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We're no stranger to the immigration hot button here; we all want some way to filter for attractive women and investment dollars where we live and less competition for labor, but the want for those things proves weaker than the iron laws of supply and demand for both. However, here's a problem in the immigration debate that I don't think has come up in discussion before: ladies and gentlemen and undecideds of the Motte: how do we fix the doctor shortage?
And I mean globally. The solution many places settled on after it became clear that it was difficult to impossible to train more doctors locally is to import them, but this simply moves the problem around and causes brain drain as market efficiencies mean doctors move where they can get paid more.
Accounting for inflation, apparently physician pay growth is lagging although I'm not sure if anyone has more up to date information on whether this is still the case.
The easy low effort swipe is to make it easier to qualify as a doctor, but doing so without lowering medical standards and/or quality of care seems more difficult. There's also the simple calculus where people are less willing to take on, in the US, large amounts of student debt and to commit to the many years of study it takes to become a qualified doctor. After which you can look forward to high stress, long hours, dealing with patients, and potential lawsuits. It's no surprise that people would rather hustle sneakers or crypto or streaming when the effort to do so is significantly less.
Previously, governments would subsidize medical training as they saw medical professionals as a necessary function. Now, why bother? If there are opportunities and more money to be made elsewhere, they'd just move elsewhere after being trained, which would be happy to take them. Is there a low effort politically achievable band-aid fix, like making mandatory provision of medical care within the country a necessary precondition of qualification? But that'd make the profession even less popular - if you're a Kenyan doctor, fuck staying in Kenya if you can get paid multiples of that elsewhere.
Disclaimer: I'm asking for entirely selfish reasons. Working on a new investment thesis after the last one turned out spot on although with limited rewards so far for being right. I foresee this problem getting much, much worse as doctors retire, populations trend upwards in age and require increased medical care.
Doctor pay feels like something “when the data doesn’t fit the anecdotes usually the data is wrong” - which I think was a Bezos management philosophy.
I feel like I have a lot of friends dads who are doctors and clearing low 7-figures. My gut says the data isn’t capturing a lot of Doctor pay. Health care spending has exploded; granted a lot of this is the expansion of the administrative state; but are you telling me Doctors have failed to capture any of the increased spending?
Biotech stocks, pharma, etc haven’t done great the last decade. Who’s getting rich in medicine? We all know overall spending has exploded.
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Okay batching out my usual response to this:
-Most people don't have a good feel for what doctors actually do, your intuitions for your outpatient PCP are probably good, but outside of that something like The Pitt is more representative than general OP clinic life, and when you ARE in the hospital and you see your doctor for under five minutes it isn't because they are just chilling in an office somewhere doing nothing. This will be important for AI later.
-No the AMA is not conspiring to cause a doctor shortage. That's an outdated meme for the 70s and 80s. For the last few decades the AMA has been lobbying for an increase in supply via the production of midlevels (for senior doctors to supervise) and watching that genie get loose from the bottle. The AMA is also extremely unpopular with doctors, most doctors want more med schools and residencies, and we HAVE made more med schools and residencies. As it turns out what is actually happening with the shortage is (shocking!) highly complicated (ex: my rants about surgical modality changes making it so we can't really increase the number of surgical training slots anymore).
-The healthcare industry and government have been workshopping this problem for a long time. They've landed on midlevels as the solutions. As designed they work okay but they quickly metastasized beyond that and are a catastrophe. Putting aside the quality difference which yes is very real, they generate more shortages in some cases by over testing (which requires physician evaluation) and over consulting (ex: cardiologists are flooded with work that midlevels cant handle but is easily within PCP physician scope of practice).
-Decreasing training length by making undergrad medical school is a mixed bag. It works well in other countries with less economic opportunity and a less painful training period. In the U.S. you get lots of career changers into medicine (and you'd lose these) and drop out rates are reasonably high in med school/residency, this would worsen that problem. Think of all the Indian moms who would decide their 16 year old will be a doctor long before it becomes clear if that is reasonable. I don't know the drop out rates for BS/MD vs. traditional MD but I bet it's bad.
-AI is obviously coming but it's incredibly far from prime time. This is for a number of reasons. Risk: if we aren't allowed to have self-driving cars and it's taking forever but any accident is an unacceptable travesty...how much worse are people going to handle an AI getting things wrong? Lawsuits: people want to be able to see. You can't sue the computer. This is also one of the problems with midlevels, you cant sue them the way you can sue doctors. Hospitals like this. The actual work: most types of physician tasks aren't "I have x, y, z, how do I treat this?" Usually you are managing several comorbid conditions that overlap, trying to interrupt what the symptoms the patient tells you actually means "I am dizzy" means different things to every patient and will send you down different rabbit holes. Patient's who can't communicate well or have to be visually eyeballed and examined are a huge part of the work. That's not counting physician leadership roles (aka motivating the nurses) and so on. The types of ambiguities that exist in actual clinical practice are huge barriers to AI taking over. It will happen one day but by that point everyone has lost their jobs.
This just seems like obvious nonsense. When you make something cheaper to do, people do it more. There's more people who would be willing to become a doctor if it means four years until you get a degree, not less.
Committing to being a doctor at age 20-28 is very different than age 16. At the latter people are mostly forced in by their parents, haven't explored their interests and haven't exhibited durable commitment. With how bad residency is, that's important.
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So this is a good writeup of what the problem isn't, but I notice you don't actually say what the problem is that's creating such a shortage of doctors. Is it just that there's so much medical knowledge now, compared to the past, that it's impossible to find enough people who can learn all of it?
It's complicated, multifactorial, and hard to convey quickly and clearly.
The population, amount of knowledge, complexity of patients, and demands on doctors have all increased sharply. This also means that training is harder and more burdensome, this can be partially fixed by increasing spots but not entirely. At the same time the positives of the profession have decreased (including respect and wages relative to inflation). It makes sense that less people would be interested, that they'd be of lower quality, and that they'd want to work less when they are in it. Back in the day you could hang your own shingle and become truly wealthy and some people did that, working 2-3 full time jobs worth of patients seen. People don't do that anymore nearly as much. Likewise we've adjusted who we choose to be doctors away from mercantile money types and hard working autists. We have more need, more complex work, less people doing to relevant to the population, and those each doing less work.
A bigger problem is the allocation one. Most of the types of work are not primary care but most of the volume of patient doctor interactions are primary care. You need to encourage people to do that, in the area that needs them, but the job is no fun, harder than other, and pays less - a solution of "pay more" does help with the problem but is gloriously unpopular for the obvious reasons.
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If I understand correctly, the big problem with training doctors is they need to see a certain number of patients (say 10,000 for neatness) before they have seen 90% of the full gamut of what they might experience while practicing on their own.
This takes time and there's a saturation effect. You can make it take shorter time by forcing medical students to work for 80 hours a week, but you can't (or at least shouldn't) make more patients for trainees to see. In a given city, there will only be 100,000 people who need to see a doctor (in that specialty) that year, and so if you have a four year residency, each resident needs to see 2,500 patients a year, and only 40 people can be in residency a year in that city.
The confusing thing is how it ever worked. Was there a huge pathway from "war medic to ER doc" that we're missing now?
It isn't quite as universal as all that, procedural skills and procedural specialties for sure need that, for medical specialties you can usually do a decent enough job with adequate extended length education and case simulation.
However the specific problem you are talking about kinda stems from improvements - as surgical technology and medical management improves you don't need to do certain kinds of things as often. This is great! But some things you simply cannot be allowed to do alone for the first time without decades of experience pecking at the margins to improve skills in aggregate.
This means that the number of surgical specialists needs to be restricted by supply of ill patients, and furthermore by supply of academic centers that can actually train them.
If you gave the SE federal funding for 2,000 extra general surgeons they just ....couldn't do a good job. The NE might be able to figure it out.
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It's fun reading the Flexner Report from 1910, when the problem was too many, too poorly-educated doctors.
Back then it was possible to get an M.D. degree by attending one or two years of evening lecture courses (sometimes without having graduated high school!), observing one dissection from a distance, and never getting experience treating any actual patients.
I'm sure you know this but it's worth reemphasizing that the amount of stuff a doctor has to know has absolutely exploded in recent decades.
Compare the size of First Aid for Step 1 between now and 2004.
Related: the us training model worked much better when most of patient care was hopes and prayers.
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Assuming we're talking about the US, why not make medicine an undergraduate degree, like it is in the rest of the world?
This would be a good step. In the US we can also likely lower standards for becoming Doctors if we increase our capacity to train Doctors. There are plenty of kids who would become Doctors if it was easy to get into medical schools and a shorter path. Plenty of kids at top 30 US universities getting filtered out who still have very high academic standards.
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Wrote a little about this in my general comment elsewhere in the thread.
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Yes, this would add four years of practice per doctor without lowering quality.
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Acrodding to a video from PolyMatter <America’s Self-Inflicted Doctor Shortage>, it seems like the issue comes from not enough funding to incentivise hospital residency program, seems like a regulation problem of introducing regulation that increase friction (residency before full licensure) without regulation to ease it (give funding to hospital to increase spots)
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Speak for yourself. While I obviously would prefer less competition for my own particular field, I want a meritocracy for other fields. If an immigrant is a better and/or cheaper home builder/chef/actor/professor/nurse/house cleaner/whatever than a native, I'd rather have the immigrant then. In the same way I'd rather have the better/cheaper robot than the worse human.
Well, automation is actually even better since while people tend to be a net positive generally, automation is generally even more efficient in the input vs output long term. It's why I don't worry about AI "taking our jobs" if all the work I could possibly do is automated then surely pretty much all the work I would want done for me is also pretty much automated then too right? A robot might take my job, but what need is a job when every material good I could want a robot gives. Control of natural resources matters more than anything else then.
If there was a magical way to carve out "meritocracy for everyone but me" it would be the optimal me orientated solution, but obviously that doesn't happen.
And many Americans agree with me, not in a culture war sense but in the business sense. Any of those jobs that gets "stolen" is another notch on the bedpost here. Whether it be high skilled work of lazy college grads losing to the extremely intelligent and hard working Asian programmers or the opioid addicted white trash dregs of society losing to the Hispanic guy who bothers to show up to work on time every day without a hangover, or the phone operators losing their jobs to automatic dialers, the decision is made by Americans everyday looking out for their businesses best interest.
Isn't the issue with this that there's a raft of externalities. If ongoing citizenship were assigned at 21 on the basis of productivity it'd work, but the natives who got outcompeted don't suddenly phase out of existence. Especially in our current system where they will be supported regardless meaning the immigrant not only needs to be better they've also gotta be sufficiently better to deal with the increased social bill created by taking the native Born's job?
Typically throughout history, automation and immigration displacement just leads to other jobs being done or even created. Work exists to do something someone wants, whether it is the work of mowing the lawn so you can have cut grass or the work of clicking on a spreadsheet so you can optimize portfolios or whatever.
So until we run out of people's wants, jobs can't really dry up in the long term. There can be temporary issues, especially with older workers who won't/can't shift gears so easily but otherwise the total amount of production in the world just goes up because instead of just having a person do X with their time, a machine does X and the person does Y different thing.
Think of it this way, you live in the past and before you have to leave for some event, you have enough time to either clean the dishes or beat the carpets down to get the dirt out of them. You can only choose one, so your production is 1. A machine that does the dishes for you allows you to beat the carpets down instead, making a production of 2 before you leave. If you have a machine that does both, you might come up with another task like hauling some wood for the fire and get a productivity of 3.
If we ever get to a point where jobs aren't really a thing you can get anymore in the long term due to AI, then what do you even want a job for at that point? That would be a world where pretty much all people's wants that can be fulfilled are already fulfilled. That we're at productivity of googol^3 or whatever and there's nothing else to do for yourself or others.
I'd argue that a lot of modern jobs in the Western service economy are just clustering awkwardly into makework on the side of vast surpluses that aren't necessarily reactive to extra peons. If the international competition was coming in for widget creation and Interational expertise could guarantee 6 widgets per hour instead of 5 for a domestic person, sure. The modern scenario seems a lot more along the lines of 'specious laptop job exists, foreigner is willing to do some combination of working for less/exaggerating qualifications more and little marginal benefit is derived by society.'
Your examples are all conspicuously physical realworld activities that can be tied easily to an actual output. In the real world, especially the sort of skilled professional laptop job reality that most Mottizens are living in, a lot of jobs are more sinecures for being on the right team/time and place than they are productive organisms. Handing those out to foreigners is literally insane behavior.
Yeah I've never bought the "bullshit jobs" sort of idea. If people are willing to pay to have you do something, then clearly they must think you are bringing them value somehow. Not every single individual job is necessarily worth it, businesses are run by people who make mistakes and miscalculations too but overall there must be some sort of value somewhere or else why would they pay? I doubt the modern job is actually just corporate charity to the employees.
I think this sentiment is more that our work has become so abstract and intangible that it's harder for us to measure. This probably does increase the error rate a bit, but it also means people don't realize how they're being productive in the same way.
I'd wager I'm in the upper percentile of Mottizens for lifetime earnings due to a early startup lottery hit and in yhe vast majority of my jobs at larger corporations my function had a lot more to do with managerial largesse and posse-forming than anything resembling an output. Even if the title were somehow associated to something resembling productivity how the individual actually contributes in a larger business is pretty damned tenuous.
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What about the things that are not so easily quantified in economic models?
eg:
But it all together and this might make for an ugly sort of cyber-feudalism, where a rich few control all the wealth and the vast underclass can only find work in humiliating servant type roles for the rich.
If there are wants and needs unmet then there's either still work to be done in meeting those or it's a deeper issue that just happens to intersect with how we currently work, but is fundamentally different from it. I don't know how exactly we're going to solve these deeper problems of the human condition.
It could be as silly as everyone willingly living in VR where their virtual AI neighbors are just slightly worse off than them, the neighbor husband and wife are slightly less attractive, the kids are slightly more misbehaved, etc. And maybe we intentionally pull back automation in some less important fields just so people can feel good working a few hours every day.
Otherwise for status and power over others, it's impossible for everyone to be winners no matter what because it's entirely based around having other people be losers. Just not solvable there. It's why I really do worry that we're gonna have a permanent AI enforced underclass slave society that exists not because of economic usage, but so the AI overlords in control of the Killbots can feel good about themselves. They will be forced into work not because they're more productive than the automation, but because there must be a loser to suffer.
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I wish I could show you the face I made reading this comment.
I'm- I'm sorry, I have nothing to add to this. I mean, you're spot on, but seeing someone say it in plain language makes me even more cynical than I was previously.
I suddenly have no sympathy for anyone working in a creative field who cannot make art better than an AI.
Yeah I don't care at all about the artists losing their jobs being "stolen" by AI. If it's something you're passionate about, just do it on your own. You should be more worried that you won't have art supplies for your passion projects cause the AI overlords can take away your access to the world without means to resist their killbots.
Especially when it's clear that most of what they're making as a job isn't even something they want to make. I don't think many artists actually consider their life calling to be drawing the furry diaper porn for horny customers and generic boring corporate art style pieces for big companies right? So if anything, outsourcing all the work parts of art should be a plus for artists who want to make their passionate and personal pieces.
I for one do have sympathy for the artists.
Traditionally, automation improved job quality. Plowing the fields manually is back-breaking work, steering a farm tractor is a huge improvement over it. Likewise, multiplying numbers all day long was probably considered soul-crushingly boring by most of the human computers, and they would rather have a job dealing with fucking Microsoft Excel.
The obvious bottom job to automate would be the workers at Amazon warehouses. Sure, some would be upset until they found other work, but nobody would claim automation stole my dream job of fulfilling customer orders while peeing into bottles.
However, creative pursuits are actually the least intrinsically soul-crushing work there actually is. I imagine that there is competition between artists -- likely not everyone who would prefer to make a living drawing furry porn can earn enough, just like there is competition in pro sports, with a lot more people interested than the field can support.
Competition from AI art is a bit like allowing motorbikes in long-distance running. Suddenly you are not competing against your fellow humans any more. We are not yet in the stage where any kid could just spend 5k$ on a used bike and trivially win against the best human runner in the world for art, but this is clearly the way things are going.
Now, that would suck a bit if we were actually in a post-employment UBI stage where the artists would be free to spend their lives to make retro human-created art as a hobby, just as they might become chess grandmasters despite any kid with a mobile being technically able to defeat them. But we are not in that stage. Instead, we tell them 'why don't you work in an Amazon warehouse as a day job and make your now non-competitive art in your spare time?'
Yeah that's the main issue. First that there's no guarantee we have this sort of futuristic utopia where work doesn't exist (because it's all done by the robots) and we just pursue pleasure and "greater meaning" in our lives instead of a hell scape where most humans are deemed undesired by the AI overlord in charge of Claude Control Killbots, but also the transition period between now and then is going to be hella rocky and people will be hurt.
But this does happen, to a lesser degree, about other forms of work already. The solution the US seems to have is disability. We had a surge of disability applications during the long period of unemployment of the great recession for instance. We say "on you're too old to meaningfully adapt and find another job anymore, so we're essentially just gonna give you this as early retirement". One of the ways you can tell we do it as early retirement too is that the disability crisis we had in the early 2010s disappeared in the late 2010s/early 2020s, they all transitioned into normal retirement.
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I suspect the dam on AI medicine is going to break quicker than anyone believed possible. Many of the gatekeeping functions of doctors, like writing prescriptions, are already being outsourced to NPs, and AI will act as the gatekeeper to them or, if you really seem to need it, an actual doctor. We don't have enough doctors to do the global doctor workload; we probably do have enough doctors to do the things only doctors can actually do.
What is the global doctor workload though? Is it bringing every single human being up to the standard of care available to a billionaire in New York? Relatively small changes like antibiotics and hand washing seem to have narrowed the life expectancy gap dramatically between the developing world and the developed.
How much medical investment and man-hours goes to end of life care that's not likely to actually create real dividends?
The global doctor workload is the aggregate effective demand for services which must be provided by MDs. Since very little of healthcare functions based on market dynamics, this mostly resolves to "how much are governments/charities/insurers willing to pay for", which is basically "how much do they need to pay for before people flip out at them to an extent it causes them problems". I suspect that line is actually surprisingly easy to move, that it will move by necessity with our aging populations, and we are already seeing it move (not just delegation of doctors' authority, but stuff like MAID).
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Isn’t the doctor shortage almost entirely because the AMA restricts medical school class sizes? I know of at least one quite smart and motivated guy who did not get into medical school when he totally should have. People are doing insane resume padding things like working in hospitals for a few years before medical school. The doctors have a midevil guild and they are restricting the supply of labor, patients be damned.
This is exactly it, but anyone with fancy letters next to their name will kvetch and contort their words all over to avoid taking responsibility. No one with a medical degree should be in charge of deciding who else can get that degree. There's no clearer modern racket to me.
Quickest way out is probably just to pass legislature allowing PAs (and maybe NPs, but I'm more skeptical of their training) to perform without an MD above them - but of course every time this comes up, the AMA lobbyists come out in full force.
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This an outdated meme, wrote a bit more about it elsewhere in the thread.
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The evil seems more than just mid, honestly
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According to Scott, the real bottleneck is residency slots, not med school. He himself spent a year without practicing because he could not find a residency after graduation. Residency is expensive for the hospital, so it depends on government subsidies, and the government doesn't subsidize enough residency slots to keep up with demand.
As I understand it, one common workaround has been to give more power to nurses and other assistants, while having the actual doctors simply look over and sign their names after the fact, effectively turning them into managers. For example, whenever I go to the local community health center, the person who sees me and prescribes my medicines is always an APRN or a PA, never an MD.
Of course, would be easier to abolish residency.
If you'd like to deep dive into the causes I recommend sheriff of sodium on YouTube.
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Nurse Practitioners and PAs aren't really Nurse or assistants as such. The are medical providers who study medicine albeit in a shorter program then doctors. They are whole new category of "midlevels" not normal nurses or medical assistants. PAs probably fit the role designed better. Nurse practitioners have more variety in the standards of their training programs and can operate totally independently in many states which seems to be going to far to me.
It's worth noting that PAs do get a somewhat condensed version of the physician curriculum, but NPs do not actually learn regular medicine.
That sounds ridiculous and it is. It should also stress you out and if it does, good.
It doesn't. I would much rather have half a doctor than no doctor. Specially when I am not legally allowed to buy any useful medicine without a prescription.
The day when MDs and PAs are so numerous that they are working for minimum wage and you can find one on every street corner is the day when I agree that NPs should be held to a higher standard. Until then, I am in favor of anything that increases the supply of healthcare.
This sounds good until you create more work by being incompetent. Psychiatric NPs are famous for doing this by putting patients on unsafe medication regimens that increase total burden to the system.
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Exactly. It seems pretty implausible that the current medical hiring split is the one that's maximally recruiting those with the capability to be good medical professionals, especially when there's a ton of random carveouts for affirmative action identities
I will absolutely complain about affirmative action in medicine but the problem is a bit more complicated - for instance we've decided to push away the autists in favor of socially minded types. This is both good and bad.
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