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They do still exist but changes to the pre-matriculation "requirements" have decreased their numbers, and being "outed" as conservative or woke-questioning will kill your social life so they tend to be super locked down.
Add on the requirements to publicly go through the motions during times of profound stress and exhaustion.... you get people who legitimately convert or experience permanent changes.
Remember that medical school clinicals and residency is not far off from outright torture in a lot of ways and people get 1984'ed while going through this.
Salary and taxes walk some people over a few decades but it is less than it used to be.
Why do they torture students so?
A lot of things are going on here, some of which are a bit more complicated to get the full picture on like the historical issues with hierarchy and abuse.
Two simpler bits:
-You don't decide where you work and learn during training and if you leave, quit, or get fired you are done. Sometimes with upwards of 500k in debt. Programs know this and will mistreat trainees knowing they can't vote with their feet and their lives are pretty close to over if they don't suck it up. Suicides and deaths from things like sleep deprived car accidents aren't common per se but are frequent enough that we all know multiple people who went out those ways.
-Unlike most high education/high skill labor you need a lot of 24/7 coverage and physicians are very expensive and in high complexity specialties like surgery you have to do a FUCKING LOT of stuff to become independently proficient in a reasonable number of years. The solution is typically to rely on trainees and long hours. On paper Residents aren't allowed to work more than 80 hours a week, must get at least 4 days off in a month, and aren't allowed to work more than 24+4 hours in a row. On paper. Very common for people to violate one or more of those in an easy specialty at an easy program. In something harder like procedural specialties? You might work 80-100 hours a week with an average of four days off a month.
For 5 years.
Shockingly!!! Substance abuse, mental illness, and medically measurable premature aging (fun study that one) are rampant.
This breaks people down and I think could be reasonably considered torture.
Add on the fact that you can't leave, and many other aspects of the training can be considered abusive (said things that are a bit harder to explain)...
Wow I had no idea the state of medicine was so bad. Jesus.
So are you saying that the state of residency is sort of justified by the difficulty of the profession?
How would you do it differently if you had the magic wand of 'fix up the medical training system'?
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Plenty of other crap is going on and much of that presents easier targets - excess regulatory burden, administrative overreach, wellness modules, U.S. malpractice environment, etc.
A large swathe of the central problem is that Americans doctors are expensive (so hiring more staff for instance is...difficult) and at the same time Americans won't work in American healthcare without those salaries (because of things like the American patient population, malpractice and so on). It makes bigger fixes extremely hard.
Many kinds of surgeons are just fucked - medicine has improved, which means we do surgery less often and the types of surgeries we do are more complicated and harder to learn. It's an order of magnitude or more easier to learn how to remove something from an option approach (think just cutting someone open) than a laparoscopic approach but the latter is much much much better for the patient. Finding ways to make this not extend training time is a nearly intractable problem.
However, a sensible target is malpractice insurance. Doctors do fuck up and do fuck up in ways that should involve penalties but functionally these seems to be entirely separated from who actually pays and gets penalized in our current system. Malpractice insurance alone for OB can be over 150,000 dollars a year. That's insane.
Stronger unions for residents and attendings is probably also a good idea. Unions can absolutely be bad but we are far off from the point where that's an issue.
Likewise kill some various forms of rent seeking and other bad behavior like egregious non-competes, physician boards that costs of tens of thousands of dollars, substance abuse programs that also costs tens of thousands of dollars if you somehow manage to get caught smoking weed, etc.
On a structural level you can probably free up money that can be use to improve healthcare and reduce burden on doctors by targeting various middlemen and administrative horseshit. Fire the front desk staff to pay for an extra useless diversity or infection control administrative and the doctor just adds that job to the list of things they do.
Walk that back, the ratio of clinical to administrative staff is insane and grows worse every year.
I'll try not to blather too much but however bad you think it is it's a lot worse. A classic example is the fact that the population of people we've selected to be doctors might be offered the option of working in NYC or getting paid 300k more a year to work 2.5 hours to the northwest and they'll pick the city. Shit's fucked.
Sidebar: 24+ hour shifts were taken away and then brought back because most people (including residents) thought they were better than the alternative. Which sounds insane and is.
Do you know how the medical system ended up in this fucked state in the first place?
On the training end it's relatively easy, residents are called residents because they live in the hospital, attendings are called attendings because they attend rounds (and then go home). This was initially somewhat sustainable because the level of respect associated with being a doctor was very high (therefore allowing the whole thing to not be a total social catastrophe) and because work was small (because billing and admin requirements were low and we didn't.....have many meds or other shit we could actually do). The whole thing got started by a guy (William Stewart Halstead) who was a huge coke addict but we didn't realize until his training model became the thing). It stuck around because things like the U.S. is wealthy and this process sucks so salaries are high which means that hiring actual night staff to replace is hard. Add in U.S. pro business decisions (lots of our bodies have antitrust exemptions and so on) and it becomes sticky.
Larges swathes of this stuff exist elsewhere though, because being a doctor has several fundamental shitty elements. You deal with the worst parts of society. You are at physical risk in a variety of ways that does not apply to most high education labor. People die, that's traumatizing and so on and so on.
Lots of the other stuff is harder to explain.
Where did America's obsession with lawsuits come from? Not entirely sure, but it's possible to get sued and objectively done the right thing but to have your malpractice settle or end up in a ten year lawsuit that you eventually lose (or win with a lot of stress).
Ya got something specific you want to target and I'll try and comment.
Thanks for dropping Halsted’s name, it led me to these papers explaining how it spread across America:
How or when did this model become unsustainable?
I mean, is it unsustainable? It sucks but one of the reasons we let it go is because residency is temporary and when you are done with residency it's great. Not sure THIS PORTION of US healthcare is gonna collapse.
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