Throwaway05
6mo ago
Hah! Thank you, that's just what I was theorizing in the other thread line.
Throwaway05
6mo ago
The supply of doctors in the US is artificially constrained which means you can increase the supply of doctors while lowering salaries.
Putting aside whether this is true or not the whole point of my post is that it doesn't matter since doctor salaries aren't the problem.
Why can't you change jobs? Every doctor in my family has done so at least once. Don't many doctors work for themselves at their own clinics?
You can't change your job or choose where you live during residency (and to a less extent medical school). 7-11+ years.
Throwaway05
6mo ago
I suspect what's happening is that in general you have to redo residency but they keep it open as a possibility to get things waived in order to potentially steal somebody important. That resolves the tension between the anecdote (which I agree with) and the language on the website.
Throwaway05
6mo ago
Now of course, the patient will probably need to sign off on something to protect you as the doctor ,so they don't come back and sue you for using a cheaper less effective option. But that is solvable.
Fundamentally I'm not against greater cost transparency if you don't break something else in the process, but some of the difficulty serves a purpose (mostly in the hospital vs insurance war).
The other piece to keep in mind is that this is pretty much how a bunch of the expense of our system came to be. Someone had a great idea for how to improve the system. The idea had uncertain benefits and costs. It got thrown out there and ended up costing more than it benefited. I'm not convinced the costs associated with cost transparency (one poster elsewhere suggested that hospitals eat the loss of cost overruns in a surgery for instance) end up being better once you add everything up. You should be damn sure.
I quoted the above part because fundamentally the rest of the system prevents us from being too cost conscious. "Here are the benefits and risks of your gyn surgery written on a paper. A routine complication is the ureter being severed. It happens. Nobody necessarily makes a mistake but it happens. Actuarially it will happen. Please don't sue us. In fact this paper says you can't sue us." Result: lawsuit. "You could die if you leave the hospital. No really your arm is literally falling off and you will die from infection within 48 hours I can fucking see the pus oozing out of you Jesus Christ. Fine sign this form saying you are leaving against medical advice and won't sue us." Result: lawsuit. (both of these examples are making fun of specific things I've seen and aren't really real).
More centrally you see things like "meemaw is a fighter, use enough resources to build a jet fighter to try and save her life even though she is 97 or we are going to sue the shit out of you."
You have to revise a lot of other things before that becomes viable.
We try and do things where we can like offering a slightly less effective but much cheaper medication.
Throwaway05
6mo ago
Thank you for sharing your experience.
I definitely did not realize that most people don't just view the deductible as a sunk cost with any significant utilization.
RSV sucks but kids bounce back thank god.
Throwaway05
6mo ago
I appreciate the N!
Most of the countries that seem to match into residency in the US seem to have pretty well developed infrastructure to help explain what to do, outside of that its hard to know what locations are programs are realistic. It's a brutal process even for US MD grads.
:/
Throwaway05
6mo ago
Your profession by and large does not give a fuck about the human aspect of medicine or the cost to individuals, and this wildly out of touch crypost from you is full of evidence of it. Luigi's only mistake is he didn't get the surgeon who ruined his back too.
Think about what you just said here.
"I wish the assassin had killed a doctor too" "doctors don't care about people."
Does that really seem reasonable, or fair? Doctors should be murdered for routine complications or things that just don't work?
Throwaway05
6mo ago
Please supply the data if you can because nothing about that makes sense. Medicare cuts to physician reimbursements are well known, several specialties are frequently sub 200k which isn't really consistent with any form of keeping up with inflation.
I don't know this writer but I think it's pretty reasonable to conclude it's likely an anti-physician agenda post given this: if physician pay is one of the biggest factors behind healthcare costs (as they say), why is it such a small percentage of healthcare costs and they don't even mention what the percentage is or note if its increased or decreased over time?
I think it is reasonable to have significant suspicions after noticing that.
Throwaway05
6mo ago
Keep on snarkily dismissing it rather than refuting it.
There is a surplus of medical students and residency slots every year. AMA lobbies for increased supply of providers.
You can verify these for yourself if you'd like.
Throwaway05
6mo ago
Are they going from UK to Australia? I know it is easy for us because we don't have to retrain but we also have the hardest training.
Throwaway05
6mo ago
I'm saying we will lose career changers if we make the system change from American to European? If there aren't any in Europe that is good evidence if we make our system European, no?
Throwaway05
6mo ago
I mean its cost disease. Ex: excess regulatory burden that does nothing helpful.
Same as in everywhere else in the economy with the cost overruns.
Throwaway05
6mo ago
I mean it's nuts and physicians hate it.
They do generally have paper thin justifications to avoid it being outright fraud but it is stupid and everyone outside of administration acknowledges that.
It's also a classic "juke the stats" type government/regulation outcome.
Throwaway05
6mo ago
I don't think career changers exist at all in Europe/elsewhere in the world. If you have information to the contrary please share.
Throwaway05
6mo ago
I am not saying I don't support switching from the American model to what we do in Europe. I'm saying that you'd see a plummeting in career change applicants. Medical school isn't very much like (current) undergrad.
For example: medical education is always consolidated programs not a la carte, right now that's mildly aggravating to biochem majors who have to redo a small amount. A European model would involve redoing a lot of coursework very consistently.
I don't think career changers exist at all in Europe/elsewhere in the world.
Throwaway05
6mo ago
I am willing to get paid less to work less but that is somewhat orthogonal to my original post given that it is unlikely to reduce total costs to the taxpayer/economy.
I did want to point out that the insane shift schedule happens for a reason however (benefits are present, it is not just costs).
Throwaway05
6mo ago
Hmm I could have sworn there was something about meaningful use carrot/stick being smuggled into the ACA but I'm not spending time hunting that down haha.
Throwaway05
6mo ago
We do see that people from all kinds of other countries (most famously India) that are willing to come to the U.S. and retrain (and need to) in order to get a dramatically increased salary and actually live in the U.S (I would).
Not sure I'd make the same decision coming from the UK.
I do think UK doctors honestly should retrain, just less than those from third world countries.
Throwaway05
6mo ago
Yeah it's a pretty sticky meme but it just isn't true.
Same with the "AMA cartel restricts supply!!!!" argument.
You can still claim that doctors are overpaid, but that overpay if present is not the cause of costs.
Throwaway05
6mo ago
Nursing still needs 24 hour coverage and uses formal hourly shift work. It works okay but gets expensive because nursing salaries are high (deserved!) and lots of people do not want to work nights/holidays/weekends. The people who do will try and hoover up endless amounts of overtime but it is still over time. Expensive to staff especially given the fact that you need a shit ton of people.
Doctors typically work a salary/until it's done style approach. This is a for a number of reasons. It's cheaper and more flexible for one. The work is not evenly distributed. Sure the ED is roughly equally busy 24/7 (and does shift work) but hospitalist shifts are massively more day time focused (but someone needs to be available for nights for obvious reasons and outcomes can be catastrophic if the person is a lazy do nothing type or if you say cover more than one hospital and more than one problem happens at once).
Do formal shift work and then suddenly you are handing off anesthesia mid surgery, leaving work undone which is impossible to effectively knowledge transfer to the next shift. In fact handoffs in general are time consuming, hard, and massively unsafe (thus the research claiming being effectively drunk is just as safe).
That said I'm sure if you doubled to tripled the number of doctors you could get wider coverage without causing too many problems. But that's nearly impossible to do. Yes blah blah supply restrictions but you run into things like "you need to perform X of a certain procedure" if you triple the number of residents and the procedure is rare its going to take three times as long to train. Quality in your doctor is important and theres no way to ramp up supply that much without tanking quality.
You also get weirder stuff like - there are three hospitals just outside of a major metro area. You need one ENT actuarially to cover that area. 6/10 nothing happens. 3/10 it gets busy but it's fine. 1/10 its a total shitshow and the ENT works 36 hours in a row.
Paying extremely highly skilled labor for the 6/10 to prepare for the 1/10 is a hard pill to swallow, especially since everyone is trying to save money right now.
Throwaway05
6mo ago
Following up on this, some of the comments on the Noah Opinion article suggest that Hollywood style accounting tricks are involved but I didn't see enough in terms of details to really buy that.
Throwaway05
6mo ago
So you don't think doctors are spending a ton of time and energy trying to improve patient care?
Throwaway05
6mo ago
Yeah that's clearly not accurate data given how far the number is off from the average 300-350 yearly salary range. Zero idea where it's coming from.
The simplest elevator pitch for decline in physician salaries is that medicare reimbursement has been cut every year for 20+ years (something like ~30 percent down from 2000 I think). At the same time inflation has happened. While pay isn't always directly driven by Medicare, private insurance often pegs itself off of Medicare rates.
An alternative is that the raw numbers haven't really gone up for many years (although COVID changed this) but inflation has gone up by a lot.
Throwaway05
6mo ago
I was initially going to say something about this not being be that bad in those specialties and then realized my understanding of what is too much work is now pretty much forever broken.
And yeah it's bad, but it's instructive. I am amenable to the idea that every hour of US and UK training are roughly equivalent, but if US trained physicians are getting that many more hours of training it really does a decent amount to justify the need to retrain to US standards. Yes those hours rapidly have diminishing returns, but I find most foreign doctors are willing to admit that training is better and more thorough here (in part because of stupid oddities of our system, in part because we have more resources than everywhere else, or our population is less healthy, or just sheer weight of hours).
Hmmm. Something still seems off, I'm not sure I can square that with the pay checks I know about. Also not sure that surgical specialities are doing well enough to raise the average by 100k (given the smaller numbers of them).
Maybe they are including residents in the numbers and its fucking it up somehow? They are technically doctors and actually have had pay gains because at some point living in downtown SF on 50k became completely impossible.
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