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Revealed preferences in the real world: black doctors.
I wonder if anyone has studied this? What is going to happen to all the black doctors who are being admitted to med school with inferior credentials and who will likely be socially promoted through residency/licensing as well.
I'm sure a large degree of affirmative action has already affected the supply of doctors, but the post-Great Awokening world seems to have taken that to a new level. Apparently rates of test-failing have increased by nearly 10x in some subjects at UCLA's medical school post 2020.
https://x.com/aaronsibarium/status/1793657774767022569
This is obviously forbidden information. I wonder how many schools will simply cover it up and graduate people as normal despite failures.
I hate to say it, but if I or a loved one was seriously ill, I would try my best to get a non-black doctor. If I wanted the best, I'd probably follow Peter Griffin's advice. I imagine others have similar revealed preferences that we would never admit in public. In the future, will black doctors magically have tons of open appointments while the cue to see Dr. Rosenblatt grows ever longer? I think probably.
The profession has a deliberately bottlenecked profession that makes it unnecessarily selective. Even if the average black doctor has lower MCATs than other doctors, they're still going to be plenty good to do basic medical procedures. I suppose part of the reason that I think this is that I generally think big chunks of medicine are significantly overrated, with only a few classes of medicine being consistently effective, and those not generally be all that hard to do. Antibiotics and vaccines work great, but they don't really take a genius to prescribe. Trauma surgery is very effective, but you're probably not going to have much time to pick who you want to fix your shattered body when you're brought in from a car accident. Without considering race, I just generally don't think I'm going to get much out of a physician with a higher MCAT.
There are a couple areas where I would want to get the absolute best. If I had cancer, I would want top-notch pathologists and oncologists working on the problem and would seek out an elite hospital. I probably wouldn't care about race in that context because the bar for being specialists working on bone marrow transplants at MD Anderson is pretty damned high. On the opposite end, if I had something that required sports medicine, I would be insistent on people that are actually knowledgeable int he field, but on this one, the intellect level shouldn't be much of a barrier.
Relatedly, I can't believe how many people that have nothing wrong with them just go to the doctor all the time for checkups, as though a physical is going to provide you any useful information about yourself. What a silly, shamanistic ritual. I'm especially amazed that people who pretty obviously don't care much about their health go through the debasement of being told annually that yep, you're still fat and should lose weight.
Health insurance wants you to.
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From the article
She knows literally less than a decent butcher.
The qualifier major is carrying a lot of weight here. There are thousands of named arteries in the human body, ranging from the aorta (which every medical student in clinical rotations really should be able to recognize, at least when it's exposed to plain view) to tiny branches that exhibit tremendous variation across individuals, and which even the absolute best students (and expert physicians) won't be able to reliably identify in cadaveric dissection (never mind in the operating theater). Viewing angle, anatomical posture, and similar (physical) factors can also make it much easier or harder to identify individual vessels.
So, even if we take this anonymous source's claim at face value (i.e., we assume that some incident occurred in which a medical trainee failed to identify a "major" artery on request, and then reacted badly), how should we understand the term "major," and why do we assume that there was a clear presentation? (And of course, one case, however egregious, doesn't establish a trend.)
Yeah as someone who agrees that AA has gone too far I don't think this anecdote proves anything. Surgeons are notorious for interrogating stressed out, sleep deprived residents and med students and then asking them questions until they get something wrong.
You can ask this question in a way which every last med student in the country should get the right answer, and you can ask it in a way that someone who goes to the anatomy lab for fun is going to fuck it up.
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Do we need the physicians to know the Latin for every small part of the body?
Yes, physicians need to know what parts of the body are called. That these terms are usually Latin has no bearing on that.
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More or less, yes. Despite my position above that I don't think of there being much of a crisis of competence in medicine, that's precisely because there are standards that everyone has to meet. Some professions are basically fake in terms of actual technical knowledge and people can get by with a combination of improvisation and charisma; my impression is that people in these jobs sometimes mistakenly believe that all jobs work that way, and it just ain't so. Things like medicine and engineering have irreducible complexity, where you actually have to know each part of it and be able to use that understanding in practice. Physicians require more actual knowledge than marketing executives.
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We need physicians to know the proper technical term for each small part of the body so they can talk to other physicians about it quickly and precisely. "Fracture of the left thumb" is not acceptable medical writing because the orthopaedic surgeon who reads it now has to find the X-ray image to know which bone in the thumb is fractured.
You can argue that Latinate technical terms make medicine harder to learn than strictly necessary, but the alternative of using technical terms that sound like ordinary words is worse (I've taught physics, I have the scars). In any case, my experience of dealing with doctors is that the technical terms named after obscure 19th century surgeons are more confusing that the Latinate ones.
I kind of want to see Ander-Saxon for medicine.
This is liefsome, but how would we win over the leeches to eft learn all their leechcraft anew?
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The latin is the proxy for competence. If the doctor can't keep up with their research and papers to know their specialized lingo then they're unlikely to understand the workings of their trade. When you're in a select high context community, language is the filter to weed out imposters.
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I don't think this is really valid. Maybe the median black doctor is fine and knows your arm from your arse. But the people on the tails... Truly bad doctors don't just mess up, they can ruin lives and leave corpses. If that's even 5% of the total, it would be a catastrophe.
Yes. Medical mistakes kill around 440k Americans per year. It is a leading cause of death. A moderate increase in medical screw ups could be deadly on a societal level.
This one is a myth, example citation: https://www.mcgill.ca/oss/article/critical-thinking-health/medical-error-not-third-leading-cause-death
This seems obvious if you run some numbers. I am not going to look up what percentage of the population dies a year or total deaths in America but 1-1.5% sounds about right.
I would guess 4-5 million deaths per year and the 440k number would imply 1/10 of deaths are medical error.
Either the definition of error is very low - like a mistake costs a person 10 minutes of life or the number is wrong. When people say medical errors they would assume they died youngish because the doctor did something like gave them the wrong drug or cut an artery during surgery.
And in some cases 'the doctor was only able to ensure 5% QOL heartbeat continuation by 3 months instead of 3 years fighting to the end' isn't necessarily a bad thing.
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Even decent doctors doing 'normal' stuff can have surprising gaps, if they're struggling with combinatorics or recall -- outside of test reqs, it's one of the big arguments against the residency-as-hazing, because being that tired makes you stupid. This seems like a joke, but it's also a joke that I know three people in meatspace with similar stories specific to Crohn's. I've personally been given a combination of prescriptions that, about six months earlier, had received a black-box label about risk of horrible wasting cancers in my demographics.
((That said, I'm skeptical on both the naive HBD take, and also on the data here being completely causative, though I expect the base problem of 'prioritizing everything over ability' is bad enough even in a perfectly blank slate world.))
The naive HBD take seems to be a complete distraction. They had a standard. They're massively lowering the standard. We can be fairly confident that this is going to go very badly, because we have prior examples of it going badly when standards were lowered at smaller scales.
This, in a situation that can already be fairly described as a shitshow. I've got a close acquaintance who had a tough pregnancy a couple years ago, and has since been having dizziness, shortness of breath, and other scary symptoms. For years, plural, since the delivery, she's been asking her doctor, only to be told that it was asthma, or leftover pregnancy hormones, or just her imagination. long story short, the pregnancy caused a degenerative heart condition, which her doctors had been studiously ignoring since her delivery. She's currently waiting to find out if the crash course of meds they've put her on can turn things around, or if she's going to need a prompt heart transplant. She isn't poor, both she and her husband have upper-middle-class jobs with excellent health coverage. Her doctor was just a waste of air. Most stories I hear from people about interactions with the medical system run along similar lines. The expense is absurd, and the results are depressing.
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Honestly this pushes me the other way. I’ve found straightforward by-the-book medicine to be largely useless in resolving any of the health issues I’ve had (other than one infection, at which point the doctor was just a hoop to jump through to get the antibiotics I knew I needed.)
As such, whenever I’ve had a doctor actually solve my problem, it was less because they were a doctor and more because they were an extremely high-iq person with enough exposure to health problems to discern the zebra-problem from the hoofbeats.
I can go through the checklists and find the normal issues myself. Hell, I can set a bone, pick medications out of the available options, or look at my bloodwork myself too. It’s like changing your car oil, just a series of steps.
What I can’t do is realize that I have a 1/1000000 congenital heart issue because of a weird head feeling I get, or know what the proper course of action is after that. Luckily for me I found a doctor who could, and it only took going through a dozen doctors who were useless.
My experience with that last doctor was completely incomparable to any of the others, and I desperately wish there was a way to differentiate the two. Frankly, they don’t even seem like they should have the same job title any more than the attendant at a Jiffy Lube and a Lamborghini mechanic should both just be called “mechanics.”
Personally, I despise having these kind of gatekeepers. An MD is the magic licence which will let you get anything (aside from controlled substances) from a pharmacy with a minimum of paperwork. Anything less than that -- even having studied pharmacy -- will get you nothing over a random person in the street.
A better system would allow amateur level qualifications which allow you to get a larger selection of drugs (like anything you had been prescribed before for a chronic problem, like thyroxine) over the counter.
Or just allow anything (possibly excepting controlled substances) OTC, and let natural selection sort it out.
Naturally, antibiotics are a special case because humans pay a collective price for irresponsible individual use (multiresistant organisms), so it makes sense to regulate that. Perhaps give licensed amateurs the right to buy one treatment of a first level antibiotic treatment per three years, plus the right to buy an appropriate specific antibiotic after lab tests show it their bacteria will respond to that. (Of course, the last line of antibiotics should be administered in insulation wards where you will either leave negative or feet first (if the bacterium develops a resistance).)
A number of degrees and licenses have prescribing rights in the U.S. right now (including NPs and PAs in most states).
Keep in mind that an overwhelming fraction of the population will prescribe themselves into bad outcomes if given the ability to do so, and often demand that their providers do so (with variable success).
Antibiotics as you note, is the classic example. People will demand antibiotics for viral infections. They will demand antibiotics when they don't need them. They will demand stronger antibiotics. They'll blow up their tendons or give themselves C Diff or one of any other number of things.
People will take thyroid medication wrong, or even easy to avoid fucking up things like most blood pressure medication. They'll take two medications that are fine alone but will fuck up your kidneys together.
Patients are idiots. That includes high education, high intelligence patients because they have a lot of overconfidence (just as doctors have overconfidence in domains outside of medicines).
But most people aren't high education and high intelligence anyway and you'll get a ton of people killed and cause extremely expensive, avoidable morbidity if you take the guardrails away.
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You can just order from Petmeds and sketchy foreign pharmacies, like the rest of us.
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This generalizes for basically every profession and even moreso since the internet exists now.
That being said 50-80% of the population likely doesn’t have that IQ I need the relatively smart doctor who can do the read the internet for cure thing.
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That would be a reassurance if it were true.
Are you familiar with Killer King? The history there seems to me to be an irrefutable demonstration that Affirmative Action can in fact have devastating effects in the medical field, and how those effects can in fact be perpetuated indefinitely despite general knowledge of the problem.
Many such cases.
Leland Memorial Hospital in Prince George's County, MD had a similar reputation, though I have no idea if there was any affirmative action involved. It was lore around the University of Maryland that if you go to Leland, you die.
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What's your epistemic certainty on this? Where is the bottle neck? What level of selection is necessary? Do you know the data on under trained providers vs traditionally trained ones? We have it.
What does a doctor actually do? I don't think you actually know, in all likelihood your primary interaction with medicine has been outpatient or maybe some emergency, where most of the work is in inpatient (and for academics, research) and necessarily invisible to patients since they aren't following us around. Most patients don't have any actual need to see the hard work but it's very much their and being done and intensely concentrated on things like the elderly, chronically ill, and people who randomly role through with a one time episode of something.
For instance proper antibiotic selection can be tremendously complicated, and we can see this by looking at things like stewardship rates between NPs -> Urgent Care -> Procedural -> Primary Care -> IM -> ID.
Doctors almost always insist that their friends and family see actual doctors instead of NPs and PAs for a reason, and that's because the job is complicated and the training is doing something useful.
Low, although I'll note that my exposure to the field is much more extensive than you're thinking (although I'm not inclined to provide details). I'd definitely be interested in the data you're referring to - do you have any summaries I can take a look at?
If you meant for educational quality:
We've already introduced "lower education" doctors in the U.S. for awhile now, they are called PAs and NPs. It's been researched. Tellingly, their best case (presented by the nursing lobby) is research that shows that NPs results in equal outcome with U.S. MDs without controlling for case complexity (basically the doctors got the complicated cases, the NPs get the easy cases, and they still ended up with similar outcomes).
More research has shown pretty wide outcome disparity and things like a dramatic increase in costs from the NPs (due to unneeded referrals and excess testing, the later of which is often a direct harm to the patient).
Here's an example link: https://www.ama-assn.org/practice-management/scope-practice/3-year-study-nps-ed-worse-outcomes-higher-costs?utm_campaign=Advocacy
If you meant for the bottle neck:
I'm asking you, as I generally find that posters with an opinion on this don't actually know where the bottleneck is.
It's worth noticing that this source is from the AMA, which is an American physicians' group that lobbies to protect American physicians' class interests, including preventing mid-level health care professionals (NPs, PAs, etc.) from encroaching on practice areas seen as reserved for physicans. The url itself identifies this article as part of an advocacy campaign. The article highlights:
That doesn't necessarily make anything it says wrong, of course. But I'd expect the article published by the corresponding NPs' association to emphasize different observations and to reach different conclusions.
It's fair to say that obviously the AMA has an agenda, but it's also pretty objective that midlevels don't save any money (and in some cases cost more), it's just also popular with hospitals because they have a tendency to cost more in ways that benefit the hospital (like unneeded testing) instead of professional fees.
It's also pretty objective to say that NPs have 500 hours of training and doctors have 10k-20k. That gap is enormous and even if each hour of training is mostly worthless....it's a lot.
It's also true that NPs after graduating from a program can practice in whatever specialty they want with no specific specialty training, and changes fields with no training. Doctors require 3-10 years of extra training and retraining if they switch fields. Those years are generally 60 hour weeks minimum if not closer to 80 or beyond.
Even if you hate doctors that's a lllootttt of extra education.
This seems to refer to clinical hours. Per wikipedia: During their studies, nurse practitioners are required to receive a minimum of 500 hours of clinical training in addition to the clinical hours required to obtain their RN. Let's leave aside the RN component. If clinical hours are the focus, then a typical NP who's been practicing professionally for 10 years has more than a physician who's been practicing professionally for 5 years.
This conversation brings to mind Yud's Is That Your True Rejection. Doctors are better than NPs, they have more clinical experience. No? Well then doctors are better, they have better outcomes. No? Well then doctors are better, they cost the system less money. No? Well then, doctors are better, their training is more rigorous. No? Well then, doctors must be better for some other reason.
The NP model was designed around the idea that experienced nurses working with significant clinical background would go back to school to get some "finishing." This is not the case anymore, it's extremely common for nurses to go for NP immediately because bedside nursing sucks and the pay is higher for NPs. Online only programs also exist now. I've seen an NP student exactly once in my entire career, she was shadowing in a family practice office doing nothing while the med students saw patients (she wanted to be an NP so she could be a medical director at a spa).
Claws out? NPs absolutely fucking suck and I see outright malpractice on a regular basis. And you can't even sue them for their idiocy.
Physician vs. Nursing training isn't apples to oranges, it's apples to wrenches. Physicians spend years being abused and called idiots in order to develop caution, intellectual humility, and limitation awareness, only when mastery has finally started to arrive does the confidence get papered over that fear. The nursing model is centered around establishing early excess confidence (so you can speak up if you feel the doctor is off base) and the what, never the why. And nursing tasks, which are incredibly important but learning how to make an IV tower stop beeping has precisely zero to do with with "this patient isn't having a neurological emergency you just got Albuterol in their eye."
If I had a dollar for every time I saw an NP managing someone in the ICU nearly kill a patient because they did the thing they always did (not realizing that with the specific patients comorbidity it'd be fatal) I'd fucking retire.
Urgent Care and Emergency Medicine (well, with the way most patients use this service) are extremely algorithmic and that gives people (both patients and yes also nurses and other healthcare workers) a false confidence in the simplicity in the provision of medical care but shit is fucking complicated and nursing training doesn't teach you jack shit, no matter how much of it you have. 30 years working in construction doing labor is nothing like going to architecture school.
A good NP can operate on the level of an Intern (first year resident) a great one can operate at the level of a second year resident. I've never, ever seen an NP operate at the level of a more senior resident or attending.
And oh god psychiatric NPs. Again if I had a dollar for every time I saw a patient managed by a psych NP who was on Benzos for their anxiety caused by excess Adderall I'd retire.
Nurses have better PR and everyone likes to hate on the doctor because we don't have time to talk to the patients, make a bunch of money (not really true anymore) and COVID etc. but the midlevel lobby is an absolute racket that is accelerating the death of the system through an excess of unnecessary consults, poor patient management, and a lack of easier breather cases for physicians.
Every physician I know who doesn't have a financial stake in midlevels (and isn't in admin) tells their friends and family to only see doctors whenever possible. That's for a reason.
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Yeah, that's what I was asking. Thanks for the link.
With regard to bottleneck, residency. Schools can't plausibly increase the number of students because they won't be able to place them.
My grumpy self has to say good, because that's more knowledge than I normally see, or perhaps Ive been ranting about this here for enough years.
We have an excess supply of med students (mostly provided by the Caribbean and outside the U.S., and therefore of much lower quality but still an excess).
However it's not as simple to increase the number of residency slots as you may think. You probably know that most residency funding comes from the federal government (and good luck getting them to fund more) but some states fund slots, as do some private hospitals (most notoriously HCA), as residents are a revenue positive thing (although hospitals will claim otherwise).
In the case of HCA the residents from those programs have been notoriously underprepared and unemployable outside the HCA ecosystem, not because the candidates are bad but because the education is bad. Robust medical education is very hard and expensive and complicated and in some cases like surgery you can't create more of it no matter how much money you spend (due to case requirements).
So increasing spots varies from "eh it's doable" in some specialties to very hard to impossible in others.
A related problematic trend is that people find primary care (biggest specialty shortage) and working outside big cities undesirable. Nobody wants to increase doctor salaries so it's incredibly hard to motivate people to go into primary care (it pays half as much and has more un-fun burdens like excess charting requirements) and nobody is ever going to convince a large number of people who had to skip their 20s to move to rural Iowa as soon as they have freedom without a massive pay bump.
But yes the problem is mostly allocation as opposed to shortage.
Residency is irrelevant. Even if you make the argument that US medical training and residency is vastly superior to Canada/UK/Germany/Australia etc, the US can and should simply skim off the top 20% of those countries’ trained doctors (who are surely at or above the American standard). They don’t because of the AMA cartel.
Let's just say for a moment that we want to take the 20% of all of the countries with good educations doctors. And that they want to come.
Is that remotely ethical? All practical and cost saving measures aside it seems kinda horrifying to just steal something so important to society like that.
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I'm with you in general. Americans overconsume health care to a ridiculous degree. I pretty much never see the doctor, just as I don't take my car into the dealership for a "routine checkup".
The reasons for the increase in life expectancy from 1900–present have little to do with doctors, and everything to do with public sanitation and vaccines.
But still, when I do access medical care, I can pretty easily tell the difference between the doctors who are quite intelligent and the midwits who also populate the field. The bar to cross is not THAT high, and medical errors kill untold numbers each year. Diagnosis in particular is not always easy and I don't think there's a skill ceiling. A higher IQ is always going to be better.
Americans have a lower life expanctancy than Costa Ricans, Thai people and Chileans. The US and China have roughly the same life expectancy. There are two scenarios: Americans live incredibly unhealthy lives and require 17% of GDP to be spent on health care to keep a decent middle income life expectancy or Americans live some worse than other countries and have somewhat better medical care yet get minimal bang for the buck.
We do. We’re rapidly approaching 50% obesity. We eat like crap and don’t exercise and that by itself I think lowers life expectancy by at least a decade. Add in stress and it’s like nobody should be shocked by the American life expectancy. It’s like asking why the car where you never change the oil needs more repairs than the one that gets regular maintenance.
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The question should be if Costa Rican, Thai, and Chilean gringos have lower life expectancies than Costa Ricans, Thais, and Chileans.
Globally, the US has unimpressive average scores (surprisingly so, for non-Noticers) on standardized tests like the PISA for… socioeconomic reasons. Yet, after a simple control, the US comes out looking solid.
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Yep.
Most medical interventions don't matter that much for people without lifestyle disorders. Skin cancer, for example, collectively only takes 9 days off U.S. life expectancy. So if we CURED skin cancer it doesn't move the needle. Rinse and repeat with a bunch of other diseases.
On the other hand, the existence of diabetes likely lowers U.S. life expectancy by years, and that's with all the treatment. Did you know that 1% of the U.S. budget is spent on dialysis and the average 40 year dialysis patient only lives 8 years?
All in all, we spend like $5 trillion a year just to undo all the damage from our lifestyle diseases. It's pretty sick.
The crazy pill is that most medical interventions don't matter that much for lifestyle disorders, either, because for the most part, they can't undo the damage from our lifestyle diseases. I was just listening to this podcast with a couple MDs, and he was talking about chronic conditions generally, and a bit about obesity, specifically:
Moreover, they often have patients who don't want to change their disordered lifestyle and wouldn't carry through with doing it even if the doctor had training and a billable way of doing it. So, they sort of default to, "When the chickens come home to roost, I guess we'll give you a drug to help manage your symptoms somewhat."
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