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PaperclipPerfector  13d ago (text post)   27210 thread views

Culture War Roundup for the week of October 13, 2025

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Thank you for taking the time to explain! I'll commit this to memory, whatever is left in it that's not receptor binding variances.

I will say that the shortage in specific competitive subspecialties is a little more complicated - I can't say for sure that they are lobbying to reduce training volumes but it wouldn't be a stupid thing for them to do. That said for many things (especially surgery) getting requisite case volumes and educational quality is an important complicating factor, especially in the era of robotic surgery.

Most of the "shortage" is inadequate primary volume, but primary care doesn't actually pay that much and people want to be in big cities so it is an allocation and funding problem.

But since "pay the doctors more" is an unacceptable response...it doesn't go anywhere.

If you'd like to learn more about the noodly bits of the American system their is a YouTuber Sheriff of Sodium who does long form videos analyzing these things.

Hmm.. I appreciate the context, but it seems somewhat orthogonal to the concerns I'd raised earlier. It is nigh universal (across professions to boot) for doctors to want to live in urban environments as opposed to some sleepy Appalachian town. You can increase the number of rural doctors by either increasing salaries (as you've mentioned as untenable) or by having so many doctors that market forces... force some of them to go to less desirable locales.

Now, I'm not advocating for the latter, I would like to live in a proper city myself. But I think it's obvious that that approach works.

You may not like the latter, but fear of it is clearly part of the reason for the strategy. Note the very first words from him when he began his justification:

The government funds a good chunk to most of the residency spots

This is hiding that the industry is playing games here. I described the game here:

"We won't train doctors to the regulatory standard unless taxpayers give us bundles of money to do so," is an obvious confluence of terrible interests in the private sector and government, especially when the industry has achieved significant amounts of regulatory capture. Surely, there is a better way.

Imagine this in other industries. Grocery stores get the government to set up a licencing requirement to stock shelves, with some boilerplate reasoning about food safety or something. The thing is, the only way to get licensed is to get a grocery store to give you the mandatory years of experience. And, of course, they refuse to have such positions unless the government pays them for it. I would predict that there would be fewer grocery store employees, their pay would be higher, industry profits would be higher, government outlays would be higher, prices to the consumer would be higher, and service quality would decrease.

The kicker is that the industry gets to choose the regulatory standards to boot. I completely agree that there are going to be some standards. In my follow-up comment, I make comparisons to how we see similar problem when universities control their own accreditation standards and leave a related thought experiment for grocery stores:

Let's put it this way - perhaps there is a "right" level of training for doctors, and perhaps there is a "right" level of training for grocery stores. Maybe the latter is much smaller than the former. Now, imagine we set up the system I described in my last comment for grocery store training. Do you think their incentives would lead to them selecting the "right" level of training?

If they successfully restricted supply, you'd see the same sort of situation where there are desirable/undesirable locales for grocery store workers, and you could imagine the same sort of ignorant-acting pleading that oh it's just not their fault that everyone wants to work in the fancy grocery stores in the cities; I guess your only choice is to raise salaries (please ignore the licensing regime).

You see the exact same self-dealing that you see in other industries that get this sort of sweetheart deal over their own regulatory apparatus, as I described here. In that comment, I was discussing Alex Tabarrock reviewing Rebecca Haw Allensworth's book "The Licensing Racket". I later saw an interview with her and discussed it here. All these industries that control their own regulatory apparatus display the same phenomenon. When it comes to actually enforcing standards on their own, the people who are part of their club, it's, "Meh. Maybe we'll get around to it." (There are horror stories.) But when it comes to shutting out competition, the tone changes entirely, and it's alllll about their supposed standards. (There are horror stories here, too.) Alex describes the phenomenon in the medical industry thus:

No system is perfect, but Ms. Allensworth’s point is that the board system is not designed to protect patients or consumers. She has a lot of circumstantial evidence that signals the same conclusion. The National Practitioner Data Bank (NPDB), for example, collects data on physician misconduct and potential misconduct as evidenced by medical-malpractice lawsuits. But “when Congress tried to open the database to the public, the [American Medical Association] ‘crushed it like a bug.’”

One of the most infuriating aspects of the system is that the AMA and the boards limit the number of physicians with occupational licensing, artificially scarce residency slots and barriers preventing foreign physicians from practicing in the U.S. Yet when a physician is brought before a board for egregious misconduct, the AMA cites physician shortage as a reason for leniency. When it comes to disciplining bad actors, the mantra seems to be that “any physician is better than no physician,” but when it comes to allowing foreign-trained doctors to practice in the U.S., the claim suddenly becomes something like “patient safety requires American training.”

I'm generally not super high on game-playing with residency slots - or even shutting out foreign doctors - being a huge factor in overall medical costs; they're probably factors, but probably not big ones. I just get annoyed at the games being played and the fractal bad justifications offered. He once offered this data to claim that there is a "surplus" of residency slots. I didn't think the data presented supported the claim, and I think he's refrained from making that exact claim anymore, instead just still demanding (while thinking nothing of it, like it's totally normal) government-funding for all training slots (that they control) and repeating that there are still some unmatched slots. I think the alternate explanation that there will always be frictions and that an increase in slots will probably still result in about the same amount of unfilled slots within some range is probably still at least as plausible.

You do very well to notice that doctors are not special in that economics still holds for them. Don't let him convince you that the same incentive problems we see in every other industry that has similar control over their own regulatory apparatus somehow don't apply to doctors as well. I argue very similar phenomena in other industries, universities, realtors, etc. Each domain does have some unique twists, but many of the basics are similar if you understand economics and incentives.

Some of it is a focus on hard blue tribe recruitment.

Getting through the undergrad and medical school filters requires a lot of woke interest and an aversion to red and rural areas.

Do some affirmative action or requirement focused on getting people who want to go to those areas and you'll have doctors who want to go as an adult, but for now a lot of people are straight up afraid of big cities in Florida because of dem Republicans.

Doesn't just need to be salary push.

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