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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.
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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