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My wife is a medical resident and the issues described by this doctor are absolutely pervasive in residency. The strange part is, the overwork also seems to be

My wife is a medical resident and the issues described by this doctor are absolutely pervasive in residency. The strange part is, the overwork also seems to be pervasive among the attending physicians who have been out of residency for decades. Not just the residents. As a tech founder analyzing the system from the outside, I think this writer has nailed the core issue: "... a doctor is just one of the many commodities in this complex industry. It’s no longer about the patient. It’s about the business of hospitals." If doctors were viewed in their industry the way software engineers are viewed in ours -- as specialized skilled labor with extreme leverage and limited time -- then we would have well-supported, well-rested, and well-compensated doctors. But as it stands, we have overworked and overtired doctors buried under a mountain of clerical work, who need to slot their patient in to 15-minute "encounters" in clinic to keep the profit machine running. Meanwhile, administrators, health insurance executives, and medical equipment CEOs work 9-to-5 and earn millions. It really boggles the mind and infuriates me, as a technologist. p.s. Don't listen to any of the comment threads here that say long hours are required to reduce patient handoffs. Yes, it's true, patient handoffs cause some danger. But tired doctors make mistakes. Period. And, as this post indicates, a perpetually tired doctor burns out and either quits the profession or (worse) commits suicide, which is the worst possible outcome for the system.

llimllib 9y ago
My wife is now an attending, and all I can say is Amen. The worst part is that many doctors often defend and work to perpetuate the system, rather than organizing to make it sane. It is truly boggling.
- falsedan 9y ago
  Is she a member of the AMA?
dikdik 9y ago
If docs didn't slot 15 minutes per patient, then they would need to charge each patient much, much more or make much, much less. There is no other way around that.
- wernercd 9y ago
  Or, perhaps, do something about the layer (lawyers) after layer (coders) after layer (nurses) after layer (administration) after layer (...) of "support" staff? I'm willing to bet that something to relieve the massive amount of "other" stuff needed besides the Doctor would go a LOOOOOONG way... That doesn't even tackle stuff like inability to see how much something actually costs - and shop around for stuff other than the ER. 15 minutes per patient isn't the answer...
- yjftsjthsd-h 9y ago
  I observe that doctors somehow managed to make a living before 15 minute visits.
  - cnnsucks 9y ago
    Indeed. I observe that women somehow managed without 32% of all births being Cesarean[1]. The last time I looked up that figure a few years ago it was 24%. What a racket. [1] https://www.cdc.gov/nchs/fastats/delivery.htm https://www.cdc.gov/nchs/fastats/delivery.htm
thearn4 9y ago
I'm not a medical professional, but the whole discussion of handoff risk always seemed to me like it was side-stepping the real issue presented, which is poor documentation and/or communication between peers. Instead, the premise is offered by the AMA that handoff risk can only be minimized by insane shift lengths.
QML 9y ago
Do you think if the United States graduated more doctors every year, it would prevent doctors as a group from being overworked and overtired? As a college student, I often wonder why pre-med is so academically competitive despite the fact that the ambition to help others is a virtue; and whether that competitiveness to get a high GPA and MCAT score is needed at all.
- killjoywashere 9y ago
  There has been angst about medical school admissions for decades. Med school admission really is the hurdle to get over in the US. There are more residency spots than US MD graduates to fill them. By a wide margin. There's a strong medical education research unit in the UK (Edinburgh?); I remember one of their reports on a series of med student interviews making the observation that it was unnerving how the top performing medical students weren't the most compassionate, they were the most ruthless. I'm taking my boards soon and I have to say, the ability to commit to the task, regardless of the emotions of your self, patients, peers, support staff, and family can definitely be an asset at times. Do I hope to take a kinder view when I start working in a few months? I'm not sure kinder would be the word. Supportive of a somewhat different set of ambitions, perhaps. Unfortunately, that ability to deny the emotions of both self and other in pursuit of good clinical care is difficult to separate from 1) the punishment of self-loathing, and 2) the behavior of someone who has been rewarded too long for blind obedience.
  - maxerickson 9y ago
    In recent years residency slots have become the bottleneck.
    - killjoywashere 9y ago
      There are ~30,000 PGY-1 spots and only about 18,000 allopathic medical school graduates. (1) All the native allopaths and all the osteopaths together can't fill all the residency spots. We inhale foreign medical graduates. (1) Pages v and 14: http://www.nrmp.org/wp-content/uploads/2017/04/Main-Match-Results-and-Data-2017.pdf http://www.nrmp.org/wp-content/uploads/2017/04/Main-Match-Re...
hammerzeit 9y ago
My spouse is a doctor as well, and I've also observed the issues the author discusses. I don't think your read of the causes here is correct. It's worth reading more about the history of medicine to truly understand what's going on here -- the culture of abusive overwork in American medicine goes at the very least back to Osler and the invention of the modern residency program, and has as much to do with cocaine than any corporate malfeasance. Certainly hospitals and the medical industry profit from this culture, but they hardly created it. Also, on what basis do you say that longer hours with fewer tradeoffs don't improve patient outcomes? You frame it as though it's obvious but is there any evidence to back that up? My wife and most other doctors I know all claim they'd rather have longer hours with fewer handoffs.
- markroseman 9y ago
  Agreed, this culture of abuse goes way back, and is as much rooted in a macho "I went through this, you're damn well going to" mentality. I do think the increasing corporatization of medicine in the USA has accelerated the loss of autonomy and satisfaction, which makes the abuse and overwork far more difficult to take.
- trowawee 9y ago
  Every single study of the effects of fatigue on human cognitive ability that I am aware of indicate that A) fatigue can have massive deleterious effects on peoples' abilities to perform even simple tasks, and B) people are generally terrible at evaluating their own levels of fatigue. There's a good overview of a lot of this research here: https://hbr.org/2015/08/the-research-is-clear-long-hours-backfire-for-people-and-for-companies https://hbr.org/2015/08/the-research-is-clear-long-hours-bac.... I don't know exactly what the costs are for more handoffs; my fiancée is a doctor, and she and multiple doctors have told me they have that same concern. But we have mountains of evidence demonstrating how rapidly cognitive ability degrades with fatigue. The idea that doctors, frequently working in a massively demanding, massively stressful setting, are somehow immune to those effects defies logic.
  - IIIIIIIIIIII 9y ago
    > The idea that doctors ... are somehow immune to those effects defies logic. That claim was never made by OP. Can we have a discussion without attacking a straw man, please? You yourself acknowledge you only know one side of equation. If the other components are larger it would not matter that you have shown one aspect - that nobody disputes, incl. OP! - to be negative. https://news.northwestern.edu/stories/2016/02/longer-shifts-surgical-residents-safe/ https://news.northwestern.edu/stories/2016/02/longer-shifts-... > A new [...] study [...] showed allowing surgical residents the flexibility to work longer hours in order to stay with their patients through the end of an operation or stabilize them during a critical event did not pose a greater risk to patients. > “It’s counterintuitive to think it’s better for doctors to work longer hours,” said principal investigator Dr. Karl Bilimoria [...]. “But when doctors have to hand off their patients to other doctors at dangerous, inopportune times, that creates vulnerability to the loss of critical information, a break in the doctor-patient relationship and unsafe care.” I have no doubt that overall the long hours are bad, I only respond because you attack a position OP didn't take. Also, the long hours may still be a logical conclusion and even beneficial - within the twisted logic of dysfunction in the larger system: "For evil to triumph, all that is required is for good men to respond rationally to incentives."
karpodiem 9y ago
Western medicine has turned into a ponzi scheme. The verifiable proof of this is to have an elderly family member in a nursing home who goes through the usual monthly trips to the hospital from 'falling'. While Medicare covers almost all of it, it became so nauseating to read the outrageous EOB totals that I tried to put a end to it - I requested that unless the on call nurse (after hours) or physician (during business hours) deems the fall to be a life threatening emergency, they are to be kept in the facility. They found a workaround for that real quick - it's nearly always deemed life threatening because they are 1) unable to determine internal bleeding 2) unable to determine if a bone was fractured/broken. The obvious solution to this is to have an xray machine on site, because since everyone in the chain gets paid huge $, and it removes the liability from the nursing home to ship them off to the hospital, the merry-go-round of insanity continues. We have two family members in an assisted care facility for almost eight years now, and between the two of them, they've tapped Medicare for just under $700K. Together, the sum of both their incomes throughout their entire working lives never totaled that amount. This is why I call it a ponzi scheme.
- rayiner 9y ago
  Everything is really easy if you hand-wave away the facts: https://www.cdc.gov/media/releases/2016/p0922-older-adult-falls.html https://www.cdc.gov/media/releases/2016/p0922-older-adult-fa.... Elderly Americans experience about 29 million falls per year, which costs Medicare $31 billion. At about $1,000 per fall that seems quite reasonable. 27,000 older Americans die from falls each year. In an institutional setting like a nursing home, the rate of death per fall is even higher. $700,000 for two people in assisted living for eight years is about $43,000 per year. That's not unreasonable for the cost of assisted care plus medical expenses.
  - maxerickson 9y ago
    Medicare wouldn't be paying for the assisted care: https://www.medicare.gov/what-medicare-covers/part-a/paying-for-nursing-home-care.html https://www.medicare.gov/what-medicare-covers/part-a/paying-... A facility generating large numbers of fall investigations that don't lead to ongoing medical care seems like it would be pretty easy (potential) fraud to go after though.
abandonliberty 9y ago
How much selective pressure do doctors experience on their performance? Healthcare is one of those fields where there's no guarantee on the quality of the service. There's no pay for performance. Actually, doctors who perform too well would reduce healthcare spending. There are plenty of reasons to keep developers happy because it directly affects the end product and profit.
- mikeyouse 9y ago
  You should do a lot more reading about healthcare if you think there isn't pay for performance. The payers in the system all have massive incentives to reduce healthcare utilization. Docs and hospitals have been dealing with 'P4P' for decades and the ACA ramped it up significantly for the CMS.
  - hkmurakami 9y ago
    The CJR pay for performance and move to bulk insurance payment is a good illustration of this. https://innovation.cms.gov/Files/x/cjr-faq.pdf https://innovation.cms.gov/Files/x/cjr-faq.pdf
  - leekyle 9y ago
    What is a good example of pay for performance in healthcare?
    - mikeyouse 9y ago
      The latest example from CMS is the Readmission Reduction program; https://www.medicare.gov/hospitalcompare/readmission-reduction-program.html https://www.medicare.gov/hospitalcompare/readmission-reducti... In general, Medicare pays a certain amount of money for a patient with a specific diagnosis. So if 70-year old woman X is admitted with condition Y, the hospital will receive $Z for treating her -- no matter what it costs. Hospitals don't love that since having patients in beds is expensive, so they would often times discharge patients before it was medically appropriate. They would take $Z and then when the patient came back in a few days, they could bill for follow-up services. With the ACA we started tracking hospital readmissions to see how big of a problem that really was, and if hospitals underperformed their peers (aka they saw a lot of readmissions indicating that patients were discharged too early), they would either not pay for the followup visits or just lower the overall reimbursement for future patients. Another good example was the Hospital-Acquired Condition reduction program. There is an enormous amount of cost associated with hosptial-acquired infections and the US was particularly bad in terms of modern systems. If patients in your hospital are consistently catching bugs, Medicare will dramatically reduce your reimbursement rate. http://www.beckershospitalreview.com/quality/769-hospitals-see-medicare-payments-cut-over-high-hac-rates-7-things-to-know.html http://www.beckershospitalreview.com/quality/769-hospitals-s... Since the 1990s though, Docs have been working with P4P -- whether it's increased reimbursement from insurance companies for prescribing an appropriate ratio of generics vs. brand name medicines, to the lump-sum payment per patient, to bonuses for hospitals adhering to best-practices (what % of patients with chest pain get an aspirin with 30 minutes or what % are cath'ed within 90 minutes of presenting).
kem 9y ago
There's one big difference between software engineers and healthcare: regulation. A software engineer is hired for their skills (at least ostensibly). No one is required by law to hire someone with a specific degree and specific post-degree training and specific exams. Contrast this with healthcare. To do certain sorts of procedures, you have to hire a physician. Not because it's demonstrably necessary to have someone with an MD and a residency in such-and-such area do this, but because it's required by law. As someone else pointed out, this is just the tip of the iceberg. That residency? Residents have no bargaining leverage over their conditions by fiat of residency rules--they cannot leave an abusive residency, for example, to change conditions. Financing the residency itself? Businesses won't cover the expenses because it's not actually worth the costs, so the government foots the bill. And once you leave residency? Well, subspecialty organizations are deciding that it's good to carve out even more regulatory capture with subspecialty credentialing. People do not grasp how much of this insanity is codified by law and rule, and when they are informed of it, they shrug it off in the name of "safety." It's like terrorism or crime: no one wants to be branded as soft on terrorism or crime, so the government becomes more and more invasive and draconian, and the costs of maintaining the military-police-industrial complex increase and increase. Similarly, no one wants to be soft on safety, so the government becomes more and more invasive and draconian, and the costs of maintaining the medical organization-physician-insurance-industrial complex increase and increase. There's something disingenuous for physicians to complain about being overworked, and then fight against the things that would alleviate their burden the most: letting perfectly competent professionals with different backgrounds do what they do just as well. But that would mean admitting that you don't need an MD at the apex of healthcare. To some extent, financial market pressures are doing what I'm saying anyway, as hospitals are realizing that MDs are too expensive as they are. So maybe this is just the first sign of things to come. But the downside of the current system is that administrators aren't allowed to go elsewhere for alternatives, so they just crank up the hours expected of MDs. The upshot is they get devalued without even being given the benefit of being let off the hook. I guess to address your comment directly: if healthcare were actually a transparent free market, my guess is physician salaries would go down, but their workload would also decrease also. What you'd see instead is much more diversity in who you see for any given service. The biggest sin of the government in the healthcare debate is willfully ignoring the costs of healthcare, by failing to increase competition, choice, and transparency in pricing. We talk about who pays, but not why we're being charged what we are, and whether or not it's worth it.
slackingoff2017 9y ago
It's well known within the medical field that being a doctor is really really tough. It takes a lot of smarts and grueling years in residency before you officially become a doctor. However it also pays incredibly well. Even moreso for specialities and surgeons, who can make over 200k a year even in low cost of living areas. Despite the difficulties of being a doctor it's harder to get into medical school than ever. The difficulties are not deterring med students. I don't feel bad for people that go into this profession then complain about how hard it is. It's extremely well known within the medical field that being a doctor is grueling. That's why it pays so well. And it's not like this is a new development. It's been like this for decades. Complaining about it is akin to working on an oil rig and complaining about poor work conditions. It's pretty damn obvious that you're going to have poor work conditions from the start. Nobody is forcing you to be a doctor, your school credentials plus MD is probably enough to swing a decent job in almost any field. Doctors are some of the most employable people out there. I just find it rediculous that were having a "poor doctors" discussion when it's the second highest paying profession in the richest country in the world. Get over it.
- maxerickson 9y ago
  It pays well because supply is constrained and demand is inelastic. It isn't clear how much the grueling training actually factors in to limiting the supply.
  - killjoywashere 9y ago
    There are plenty of dropouts at every step. Probably the biggest drop-off is the PGY-1 year (internship). That's when you really find out if you can cope with clinical medicine. Staff physicians only want interns and residents to do the scut work they don't want to do: in house call, dis-impacting old ladies in the ER, etc. If it wasn't for the parts that suck, they would assure you they can handle the hospital without residents just fine. I suppose that's why teaching hospitals consistently deliver better care: because the staff can do everything just fine. If it wasn't for parts that suck.
- kingbirdy 9y ago
josh33 9y ago
I'm a former healthcare administrator and just want to point out that many many administrators work much more than the 9-5. I'm also working at a healthcare tech startup aimed at reduced the administrative burden to doctors, administrators and insurers of managing their patients at home, which is where the worst outcomes often happen. Each segment we work with feels this burden, it is not isolated to the physicians.
- Mz 9y ago
  You might be interested in joining: https://groups.google.com/forum/#!forum/health-techies https://groups.google.com/forum/#!forum/health-techies
robk 9y ago
Leverage is the exact point. The problem is that due to their compassion and altruism they have no leverage. Design a system where doctors have to choose between destroying themselves and saving patients and they ethically are forced to destroy themselves. It's tragic and just as bad under socialised medicine if not worse.
kwhitefoot 9y ago
If handoff risk were inversely related to shift length then one would expect European hospitals that adhere to the EU Working Time Directive to have significantly worse outcomes than both US and UK. Is this the case? Or do they not adhere to the working time directive?
- sanotehu 9y ago
  We don't adhere to the EWTD. I think a UK doctor's hours are probably easier than a US doctor's but we all break the EWTD (except for some specialties like psychiatry). For example I am rostered to work an average 48 hours a week, although there are some weeks I work more, and I will often stay behind to get things done. My total hours per week is probably around 50 - and I'm in a job that isn't considered busy!

llimllib 9y ago

My wife is now an attending, and all I can say is Amen. The worst part is that many doctors often defend and work to perpetuate the system, rather than organizing to make it sane. It is truly boggling.

falsedan 9y ago
Is she a member of the AMA?

dikdik 9y ago

If docs didn't slot 15 minutes per patient, then they would need to charge each patient much, much more or make much, much less. There is no other way around that.

wernercd 9y ago
Or, perhaps, do something about the layer (lawyers) after layer (coders) after layer (nurses) after layer (administration) after layer (...) of "support" staff? I'm willing to bet that something to relieve the massive amount of "other" stuff needed besides the Doctor would go a LOOOOOONG way... That doesn't even tackle stuff like inability to see how much something actually costs - and shop around for stuff other than the ER. 15 minutes per patient isn't the answer...
yjftsjthsd-h 9y ago
I observe that doctors somehow managed to make a living before 15 minute visits.
- cnnsucks 9y ago
  Indeed. I observe that women somehow managed without 32% of all births being Cesarean[1]. The last time I looked up that figure a few years ago it was 24%. What a racket. [1] https://www.cdc.gov/nchs/fastats/delivery.htm https://www.cdc.gov/nchs/fastats/delivery.htm

thearn4 9y ago

I'm not a medical professional, but the whole discussion of handoff risk always seemed to me like it was side-stepping the real issue presented, which is poor documentation and/or communication between peers. Instead, the premise is offered by the AMA that handoff risk can only be minimized by insane shift lengths.

QML 9y ago

Do you think if the United States graduated more doctors every year, it would prevent doctors as a group from being overworked and overtired? As a college student, I often wonder why pre-med is so academically competitive despite the fact that the ambition to help others is a virtue; and whether that competitiveness to get a high GPA and MCAT score is needed at all.

killjoywashere 9y ago
There has been angst about medical school admissions for decades. Med school admission really is the hurdle to get over in the US. There are more residency spots than US MD graduates to fill them. By a wide margin. There's a strong medical education research unit in the UK (Edinburgh?); I remember one of their reports on a series of med student interviews making the observation that it was unnerving how the top performing medical students weren't the most compassionate, they were the most ruthless. I'm taking my boards soon and I have to say, the ability to commit to the task, regardless of the emotions of your self, patients, peers, support staff, and family can definitely be an asset at times. Do I hope to take a kinder view when I start working in a few months? I'm not sure kinder would be the word. Supportive of a somewhat different set of ambitions, perhaps. Unfortunately, that ability to deny the emotions of both self and other in pursuit of good clinical care is difficult to separate from 1) the punishment of self-loathing, and 2) the behavior of someone who has been rewarded too long for blind obedience.
- maxerickson 9y ago
  In recent years residency slots have become the bottleneck.
  - killjoywashere 9y ago
    There are ~30,000 PGY-1 spots and only about 18,000 allopathic medical school graduates. (1) All the native allopaths and all the osteopaths together can't fill all the residency spots. We inhale foreign medical graduates. (1) Pages v and 14: http://www.nrmp.org/wp-content/uploads/2017/04/Main-Match-Results-and-Data-2017.pdf http://www.nrmp.org/wp-content/uploads/2017/04/Main-Match-Re...

hammerzeit 9y ago

My spouse is a doctor as well, and I've also observed the issues the author discusses. I don't think your read of the causes here is correct. It's worth reading more about the history of medicine to truly understand what's going on here -- the culture of abusive overwork in American medicine goes at the very least back to Osler and the invention of the modern residency program, and has as much to do with cocaine than any corporate malfeasance. Certainly hospitals and the medical industry profit from this culture, but they hardly created it. Also, on what basis do you say that longer hours with fewer tradeoffs don't improve patient outcomes? You frame it as though it's obvious but is there any evidence to back that up? My wife and most other doctors I know all claim they'd rather have longer hours with fewer handoffs.

markroseman 9y ago
Agreed, this culture of abuse goes way back, and is as much rooted in a macho "I went through this, you're damn well going to" mentality. I do think the increasing corporatization of medicine in the USA has accelerated the loss of autonomy and satisfaction, which makes the abuse and overwork far more difficult to take.
trowawee 9y ago
Every single study of the effects of fatigue on human cognitive ability that I am aware of indicate that A) fatigue can have massive deleterious effects on peoples' abilities to perform even simple tasks, and B) people are generally terrible at evaluating their own levels of fatigue. There's a good overview of a lot of this research here: https://hbr.org/2015/08/the-research-is-clear-long-hours-backfire-for-people-and-for-companies https://hbr.org/2015/08/the-research-is-clear-long-hours-bac.... I don't know exactly what the costs are for more handoffs; my fiancée is a doctor, and she and multiple doctors have told me they have that same concern. But we have mountains of evidence demonstrating how rapidly cognitive ability degrades with fatigue. The idea that doctors, frequently working in a massively demanding, massively stressful setting, are somehow immune to those effects defies logic.
- IIIIIIIIIIII 9y ago
  > The idea that doctors ... are somehow immune to those effects defies logic. That claim was never made by OP. Can we have a discussion without attacking a straw man, please? You yourself acknowledge you only know one side of equation. If the other components are larger it would not matter that you have shown one aspect - that nobody disputes, incl. OP! - to be negative. https://news.northwestern.edu/stories/2016/02/longer-shifts-surgical-residents-safe/ https://news.northwestern.edu/stories/2016/02/longer-shifts-... > A new [...] study [...] showed allowing surgical residents the flexibility to work longer hours in order to stay with their patients through the end of an operation or stabilize them during a critical event did not pose a greater risk to patients. > “It’s counterintuitive to think it’s better for doctors to work longer hours,” said principal investigator Dr. Karl Bilimoria [...]. “But when doctors have to hand off their patients to other doctors at dangerous, inopportune times, that creates vulnerability to the loss of critical information, a break in the doctor-patient relationship and unsafe care.” I have no doubt that overall the long hours are bad, I only respond because you attack a position OP didn't take. Also, the long hours may still be a logical conclusion and even beneficial - within the twisted logic of dysfunction in the larger system: "For evil to triumph, all that is required is for good men to respond rationally to incentives."

karpodiem 9y ago

Western medicine has turned into a ponzi scheme. The verifiable proof of this is to have an elderly family member in a nursing home who goes through the usual monthly trips to the hospital from 'falling'. While Medicare covers almost all of it, it became so nauseating to read the outrageous EOB totals that I tried to put a end to it - I requested that unless the on call nurse (after hours) or physician (during business hours) deems the fall to be a life threatening emergency, they are to be kept in the facility. They found a workaround for that real quick - it's nearly always deemed life threatening because they are 1) unable to determine internal bleeding 2) unable to determine if a bone was fractured/broken. The obvious solution to this is to have an xray machine on site, because since everyone in the chain gets paid huge $, and it removes the liability from the nursing home to ship them off to the hospital, the merry-go-round of insanity continues. We have two family members in an assisted care facility for almost eight years now, and between the two of them, they've tapped Medicare for just under $700K. Together, the sum of both their incomes throughout their entire working lives never totaled that amount. This is why I call it a ponzi scheme.

rayiner 9y ago
Everything is really easy if you hand-wave away the facts: https://www.cdc.gov/media/releases/2016/p0922-older-adult-falls.html https://www.cdc.gov/media/releases/2016/p0922-older-adult-fa.... Elderly Americans experience about 29 million falls per year, which costs Medicare $31 billion. At about $1,000 per fall that seems quite reasonable. 27,000 older Americans die from falls each year. In an institutional setting like a nursing home, the rate of death per fall is even higher. $700,000 for two people in assisted living for eight years is about $43,000 per year. That's not unreasonable for the cost of assisted care plus medical expenses.
- maxerickson 9y ago
  Medicare wouldn't be paying for the assisted care: https://www.medicare.gov/what-medicare-covers/part-a/paying-for-nursing-home-care.html https://www.medicare.gov/what-medicare-covers/part-a/paying-... A facility generating large numbers of fall investigations that don't lead to ongoing medical care seems like it would be pretty easy (potential) fraud to go after though.

abandonliberty 9y ago

How much selective pressure do doctors experience on their performance? Healthcare is one of those fields where there's no guarantee on the quality of the service. There's no pay for performance. Actually, doctors who perform too well would reduce healthcare spending. There are plenty of reasons to keep developers happy because it directly affects the end product and profit.

mikeyouse 9y ago
You should do a lot more reading about healthcare if you think there isn't pay for performance. The payers in the system all have massive incentives to reduce healthcare utilization. Docs and hospitals have been dealing with 'P4P' for decades and the ACA ramped it up significantly for the CMS.
- hkmurakami 9y ago
  The CJR pay for performance and move to bulk insurance payment is a good illustration of this. https://innovation.cms.gov/Files/x/cjr-faq.pdf https://innovation.cms.gov/Files/x/cjr-faq.pdf
- leekyle 9y ago
  What is a good example of pay for performance in healthcare?
  - mikeyouse 9y ago
    The latest example from CMS is the Readmission Reduction program; https://www.medicare.gov/hospitalcompare/readmission-reduction-program.html https://www.medicare.gov/hospitalcompare/readmission-reducti... In general, Medicare pays a certain amount of money for a patient with a specific diagnosis. So if 70-year old woman X is admitted with condition Y, the hospital will receive $Z for treating her -- no matter what it costs. Hospitals don't love that since having patients in beds is expensive, so they would often times discharge patients before it was medically appropriate. They would take $Z and then when the patient came back in a few days, they could bill for follow-up services. With the ACA we started tracking hospital readmissions to see how big of a problem that really was, and if hospitals underperformed their peers (aka they saw a lot of readmissions indicating that patients were discharged too early), they would either not pay for the followup visits or just lower the overall reimbursement for future patients. Another good example was the Hospital-Acquired Condition reduction program. There is an enormous amount of cost associated with hosptial-acquired infections and the US was particularly bad in terms of modern systems. If patients in your hospital are consistently catching bugs, Medicare will dramatically reduce your reimbursement rate. http://www.beckershospitalreview.com/quality/769-hospitals-see-medicare-payments-cut-over-high-hac-rates-7-things-to-know.html http://www.beckershospitalreview.com/quality/769-hospitals-s... Since the 1990s though, Docs have been working with P4P -- whether it's increased reimbursement from insurance companies for prescribing an appropriate ratio of generics vs. brand name medicines, to the lump-sum payment per patient, to bonuses for hospitals adhering to best-practices (what % of patients with chest pain get an aspirin with 30 minutes or what % are cath'ed within 90 minutes of presenting).

kem 9y ago

There's one big difference between software engineers and healthcare: regulation. A software engineer is hired for their skills (at least ostensibly). No one is required by law to hire someone with a specific degree and specific post-degree training and specific exams. Contrast this with healthcare. To do certain sorts of procedures, you have to hire a physician. Not because it's demonstrably necessary to have someone with an MD and a residency in such-and-such area do this, but because it's required by law. As someone else pointed out, this is just the tip of the iceberg. That residency? Residents have no bargaining leverage over their conditions by fiat of residency rules--they cannot leave an abusive residency, for example, to change conditions. Financing the residency itself? Businesses won't cover the expenses because it's not actually worth the costs, so the government foots the bill. And once you leave residency? Well, subspecialty organizations are deciding that it's good to carve out even more regulatory capture with subspecialty credentialing. People do not grasp how much of this insanity is codified by law and rule, and when they are informed of it, they shrug it off in the name of "safety." It's like terrorism or crime: no one wants to be branded as soft on terrorism or crime, so the government becomes more and more invasive and draconian, and the costs of maintaining the military-police-industrial complex increase and increase. Similarly, no one wants to be soft on safety, so the government becomes more and more invasive and draconian, and the costs of maintaining the medical organization-physician-insurance-industrial complex increase and increase. There's something disingenuous for physicians to complain about being overworked, and then fight against the things that would alleviate their burden the most: letting perfectly competent professionals with different backgrounds do what they do just as well. But that would mean admitting that you don't need an MD at the apex of healthcare. To some extent, financial market pressures are doing what I'm saying anyway, as hospitals are realizing that MDs are too expensive as they are. So maybe this is just the first sign of things to come. But the downside of the current system is that administrators aren't allowed to go elsewhere for alternatives, so they just crank up the hours expected of MDs. The upshot is they get devalued without even being given the benefit of being let off the hook. I guess to address your comment directly: if healthcare were actually a transparent free market, my guess is physician salaries would go down, but their workload would also decrease also. What you'd see instead is much more diversity in who you see for any given service. The biggest sin of the government in the healthcare debate is willfully ignoring the costs of healthcare, by failing to increase competition, choice, and transparency in pricing. We talk about who pays, but not why we're being charged what we are, and whether or not it's worth it.

slackingoff2017 9y ago

It's well known within the medical field that being a doctor is really really tough. It takes a lot of smarts and grueling years in residency before you officially become a doctor. However it also pays incredibly well. Even moreso for specialities and surgeons, who can make over 200k a year even in low cost of living areas. Despite the difficulties of being a doctor it's harder to get into medical school than ever. The difficulties are not deterring med students. I don't feel bad for people that go into this profession then complain about how hard it is. It's extremely well known within the medical field that being a doctor is grueling. That's why it pays so well. And it's not like this is a new development. It's been like this for decades. Complaining about it is akin to working on an oil rig and complaining about poor work conditions. It's pretty damn obvious that you're going to have poor work conditions from the start. Nobody is forcing you to be a doctor, your school credentials plus MD is probably enough to swing a decent job in almost any field. Doctors are some of the most employable people out there. I just find it rediculous that were having a "poor doctors" discussion when it's the second highest paying profession in the richest country in the world. Get over it.

maxerickson 9y ago
It pays well because supply is constrained and demand is inelastic. It isn't clear how much the grueling training actually factors in to limiting the supply.
- killjoywashere 9y ago
  There are plenty of dropouts at every step. Probably the biggest drop-off is the PGY-1 year (internship). That's when you really find out if you can cope with clinical medicine. Staff physicians only want interns and residents to do the scut work they don't want to do: in house call, dis-impacting old ladies in the ER, etc. If it wasn't for the parts that suck, they would assure you they can handle the hospital without residents just fine. I suppose that's why teaching hospitals consistently deliver better care: because the staff can do everything just fine. If it wasn't for parts that suck.
kingbirdy 9y ago

josh33 9y ago

I'm a former healthcare administrator and just want to point out that many many administrators work much more than the 9-5. I'm also working at a healthcare tech startup aimed at reduced the administrative burden to doctors, administrators and insurers of managing their patients at home, which is where the worst outcomes often happen. Each segment we work with feels this burden, it is not isolated to the physicians.

Mz 9y ago
You might be interested in joining: https://groups.google.com/forum/#!forum/health-techies https://groups.google.com/forum/#!forum/health-techies

robk 9y ago

Leverage is the exact point. The problem is that due to their compassion and altruism they have no leverage. Design a system where doctors have to choose between destroying themselves and saving patients and they ethically are forced to destroy themselves. It's tragic and just as bad under socialised medicine if not worse.

kwhitefoot 9y ago

If handoff risk were inversely related to shift length then one would expect European hospitals that adhere to the EU Working Time Directive to have significantly worse outcomes than both US and UK. Is this the case? Or do they not adhere to the working time directive?

sanotehu 9y ago
We don't adhere to the EWTD. I think a UK doctor's hours are probably easier than a US doctor's but we all break the EWTD (except for some specialties like psychiatry). For example I am rostered to work an average 48 hours a week, although there are some weeks I work more, and I will often stay behind to get things done. My total hours per week is probably around 50 - and I'm in a job that isn't considered busy!