11 ms·

I have a hard time rectifying the claim that you are a health economist with the fact that you don’t appear to understand that the bottleneck for increasing the

by syki 5y ago

I have a hard time rectifying the claim that you are a health economist with the fact that you don’t appear to understand that the bottleneck for increasing the supply of doctors is the number of residency slots. Foreign medical school certifications are largely accepted at face value but graduating a foreign residency program largely is not. I think it’s pretty much universal that each country wants doctors to go through their own version of residency. My wife is a physician. She needs a large salary to pay off her large medical debt. When the medical debt is paid off her salary will still be large. A much more sensible system would to make medical school free so that the salaries don’t have to start off so high. There are people with hundreds of thousands in med school debt who didn’t match. We should feel sorry for those people.

allcentury 5y ago
The limit of residency slots is in the article. > A much more sensible system would to make medical school free so that the salaries don’t have to start off so high. That's not how any labor market works. Your salary isn't determined by how much debt you rack up. Doctor's salary's are high because the supply of doctor's is so low (especially primary care). The article covers all the points you're debating (much better than I).
- lupire 5y ago
  Primary care is a low paying job because nurses and PAs can provide primary care.
- N1H1L 5y ago
  > That's not how any labor market works. Your salary isn't determined by how much debt you rack up. True, or else college dropouts from a private school will have higher incomes than a state school undergrad, which is not the case at all.
- syki 5y ago
  My response was about the claim that OP is a health economist while not understanding where the bottleneck in the supply for doctors comes from. I believe you are incorrect as it pertains to doctor salaries. Demand is high and supply relatively low. That is true but this isn’t the only factor that goes into determining pay. That’s an overly simplistic view of things. Supply/demand does not account for everything in this situation. If med students came out of med school with zero debt then the healthcare industry could make being a doctor sufficiently lucrative with salaries that are smaller than they currently are. Lowering the salary a bit in this scenario would not lower supply. You should read about David Carr’s work.
  - CogitoCogito 5y ago
    I believe you have it backwards. The high salaries increase the levels of debt potential doctors consider acceptable.
  - vsskanth 5y ago
    I don't agree the cost of university is driving the salaries here. It's all about how many doctors are available to meet demand. If there are less, it's going to drive up salaries. There are other countries where the cost of getting a degree in a certain specialty is very low due to state subsidies but the salaries are very high once they graduate since they are scarce.
    - syki 5y ago
      In countries with mostly free higher education doctor’s salaries are less on average than in the U.S. You really think having several hundred thousand dollars in student loans doesn’t in any way affect salaries?
      - huitzitziltzin 5y ago
        There are important differences in most of those countries including (importantly!) direct government regulation of prices, including salaries in the medical market. British doctors, for example, work under a contract negotiated between a British version of the AMA and the British government. The government and the providers both have leverage, but the British government is the primary purchaser of services in that country. Salaries are lower since the government exerts pressure on them, as they are paid for out of direct taxation. I understand that you feel very strongly that student debt for doctors is unjustifiable or too high or something. Student debt is not the main driver (or even a driver) of high salaries among US doctors. The level of their student debt is a completely separate topic.
        syki 5y ago
        There are private doctors in Canada and the UK and they don’t make as much as their American counterparts. Anecdotal evidence. My wife has $400,000 in med school debt. She needs a $300,000 salary to afford paying that debt off whilst also maintaining a “good” lifestyle. Med school, residency, etc. were hard and sacrifices were made to go through them. It would not be worth it to go through that without a reasonably high salary. She’d gladly have gone through the process for a $200,000 a year job. It is certainly the case that highly motivated, highly intelligent people take into account the ability to service med school debt when deciding to become a doctor vs. another going into another field. It is obvious that high med school debt has an effect on the salary needed to attract talent. David Carr won the Nobel Prize in part for his work questioning the traditional supply/demand view of labor economics. Here is a link to an interesting (to me) paper. https://www.jstor.org/stable/24695058 https://www.jstor.org/stable/24695058
strikelaserclaw 5y ago
To be perfectly honest, i have found primary care doctors pretty useless in the last 5 - 10 years, not only did i find that their answers were things i could easily find on google, i also noticed that most of them didn't actually care about patient well being. It seems like most doctors these days are only in it for the money, which is fine if they are actually providing a valuable service, but low level doctors are nothing more than glorified drug dealers at this point.
- thfuran 5y ago
  A doctor in it for the money is pretty unlikely to go into primary care.
  - strikelaserclaw 5y ago
    They usually set up their own clinic and rake it in, tons of primary care doctors i know did this.
- namelessoracle 5y ago
  This is sadly true. There is basically no value in a general medicine doctor that i can see. General health issues can be handled by a nurse practitioner, they can see if you have an ear infection, are sick with the flu, and proscribe you the antibiotics, or other controlled medicines just fine. They could easily switch to a model where the General Medicine doctor acts as like the staff engineer over the senior devs, and just does a quick plus one on their results and makes sure no mistakes were made. (this is how most doctors visits play out anyways) When there IS something seriously wrong, they almost always send you to a specialist who can actually treat your specific issue. Have a really bad ear infection / something is lodged in your ear? Here is the ENT referral! Pay me for telling you to go see the ear doctor when you had ear problems.
  - kashunstva 5y ago
    Former general internist here. I obviously have opinions about the assertion that generalists provide no incremental value. The model you posit, wherein a generalist oversees a panel of NP’s and PA’s is already common. Many primary care problems can be handled in this way. No disagreement. But there is a host of multi-systemic disorders that most mid-level practitioners would never recognize. And do you think most subspecialists are interested, aside from the occasional rheumatologist, in comprehensive management of the protean manifestations of most of these types of disorders. This coordination of care for complex disorders has to be done by someone. And for the sake of the patient I hope it’s someone with a solid command of pathology, physiology, pharmacology and so forth. And maybe someone with the time and empathy to talk to actual humans. If you think coordination of care is handing out referrals, that’s a massively reductionist view.
huitzitziltzin 5y ago
> I have a hard rectifying the claim that you are a health economist with the fact that you don’t appear to understand ... Don't tell my PhD thesis adviser, I guess? He could have sworn he approved a dissertation about health economics but you've uncovered my secret, or something? (And what was I working on for all that time then? It was years of my life! Apparently nothing?!?) > the bottleneck for increasing the supply of doctors is the number of residency slots. No, _you_ are misunderstanding what change I want. There is no reason at all for a German, Mexican, British, etc. practicing doctor to have to do a US residency at all after they finish whatever training qualifies them to be a doctor in their home countries. Read the article again. US medical education takes much longer than medical education almost anywhere else in the world, yet our outcomes are almost always worse along nearly any measurable dimension. You will say: "yeah, but that's the result of many factors!" Great - I agree. But in that case it really isn't obvious that the extra years of medical education in the US do a lot for patient outcomes. In fact, not only do I want more residency slots in the US, I want to reconsider that whole residency system, especially for doctors trained abroad. > I think it’s pretty much universal that each country wants doctors to go through their own version of residency. Why? That's a big part of the problem. There is literally no reason in the world for a German doctor who has been practicing there for a few years to have to come here and do a residency again. It makes no sense. You wouldn't do it for a C programmer, right? Example: "Sorry - you learned C in Germany. If you want to program here, you'll have to get a four-year degree in CS again." This obviously makes no sense. C is (ideally) the same language wherever it is written. And yet, while you have the same number of kidneys as a German and the same nervous system as Russian ... are you seeing the point I'm trying to make? Why require years of extra training for a doctor from one of those countries to work here? That keeps them out of our market and keeps prices high. > A much more sensible system would to make medical school free so that the salaries don’t have to start off so high. Let me pull out my economist card again and say: "this is not how that works." Salaries are not high because medical school is expensive. Salaries are high because supply is restricted. That's how supply and demand work.
- syki 5y ago
  There is no reason at all for a German, Mexican, British, etc. practicing doctor to have to do a US residency at all after they finish whatever training qualifies them to be a doctor in their home countries. You should have stated it this way. In your original post you referenced medical school and that gave the impression that you aren’t aware of the credentialing process to becoming a licensed physician. You had written: There is no reason why Mexican, Canadian, British, Indian, German, ... doctors should not be allowed to come and practice in the US with more than some cursory verification that they actually attended a medical school where they are from. There is actually a valid reason to make it hard for doctors to move from one country to another. Training doctors is time consuming and expensive. There is a moral aspect to luring doctors trained in poor countries to rich countries. David Carr would like a word with you regarding your belief that supply/demand alone accounts for the pay of doctors. The supply would not go down if med school was free but starting salaries were x% what they currently are. The experiments have been run. Countries with mostly free higher education have lower doctor pay than the U.S.

by syki 5y ago

allcentury 5y ago

The limit of residency slots is in the article. > A much more sensible system would to make medical school free so that the salaries don’t have to start off so high. That's not how any labor market works. Your salary isn't determined by how much debt you rack up. Doctor's salary's are high because the supply of doctor's is so low (especially primary care). The article covers all the points you're debating (much better than I).

lupire 5y ago
Primary care is a low paying job because nurses and PAs can provide primary care.
N1H1L 5y ago
> That's not how any labor market works. Your salary isn't determined by how much debt you rack up. True, or else college dropouts from a private school will have higher incomes than a state school undergrad, which is not the case at all.
syki 5y ago
My response was about the claim that OP is a health economist while not understanding where the bottleneck in the supply for doctors comes from. I believe you are incorrect as it pertains to doctor salaries. Demand is high and supply relatively low. That is true but this isn’t the only factor that goes into determining pay. That’s an overly simplistic view of things. Supply/demand does not account for everything in this situation. If med students came out of med school with zero debt then the healthcare industry could make being a doctor sufficiently lucrative with salaries that are smaller than they currently are. Lowering the salary a bit in this scenario would not lower supply. You should read about David Carr’s work.
- CogitoCogito 5y ago
  I believe you have it backwards. The high salaries increase the levels of debt potential doctors consider acceptable.
- vsskanth 5y ago
  I don't agree the cost of university is driving the salaries here. It's all about how many doctors are available to meet demand. If there are less, it's going to drive up salaries. There are other countries where the cost of getting a degree in a certain specialty is very low due to state subsidies but the salaries are very high once they graduate since they are scarce.
  - syki 5y ago
    In countries with mostly free higher education doctor’s salaries are less on average than in the U.S. You really think having several hundred thousand dollars in student loans doesn’t in any way affect salaries?
    - huitzitziltzin 5y ago
      There are important differences in most of those countries including (importantly!) direct government regulation of prices, including salaries in the medical market. British doctors, for example, work under a contract negotiated between a British version of the AMA and the British government. The government and the providers both have leverage, but the British government is the primary purchaser of services in that country. Salaries are lower since the government exerts pressure on them, as they are paid for out of direct taxation. I understand that you feel very strongly that student debt for doctors is unjustifiable or too high or something. Student debt is not the main driver (or even a driver) of high salaries among US doctors. The level of their student debt is a completely separate topic.
      - syki 5y ago
        There are private doctors in Canada and the UK and they don’t make as much as their American counterparts. Anecdotal evidence. My wife has $400,000 in med school debt. She needs a $300,000 salary to afford paying that debt off whilst also maintaining a “good” lifestyle. Med school, residency, etc. were hard and sacrifices were made to go through them. It would not be worth it to go through that without a reasonably high salary. She’d gladly have gone through the process for a $200,000 a year job. It is certainly the case that highly motivated, highly intelligent people take into account the ability to service med school debt when deciding to become a doctor vs. another going into another field. It is obvious that high med school debt has an effect on the salary needed to attract talent. David Carr won the Nobel Prize in part for his work questioning the traditional supply/demand view of labor economics. Here is a link to an interesting (to me) paper. https://www.jstor.org/stable/24695058 https://www.jstor.org/stable/24695058

strikelaserclaw 5y ago

To be perfectly honest, i have found primary care doctors pretty useless in the last 5 - 10 years, not only did i find that their answers were things i could easily find on google, i also noticed that most of them didn't actually care about patient well being. It seems like most doctors these days are only in it for the money, which is fine if they are actually providing a valuable service, but low level doctors are nothing more than glorified drug dealers at this point.

thfuran 5y ago
A doctor in it for the money is pretty unlikely to go into primary care.
- strikelaserclaw 5y ago
  They usually set up their own clinic and rake it in, tons of primary care doctors i know did this.
namelessoracle 5y ago
This is sadly true. There is basically no value in a general medicine doctor that i can see. General health issues can be handled by a nurse practitioner, they can see if you have an ear infection, are sick with the flu, and proscribe you the antibiotics, or other controlled medicines just fine. They could easily switch to a model where the General Medicine doctor acts as like the staff engineer over the senior devs, and just does a quick plus one on their results and makes sure no mistakes were made. (this is how most doctors visits play out anyways) When there IS something seriously wrong, they almost always send you to a specialist who can actually treat your specific issue. Have a really bad ear infection / something is lodged in your ear? Here is the ENT referral! Pay me for telling you to go see the ear doctor when you had ear problems.
- kashunstva 5y ago
  Former general internist here. I obviously have opinions about the assertion that generalists provide no incremental value. The model you posit, wherein a generalist oversees a panel of NP’s and PA’s is already common. Many primary care problems can be handled in this way. No disagreement. But there is a host of multi-systemic disorders that most mid-level practitioners would never recognize. And do you think most subspecialists are interested, aside from the occasional rheumatologist, in comprehensive management of the protean manifestations of most of these types of disorders. This coordination of care for complex disorders has to be done by someone. And for the sake of the patient I hope it’s someone with a solid command of pathology, physiology, pharmacology and so forth. And maybe someone with the time and empathy to talk to actual humans. If you think coordination of care is handing out referrals, that’s a massively reductionist view.

huitzitziltzin 5y ago

> I have a hard rectifying the claim that you are a health economist with the fact that you don’t appear to understand ... Don't tell my PhD thesis adviser, I guess? He could have sworn he approved a dissertation about health economics but you've uncovered my secret, or something? (And what was I working on for all that time then? It was years of my life! Apparently nothing?!?) > the bottleneck for increasing the supply of doctors is the number of residency slots. No, _you_ are misunderstanding what change I want. There is no reason at all for a German, Mexican, British, etc. practicing doctor to have to do a US residency at all after they finish whatever training qualifies them to be a doctor in their home countries. Read the article again. US medical education takes much longer than medical education almost anywhere else in the world, yet our outcomes are almost always worse along nearly any measurable dimension. You will say: "yeah, but that's the result of many factors!" Great - I agree. But in that case it really isn't obvious that the extra years of medical education in the US do a lot for patient outcomes. In fact, not only do I want more residency slots in the US, I want to reconsider that whole residency system, especially for doctors trained abroad. > I think it’s pretty much universal that each country wants doctors to go through their own version of residency. Why? That's a big part of the problem. There is literally no reason in the world for a German doctor who has been practicing there for a few years to have to come here and do a residency again. It makes no sense. You wouldn't do it for a C programmer, right? Example: "Sorry - you learned C in Germany. If you want to program here, you'll have to get a four-year degree in CS again." This obviously makes no sense. C is (ideally) the same language wherever it is written. And yet, while you have the same number of kidneys as a German and the same nervous system as Russian ... are you seeing the point I'm trying to make? Why require years of extra training for a doctor from one of those countries to work here? That keeps them out of our market and keeps prices high. > A much more sensible system would to make medical school free so that the salaries don’t have to start off so high. Let me pull out my economist card again and say: "this is not how that works." Salaries are not high because medical school is expensive. Salaries are high because supply is restricted. That's how supply and demand work.

syki 5y ago
There is no reason at all for a German, Mexican, British, etc. practicing doctor to have to do a US residency at all after they finish whatever training qualifies them to be a doctor in their home countries. You should have stated it this way. In your original post you referenced medical school and that gave the impression that you aren’t aware of the credentialing process to becoming a licensed physician. You had written: There is no reason why Mexican, Canadian, British, Indian, German, ... doctors should not be allowed to come and practice in the US with more than some cursory verification that they actually attended a medical school where they are from. There is actually a valid reason to make it hard for doctors to move from one country to another. Training doctors is time consuming and expensive. There is a moral aspect to luring doctors trained in poor countries to rich countries. David Carr would like a word with you regarding your belief that supply/demand alone accounts for the pay of doctors. The supply would not go down if med school was free but starting salaries were x% what they currently are. The experiments have been run. Countries with mostly free higher education have lower doctor pay than the U.S.