9 ms·

All of my close friends are doctors and the toll that school and residency does on the body and mind is honestly shocking. I'd want to open up the residency and

All of my close friends are doctors and the toll that school and residency does on the body and mind is honestly shocking. I'd want to open up the residency and med school programs for nothing else but to not force our young doctors into 24 hour shifts. They're treating these young doctors like it's Hell Week in a fraternity, and the main excuse you'll get from the AMA is because that's what they (the older doctors) did so all of this fanfare is a right of passage towards full membership (attending physician) which unlocks all of these riches to justify sacrificing your youth for. To me, that's a much better narrative to support increasing the number of doctors than "they get paid too much." Instead, this article reads like a con artist who is using slight-of-hand to distract you from the watch he's taking from your pocket. The trick is the doctor's salaries, but the real stealing is happening from the health insurance companies. The article mentions how many billions of dollars this "problem" impacts the Federal budget. "Billions" - it's a large number in absolute terms, but relative to the problems with our inflated military budget ($850B), it's a pittance. What I'm trying to get at is this feels like the kind of thing a propaganda outlet would do to give you a false enemy to hate. Even if the premise is grounded in truth (that US doctors are paid twice as much as everywhere else), it just feels like the wrong villain.

jseliger 9y ago
All of my close friends are doctors and the toll that school and residency does on the body and mind is honestly shocking Absolutely true: http://jakeseliger.com/2012/10/20/why-you-should-become-a-nurse-or-physicians-assistant-instead-of-a-doctor-the-underrated-perils-of-medical-school http://jakeseliger.com/2012/10/20/why-you-should-become-a-nu...
giarc 9y ago
I work in healthcare and know, and went to school with many doctors. I hear this "long hours" compliant all the time. The problem is, they all seem to assume it's someone else's problem to fix. If physicians and med students want to get rid of the 24 hour shifts during residency, well they have to make that happen internally. They drive that decision, not the patients.
0xB31B1B 9y ago
The 24 hour shifts are there because it results in a higher standard of care for patients with life threatening and time sensitive treatment schedules. If they worked in 8 hour shifts, there would be a handoff and loss of information at each shift change that resulted in worse outcomes. It’s a fairly well studied phenomenon. My SO is in med school right now and they just changed the regs from 16 hour shifts back to 24 hour shifts.
- crimsonalucard 9y ago
  But there would still be a loss of information after 24 hours. Improving quality means upping the shift to 96 hours. We should encourage doctors to not sleep as sleeping means loss of information. This totally makes sense.
  - yequalsx 9y ago
    So it's not reasonable for a person to work 96 hours. But apparently it is reasonable for 24 hours. The goal is to minimize information loss while maximizing performance. There's a tradeoff. Apparently 24 hours is a local max in this tradeoff.
  - paviva 9y ago
    Absolutely does. And that's precisely the reason why inpatients are treated by the same doctor for as long periods as is humanely possible, i.e. usually one-week stretches on call.
- carbocation 9y ago
  It's pretty widely discussed but I don't think it's as well studied as it should be. The shift from 24 to ~16 was made without much evidence, and analyses subsequently didn't support the change. An awareness that we need to study these decisions before making them has finally taken hold. To that end, trials are now ongoing that have randomized residency programs to the (shorter+more handoffs) vs (longer) shifts. Patient outcomes are obviously the most important, but measures of physician wellness would be a valuable secondary outcome.
- 9y ago
xr4ti 9y ago
Good comment. One disagreement I have is the implicit dichotomy that it's either the doctors or the insurance companies who are soaking the patients/consumers, and not both. Both the MDs and the insurance companies are rife with a number of rotten incentives and bad actors that contribute to expensive medical care without quality commensurate with costs. In fact, the entire policy debate over risk-based vs fee-for-service payment models is essentially the payers and providers arguing over who gets to rip you off.
- maxxxxx 9y ago
  You are 100% right. You can't identify a single factor that's causing high cost because all players are rotten. Insurances, doctors, hospitals, pharmaceuticals are all bad players in a system that benefits them at the expense of patients.
sliverstorm 9y ago
The whole 24hr thing seemed ridiculous to me, until I learned about the concept of continuity of care and a loved one spent a few stays in inpatient care. Now I don't really know what the answer is anymore. It sucks to be regularly handed off when you've just established some rapport with your provider and reached treatment plans, and the evidence shows it impairs outcomes. I speculate whether we could have duos who rotate with each other, rapidly trading naps and duty & working closely together, over say a 48, 72, or 96 hour period. Barring emergencies, each gets 12 hours rest a day, and from the patient perspective they function as a tag team. But, not a healthcare professional.
- paviva 9y ago
  In most services, the treating physician is rotating on a weekly basis. That's pretty much the most convenient/tolerable/safe period of continuous work, as long as you do not receive more than 2-3 calls per night. Call number is dependent on the acuity of patients' condition, and the ability of the house staff (i.e. residents on site) to manage minors problems without immediately consulting the attending by phone.
lloyd-christmas 9y ago
> They're treating these young doctors like it's Hell Week in a fraternity, and the main excuse you'll get from the AMA is because that's what they (the older doctors) did so all of this fanfare is a right of passage towards full membership (attending physician) which unlocks all of these riches to justify sacrificing your youth for. For the sake of nipping generational warfare in the bud... My father runs a oncology fellowship. There are laws that prevent them from doing to our generation what was done to them. In addition, they don't want was done to them to be done to us. It doesn't benefit patients, increases drop out rates, and (especially in my father's field) drastically increases suicide risk and physician counseling costs. My father is currently 67, working 80 hours per week. He's not protected by those laws so he ends up covering for those hours that no longer fit the old formula, which means he did it both as a youth and in his 50s and 60s. There is a ton to crucify their generation for, but I really don't think this one is it. > What I'm trying to get at is this feels like the kind of thing a propaganda outlet would do to give you a false enemy to hate Once you account for hours worked, time spent in the workforce, and debt accumulated to achieve their income, a doctor will only have a 10-20% boost in lifetime earnings compared to a UPS driver. People seem to conflate income and wealth, which is a TERRIBLE fallacy to fall into. For some personal numbers, my father's income is double mine. Once you've adjusted for the those aspects I mentioned above, I'll have earned 80% more than him in my career.
- potatote 9y ago
  > Once you account for hours worked, time spent in the workforce, and debt accumulated to achieve their income, a doctor will only have a 10-20% boost in lifetime earnings compared to a UPS driver. Do you have any reference to back that up? Not doubting it. Just curious.
  - lloyd-christmas 9y ago
    This is a fairly old source, but it demonstrates the concept. http://www.er-doctor.com/doctor_income.html http://www.er-doctor.com/doctor_income.html In case people don't bother reading it in depth, here is one of it's updated links: https://www.linkedin.com/pulse/70000-per-year-start-now-kevin-pezzi-md/ https://www.linkedin.com/pulse/70000-per-year-start-now-kevi... I ran the numbers recently and the numbers were even more grim, but I'd need to track down all my sources again. I just think the main point is that income is not the number to focus on. Wealth is the end result of the equation, and income is only one part of that.
crimsonalucard 9y ago
Why talk about reality in terms of stories and angles? Why not talk in terms of facts and truths? You speak as if it is better to blame an insurance company rather then your doctor buddies because of a narrative. Are we so weak that we can't take the truth at face value? These are the facts: 1. Doctors the US are paid more than doctors in other countries. 2. Medical care in the US is lowest in quality among most 1st world countries. There is a logical outcome from these two facts: The high bar required to enter medical school or residency does not produce better doctors. The other thing that gets me is why are we attacking insurance? Obama did it. It didn't work. You know logically if health insurance companies are all so evil, a good business startup idea would be to form a company that isn't so evil and cheap. This company will of course out compete all other insurance companies, by being the first cheap and moral insurance company! What a genius idea. Sounds really similar to obamas plan of simply using the federal government to enforce some moral principles onto the whole industry. Maybe none of this works because insurance companies are already operating on edge. To stay competitive and offer customers competitive premiums they have to screw over people asking for claims. Maybe this occurs because medical costs in the US are too high? Why are all these costs so high? Probably to payoff someones' super high salary... Look. Every medical cost in the us from insurance to hospital bills is higher than other countries. In terms of regulation the only difference between us and other 1st world countries is the supply of doctors and the supply of medicine. The united states places the most restrictive cartel policies on these two areas. All other problems in the medical world stem from these policies.
- fifteenforty 9y ago
  AFAICT, US doctors aren’t paid that much more than Australian or British doctors, yet the overall cost of health care is very different.
  - noobermin 9y ago
    The article's point is they are paid more!
    - fifteenforty 9y ago
QAPereo 9y ago
Part of the need for the higher pay is to accommodate the highest student debt in the world, and the highest risk of malpractice debt in the world.
jeffbax 9y ago
Doctors have a hard time, but you can't lower US healthcare costs without lowering the salaries of those involved (which is why it is so hard). The fact of the matter is that they are high for reasons both justifiable and other less so. Insurance companies profit margin is actually not very large on average (~11% I believe -- even worse for those in states with cost-spiraling providers post Obamacare), and while they are nobody's favorite they take a disproportionate amount of heat for what is driving up costs in healthcare. Healthcare salaries are the bulk of the costs of the healthcare industry, just like administrative & teacher salaries are the bulk in bloated education budgets (well, outside of things like waste on things like sports programs). That's just the breaks, and its important to acknowledge they are a lobbying interest group as strong as any other (actually, one of the strongest/highest spending) So, shortage of doctor supply (like with housing) really really has an impact. It also does not help that hospitals frequently have veto rights over other health institutions opening up on their turf. Really. Another problem is regulations that encourage consolidation of providers (see BCBS & Partners here in MA) further diminishing pricing ability (and this is additionally really bad for insurance companies, who have less leverage to fight back against high charges from fewer hospital networks) The fact of the matter is that the US over-spends on just about every sector of the economy because the US is richer. Richer countries also disproportionately spend on healthcare of frequently marginal benefit at best. https://www.bloomberg.com/view/articles/2017-07-20/spending-a-lot-on-health-care-is-the-american-way https://www.bloomberg.com/view/articles/2017-07-20/spending-... Not sure what the military budget has to do with this. It's a lot, but that it is bloated doesn't mean more health spending is justified or that we do not over-spend on doctors -- they aren't comparable things. Whatever sacrifice doctors make in school is what justifies the salaries, but you also have other forces at play (largely regulatory burden, or bad regulations generally) that are causing them to drop out of being a GP in the first place as they chase higher paying spots as specialists.

jseliger 9y ago

All of my close friends are doctors and the toll that school and residency does on the body and mind is honestly shocking Absolutely true: http://jakeseliger.com/2012/10/20/why-you-should-become-a-nurse-or-physicians-assistant-instead-of-a-doctor-the-underrated-perils-of-medical-school http://jakeseliger.com/2012/10/20/why-you-should-become-a-nu...

giarc 9y ago

I work in healthcare and know, and went to school with many doctors. I hear this "long hours" compliant all the time. The problem is, they all seem to assume it's someone else's problem to fix. If physicians and med students want to get rid of the 24 hour shifts during residency, well they have to make that happen internally. They drive that decision, not the patients.

0xB31B1B 9y ago

The 24 hour shifts are there because it results in a higher standard of care for patients with life threatening and time sensitive treatment schedules. If they worked in 8 hour shifts, there would be a handoff and loss of information at each shift change that resulted in worse outcomes. It’s a fairly well studied phenomenon. My SO is in med school right now and they just changed the regs from 16 hour shifts back to 24 hour shifts.

crimsonalucard 9y ago
But there would still be a loss of information after 24 hours. Improving quality means upping the shift to 96 hours. We should encourage doctors to not sleep as sleeping means loss of information. This totally makes sense.
- yequalsx 9y ago
  So it's not reasonable for a person to work 96 hours. But apparently it is reasonable for 24 hours. The goal is to minimize information loss while maximizing performance. There's a tradeoff. Apparently 24 hours is a local max in this tradeoff.
- paviva 9y ago
  Absolutely does. And that's precisely the reason why inpatients are treated by the same doctor for as long periods as is humanely possible, i.e. usually one-week stretches on call.
carbocation 9y ago
It's pretty widely discussed but I don't think it's as well studied as it should be. The shift from 24 to ~16 was made without much evidence, and analyses subsequently didn't support the change. An awareness that we need to study these decisions before making them has finally taken hold. To that end, trials are now ongoing that have randomized residency programs to the (shorter+more handoffs) vs (longer) shifts. Patient outcomes are obviously the most important, but measures of physician wellness would be a valuable secondary outcome.
9y ago

xr4ti 9y ago

Good comment. One disagreement I have is the implicit dichotomy that it's either the doctors or the insurance companies who are soaking the patients/consumers, and not both. Both the MDs and the insurance companies are rife with a number of rotten incentives and bad actors that contribute to expensive medical care without quality commensurate with costs. In fact, the entire policy debate over risk-based vs fee-for-service payment models is essentially the payers and providers arguing over who gets to rip you off.

maxxxxx 9y ago
You are 100% right. You can't identify a single factor that's causing high cost because all players are rotten. Insurances, doctors, hospitals, pharmaceuticals are all bad players in a system that benefits them at the expense of patients.

sliverstorm 9y ago

The whole 24hr thing seemed ridiculous to me, until I learned about the concept of continuity of care and a loved one spent a few stays in inpatient care. Now I don't really know what the answer is anymore. It sucks to be regularly handed off when you've just established some rapport with your provider and reached treatment plans, and the evidence shows it impairs outcomes. I speculate whether we could have duos who rotate with each other, rapidly trading naps and duty & working closely together, over say a 48, 72, or 96 hour period. Barring emergencies, each gets 12 hours rest a day, and from the patient perspective they function as a tag team. But, not a healthcare professional.

paviva 9y ago
In most services, the treating physician is rotating on a weekly basis. That's pretty much the most convenient/tolerable/safe period of continuous work, as long as you do not receive more than 2-3 calls per night. Call number is dependent on the acuity of patients' condition, and the ability of the house staff (i.e. residents on site) to manage minors problems without immediately consulting the attending by phone.

lloyd-christmas 9y ago

> They're treating these young doctors like it's Hell Week in a fraternity, and the main excuse you'll get from the AMA is because that's what they (the older doctors) did so all of this fanfare is a right of passage towards full membership (attending physician) which unlocks all of these riches to justify sacrificing your youth for. For the sake of nipping generational warfare in the bud... My father runs a oncology fellowship. There are laws that prevent them from doing to our generation what was done to them. In addition, they don't want was done to them to be done to us. It doesn't benefit patients, increases drop out rates, and (especially in my father's field) drastically increases suicide risk and physician counseling costs. My father is currently 67, working 80 hours per week. He's not protected by those laws so he ends up covering for those hours that no longer fit the old formula, which means he did it both as a youth and in his 50s and 60s. There is a ton to crucify their generation for, but I really don't think this one is it. > What I'm trying to get at is this feels like the kind of thing a propaganda outlet would do to give you a false enemy to hate Once you account for hours worked, time spent in the workforce, and debt accumulated to achieve their income, a doctor will only have a 10-20% boost in lifetime earnings compared to a UPS driver. People seem to conflate income and wealth, which is a TERRIBLE fallacy to fall into. For some personal numbers, my father's income is double mine. Once you've adjusted for the those aspects I mentioned above, I'll have earned 80% more than him in my career.

potatote 9y ago
> Once you account for hours worked, time spent in the workforce, and debt accumulated to achieve their income, a doctor will only have a 10-20% boost in lifetime earnings compared to a UPS driver. Do you have any reference to back that up? Not doubting it. Just curious.
- lloyd-christmas 9y ago
  This is a fairly old source, but it demonstrates the concept. http://www.er-doctor.com/doctor_income.html http://www.er-doctor.com/doctor_income.html In case people don't bother reading it in depth, here is one of it's updated links: https://www.linkedin.com/pulse/70000-per-year-start-now-kevin-pezzi-md/ https://www.linkedin.com/pulse/70000-per-year-start-now-kevi... I ran the numbers recently and the numbers were even more grim, but I'd need to track down all my sources again. I just think the main point is that income is not the number to focus on. Wealth is the end result of the equation, and income is only one part of that.

crimsonalucard 9y ago

Why talk about reality in terms of stories and angles? Why not talk in terms of facts and truths? You speak as if it is better to blame an insurance company rather then your doctor buddies because of a narrative. Are we so weak that we can't take the truth at face value? These are the facts: 1. Doctors the US are paid more than doctors in other countries. 2. Medical care in the US is lowest in quality among most 1st world countries. There is a logical outcome from these two facts: The high bar required to enter medical school or residency does not produce better doctors. The other thing that gets me is why are we attacking insurance? Obama did it. It didn't work. You know logically if health insurance companies are all so evil, a good business startup idea would be to form a company that isn't so evil and cheap. This company will of course out compete all other insurance companies, by being the first cheap and moral insurance company! What a genius idea. Sounds really similar to obamas plan of simply using the federal government to enforce some moral principles onto the whole industry. Maybe none of this works because insurance companies are already operating on edge. To stay competitive and offer customers competitive premiums they have to screw over people asking for claims. Maybe this occurs because medical costs in the US are too high? Why are all these costs so high? Probably to payoff someones' super high salary... Look. Every medical cost in the us from insurance to hospital bills is higher than other countries. In terms of regulation the only difference between us and other 1st world countries is the supply of doctors and the supply of medicine. The united states places the most restrictive cartel policies on these two areas. All other problems in the medical world stem from these policies.

fifteenforty 9y ago
AFAICT, US doctors aren’t paid that much more than Australian or British doctors, yet the overall cost of health care is very different.
- noobermin 9y ago
  The article's point is they are paid more!
  - fifteenforty 9y ago

QAPereo 9y ago

Part of the need for the higher pay is to accommodate the highest student debt in the world, and the highest risk of malpractice debt in the world.

jeffbax 9y ago

Doctors have a hard time, but you can't lower US healthcare costs without lowering the salaries of those involved (which is why it is so hard). The fact of the matter is that they are high for reasons both justifiable and other less so. Insurance companies profit margin is actually not very large on average (~11% I believe -- even worse for those in states with cost-spiraling providers post Obamacare), and while they are nobody's favorite they take a disproportionate amount of heat for what is driving up costs in healthcare. Healthcare salaries are the bulk of the costs of the healthcare industry, just like administrative & teacher salaries are the bulk in bloated education budgets (well, outside of things like waste on things like sports programs). That's just the breaks, and its important to acknowledge they are a lobbying interest group as strong as any other (actually, one of the strongest/highest spending) So, shortage of doctor supply (like with housing) really really has an impact. It also does not help that hospitals frequently have veto rights over other health institutions opening up on their turf. Really. Another problem is regulations that encourage consolidation of providers (see BCBS & Partners here in MA) further diminishing pricing ability (and this is additionally really bad for insurance companies, who have less leverage to fight back against high charges from fewer hospital networks) The fact of the matter is that the US over-spends on just about every sector of the economy because the US is richer. Richer countries also disproportionately spend on healthcare of frequently marginal benefit at best. https://www.bloomberg.com/view/articles/2017-07-20/spending-a-lot-on-health-care-is-the-american-way https://www.bloomberg.com/view/articles/2017-07-20/spending-... Not sure what the military budget has to do with this. It's a lot, but that it is bloated doesn't mean more health spending is justified or that we do not over-spend on doctors -- they aren't comparable things. Whatever sacrifice doctors make in school is what justifies the salaries, but you also have other forces at play (largely regulatory burden, or bad regulations generally) that are causing them to drop out of being a GP in the first place as they chase higher paying spots as specialists.