site banner
PaperclipPerfector  6mo ago (text post)   31561 thread views

Culture War Roundup for the week of December 9, 2024

This weekly roundup thread is intended for all culture war posts. 'Culture war' is vaguely defined, but it basically means controversial issues that fall along set tribal lines. Arguments over culture war issues generate a lot of heat and little light, and few deeply entrenched people ever change their minds. This thread is for voicing opinions and analyzing the state of the discussion while trying to optimize for light over heat.

Optimistically, we think that engaging with people you disagree with is worth your time, and so is being nice! Pessimistically, there are many dynamics that can lead discussions on Culture War topics to become unproductive. There's a human tendency to divide along tribal lines, praising your ingroup and vilifying your outgroup - and if you think you find it easy to criticize your ingroup, then it may be that your outgroup is not who you think it is. Extremists with opposing positions can feed off each other, highlighting each other's worst points to justify their own angry rhetoric, which becomes in turn a new example of bad behavior for the other side to highlight.

We would like to avoid these negative dynamics. Accordingly, we ask that you do not use this thread for waging the Culture War. Examples of waging the Culture War:

  • Shaming.

  • Attempting to 'build consensus' or enforce ideological conformity.

  • Making sweeping generalizations to vilify a group you dislike.

  • Recruiting for a cause.

  • Posting links that could be summarized as 'Boo outgroup!' Basically, if your content is 'Can you believe what Those People did this week?' then you should either refrain from posting, or do some very patient work to contextualize and/or steel-man the relevant viewpoint.

In general, you should argue to understand, not to win. This thread is not territory to be claimed by one group or another; indeed, the aim is to have many different viewpoints represented here. Thus, we also ask that you follow some guidelines:

  • Speak plainly. Avoid sarcasm and mockery. When disagreeing with someone, state your objections explicitly.

  • Be as precise and charitable as you can. Don't paraphrase unflatteringly.

  • Don't imply that someone said something they did not say, even if you think it follows from what they said.

  • Write like everyone is reading and you want them to be included in the discussion.

On an ad hoc basis, the mods will try to compile a list of the best posts/comments from the previous week, posted in Quality Contribution threads and archived at /r/TheThread. You may nominate a comment for this list by clicking on 'report' at the bottom of the post and typing 'Actually a quality contribution' as the report reason.

6
Top Bottom Old Controversial Comments
Jump in the discussion.

No email address required.

On physician salaries:

This topic comes up from time to time and is more in the news now for obvious reasons.

Here I will point out that cutting physician salaries does little to address the healthcare cost crisis and also argue that the salaries are deserved.

Obviously yes, I am a physician and don’t want my salary to get cut, but nobody wants that to happen to them, how would you feel if people on the internet were saying you were over-compensated and demanding you take a 50% pay cut?

It’s also worth noting that everybody in the U.S. is compensated well (too well?). That includes within healthcare (see: nurses) but also outside of it. We make good money here; it’s one of the reasons so many of the successful elsewhere want to come to America.

-Okay how much of healthcare spending is doctor’s salaries?

About 8%. If you cut physician salaries by half you get 4% savings. That’s not a little but it is also not a lot.

-Can we do this?

Sure, you could, maybe, but you’ll introduce new problems, people will retire or leave the field, shortages will get even worse, and so on. Depending on how you did it, certain critical fields like surgery would vanish overnight. OB care would be financially impossible to provide (due to incredibly high malpractice burden (can be 150k per year). You can’t spend your entire salary on malpractice insurance and other expenses.

-Okay, but how are physician salaries trending, are you making more than you used to?

Doctors have been getting year after year real wage cuts for 20-30 years. Everyone else’s (in healthcare) salaries have been going up. Percentage of healthcare spending on physician salaries is going down. So, if you really want us to get paid less just wait. Our salary shrinks every year and the portion of the pie we are taking shrinks too.

-Alright, again. So, does cutting physician salaries help?

No not really, we aren’t a large enough slice of the pie and you’d cause a shit ton of new problems. We’ve already seen this a bit. More people are working part time, quitting, dropping out of residency, graduating from medical school and not doing medicine, not providing certain types of services or working in certain locations. That’s with a modest decline in salary and things like an increase in administrative burden and a decline in respect. This would shoot up if you dramatically cut salaries.

-Okay but let us just import a ton of foreign doctors.

Again, 8%. It’s not going to help that much. However, it’s worth keeping mind that a lot of what pisses people off about healthcare gets worse with foreign doctors. Yes, I believe that foreign doctors have worse training and experience than American doctors. People here seem to not like that argument, but we don’t need it. Foreign doctors are almost always coming from third world countries, not Western Europe. People hate when their doctor barely speaks English, spends little time with them, and acts like a cultural alien. All of those things are what cheaper foreign labor brings to the table. Patients in the 90s and 00s heavily pushed better customer service in medicine. It’s made things more expensive but has resulted in better customer service. Walk that back and make things cheaper if you are okay with worse customer service we can do that without breaking everything else.

-Okay DW what’s the most histrionic thing you can say on this topic, just for fun.

If you cut MD salaries by half, I think healthcare costs would actually increase. You’d see a decline in certain types of care which is unexpensive, preventative, and annoying for us to do. Example: nearly every single endocrinologist would stop practicing and go back to doing hospital medicine (they already make less than hospitalists, often to the tune of 150k and have already completed the training for that). All those unmanaged conditions would end up costing more in the long run. You’d also see an increase in “well fuck you, I’m going to be shady now in order to make this worth it.” And you’d see a huge increase in low value – high expense defensive medicine since protecting your salary becomes even more important. A more modest boiling the frog approach is already in use, and involves far too little money to solve the problem.

Switching gears.

-Okay give me some numbers.

It’s hard to tell for a variety of reasons but the number going around right now is an average of 350k (it may actually closer to 300k and we are seeing a complicated post-COVID mirage). That’s a big number but this is a situation where the median and average diverge a lot. Pediatricians often make between 180k-200k. Family medicine makes more than that but not a lot more. Those are a huge percentage of the overall jobs. Yeah, neurosurgeons can make 5-10 times that, but there aren’t a lot of them, and they work close to 24/7, they still make the average weird. A lot of “rich” doctors are a small number of people in a complicated specialty working egregious hours and not really enjoying the money. At one point the neurosurgery divorce rate was over 120%. The median physician has much more reasonable compensation. They also used to make a lot more, the mental framing of this for some is anchored around 90s compensation which just isn’t true anyway. Doctors work a lot. People who run entire departments, manage millions of dollars in research grants, or own patents and other companies are sometimes presented in these numbers.

-That’s still too much.

Okay let us talk tradeoffs. Some things to keep in mind. Doctors don’t typically make money until after they turn 30. Up till that point physicians can often live in more or less in poverty (want to live next to your hospital in the nicest part of a major city on 60k? Good luck). Once you start making money you can start paying off your 500+ thousand dollars in loans. Delightful. Up until that point you have no flexibility. You can’t leave your job or your life is over. You can’t choose where you live. If you get fired your life is over. If your boss is abusive, you say nothing. Probably most importantly, you can’t get back time. Money and time are probably most useful in your 20s. Our peers are meeting partners, going on vacation, clubbing. We are working 24-hour shifts. That’s a huge cost.

-Boring. You chose this.

Fair. But if you want American to keep choosing this you have to be aware, otherwise it ends up like the other jobs that nobody in this country wants to do.

-Okay fine, like is it even that bad of a job though?

Yes. Consider that many doctors are functionally working 2-3 full time jobs worth of work.

-Okay hold up, yeah you work 80 hours in residency but not as an attending and certainly not 120 hours.

Okay, okay lemme explain. Yes, some people are working 80 hours a week (or a lot more) as an adult. However, you are more often doing things like working 60 hours a week, but that is including things like nights, weekends, and Holidays. How many jobs involve regularly working Christmas, or three weeks in a row without a day off, or 24+ hours in a row? Any job with hourly wage and overtime is going to add up to 2 times the base salary really quick under those conditions.

Also, unlike most blue-collar labor (which is laden with mandatory and very real breaks) or white-collar labor (which involves a lot of downtime), most doctors are working nearly 100% of the time while working.

That may sound unfathomable to you, and to some extent varies specialty by specialty but can be very close to literally true. On days when I’m in the hospital for three or meals I’m lucky if I sit down and eat for one of them. Usually if I’m lucky I’m just cramming a protein bar in my face. Trainees always go “what the fuck when do you eat. Or drink. Or pee.” We usually don’t. Surgeons are notorious for regularly giving themselves mild kidney injuries because of dehydration.

Almost nobody I know who isn’t a physician has worked a 24-hour shift. Most people I know have never worked 8 hours in a row for real with no breaks, certainly not for weeks and weeks in a row. Your year-end scramble or Go-Live or tax season is our baseline, and often we are doing it for 24+ hours at age 55.

Once you break this down to hourly wage the numbers get much more reasonable.

-Hold up you work 24 hours in a row with no breaks? Is that real? Isn’t that unsafe?

Yes, at around hour 18 you become disoriented to the point where it’s not safe to drive anymore. Yes, this schedule ends up actually making a lot of sense somehow. Yes we sometimes work more than that, at any given time in a hospital there’s probably someone working a single shift longer than some of the nurses whole work-week.

-Okay but like, outside of the sheer hours it is not that bad right?

Well lack of breaks is part of that. Plenty of other stuff though. Perks are non-existent these days. Most places got rid of the physician lounge and parking lots, which mostly exist to make us faster and more efficient so not the best move in the world. Keep in mind that the chair in my office is maybe older than I am, and most places I work my personal laptop screen is bigger than the screen I’m doing my work on. Most corporate jobs are comfortable. Medicine is not. Little things like that add up and are part of why a lot of us get lured into the general workforce. For some reason I pay for parking.

Also, the job is intrinsically hard. Treat us like kings and pay us millions of dollars a year…and you are still dealing with death and entitled and demanding people all day. You can get sued and lose all your money, your job, or more likely just be miserable for five to ten years while the case gets sorted out in your favor. Most jobs if you make an inattentive mistake, you say oh shit and fix it, or somebody loses some money. Doctor fucks up and somebody dies, and you make thousands of decisions each day where if you lose that focus…

Alcoholism, drug abuse, and depression rates are high. As are suicide rates.

Sidebar: most white-collar work does not involve dealing with the dregs of society. This occasionally makes useful for for instance talking about the practicalities of the criminal underclass but is absolutely stressful.

-Okay but like, not everything is clinical work, right?

Well yes, to some extent that is part of the problem. An increase in charting and administrative work has made healthcare more expensive and restricted supply and quality since I spend less time with and working on patients. Writing bullshit notes does not increase my job satisfaction.

However, there are good other parts – leadership roles, research, teaching. Most doctors are clinical care providers, mentors and educators, and team leaders and managers all at the same time. With the demands of all of those things.

-That’s a lot of shit, anything else you want to unload?

Yeah, there’s other stuff that makes being a doctor be expensive. Board examinations and licensing can cost tens of thousands of dollars. If you get caught smoking weed you could end up losing your job and have to pay hundreds of thousands to get it back for some god forsaken reason. Everyone wants to siphon off of us because they know where the money is. This is also why NPs don’t get sued despite having less training and more bad outcomes. Less money involved.

You constantly get expensive retraining, tests and learning for the rest of your career also. Medicine changes all the time and we are required to stay up to date.

-Okay but like if I’m in the hospital I don’t see you at all what the fuck are you doing?

Operating. Teaching. Calling the lab. Writing notes. Seeing other patients. In committee meetings. I swear we are working you just aren’t seeing it, and a lot of what we do isn’t direct clinical medicine.

-Thank you for coming to my TED talk.

The supply of doctors in the US is artificially constrained which means you can increase the supply of doctors while lowering salaries.

Up until that point you have no flexibility. You can’t leave your job or your life is over. You can’t choose where you live. If you get fired your life is over.

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?

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.

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.

I don't see how they're not part fo the problem. If they increased the supply of doctors, they'd be cheaper and healthcare costs would go down.

I don't see how they're not part fo the problem. If they increased the supply of doctors, they'd be cheaper and healthcare costs would go down.

A realistic salary cut brings down healthcare spending by 2%. That's barely anything. Bring administrative spending down to 1980 levels and you probably save something like 25%.

-Okay, but how are physician salaries trending, are you making more than you used to?

Doctors have been getting year after year real wage cuts for 20-30 years. Everyone else’s (in healthcare) salaries have been going up. Percentage of healthcare spending on physician salaries is going down. So, if you really want us to get paid less just wait. Our salary shrinks every year and the portion of the pie we are taking shrinks too.

Alex Tabarrok wrote an article in 2019 that showed this is simply incorrect. Real physician wages tripled over the past several decades, and are doing far better in terms of wage growth than many other professions. Maybe he's doing something weird with the numbers here, but you didn't post any numbers, just an assertion.

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.

So if it's not your salary that's at fault, and it's not the medical cartel's restriction of the supply of doctors that is at fault, and it's not the insurance companies because they're legally required to pay out such a large portion of their revenue, whose fault is it? All I see in this thread is a bunch of deflecting and blame shifting but without one concrete indication from you as to what the actual problem is that needs to be solved. When you've attempted to shift the blame to other elements of the healthcare system, other commenters have replied with evidence to the contrary that seems to surprise you. So who is at fault?

Bureaucratic institutions, if given access to funding are going to proliferate indefinitely.

Parkinson's laws are undefeated. Famously predicted RN with more admirals than ships.

Came true in '90s. These days, there's more army general in the British Army than there are tanks in it. Probably more generals than big artillery pieces too.

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.

You're only tossing that out now that other commentors poked holes in your other attempted explanations. You may as well blame the tooth fairy. If you genuinely thought that you would have opened with it, and you'd have some concrete ideas about what regulations are in the way. 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.

Please refrain from attacking others as insincere. The generalized rage isn’t particularly constructive, either.

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?

My friend Fred says that median real wages for doctors have been going up since 2000 at least. Although $2700/week seems pretty low. What's your source for the claim that they're going down?

Anyway, I don't think we should cut doctors' salaries as such. We should allow more people to become doctors and let the market sort it out.

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.

The numbers are divided by CPI, "Index Dec 1999=100". Multiplying by 175 gets to $245,700/year in 2024 dollars. It's also a median; the mean would be higher.

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.

I wonder if there has been a flattening of wages since now doctors are effectively all employees and few are owners.

-Okay how much of healthcare spending is doctor’s salaries?

About 8%. If you cut physician salaries by half you get 4% savings. That’s not a little but it is also not a lot.

Obvious question - is this the total income paid to doctors or just the salaries of salaried doctors? The fraction of doctors who are salaried is increasing over time, but most of the doctors who are allegedly overpaid are not salaried - they are surgeons being paid a fee-per-procedure, or owner-partners in physician-owned clinics.

Here's a source:

https://siepr.stanford.edu/news/just-how-much-do-physicians-earn-and-why

Thanks. So modulo a relatively minor argument about capital gains when retiring doctors sell their practices, this is total physician earnings and not just salaries.

That does indeed point to "overpaid doctors" not being the problem.

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.

Yes you’re important

Yes you work hard

Yes you should be well compensated

…

Yes there’s too many barriers to being a Dr … especially just a family practice type

Yes there’s not enough Drs because of the artificial barriers that you ‘ you ‘ put in place

This is your fault / the fault of the institutions that made you

I don’t want several hundred thousand Indian doctors … I want several hundred thousand American doctors with slightly lowered standards

Yeah this is the fault of the doctors. Also, as @2rafa said, they are absolutely overpaid. Very few professionals make anywhere near doctor salaries, and they have incredible status to boot. Doctors are basically the priests of our society.

I say we gut the doctor’s system and open the floodgates to immigrants. High time they earned their salaries. I don’t like doctors for personal reasons anyway, they are far too confident when they shouldn’t be.

and they have incredible status to boot

I don't think this is true anymore. Anti-doctor viewpoints are super common right now. The left and the right hate us. Corporate media blames us for cost overruns. We aren't independent anymore. Patients murder us and it doesn't make the news. We get threatened all the time at work and the police and the hospital both shrug, even in places where there are specific laws against that.

Look at the tone here. Sure I'm not a perfect communicator but every time I try and refute lies about the AMA I get buried in downvotes, the "doctor bad" and "doctor is the problem" memes are rampant, and that extends to general society.

Not saying it isn't true, just saying that people absolutely feel that way.

For a practical example - you used to be able to get laid or find a partner b/c you were a doctor. Doesn't really work any more.

Fwiw, I appreciate your posts, but don't fret too much about downvotes, that way lies madness. As much as we wish people would vote according to how well an argument is articulated, whether they agree with it or not, I believe most people still use it as an "I agree/disagree" button, and a substantial fraction vote in a reflexively tribal manner.

That being said, while I believe you that being a doctor is difficult and not as rewarding (financially or emotionally) as it might once have been, it's still really hard to convince me that being one of the 4% or so sucks as much as you imply. We could probably do all sorts of reforms that would improve doctor QAL, but some of those would also reduce doctor remuneration, and for some reason doctors seem to prefer the high barriers to entry and what amounts to years of grueling hazing before you're in the money.

I don't think the hostility you describe is some new wave of anti-doctor sentiment. It's a general breakdown in social norms making it more dangerous to be a bus driver or airline attendant or a counter person at McDonalds too. Most hostility about the health care industry is not directed at doctors. It's the hospitals, the front offices, and the insurance companies. And probably nurses take the brunt of patient hostility more than doctors.

I don't think I disagree with any individual thing you said there - downvotes aren't representative and shouldn't be over analyzed, the job and pay are worth it (but less so than the past), people are meaner and angrier in person (to say nothing of online) these days, and so on.

That said - the excess of disagreeableness and decline of respect for institutions and expertise is real (everywhere and sometimes deserved). It's extremely noticeable in our jobs though, because most of life and health takes place outside of the hospital so we can easily see when people don't listen (and come back or die) or make a mess during their stay/visit.

Our oldest can tell us how different it was in Ye Olden Days, or if we work in settings with radically different populations we can see the gap (Vets).

These days we see more and more patients doing things like walking away from treatable cancer to ending up terminal on homeopathic arsenic from someone who is legit licensed in Oregon because that's a thing they do. While I'm not immune to slinging mud at times...people yelling at me on the internet scratches the fundamental same itch writ small.

What bothers me a little more is when people don't realize the decline, especially when it is the respectable types, because of course that hurts more.

Yes I want to be respected (who doesn't?) but it's so intrinsic to the job for us. Yeah its kinda funny when I whinge about it being harder to pick up women as a doctor, but patients shooting their doctors (real but rare), people demanding things that are dangerous to themselves and others like antibiotics for a virus (common as all hell and a problem but individually small potatoes) to the expansion of midlevels because people don't realize how much worse they are (metastasizing everywhere and I'm tired of seeing my patients and friends end up with bad outcomes from it)...these things are real and bringing my end of things closer to collapse.

Like much of everyone's current ills I don't know what the solution is, but I will get on the soapbox and mumble a bit.

And on traditional and all together saltier note, since I was a young intern on call at one point in the distant past: yes nurses get it worse from patients but they totally deserve it.

Indians who would make up the bulk of these are well known for being modest, competent and not over overconfident.

It was more a line against importing doctors rather than fixing our own issues

I found many doctors to be dull. They clearly “learned” a lot of material but they don’t seem to have any interesting thoughts or creativity. Maybe the medical field selects for those kinds of people.

No not really, we aren’t a large enough slice of the pie and you’d cause a shit ton of new problems. We’ve already seen this a bit. More people are working part time, quitting, dropping out of residency, graduating from medical school and not doing medicine, not providing certain types of services or working in certain locations. That’s with a modest decline in salary and things like an increase in administrative burden and a decline in respect. This would shoot up if you dramatically cut salaries.

Yeah, this is the eternal threat, right? But ok, what are these people going to do? How many jobs in America are there that pay as much as medicine and aren’t ’top of the corporate pile after a 40 year career’ type jobs?

Very, very few.

A few jobs in big tech. A few jobs in front office high finance. A few jobs in big law. A relative handful in (other) professional services.

None of those professions have medicine-tier job security. All of them (save maybe big tech) have very long hours. All of them are ultra-competitive.

Doctors on the internet always seem to assume they could be investment bankers or deepmind engineers instead, but I don’t think they could. The truth is that medicine is a lot less competitive and more midwit than most of these jobs. Plus, most of these jobs have an extreme up-or-out career progression that medicine just doesn’t have. Of a thousand junior investment bankers at Goldman Sachs who already passed an application process with a 1% acceptance rate, how many become managing directors or seniors in PE? Maybe thirty or forty. Most end up failing out into comfortable PMC professions, often paid less than many medical specialties and again still with far, far less job security.

Plus, there’s status. Nobody in modern American society has higher status than doctors, not billionaires and certainly not bankers, lawyers or engineers. That also has value - socially and for one’s own ego - that can’t be measured solely in pecuniary terms.

Even if medicine paid half as much there would still be doctors. There are still huge numbers of bright eyed, intelligent college students with elite credentials who want to be journalists.

There are still huge numbers of bright eyed, intelligent college students with elite credentials who want to be journalists.

Journalism is a non-central case because there's a very large non-monetary compensation in the form of influence/power.

Most journalists even at the NYT don’t have very much influence/power.

It's highly nontrivial to get "very much" influence/power, and the main ways involve quite a bit of luck. Journalism reliably gets some, can get quite a bit, and while it's tricky to get "very much" strictly as a journalist, journalism -> politics isn't unheard of.

I know you hate that argument so I very specifically didn't make it this time.

Based off your historical unwillingness to update your understanding of anesthesia compensation and work duties I don't think we are going to have a fruitful discussion on the doctor skills/role and work alternatives side of things.

By the way, and I truly am sorry if you’ve gotten that impression, I have a great deal of respect for doctors. I think you do a great job, and I think you should be well-paid for it. And and, I think doctors’ pay is only one part of the issue with the US system’s immense inefficiencies, of which a great deal can be laid at the feet of Congress, insurance companies (not out of ‘evil’ or even the profit motive, but just because of the perverse regulatory and incentive environment they’ve been out in), the way big pharma is funded and to some extent the tragedy of the commons.

My only real ‘thought’ on doctor pay is that we should have more doctors. Let’s train them, let’s import them (from native english-speaking countries with decent standards, like our peers in the anglosphere), let’s do whatever it takes to increase residency spaces. And let’s make residency easier, let’s limit medical liability to bring down the ridiculous cost of malpractice insurance, let’s make medicine an undergraduate course like it is elsewhere so doctors don’t have to waste four years and more money going into debt.

But yes, ultimately, let’s work to bring down some salary costs. Is that so unreasonable?

let’s import them (from native english-speaking countries with decent standards, like our peers in the anglosphere)

Do these people want to come? I'm not sure they do.

Other stuff.

Usually when this conversation comes up what happens is that I say something like "sure increase supply just don't compromise quality" and then someone says "being a doctor is easy, there aren't really quality differences or problems" I recall this argument from you in the past but if you don't endorse it now no problem, but ultimately most supply increasing options involve compromising quality in some way. Americans are mostly uninterested in decreasing quality, but if we decide that's on the table then we have a lot more tools available to solve some of these problems without touching supply at all.

Also, right now we seem to be in a situation where shortages are pronounced enough that the market can absorb a much higher number of physicians without bringing salaries down. In fact we likely need to increase salaries (specifically: one of the biggest problems right now is that people will refuse to work in red states or rural areas, these jobs already offer higher salaries, sometimes as much as twice as much, but in some cases that's not enough).

We already have some evidence that salaries are too low for some needs, taking salaries down further is liable to make those issues first (and again does little to decrease the overall healthcare costs).

Paging @self_made_human

I believe he’s one doc who wants to come! And I would have him. Hell maybe I’ll even marry him to get him over here.

Heh, it's a dream alright. If you're willing to marry me, I'll promise to be the sub ;)

LOL you better. I couldn’t handle being with a doctor who’s also a dom. Sounds intense.

specifically: one of the biggest problems right now is that people will refuse to work in red states or rural areas, these jobs already offer higher salaries, sometimes as much as twice as much, but in some cases that's not enough

Is this a ‘flyover’ issue that clears up for Miami, or is this progressive lying about Texas laws again?

A good half of it is medical people being hysterical idiots about "right wing legislation." Dumb shit for sure.

The other half is people refusing to work in rural Mississippi or whatever because they are educated, selected to be blue tribe, and want to actually have fun when they finally have the money and ability to actually choose where they live.

Stop being woke AF and this will self correct to some extent.

The other half is people refusing to work in rural Mississippi or whatever because they are educated, selected to be blue tribe, and want to actually have fun when they finally have the money and ability to actually choose where they live.

A lake house and a boat and a housekeeper(because getting paid $300k+ in Mississippi makes domestic labor cheap) isn't enough of a draw?

No, running theory is that the people in the pipeline currently are simply too culturally blue and want to avail themselves of big city resources when they finally have the ability to do so.

Given how many people leave residency single there is also the reality of finding a partner, and since most people want a class/wealth/intelligence equal and being a doctor isn't really a draw anymore, they go where the other young professionals are (and stay).

More comments

Do these people want to come? I'm not sure they do.

I would be interested to hear @self_made_human respond to this, if willing.

Doctors from the Anglosphere?

Yes. At least some parts of it.

For example, British doctors are massively disgruntled, and a significant portion of them are trying to leave the country, though as always, the majority of people anywhere don't really want to emigrate. When Brits run, it's usually easier to go to Australia or New Zealand, where wages are markedly higher, work life balance is better, and their credentials are recognized as equivalent with little faffing around. Some opt for Canada.

Aus/NZ doctors are largely content, and only a small number want to move, and when they do the US is their goal most of the time.

If licensing regimes like the USMLE were relaxed for these specific countries, I doubt you wouldn't see a 2-5x efflux, comparable to the boost in salary they'd see, even if the working hours are worse.

Hell, I'd go if I could, I opted for the UK because I didn't have a better choice for long and painful reasons. Depending on how the job market looks in 3-6 years and if the barriers go, I could well be tempted in the future.

I'd say doctors from these countries are competent, especially native ones, I've certainly been nothing but impressed. They make do with shit wages and a QOL that is worse in many ways because of the UK being a stagnant country, but they're sticking around both because of inertia and because the US isn't easy to go to. They're seeing their own wages stagnate, and face stiff competition from international medical graduates (like yours truly, I have to look out for my own interests), training is unnecessarily long and painful, and many don't need more than a nudge to reconsider.

Thanks! I guess for context I considered you as "part of the Anglosphere", although there are different degrees of centrality to that concept. I remember you had a couple (interesting, IMHO) posts a while back about how difficult the US regime would have made transferring your education credentials.

I'd imagine most people here would consider the "Anglosphere" to be the Commonwealth countries plus the US, I doubt India would come to mind for them. While we have a gazillion English speakers, it's not strictly the language of the majority! I would hope that I qualify for honorary membership nonetheless haha.

I'm uniquely screwed when it comes to practising in the US, I won't elaborate since you seem to recall my moaning before, but even in an ideal world, I'd be looking at the USMLE and 3 years of residency. I haven't heard of anyone actually getting those requirements waived if they're a credentialed specialist elsewhere, but that could be my ignorance as opposed to me denying @Throwaway05 's claims. It's not a formalized route at any rate.

More comments

IF the US wanted to poach British doctors, you could get about half of them (including some of the ones who are currently heading to Australia). Please don't. I love my family, and several of them are dependent on healthcare to stay alive.

Same! When I see this online it's mostly people bitching about the U.S. being terrible but I'm sure that's not representative of how people actually feel.

Do these people want to come? I'm not sure they do.

From my experience talking to Anglosphere doctors, you would instantly collapse British, Canadian, South African, and probably Australian/New Zealand healthcare if you opened up the American medical system. (Don't laugh about the South Africans, they turn out some incredible doctors.) The big issue I've heard from them is less about the objective difficulty of getting US certified, and more that you're sacrificing even more years of your youth on a particularly pointless altar.

I 100% believe they want to come here for South African (I actually had supervisor at one point who was South African, he was incredible). Australian, and NZ healthcare actually pays comparable to the U.S. to the point where we have people going there. I'm sure if you opened it up you'd get a mix in both directions. Canada is already pretty open to transfer with the U.S. is my understanding with some jobs making the same some making less, some making more.

Britain is the odd one. Granted redoing say IM/FM/Peds/EM residency here is only three years and be a huge life gain. They don't seem to sign up for it. Most of the time I see this online it's associated with a bunch of anti-Americanism.

It isn't just "three years" - it's "three years of hell", and if you are doing it for the second time to tick a bureaucratic box, it's unedifying hell. People who are already upper-middle class don't put themselves through just to double their salary. You either need to offer enough upside potential to take the winners out of the upper-middle class (startup founders, finance jobs) or something that speaks to the soul.

Also those are the specialties that are at the bottom of the food chain in the US in a way they are not in the UK, so they are the ones where the benefit of moving is least. NHS GPs who want to graft can make as much money as successful surgeons.

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).

More comments

Do these people want to come? I'm not sure they do.

From the UK? I assure you they do.

Why don't they then?

I wasn't able to find a good single source of truth but medical students can do it (which Scott did(ish)) if they are interested. It's harder than it would be a for a U.S. grad but likely much much easier than an Indian medical school grad.

The BMA website implies that some "adult" (saying it this way because I can never remember the British terms) doctors may be able to come over without any specific retraining but does not provide details.

Training is probably somewhat worse in the UK but not enough that I'd have any complaints about anyone coming over (although this would obviously be bad for the UK).

The one I'm married to wanted to in 2014/15. She passed the USMLE had her ECFMG certificate, recent clinical experience in a western European native English speaking country and didn't require visa sponsorship as the spouse of a US citizen, applied to a variety of programs and failed to match, not even any interviews. ☹️

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.

:/

More comments

You need to redo your residency if you want to become a US doctor even if you are a consultant with 15 years of experience in the UK. That is enough of a barrier that prevents people from coming over, never mind the extremely onerous visa requirements the US imposes on foreign professionals of every trade and type.

The official stance of the BMA per their website is:

"Doctors who are already on the UK specialist register may be able to apply for partial exemption from the residency programme requirement. To check if you are eligible, you should contact the relevant specialty board in the US."

My guess is that the answer is not yes or no but "it depends."

More comments

Consider that many doctors are functionally working 2-3 full time jobs worth of work.

Okay, but the only reason this is the case is because the doctor cartel limits the number of residency slots to keep physicians in demand and well paid. You don't like your hours, but at the same time, you are against increasing supply: you don't want to bring in foreign doctors (doesn't have to be third world, American doctors earn way more than NHS doctors) and you don't want more American doctors because it will eat into your salary. You've painted yourself into a corner here, unless you have a clever idea for demand destruction.

@Throwaway05 says that the doctor cartel limiting the number of residency slots is an urban legend. I'll live it to him/her to provide details.

This is the data he offered to support his claim the last time. I pointed out that Figures 1, 3, and Table 5 might tell a different story to some folks. This time, he apparently didn't use this citation to support his claim; he only picked out the one statistic from it that sounds like it supports his position, preventing others from seeing the rest of the context.

Partially addressed with this user down thread.

This is no longer the case (your citation is from 1965) and is a non-sequitur anyway.

If you cut doctor salaries in half and double the number of doctors, you have improved physician lifestyle at the expense of compensation but not changed costs at all.

If you cut doctor salaries in half and double the number of doctors, you have improved physician lifestyle at the expense of compensation but not changed costs at all.

This is only true if you also cut the hours doctors work.

If you were working 24 hour shifts, weekends, and holidays - and then someone decided to cut your pay in half. Would you keep working period? Probably not. Would you entertain those hours? Zero chance.

Nurses typically work 3 12s or 4 10s and in some cases make six figures and we already have a nursing shortage problem because they don't like the schedule (because clinical work can suck and nights, weekends, and holidays also suck).

I wouldnt work 24 hour shifts in the first place, and I'd be pissed if I found out that a doctor who was seeing me and potentially making huge decisions or recommendations about my health was 23 hours into a shift.

Anyways, average seems to be somewhere in the 50s of hours per week. Increasing the amount of doctors such that they no longer have to work stupid hours seems like a no brainer, I would easily take a ~30% pay cut to go from 55 hours to 40 and not have 24 hour shifts. No idea why doctors wouldnt either.

https://www.statista.com/statistics/1385440/physicians-work-hours-united-states/

Attending physician work life definitely lands more in the 40-60 range "on average." Surgical specalities can still end up in the 60-80 hour range as an adult.

As a resident 60-80 is more common with 80 being the "max" allowed but many places go over that. Neurosurgeons may end up working 100-120 hour weeks more often than not for like seven fucking years.

The devil is in the details though. Most medical jobs require someone to cover weekends, nights, and holidays. How that shakes out is pretty variable but you can be an attending with a relatively normal 60 hour work week.....but a few times a month you work 24s. Maybe you do trauma at a midsized trauma center. If it's Tuesday you actually sleep through the night. If it's Friday you are working 24 hours in a row. That is ass at age 27. At age 55 it is catastrophic.

pissed if I found out that a doctor who was seeing me...

Um.....about that.

If you go to a university hospital (you should if you have the choice) you WILL be cared for by a resident who hasn't slept in a day. If you get a surgery done the person operating on you might be on hour 28 and gotten 4 hours of sleep the night before that long ass shift.

Edit: these days theres a good number of women in medicine who decide to work part time for a pay cut. It is a thing but given how time consuming and expensive it is to train someone it's usually unwise.

If you get a surgery done the person operating on you might be on hour 28 and gotten 4 hours of sleep the night before that long ass shift.

I'm from the UK, where a typical long shift for a doctor is 13 hours, so I cant really tell if this is an exaggeration.

But if this is true, holy shit. That is absolutely outrageous. how can you with a straight face protest that doctors are so desperately committed patient wellbeing, while accepting a 28 hour long surgery shift? There's no other way to describe it - that's dangerous. You, above all, should know what the science tells us about decreasing performance with fatigue. Any airline pilot that accepted a shift even close to that would lose their license.

The 36 hour shifts are an exaggeration (well, more specifically in some specialties it happens in others it doesn't).

24s are the standard.

To briefly summarize residents are called residents because they lived in the hospital, back in the day when that made sense - the social technology existed to support it (everyone had supportive wives who would still be there after and bring them food) and the medical technology was limited (yeah you lived in the hospital but most overnight work was "shit hope he is still alive in the morning), also the inventor of residency was a massive coke head and we didn't figure that out until later.

Now it is a bit more complicated. Bad outcomes happen, see https://en.wikipedia.org/wiki/Libby_Zion_Law

But 24s are often more popular than the alternative. Often the alternative is something like working 16 hours a day 7 days a week. No or less days off. After a 24 you get home between 6am-12pm and get to sleep until the next day. Or run errands while fucked on sleep deprivation.

The problem is that you need 24/7 365 coverage and that's complicated to do and expensive, residents take the burden.

Importantly our regulatory entities have a bunch of research showing that working 24+ hours is better for patients than handing off to a new team. Things get missed. Your drunk (on lack of sleep) doctor is more reliable than a new doctor that doesn't know you.

More comments

Sometimes there's just no other option. An airline can simply delay the flight until a new pilot is available, but you can't always delay a surgery like that, and there might not be any other surgeons available. We have a massive shortage of doctors because of the dumb med school/residency system.

More comments

This is no longer the case (your citation is from 1965) and is a non-sequitur anyway.

The dynamics today are largely the same.

If you cut doctor salaries in half and double the number of doctors, you have improved physician lifestyle at the expense of compensation but not changed costs at all.

I acknowledge that physician salaries are only a small part of healthcare spending.

However, your opposition to additional doctors seems to obviously conflict with your complaints about working conditions. How can physician working conditions be improved without additional physicians?

The dynamics today are largely the same.

Negative, the AMA has spent the last few decades arguing for an expansion of supply not a restriction, nearly ten percent of residency slots are unfilled every year, and alternate funding for residency spots has been a part of the landscape for a long time.

This meme hasn't been accurate for ages but is very pervasive.

Considering the AMA controls accreditation for medical schools, there's no good reason for slots to go unfilled against their will. Let a thousand med schools bloom.

There is also an excess of medical students applying for spots each year (primarily driven by shitty Caribbean schools and foreign applicants). Even a small number U.S. MDs and DOs go unmatched each year.

We have an excess of supply in the form of medical students and residency spots but for both the excess is of insufficient quality.

Great post, although I think the word "salary" might be doing too much work.

I would argue that 250k-300k for a internal medicine doctor is very reasonable, as is the 1 million dollar a year that the top neurosurgeon gets.

But payments to doctors can be more than salaries. As we all know, seeing patients pays very poorly. But procedures and tests pay very well. The orthopedist who owns an MRI machine has a license to print money. He many only draw a "salary" of 200,000 while clearing over a million in profit.

Other specialties which involve procedures seem to pay an abnormally high amount as well, including anesthesiologists, radiologists, and dermatologists. The ease of these specialities compared with the outsize salaries make them some of the more competitive residencies. But is society better off having our most talented young people chasing these specialties? No, of course not. Some even argue that most anesthesiology could be done by a non-MD.

Rather than cut salaries, which I agree would be a bad idea, we need to fix the problem of outsized payments to doctors. We can do that in a market-based way.

  1. Create more med schools and residency programs to increase the supply of doctors. If the AMA doesn't play ball, remove their involvement.

  2. Reduce the regulation that leads MD's to do things that non-MD's can do.

  3. Price transparency for procedures. I need to know exactly how much that ultrasound will cost, and I need to be able to shop around. Same for prescription drugs, which doctors often proscribe completely blind to how much they cost.

If you are a doctor making 250k a year seeing patients, no one is coming for your salary. At least I hope not. You deserve it. But doctors (in aggregate) do bear a large amount of responsibility for the cost explosion we are seeing.

Some even argue that most anesthesiology could be done by a non-MD.

I recommend these people as the first to be sedated by non-MD’s.

Okay, I’ll bite. Why does it take 11 years to train an anesthesiologist and why are they so precious they need to make 400k a year?

To my uninformed eyes it seems like a relatively easy technical skill that could be learned in much less time and without such a rigorous filter.

What’s the delta between in a 90th percentile anesthesiologist and a 10th percentile one in terms of patient QALY over their career. It feels more like a systems problem, in that if the system is set up correctly then skill doesn’t matter too much. And if the skill of the anesthesiologist does come into play it’s because things are already pear shaped. Kind like commercial airline pilots.

Could less skilled technicians + remote monitoring lead to even better outcomes than today?

I’m probably wrong but it’s not obvious why.

Gas is a lot like being a pilot and flight attendant in that you receive a lot of training for things that aren't often happening and that the average person doesn't see or notice. Job looks easy when things are going smooth. Every time you do something you do a lot of preparation and planning that seems to happen automagically to outsiders.

Unlike aviation, the plane tries to crash repeatedly and active actual plane crashes happen a few times a week. Fundamentally you are fighting to keep the patient alive while the surgeon tries to kill the patient. Think about things like open heart surgery. Even something as simple as an open gallbladder involves radically changing the patient's physiology. Bad outcomes get blamed on you and are your fault.

Surgery isn't everything gas does though.

Imagine you are working a 24 hour shift overnight, it's 4am and you are sitting in a break room watching jeopardy reruns and eating shitty chips from a bag, your pager goes off. You have 90 seconds to get to the trauma bay, where you find a patient has got hit in the face with a sledgehammer. His anatomy looks a cheeseburger put in a food processor and pulsed. You have to keep the guy alive long enough to put a tube down this throat, get fluids and blood running, and get the guy to the OR where another doc and the surgical team repairs the guy's face in an 16 hour surgery.

Ten minutes later you are back to eating chips and watching jeopardy.

OB, psych, and gas have serious tempo issues which more resemble the military and police and are not for everyone.

The explanation that convinced me was essentially "removing all senses from a human for a specific time and then giving them back without irreversible damage is hard, especially since humans have a very wide range of medicine tolerances and reactions".

If I had to write code, with no syntax highlight, no test cases, in subtly different environments every time, and a single compiler error might kill someone, I'd definitely want some training.

Some even argue that most anesthesiology could be done by a non-MD.

Jesus Christ please no haha.

The rest of your comment.

Physician ownership is dead in most specialties, nearly everybody is employed now. There are some people who still own things now but the majority of people get paid salary with some element of bonus that is RVU based (eat what you kill type stuff). It did not use to be this way, and I won't argue that era had some excess, but it is dead now.

Procedural work does pay more and there are problems with that, but it is generally much harder (on an hours worked basis if nothing else) and as a result we have much less of a problem with rationing of surgery than most countries.

There's also a lot less of these people - there's 35 times as many (Family Med/IM/EM/Peds) doctors as dermatologists.

Skim 100k-200k off of the dermatologist and you do fuck all for total healthcare costs.

Decrease doctor salaries and increase doctor supply and you'll have doctors refuse to do out of title work and demand to work a normal day. If you half doctor salary and double the number of doctors you haven't done much. Every doc is doing 2-3 people worth of work and they do it because the money is good, money stops being good and then they stop...

I'm burnt out on the price transparency issues because of other conversations on this board but keep in mind that a lot of this already exists. Check out GoodRX.com Most doctors will use these tools nowadays when they can (lots of EMRs automatically tell you the drug cost for instance) but if given the choice of a drug that costs X or 10X they are going to choose 10X 10/10 times if they think its going to reduce the risk of a lawsuit.

I'm burnt out on the price transparency issues because of other conversations on this board but keep in mind that a lot of this already exists.

Maybe you don't see it as an MD, but price transparency really doesn't exist to your average patient. You go in, you get your thing, and then you get a shocking, incomprehensible bill somewhere between 2 weeks to 2 years later. Sure, part of this is insurance. A lot of it isn't.

Providers will happily charge you $1000 for a routine test if you don't have insurance and then I guess you're supposed to like call them up and negotiate. In the real world, that's just not going to happen.

Yeah, savvy customers will find a way to reduce costs. You can ask the doctor what blood test they want, go on ultalabtests.com (highly recommend), get your tests results for incredibly cheap and without having to wait in line, then print them out and give them to your doctor (or, shudder, fax them in). Maybe the system will tolerate this. But they are not set up for it, and it will be a ridiculous burden on the patient, who will have to fight his doctor and clueless staff every step of the way.

Drugs are a little easier to save on, but face much of the same burden on the patient to proactively battle to save money. And since something like 80-90% of health care is paid for someone who is NOT the patient, there is little incentive anyway.

On a personal note, I don't think you should fear reform. As an average doctor making 250k, you have nothing to worry about. The system needs you more than you need it. And maybe we can even find a way to reduce the bullshit that doctors have to deal with. But not everything always has to be the way it is now forever. The $5 trillion we spend every year is clearly going somewhere. The people who take surplus profits from the system are not exactly going to stand up and advertise themselves.

In the real world, that's just not going to happen

Why not? My hysterical aunt managed it, basically on her own. I’m sure that people who aren’t in the 95th percentile of neurosis will have an easier time:

price transparency really doesn't exist to your average patient.

I mean price transparency doesn't really exist for most things.

Two major problems:

  1. Physician's are employed now and are therefore generally not in charge of anything when it comes to billing. This adds an extra layer of abstraction and problems. You correctly identify useless clueless staff as part of the problem and as the doc I generally have other stuff I need to be focusing on.

  2. Most of the total types of costs are unreasonable or impossible to have useful price transparency on. The average patient may almost entirely interact through the medical system (just off the top of my head) through the window of just drug prices, professional fees, and lab tests/imaging. That's certainly plenty but it might just be 3/100 total things we deal with, and those three are a lower percentage of my actual workload than you might think. Two of the three are totally reasonable and many places will actually have better price transparency if you ask for it but if you try and pass legislation and include the other 97 it becomes an exploding fucking mess.

Meds (well, outpatient ones) and testing (well...outpatient again) are generally reasonably self-contained and it would be sensible to try and get it done at a cheaper place. Hospital based care? Procedures outside of very careful ASCs? Useless. Lots of things get sneaky though - the ultrasound is cheap, but who is going to read it? Is it going to get done automatically and a hidden professional charge or not covered by your insurance charge? Easy to mislead patients if you are unethical or by accident. Then people get mad and demand legislation which makes it even more complicated and confusing.

Professional fees also get super weird. I'm going to give a made up number for opsec reasons. If you come to see me and offer to cash pay my employer may or may not be okay with that. If they are it's going to be be a fairly reasonable number. Let's say 100 dollars for an hour long initial appointment (psychiatry shut the fuck up and stay out of this). If you are paying with insurance there is no number. None. It doesn't translate to anything directly, and if I have no cash fee schedule you can't even squint and go "it's 100 right?" No, it's a billing code, it doesn't relate to what's "fair" or what is "cost" it is all negotiation. State Medicaid pays me 20 bucks an hour for that billing code. We still take state medicaid even though that's less than the cost to run the front desk because my hospital gets a grant from the state government. Private insurance pays me between 40 and 140 dollars for that billing code depending on the insurance. If they decide to cover it. They may decide that on Tuesdays I must include the word "sneeze" in my note, and since I didn't no money for me (well, for my employer). Medicare pays 40 dollars and doesn't ask any questions normally but a few times a year they show up in my office and decide that half the charts need to include the word "mega-ultra-sneeze" since I didn't they are going to take back all of the money they paid me and fine the shit out of everyone.

That's just one way this is done, the more famous one is that my professional fees are 100 dollars but my employer charges 1,000 dollars and puts that on the bill and then the insurer pays between 15 and 200 dollars.

Sidebar: I don't recommend ordering yourself lab tests without physician involvement, it's easy to fall afoul of pretest probability and sensitivity/specificity issues. A big one I see right now is college age people will order themselves STD testing because they don't want to ask their doctor cause awk. Eh kinda harmless. Except these places will add on HSV, which you are not supposed to do (per AAFP) because a positive test result causes a ton of misery but only has a 50% change of being a true positive and there isn't any option for follow-up confirmation testing.

I just want to add, I mostly think your comment chain here is rad, even if I had a slight disagree, but there’s absolutely zero price transparency in medicine.

Zero.

I’m 40 and even tho I don’t go to the Dr a lot … there has never, ever been price transparency. In anything remotely close to medicine, for myself or anyone else I know.

That’s not your fault.

But not defaulting to the obviousness of a lack of price transparency is driving me up a wall.

I don’t find the doctor to have any less price transparency than the mechanic?

The mechanic will have a plan for what he is going to do (e.g., "I'm going to replace your CV joint."). He will then assemble an estimate for how much that is likely to cost. He will probably even break down that estimate in terms of parts and labor. He might even provide you options for different brands of parts at different price points.

Everyone involved knows that there is some uncertainty in that estimate. They might get in there and discover that something else needs to be done, too. Usually, at that point, they will reformulate their plan, potentially with multiple options, assemble similar price estimates for those options, then contact the customer, try to explain the situation (knowing that there is an inherent knowledge gap), and ask which of the options the customer would like to take. I did this as a job long ago. There are some sketchy mechanics out there, for sure. But if you want to succeed, especially in a market where being sketchy will become 'known', you need to be very proactive in your communication with your customers, including on pricing information.

Doctors take the same exact sort of uncertainty in their work as a gospel truth that the price is "fundamentally unknowable"... and so, they just refuse to tell you. If you really press them, sometimes they'll do it, but sometimes, they just won't (and sometimes, they'll lie to you and make something up; there are sketchy mechanics everywhere). They certainly don't provide anything comparable to what the 25th percentile auto shop provides on a routine basis.

Perhaps you were thinking of a slightly different concept, that they're similar in that there is a significant information asymmetry. Customers don't necessarily know if the mechanic's plan is motivated by the car really needing whatever it is, whether it's barely justifiable and mostly a scam to increase billing, or whatever else. Similarly, patients don't always know that sort of thing with doctors; they could also be concerned that a doctor is practicing defensive medicine rather than thinking about the patient's pocketbook and giving them only what they really need. These questions are probably near impossible to estimate; I would like to believe that doctors are actually equal to or better than mechanics (the median doctor is almost certainly better than the 25th percentile mechanic if I had to guess, unlike with price transparency). In both cases, the most common solutions are to just diversify your sources of knowledge. I gave an example of how diverse those sources of knowledge can be here, but an extremely common suggestion in both domains is to just get a second opinion.

Again, I don't find it difficult to get healthcare providers to give me pricing information. I go to lower-rent(often bilingual) healthcare providers in a blue collar part of a red state, so maybe it's just different sorts of clinics.

More comments

Ultimately the lack of price transparency is not something that should be relevant to patients, you functionally need insurance in the US and every having to do with payment outside of your insurance fees is a total nonsense dance between various entities. If your ultrasound costs 300 dollars or 350 dollars shouldn't be relevant if you are paying 0, 5, or 20 for the thing.

It's certainly annoying not to know stuff if you are a curious person, but I'm not really sure it is ever relevant.

I'm not really sure it is ever relevant. [emphasis added]

You really cannot be serious. You do not get to decide that it is never relevant. There are many many many stories of it being relevant (some on the storied pages of the Times). You may be in a narrow slice of a specialty where it happens to be rarely relevant, but across the entire swath of healthcare services, with the entire swath of different patients, with different insurance terms and different financial situations, it's going to be relevant often enough. At times, you've even admitted that it "is viable for some services". It beggars belief that you can say with a straight face that you think it is never relevant.

The problem is for example, me going for a colonoscopy, I contacted my insurance company to ask how much would be covered. They said if my doctor coded it as preventative (i.e. I was just being screened due to my age) it would be essentially entirely covered, however if it was because the doctor was trying to find a diagnosis it would be 50% co-pay. So I asked well how much would that be, and they said depends on your doctor and their facility but somewhere between 3 and 10,000 dollars, perhaps more.

Now the problem is I was having symptoms, which is why my GP referred me to a GE (the only GE I can get into see inside 3 months in the area as it happens) in the first place. So I ask the GE how they are going to code it and he says, no idea, you'll have to ask the front desk staff who do my billing. So I ask them and they say, depends on what the doctor puts in his notes. If he mentions pre-existing symptoms we'll code it as exploratory. So I ask how much that will cost and they say, we have no idea, so I ask how much does it usually cost OOP on average and they mumble around a lot and eventually say 2-4000 dollars.

So I get the colonoscopy because I am feeling pretty bad, and I get diagnosed with ulcerative colitis, they code it as exploratory and I end up having to pay about 4 and half grand out of pocket (most of which as it happened went to the facility and the anesthetist and the lab that analyzed the removed polyps and tissue, it appears). Now luckily I can afford that, because I am a responsible person with a decent paying job. But I asked my doctor what would have been different if it was just a routine screening and he said nothing at all. He would still have checked polyps in the lab, he would still have done everything he did, except I wouldn't have had to pay more than 50 bucks. And of course he is recommending I get a colonoscopy every 6 months because I am at elevated risk of bowel cancer. Now my GE doctor says he does 5 or 6 colonoscopies a day. It is essentially the main thing he does, and my insurance company is the biggest in the state. There has to be a better way than telling me, well it can be somewhere between zero and unknown but probably between zero and 10K, for a procedure which is pretty well defined.

Reminds me of "How to Do Health Care Right" by The Dreaded Jim:

My wife was advised to get a colonoscopy. We shopped around, got a reasonable price at a doctor with a good reputation, negotiated with the insurance company, did all the stuff one does in an environment which actually has prices. Then after the colonoscopy was done, the hospital pulled a huge list of stupendously expensive charges out of their ass, most of which were obviously ridiculous or completely made up out of thin air, just trying it on to see what they could get away with, and all of which were charges we had definitely not agreed to, nor consented to in any way, formal or informal, written or unwritten. They just were not used to doing stuff on the basis that one has a definite price, and that the price one charges affects demand for one’s services. The concept seemed alien and incomprehensible to them. Mentally, they were socialists.

In Singapore, they advertise prices.

Some years later, I had the following conversations with various US health care providers. I recorded the conversations:

Conversation with Stanford Hospital:

Me

My wife needs a colonoscopy: Could you give me a price on it?

Stanford Hospital: (businesslike tone)

Twenty five hundred to thirty five hundred.

Me

You do this all the time. Can’t you give me a specific price?

Stanford Hospital: (cooler tone)

Sorry

Me

Is $3500 the all up, all included price to both myself and my insurance?

Stanford Hospital: (businesslike tone)

It only includes the doctors fee, and does not include any additional services

Me

So after I have this done, any number of people could then charge me any fee they like in addition to the thirty five hundred?

Stanford Hospital: (distinctly chilly tone)

I am afraid so.

O’Connor Hospital

Me

My wife needs a colonoscopy: Could you give me a price on it.

O’Connor Hospital

Do you have a primary physician?

Me

Yes, my primary physician has advised this procedure, but it seems expensive. I am looking for a price.

O’Connor Hospital (outraged and indignant)

We don’t give out prices!

Mercy General Hospital

Me

I am looking for a price on a colonoscopy.

Mercy General Hospital hangs up without a word.

Saint Joseph’s medical center of Stockton:

I am transferred to financial counselling, who transferred me to “Estimates” The estimating lady appreciated my problem and made sympathetic noises.

She then asks me for a CPT code. I then research what CPT codes are, and discover that an operation can result in any CPT, and any number of CPTs. I discover that no matter what CPT I give, it is unlikely to be correct or sufficient, that additional CPTs can show up any time. A CPT would only be useful if it was possible to know in advance what CPTs would result from a colonoscopy, but the CPTs are only decided after the colonoscopy, usually long after the colonoscopy.

Thank you for providing a good example, last pile on about this nobody gave me anything to work with. I'm assuming in this case that your plan is a high deductible one and once that runs out you no longer pay co-insurance right? (If not... I didn't think that was legal anymore?).

My mental model of the deductibles is that if anything remotely complicated happens you'll burn them instantly but it appears that isn't the expectation for most people. Probably because in hospital medicine if you so much as sniff a patient they've been charged an arm and a leg but our population on this board is mostly young people who aren't utilizing medicine too much with related expectations.

That said 25% your doctor is being lazy asshole for not trying to work with you, but 75% he's employed and not in charge which is pretty common these days. He can write his note however the hell he wants but the backend people are just going to do something else. He doesn't want to promise you anything because you'll take it at face value (because doctor!) but then somebody he never talks to in a building he's never been to changes some shit and you go form 0 to thousands of dollars.

Your story smells a little more lazy asshole doctor and I'm sorry that happened to you, during my training most of the attendings I worked with would try and save patients time and money, even when a little tiny bit fraud was involved to make that happen. I tried and remember that and encourage the people I train to remember that. I don't do any fraud though. Obviously.

Asking the doctor to know what somebody else is going to do (in this case, sometimes it's for knowledge he doesn't have) isn't super reasonable but that's a lot of this stuff at times.

The whole system is arranged around insurance plans where this kinda stuff never really applies but it hurts those in edge cases.

Also your plan sounds shitty.

Also also: shit. UC sucks. Follow the screening recs they give you. Seriously.

More comments

It doesn't translate to anything directly, and if I have no cash fee schedule you can't even squint and go "it's 100 right?" No, it's a billing code, it doesn't relate to what's "fair" or what is "cost" it is all negotiation. State Medicaid pays me 20 bucks an hour for that billing code. We still take state medicaid even though that's less than the cost to run the front desk because my hospital gets a grant from the state government. Private insurance pays me between 40 and 140 dollars for that billing code depending on the insurance.

Good news, since you pointed out that physicians are employed now and aren't in charge of anything! Your employer signed agreements for all those things, so your employer has all of those numbers. Your employer also knows which category the patient falls in (they took the patient's insurance information when they came in the door), so they know which number was negotiated for that patient. This is a solved problem with a computer even in an auto parts store in [current year]. It's a solved problem in every other industry. I've very occasionally had medical providers look it up for me; I have even seen what was on the screen on their computer; it's a solved problem.

Medicine faces the same problem that computer programming has, I think: it’s a prestige job, with a high salary, and has therefore attracted strivers.

Strivers are great at taking tests, going to meetings, taking photos, networking, self promotion, speaking, etc. and are sometimes okay at the underlying skill, but to them the underlying skill is an afterthought.

I think this is why I’m frustrated at doctor pay. I want the type of autists that are obsessed with being good doctors, and I’m happy to pay them $1M+ a year (what some of the doctors I’m friends with make), but I want to filter out the strivers. How do we do this?

Interestingly, this is similar to the problem Google has faced WRT search. They defined how they measured a good page, and then everybody just adhered to that. The actual underlying quality went to near-zero, and they just overfit to the test.

The way to filter out strivers is extreme classism of the old-school sort. Gate professions by last name, by prep school, by who your father is friends with and you keep the scummy, first-generation strivers with their bad manners and grubby hands out.

This system is actually ideal. It doesn’t preclude class movement, it just requires that it be a multi-generational project. By the time new money is accepted into the striver jobs, the kids are as accustomed to success and fat and lazy from it as everyone else.

By the time new money is accepted into the striver jobs, the kids are as accustomed to success and fat and lazy from it as everyone else.

Do you have a general presentation of the model here? What I see around me is a lot of people trying to prevent their kids from getting fat and lazy.

What you are describing sounds quite a bit worse, though, doesn't it? Maybe "I don't care about becoming high class through becoming a doctor because I'm already high class so it doesn't matter"? Hmm.

Basically I don't want these jobs to be prestigious, I want to filter for the people who are interested in the work, and look at the class-effects as secondary.

The idea is that the only people socially qualified to be doctors don’t have to strive or get a prestigious job because they’re upper class already, but they do it anyway because they want to.

I know someone who inherited enough money that he never HAD to work a day in his life, but he became a rather overworked agricultural vet because he wanted to.

The physician pipeline is a whole separate problem that is infested with culture war (DEI and AA) and pre-culture war (autists bad, I want better customer service and English speakers!!!) bullshit.

If you throw out the customer service angle, then to some extent you want psychopathic hard workers AND autists. The supply of people who are both is limited.

Walking back all of the box checking side of things is also hard. These days autists get furious at mandatory wellness modules and other asinine useless horseshit and burn out. Banning that stuff is hard and box checkers are much better at dealing with it.

I generally see the smarty pants contrarian "reduce MD salaries" suggestion paired with a proposal to change the training pipeline, notably by going straight to med school instead of making it a postgraduate program (which I gather is how things work in much of the rest of the Western world.). I don't know whether other countries run their residencies like the US does but presumably worth looking into as well.

Sure people talking about increasing the supply of physicians and therefore driving costs down, but that only matters if reducing physician salaries does anything useful. It's not a large enough slice of the pie.

Removing the undergrad requirement would be nice for American doctors, who wouldn't have to spend an extra 4 years and $200,000 for literally no reason, but it wouldn't do anything to help patients. That's because the real bottleneck on the number of doctors is the residency requirement, not the medical degree. To increase the supply of doctors, need to either shorten residency or increase the number of residency slots.

I've talked elsewhere about the whole residency and medical school slot thing. The residency length thing is a very complicated discussion.

I do want to point out there are some advantages to the U.S. system of 4+4 years. Yes lots of places do 4 or 6 years, but the ability to go through undergrad first gives you a few advantages:

-You actually have a college experience/fun. That's important!

-You are absolutely sure this is what you want. Really fucking important.

-Better balanced people - less medical school robots.

-Opens the door for career changers, who are some of the best doctors.

Medical school students who start at 18 in other countries still have a “college experience”, they’re still on campus, can still party, join clubs, whatever, they’re just doing a more intense course.

I mean preclinical years are an undergraduate class every 1-2 weeks. That pace cuts out a lot of traditional college activity. Once clinicals start you aren't on campus anymore and don't have time for fun. I'm sure this isn't the case in Europe but you can't change the work culture that easily (nor the geography which is a big piece of it).

Abolishing pre-med and pre-law does not close the door for career-changers, though. People can still do 4+4 if they want.

How would that work though? You "go back to college" instead of medical school - all the students are 18 instead of 22-26 and you do the curriculum designed with 18 year old maturity. I'm sure some people would still do it but that the amount would absolutely tank.

People "go back to college" all the time, what are you talking about? You think people wouldn't career change into medicine if it was only a 4 year thing because the curriculum being designed for 18 year olds would make it, what, too easy? Your messages in this entire thread are alien but this takes the cake.

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.

People do that all the time. People enter undergrad after enlisting in the military, or working a few years, all the time. People take a degree part time, nights and weekends, while working. It's not crazy.

I don't think career changers exist at all in Europe/elsewhere in the world. If you have information to the contrary please share.

Uh, my understanding is that the continental Euro education system is completely different and most students are locked in to a particular set of postsecondary education(often sharply limited) by their mid-teens at the latest. Applying directly to medical school, or applying to medical school with a two year degree in biology or chemistry, shouldn't necessarily bring the entire Prussian education system with it.

Now that being said, while I assuredly do not think that making doctors get bachelor's degrees before applying to med school does anything useful, we do not live in a society where med school applicants will stop getting bachelor's degrees if it's not technically required anyways.

More comments

What are you talking about? Why does it matter whether people change medical careers in Europe when people change careers in America all the time despite needing a new degree?

If doctors don't change careers in Europe that would tell us more about Europe and it's education system and career choices than it would about how it would go in America, right?

More comments

Can I ask what motivates you to be a doctor? Is it that if you don't rage out and quit by the time you enter your 40s you can start expecting a really sweet lifestyle, if you properly monetize your certifications and experience?

I feel a little guilty that I never went to college and liked computers instead and was clearing $500k/year and retired in my 30s. But at least when a doctor has a garage full of sports cars society nods and says "oh yeah well he's a doctor that's why" whereas I have to do shit like live a low key life and give to EA so I don't trigger class rage.

All the doctors like that are DINCs, from a prior time (aka the 90s), or from one of the well paying specialties. 300k a year starting in your 30s with 500k in debt isn't enough to make you rich until late in the game if you intend to put 2-3 kids through college and so on, if ever. Sure you can push state school or not pay but if you went through it you want to protect your kids from dealing with it.

These days the doctors are on the receiving end of class rage though, everyone is mad at us on both the left and the right, thinks our job is easy and easily automated, and wants us to make less money. Thus my long ass rant.

That said I do it because I want to help people and I like teaching. It's also interesting as hell. Medicine is hard because it is much poorer define than most knowledge work which means there is a lot of room to learn and research and for your job to stay interesting over the course of your career.

These days the doctors are on the receiving end of class rage though, everyone is mad at us on both the left and the right, thinks our job is easy and easily automated, and wants us to make less money. Thus my long ass rant.

It is pretty astounding to hear that health spending occupies an increasingly larger share of GDP yet doctor compensation is worsening.

That said I do it because I want to help people and I like teaching. It's also interesting as hell. Medicine is hard because it is much poorer define than most knowledge work which means there is a lot of room to learn and research and for your job to stay interesting over the course of your career.

I obviously don't know anything but from the outside it does seem like one of those things where the more you learn and the faster you think on your feet the more good you can do. When, you know, the cases aren't boring and you have to remind the patient yet again that they don't get better unless they actually take the meds as prescribed.

It is pretty astounding to hear that health spending occupies an increasingly larger share of GDP yet doctor compensation is worsening.

I think this should be pretty intuitive if you think about government and academic spending. More administrators and more middle managers are rampant everywhere and drive up costs. Market activity is somewhat protective against this, but healthcare has too much going on that doesn't resemble a market.

...faster you think on your feet the more good you can do...

One of the remaining perks that hasn't eroded is that you bring in the revenue for the hospital. Even an IM doc brings in 4-5 times their salary in revenue to the hospital. This gives some independence, should we choose to use it (we often don't because residency beats that out of us). You want me to fill out a yearly HIPAA training. Fuck off, fire me if you want. You won't.

This patient is having an emotional breakdown and really needs it? I'm skipping my mandatory meeting and spending time with the patient and their family.

Moments like that matter a lot.

Also, if you are smart and motivated you can discover entire new ways of helping people, stay on the bleeding edge, redefine what the standard of care is...and so on.

Even bad patients can be rewarding when you finally help them to the ah-ha moment.

Good stuff is out there.

So where’s all the money going?

Whenever someone has a proposal for healthcare reform, the response is “actually that’s not the main driver of costs”. The money’s not going to insurers, their profit margins are slim enough as it is. It’s not going to doctors, they only make up 8% of the pie. So who’s actually getting paid? The money can’t be disappearing into thin air.

Not trying to do a gotcha here. I’m genuinely uninformed on this topic and willing to hear you out.

I mean, to start with, 8% is not nothing. And I think it’s quite reasonable to pay doctors like doctors, for the record. But there’s also everyone else’s salaries(hello, nurses), there’s admin expenses and capital costs, there’s profits for the hospital and the drug companies, there’s a bunch of healthcare that just doesn’t get paid for, etc. There’s no one culprit with a smoking gun.

A bunch of it is going to insurers. Profit margins are thin but if expenses are high from inflated salaries and the gross amount of money is hundreds of billions of dollars that adds up.

Clinical staff add value, most of the other salaries involved are siphoning value. Hospital and healthcare admin staff has ballooned. Practice managers. Billing staff. HIM staff. Midlevel mangers etc etc.

The system has a lot of room to be more lean but as with academia it's just expanded into an inefficient mess.

Many of the people who get paid unnecessarily essentially have the job of fighting other people who get paid unnecessarily (ex: hospital billing staff warring with insurance).

Comparatively little goes to insurers. On top of that insurers are obligated to pay out 80% of premiums.

This article has been litigated elsewhere so I won't belabor the point, but it's very easy to use loop holes for this sort of stuff. Non-profits do it all the time. Oh yes we didn't make any profit, but all the executives and their nephews have massive salaries...weird that.

(the insurance companies can likely be run a lot more lean).

Not really.

if UnitedHealth Group decided to donate every single dollar of its profit to buying Americans more health care, it would only be able to pay for about 9.3% more health care than it’s already paying for. If it donated all of its executives’ salaries to the effort, it would not be much more than that.

In any case, insurers are obligated to pay out a percentage of premiums, not profits, so the accounting tricks you described are not relevant. Indeed, UHC paid out 83% of premiums in the year shown. Since the most anyone could expect from them is to pay out 100% (and they obviously can't pay that much), there is clearly not a lot of room to maneuver.

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.

Hmmmm, what's the explanation/incentive for their wildly shittier business practices then? They must be making money somewhere off of the sky high denial rates, no?

They make money off of denied claims, but the strategy can only go so far without falling afoul of ACA profit caps. They certainly aren't incentivized to pay out much more than 80%, it's just that even with high denial rates they can hit that target due to the difference in what they pay providers vs what they charge customers.

I mean I didn't realize it was premiums and not profits that's a my b, but there has to be some explanation for why their behavior is so much more obnoxious than providers and way their denial rate and so on is so different (30% more I think?)

More comments

-Okay how much of healthcare spending is doctor’s salaries?

About 8%. If you cut physician salaries by half you get 4% savings. That’s not a little but it is also not a lot.

This seems like a super-important number. I'd like to see the rest of healthcare broken out this way. Who, ultimately, are the people getting paid? Health insurance has a profit margin of 3.4%. So, stylizing a little, if I put $1 into the healthcare system, I have:

  • $0.08 goes to doctors via salary and benefits
  • $0.03 goes to teachers, engineers, and other retail investors via dividends
  • Remaining $0.89 goes to [???]

All the breakdowns I see look at institutions; but institutions are just placeholders. When we say "Drug Companies" got paid $1M, is that $800k in researcher salaries, $100k in admin, and $100k in marketer salaries? Or is that $500k in corporate dividends, $100k in researcher salaries, and $400k in marketer salaries?

The difference matters a lot, since - like you're saying - cutting healthcare means that someone is going to stop getting paid for work they're currently doing. And who it is / how much they're getting paid now matters a lot.

I've never seen it broken out in a way that granular but I expect a bunch of it would be line items like "secretary to assistant infection control nurse" and you'd be like "who the fuck is that and what do they do" to which my response would be "well I don't know who that person is, but I know the infection control nurse is the person who goes around cancelling all of our tests that will show that the patient got a hospital acquired infection" (through nobody's fault) because the government doesn't like when we have those.

The sheer number of admin and regulatory compliance people who don't really do anything has massively ballooned.

It's very much like universities.

"well I don't know who that person is, but I know the infection control nurse is the person who goes around cancelling all of our tests that will show that the patient got a hospital acquired infection" (through nobody's fault)

"this is the person who goes around committing what amounts to fraud because we don't want to get caught having caused an infection" (which is totally our fault, they got it while they were in our care). What do you think this sort of a thing sounds like to other people?

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.

but I know the infection control nurse is the person who goes around cancelling all of our tests that will show that the patient got a hospital acquired infection" (through nobody's fault) because the government doesn't like when we have those.

First thought: How is this a thing?

Second thought: Oh yeah, economics. Of course this is a thing.

Third thought: Can we shoot these people instead?

Fourth thought: It totally was somebody’s fault. I realize that meticulous clinical hygiene is hard. People will still die if you screw it up.

OH LET ME TELL YOU ABOUT WELLNESS MODULES.

Problem: Our resident physicians keep killing themselves.

Solution: Make them come in at 6am on their day off to spend 2 hours filling out un-skippable e-learning trainings reminding them that they should sleep. The person who worked a 24 hour shift over night and is being prevented from going home starts screaming incoherently. Then the hospital hires a "chief wellness officer" at executive pay scale who comes up with more wellness modules. If you are lucky they throw the residents a pizza party while they are working and the nurses eat their pizza.

Sorry one of the other comments made me think about wellness modules.

What is this place?

This website is a place for people who want to move past shady thinking and test their ideas in a court of people who don't all share the same biases. Our goal is to optimize for light, not heat; this is a group effort, and all commentators are asked to do their part.

The weekly Culture War threads host the most controversial topics and are the most visible aspect of The Motte. However, many other topics are appropriate here. We encourage people to post anything related to science, politics, or philosophy; if in doubt, post!

Check out The Vault for an archive of old quality posts. You are encouraged to crosspost these elsewhere.


Why are you called The Motte?

A motte is a stone keep on a raised earthwork common in early medieval fortifications. More pertinently, it's an element in a rhetorical move called a "Motte-and-Bailey", originally identified by philosopher Nicholas Shackel. It describes the tendency in discourse for people to move from a controversial but high value claim to a defensible but less exciting one upon any resistance to the former. He likens this to the medieval fortification, where a desirable land (the bailey) is abandoned when in danger for the more easily defended motte. In Shackel's words, "The Motte represents the defensible but undesired propositions to which one retreats when hard pressed."

On The Motte, always attempt to remain inside your defensible territory, even if you are not being pressed.


New post guidelines

If you're posting something that isn't related to the culture war, we encourage you to post a thread for it. A submission statement is highly appreciated, but isn't necessary for text posts or links to largely-text posts such as blogs or news articles; if we're unsure of the value of your post, we might remove it until you add a submission statement. A submission statement is required for non-text sources (videos, podcasts, images).

Culture war posts go in the culture war thread; all links must either include a submission statement or significant commentary. Bare links without those will be removed.

If in doubt, please post it!


Rules


Recommended Posts And Communities

Recommended Realtime Chats