to say the least).

andrewpi 11y ago
I actually prefer the US system in that it potentially provides doctors with a more well-rounded education.
- XorNot 11y ago
  Ah yes, the moral duty American colleges feel for ensuring a rounded education at the low low price of tens of thousands of dollars per year.
  - PhasmaFelis 11y ago
    My CS degree focused on a rounded education, which would have been okay if it had also taught me how to, say, write a useful program. I didn't realize 'til I'd graduated that I would have to teach myself if I wanted a career.
    - krisdol 11y ago
      To be fair it was never called a degree in programming.
      - PhasmaFelis 11y ago
        When I signed up for classes, I said I wanted to be a programmer, and the advisor said "oh, you want Computer Science, then." That was just as much a lie as if they'd called it Programming outright.

c3534l 11y ago

Doctors are already paid absurd salaries in the US and the barriers to entry already high. As much as we all hate dealing with insurance companies, when I lost my insurance and had to pay for things out of pocket, the difference between what they charged me and what they would have charged an insurance company was obscene. Insurance companies actually do a pretty good job of reducing the costs of medical care, although some of the same power and information asymmetries still exist (that is, I'm saying that doesn't necessarily make the insurance companies the good guys). But the consumer has no bargaining power on his own and he doesn't know enough to challenge or negotiate. And the entire regulatory structure puts all the power in the hands of the doctor, not the patient. I don't see this as being a good trend for consumers. I find this to be very worrying. Edit: since this my "absurd salaries" remark seems like it might be the most controversial bit, I was thinking of I was referring more to information like this: http://www.motherjones.com/files/blog_physician_compensation_0.jpg http://www.motherjones.com/files/blog_physician_compensation... That's because it sidesteps many issues like how hard it is to become a doctor by simply comparing the pay of American doctors to the pay of doctors in countries with national healthcare. By "absurd salaries" what I really should have said was that American doctors are paid significantly more than other countries. Of course everyone, no matter what their job, thinks they work too hard for too little pay.

pragone 11y ago
> Doctors are already paid absurd salaries in the US To put it in context, when I finish all my training, I will owe over $600,000. It's not the doctors being "paid absurd salaries" that makes medical care in this country expensive. It's lawyers - malpractice insurance can take upwards of 25+% of your income - and it's insurance companies, who have shareholders they are responsible to, and it's hospital administration, whose positions keep multiplying.
- Dr_tldr 11y ago
  And yet, when Texas put a cap on medical malpractice awards, the cost of medical care didn't go down at all. Surely you have a good explanation for that and you're not just repeating discredited talking points for personal gain.

parennoob 11y ago

With the whole "Everyone Should Learn to Code" movement taking on so much steam, I cannot help but wonder why there isn't a similar "More People Should Learn to Do Basic Diagnosis" movement. We need a shit ton more Nurse Practitioners and "basic" doctors to diagnose and treat minor ailments, so doctors who have gone to 6-year plus medical school can spend time on the more serious ailments.

acveilleux 11y ago
Some of it is a perception issue, no one wants anything but the very best for their loved ones. So nurse practitioners, while great in theory, are only acceptable for others... Of course if you live in the boonies, a nurse here is a heck of a lot better than a doctor 4h away.
- veritas3241 11y ago
  Similar line of reasoning happens with anesthesiologists versus nurse anesthetists (CRNA). Most anesthesia is administered by a CRNA with a anesthesiologist overseeing most, but there's been pushback b/c it cuts into the salaries of the anesthesiologists.

induscreep 11y ago

I don't understand this about healthcare in the USA. Why not import a few thousand doctors from Asia through H1Bs, and drive down the cost of medical care? Remove artificial caps on licenses imposed by the AMA while at it.

TDL 11y ago
The AMA is a very powerful lobbying group in the U.S. They have been able to steer regulations/laws on the state & federal level to limit competition.
objclxt 11y ago
Because you have to spend years re-training and certifying to US standards, all the time without a job and earning money to pay for said training: http://www.npr.org/sections/money/2013/02/15/172108835/should-the-u-s-import-more-doctors http://www.npr.org/sections/money/2013/02/15/172108835/shoul... And that's putting aside the fact H1-Bs are not exactly easy to come by right now.
- potatote 11y ago
  Not trying to undermine your point, but I believe it won't take much long to re-train those "imported" doctors. Only those who are ambitious and bright would come to the US and I have at least a handful of friends from the medical school in Myanmar, who were in the same class year as I was, already doing their residencies. Most of them took ~2-3 years of taking the USMLE and applying for hospitals in the US which sponsors H1B (mostly the rural ones). They seem to be liking what opportunity they've been given to as far as I can tell. I actually regret quitting med school there and leaving for college in the US after my 2nd year just because I want to be an aerospace engineer (turns out, I cannot because there's almost no company that would hire an H1B aerospace engineer, so I had to change my studies back to comp sci).
douche 11y ago
Culturally, I suspect this would not go over well. There are a shocking number of people that would be less than impressed to be served by a doctor with a non-Anglo-Saxon last name, even if they spoke perfect English. Especially older people, who are the largest consumers of healthcare.

lordnacho 11y ago

Why do people insist on having objective criteria for performance when it's inherently subjective whether your care was any good? I've seen this with the NHS in the UK. They have a bunch of numbers they have to make, but what do the numbers actually mean? What happens when people end up gaming the system, because the rules tell them to?

DanBC 11y ago
> objective [...] subjective They should be trying to capture the subjective stuff too. See, for example, the Friends and Family test which is everywhere. Service Use Experience Committees also try to capture the subjective stuff. Complaints department mostly deal with subjective stuff. Healthwatch independently deal with mostly subjective stuff too. There's a wide range of subjective stuff that's measured using things like PLACE (Patient Led Assessment of the Care Environment) or 15 Steps Challenge. But people paying the money tend to like things that are more directly measurable. They might have CQUINs (Commissioning Quality through Innovation (or something like that) to ask people to implement 15 steps challenge, without worrying too much about what the results are. > They have a bunch of numbers they have to make, but what do the numbers actually mean? What happens when people end up gaming the system, because the rules tell them to? I dislike the focus on numbers, but if you compare areas where they have strict numbers (4 hour A&E limit) and areas where they don't (access to talking therapy) you see that most (it was national scandal when it dropped to 85%) people who attend A&E are triaged and then treated + released or admitted into hospital within four hours versus, well, untold wait. Very recently (or maybe it's not in place yet) there's an 18 week limit for access to community based psychological therapies, so it'll be interesting to see if it makes a difference. > What happens when people end up gaming the system, because the rules tell them to? Various regulators and scrutineers hate that, and they have some power to drive change. Or NHS England / DoH force change. Some hospitals were transferring people to an observation ward from A&E, rather than treating them or admitting them into hospital. That got stopped pretty quick.

BingsF 11y ago

I first read this as "un-ionize". Poster's username probably helped prompt that.

marcoperaza 11y ago

Milton Friedman gave a lecture on the economics of the medical industry: https://www.youtube.com/watch?v=ss5PxPlnmFk https://www.youtube.com/watch?v=ss5PxPlnmFk . He discusses the AMA's guild-like tactics at one point (https://www.youtube.com/watch?v=MAjOryNaDkA https://www.youtube.com/watch?v=MAjOryNaDkA), but their folly is a theme throughout.

Shivetya 11y ago

Best of luck with that union, it might win you a little reprieve but that profession is now more susceptible to foreign trained Doctors coming here to take their place. Unions of professional workers are last resort actions. If you are at that point the chance has blown by to take corrective action, all they can do is slow it down. Plus, if the ACA doesn't get axed next year hospitals and management companies won't be the biggest threat to their pay or number of patients they will see. The government will set rates and if they want to eat they are going to have to see more patients, if they even get them as there will be nurses who will step into those roles too

stephenboyd 11y ago

> The basic accounting problem for hospitalists is that they are not a profit center. That is, when they treat patients, the amount a hospital can bill Medicare and insurance companies is typically less than what the hospital must pay them. The opposite is true for other specialists, like surgeons. The rest of the article focused on peoples' emotional reactions, but that paragraph is key. Medicare, Medicaid, and the insurance companies will pay more than enough for tests and surgeries, but not for the diagnoses and treatments that hospitalists and GP's perform themselves. So the folks running the hospital budgets are naturally trying to change the model so that the hospitalists quickly refer patients to the more profitable departments. The only actor able to change this model is the US Congress, which makes the legislation that sets the Medicare and Medicaid reimbursement rates. There were major improvements with the ACA/Obamacare, but it's a dysfunctional system that can only be fixed by an even more dysfunctional system.

dmix 11y ago
> it's a dysfunctional system that can only be fixed by an even more dysfunctional system Indeed, the health industry is probably one of the worst places for capitalism/markets to rule. Not that I believe unionization and a further regulated industry is the answer either. While I'll defend markets to death in most other areas, there are admittedly a few industries where it the corrective benefits of competition/market pricing just doesn't make sense. Healthcare is the perfect example of where abiding strictly by these incentives create perverse side-effects which ultimately create a net-negative environment for the industry and the consumers. Living in Canada has given me perspective on this matter, where our public health insurance system functions very well without markets. It's a shame politics drives everyone to think they should be purists on each matter. Sometimes the data and emotional experience will demonstrates otherwise. Or worse, politics often create a muddled middle-of-the-road compromise, easily manipulated by either-side's special interests. It takes quite a bit of self-delusion to believe a particular economic theory should be applied uniformly everywhere when results show otherwise.