5 ms·

We already have an excess of medical schools. We have a shortage of residency training spots; we have med students every year that are stuck as non-practicing p

We already have an excess of medical schools. We have a shortage of residency training spots; we have med students every year that are stuck as non-practicing physicians because of this. Residency training spots are, while not a snap of the fingers to increase, not difficult - if congress was willing to actually legislate the increase in funding, as it comes through CMS.

treis 6y ago
There's no real reason for the government to be funding residency slots. Residents are profitable for hospitals and the slots are objectively valuable things. Hahnemann Hospital shut down and auctioned off their residency slots for 1 million per slot. In other words, the right to hire a resident and collect their subsidy is worth 1 million dollars. The government is a convenient scapegoat to protect a system that restricts the supply of doctors to maintain their wages.
- space_fountain 6y ago
  What is the system then? Do hospitals being made out of doctors not want to do it? Is the bottle neck actually at a different stage?
  - treis 6y ago
    To put it in tech terms, imagine if the FAANGs + 20 other big software companies had universities. Along comes the government and says that the only way for you to be a programmer is to work at one of these companies for 3-7 years. Oh yeah, and the FAANGs et.al. have an anti-trust exemption that allows them to collude on wages/benefits. Pretty clear why that system gets abused. The result is that doctors have to pay 50k+ tuition for 4 years and then get paid (relatively) crap wages for 3-7. After that, they make bank because of how hard it is to become a doctor. Existing doctors have been all to happy to pull the ladder up behind them. They continue to make it harder and harder to become a doctor by extending the training time. As a recent example, to work in a pediatric hospital now requires an addition two years time as a fellow. Of course, no current pediatrician is going to be required to do more training. Just anyone that wants to enter the field and compete now has to accept an additional two years of lower wages. The linchpin holding this all together is the government license requirements for doctors. Take that away and it all crumbles.
- trhway 6y ago
  So a hospital has to pay a 1M per slot - sounds surprisingly similar to NYC medallions right before Uber. Artificial scarcity.
- nathanvanfleet 6y ago
  Wait didn't you say the slots are worth a million dollars _because_ of the subsidy? But that it shouldn't be subsidized because it's profitable?
  - tgb 6y ago
    Presumably most of the subsidy goes toward paying the resident, so most of the value to the hospital of the residency is the work done by the resident.
    - nathanvanfleet 6y ago
      Nice to know there is someone out there willing to make all presumption
    - omgwtfbyobbq 6y ago
      Some of it does, but most of it does not. I believe most residents make something like $50k-$60k/year, and work ~60-80 hour weeks. https://www.reddit.com/r/Residency/comments/hdx3gw/no_laughing_matter_clowns_make_more_than_us/ https://www.reddit.com/r/Residency/comments/hdx3gw/no_laughi...
      - programmertote 6y ago
        Can confirm this comment. Residents earn ~60-70K/year (usually close to 60K) and work ~60-65 hours/week (not 80 hours/week; there's a bit of exaggeration in that number). My wife is a current US medical resident and we have a lot of friends who are at various US residency programs.
      - tgb 6y ago
        Yes but how much is the subsidy and how much goes towards expenses the hospital only has due to the resident? For example the subsidy also covers the resident's malpractice insurance but the hospital isn't profiting from that. It also looks like there is the IME, a system where all Medicare payments are increased proportional to the number of residents intended to cover the extra work and expenses of training residents. So it's a rather thorny question and probably depends on the hospital (how many Medicare patients they have, etc). I imagine it's like NIH grants where the overhead is like 40% - substantial but I think the work done by the residents is likely to be a significant fraction of the value.
- deleted 6y ago
  [deleted]
- programmertote 6y ago
  100% this. If the hospitals are desperate to increase the supply of doctors in the states (US), they can easily fund the residency spots themselves. They pay ~60-70K USD/year for each resident for three years anyway. Those residents do most of the grunt work that more senior doctors (like attendings and hospitalists) in the hospital don't want to do. In comparison, generalist attendings and hospitalists (full-blown doctors) at hospitals earn salaries in the range of 210-250K USD/year easily. To become a full-blown doctor in the US, one has to jump too many hoops and hurdles including -- 1. maintaining 3.8+ GPA (out of 4.0 max) in undergrad while paying overpriced college tuition (which encourages students to take relatively easy course load other than the required ones like organic chemistry, biochem, a couple of basic math and physics classes, etc.); 2. pay yet another loads of money to attend med school, which is where you actually begin to learn something relatively useful; 3. volunteer unpaid at various research and/or healthcare institutions to beef up one's resume (which is only affordable/possible if you are well-connected and/or have money to volunteer); 4. pay exorbitant and unnecessary exams (each 8-9 hours long spanning sometimes 2 days for Step 3 USMLE: https://www.princetonreview.com/med-school-advice/usmle https://www.princetonreview.com/med-school-advice/usmle) that promotes rote learning (and you forget what you memorized ~2 months after the exam anyway); 5. pay a lot of money to apply for residency programs while footing the bill (hotels and air travels) yourself to go around the country for residency interviews; 6. spend 3 years (minimum) in residency while spending ~60+ hours per week in your first year doing the grunt work that no senior doctors want to do (e.g., night shifts/floats) 7. maybe spend another 2+ years in fellowships if you want to be a specialist In contrast, one just need to do these in my home country to become a doctor (I know India has a very similar system to train their doctors): 1. get a high score in national standardized/matriculate exam (in my country, ~5% of top students have option to go to medical school) to get into public medical schools (there are four of them and three of them are definitely pretty good) 2. spend 5 years studying medicine (to be honest, they can cut out the first year if they want to, but it's still better than spending 4 years as undergrad in the US) 3. spend another 2 years as a rotational intern at major government hospitals (OBGYN, Surgery, Child, etc.) doing what the residents in the US system do [from what I've been told, those 2 years are certainly more demanding than the residency years in the US system] 4. take masters degree to specialize (takes ~3-4 years) The quality of the doctors produced by these two aforementioned systems is not that different. How do I know this? My wife (foreign medical graduate) is a current medical resident at a US hospital and we have a lot of friends in the US residency programs, some of whom are foreign medical graduates. In order for them to get into these residencies as foreign graduates, they have to score on average better than their US counterparts (on top of having to work pretty hard to gain experience in the US because 99% of hospitals/medical institutions in the US don't allow volunteers/externs/interns unless one is trained from the US pipeline and is a citizen). So the question is why is the path to becoming a doctor in the US needs to be paved with so much expenses and hurdles? Who established this path? I'll close my long rant with what my wife recently told me after spending a year as a medical resident in the US, (I'm paraphrasing her a bit here) "I don't want to be a patient in the US hospital when I'm old. We need to go to somewhere like Singapore for treatment (she worked at a hospital in Singapore for a bit before coming to the US)."

treis 6y ago

There's no real reason for the government to be funding residency slots. Residents are profitable for hospitals and the slots are objectively valuable things. Hahnemann Hospital shut down and auctioned off their residency slots for 1 million per slot. In other words, the right to hire a resident and collect their subsidy is worth 1 million dollars. The government is a convenient scapegoat to protect a system that restricts the supply of doctors to maintain their wages.

space_fountain 6y ago
What is the system then? Do hospitals being made out of doctors not want to do it? Is the bottle neck actually at a different stage?
- treis 6y ago
  To put it in tech terms, imagine if the FAANGs + 20 other big software companies had universities. Along comes the government and says that the only way for you to be a programmer is to work at one of these companies for 3-7 years. Oh yeah, and the FAANGs et.al. have an anti-trust exemption that allows them to collude on wages/benefits. Pretty clear why that system gets abused. The result is that doctors have to pay 50k+ tuition for 4 years and then get paid (relatively) crap wages for 3-7. After that, they make bank because of how hard it is to become a doctor. Existing doctors have been all to happy to pull the ladder up behind them. They continue to make it harder and harder to become a doctor by extending the training time. As a recent example, to work in a pediatric hospital now requires an addition two years time as a fellow. Of course, no current pediatrician is going to be required to do more training. Just anyone that wants to enter the field and compete now has to accept an additional two years of lower wages. The linchpin holding this all together is the government license requirements for doctors. Take that away and it all crumbles.
trhway 6y ago
So a hospital has to pay a 1M per slot - sounds surprisingly similar to NYC medallions right before Uber. Artificial scarcity.
nathanvanfleet 6y ago
Wait didn't you say the slots are worth a million dollars _because_ of the subsidy? But that it shouldn't be subsidized because it's profitable?
- tgb 6y ago
  Presumably most of the subsidy goes toward paying the resident, so most of the value to the hospital of the residency is the work done by the resident.
  - nathanvanfleet 6y ago
    Nice to know there is someone out there willing to make all presumption
  - omgwtfbyobbq 6y ago
    Some of it does, but most of it does not. I believe most residents make something like $50k-$60k/year, and work ~60-80 hour weeks. https://www.reddit.com/r/Residency/comments/hdx3gw/no_laughing_matter_clowns_make_more_than_us/ https://www.reddit.com/r/Residency/comments/hdx3gw/no_laughi...
    - programmertote 6y ago
      Can confirm this comment. Residents earn ~60-70K/year (usually close to 60K) and work ~60-65 hours/week (not 80 hours/week; there's a bit of exaggeration in that number). My wife is a current US medical resident and we have a lot of friends who are at various US residency programs.
    - tgb 6y ago
      Yes but how much is the subsidy and how much goes towards expenses the hospital only has due to the resident? For example the subsidy also covers the resident's malpractice insurance but the hospital isn't profiting from that. It also looks like there is the IME, a system where all Medicare payments are increased proportional to the number of residents intended to cover the extra work and expenses of training residents. So it's a rather thorny question and probably depends on the hospital (how many Medicare patients they have, etc). I imagine it's like NIH grants where the overhead is like 40% - substantial but I think the work done by the residents is likely to be a significant fraction of the value.
deleted 6y ago
[deleted]
programmertote 6y ago
100% this. If the hospitals are desperate to increase the supply of doctors in the states (US), they can easily fund the residency spots themselves. They pay ~60-70K USD/year for each resident for three years anyway. Those residents do most of the grunt work that more senior doctors (like attendings and hospitalists) in the hospital don't want to do. In comparison, generalist attendings and hospitalists (full-blown doctors) at hospitals earn salaries in the range of 210-250K USD/year easily. To become a full-blown doctor in the US, one has to jump too many hoops and hurdles including -- 1. maintaining 3.8+ GPA (out of 4.0 max) in undergrad while paying overpriced college tuition (which encourages students to take relatively easy course load other than the required ones like organic chemistry, biochem, a couple of basic math and physics classes, etc.); 2. pay yet another loads of money to attend med school, which is where you actually begin to learn something relatively useful; 3. volunteer unpaid at various research and/or healthcare institutions to beef up one's resume (which is only affordable/possible if you are well-connected and/or have money to volunteer); 4. pay exorbitant and unnecessary exams (each 8-9 hours long spanning sometimes 2 days for Step 3 USMLE: https://www.princetonreview.com/med-school-advice/usmle https://www.princetonreview.com/med-school-advice/usmle) that promotes rote learning (and you forget what you memorized ~2 months after the exam anyway); 5. pay a lot of money to apply for residency programs while footing the bill (hotels and air travels) yourself to go around the country for residency interviews; 6. spend 3 years (minimum) in residency while spending ~60+ hours per week in your first year doing the grunt work that no senior doctors want to do (e.g., night shifts/floats) 7. maybe spend another 2+ years in fellowships if you want to be a specialist In contrast, one just need to do these in my home country to become a doctor (I know India has a very similar system to train their doctors): 1. get a high score in national standardized/matriculate exam (in my country, ~5% of top students have option to go to medical school) to get into public medical schools (there are four of them and three of them are definitely pretty good) 2. spend 5 years studying medicine (to be honest, they can cut out the first year if they want to, but it's still better than spending 4 years as undergrad in the US) 3. spend another 2 years as a rotational intern at major government hospitals (OBGYN, Surgery, Child, etc.) doing what the residents in the US system do [from what I've been told, those 2 years are certainly more demanding than the residency years in the US system] 4. take masters degree to specialize (takes ~3-4 years) The quality of the doctors produced by these two aforementioned systems is not that different. How do I know this? My wife (foreign medical graduate) is a current medical resident at a US hospital and we have a lot of friends in the US residency programs, some of whom are foreign medical graduates. In order for them to get into these residencies as foreign graduates, they have to score on average better than their US counterparts (on top of having to work pretty hard to gain experience in the US because 99% of hospitals/medical institutions in the US don't allow volunteers/externs/interns unless one is trained from the US pipeline and is a citizen). So the question is why is the path to becoming a doctor in the US needs to be paved with so much expenses and hurdles? Who established this path? I'll close my long rant with what my wife recently told me after spending a year as a medical resident in the US, (I'm paraphrasing her a bit here) "I don't want to be a patient in the US hospital when I'm old. We need to go to somewhere like Singapore for treatment (she worked at a hospital in Singapore for a bit before coming to the US)."