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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 That's an outdated meme for the 70s and 80s.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.
Why would someone need to commit to being a doctor at the age of 16 instead of at the end of / after high school?
Because this process takes like 10 years and we'd like to hurry up so they aren't denied the objectively best years of their life? (Note that this also applies to every other college degree.)
What does that have to do with committing at 16?
Finish high school at 18-19, study medicine for 5-6 years, become a doctor like in Europe. This discussion is afterall about eliminating the pointless separate undergrad degree that artificially lenghtens that time in US.
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In most countries with this model everyone takes one giant exam that determines what you are allowed to do based off of scores. That's pretty self-explanatory and enables placement very proximal to graduation.
In the U.S. everyone (even for regular undergrad) does this whole thing with letters, and exams, and grades, and extracurriculars and a whole bunch of shit. This takes time. For Medical School as is - you have a full application year, given that this other stuff would not go away (for all kinds of reasons - including wokeness, racism, and more).
So you need to apply in the 15-17 range and have interest before that (assuming graduation age is 17-19).
The U.S. doesn't really have a culture of time off between high school and college (which to my understanding much of Europe does).
Over here the entry to study medicine is based on the nation wide matriculation exam and an entrance exam. The only time off is a couple of months in the spring of last year of high school to study for those exams (where the matriculation study is more or less considered part of the high school itself). In the good old days (ie. until around a decade ago), this would apply to most university level subjects. The only time "off" for studying for the entrance exams is around a month and half, certainly not an entire year (unless you are a middling student with delusions of higher performance or just too lazy to study that year in which case you probably won't get in after a gap year either).
Up until the winter of final year the only preparation you have to ensure is to take enough math courses (because math applies for anything remotely STEM-like) and whatever other subjects that give points for entrance (or are relevant in the exam). Thus the only extras you'd need to go from "pure engineering route" (ie. max math, physics & chemistry) to medicine would be a handful of extra biology courses, a fairly trivial undertaking for anyone actually capable of thriving in med school and something you'd probably do out of interest anyway if you were such person.
I don't see any reason why med school in the US couldn't use a similar combination of SAT scores and a dedicated entrance exam if they wanted to. Move the exam date slightly later, have the high school graduation in May and there's really nothing that would prevent a similar entrance exam based system.
I mean other than that's not how we do it here?
The woke have just run through a multi decade mostly successful plan to get rid of the ACT/SAT for general undergrad admissions and it's only now starting to cool off. They even managed to kill one of the physician licensing exams (making Step 1 pass/fail - was the main way to discriminate amongst candidates prior, and now the situation is awful).
Even beyond that extracurriculars have been a core part of admissions of all kinds in the U.S. for over a hundred years. It started as a way to discriminate against Jews and is now a way to discriminate against Asians and for other minorities but it's part of the environment and making it go away is a total non-starter.
You won't be able to change it just for medical education.
If your answer is "because the schools outright don't want to", then you should go and actually say it. Otherwise you're just stuck in a "We have to do it like this because this is how we do it"-loop that leads to absolutely nowhere.
I still don't see any reason that would prevent those med schools from just doing it if they wanted to. Which student is going to say "No, I'll just go and do a pointless and expensive intermediate degree instead and only then apply to what I actually want to study." Having entrance exams certainly doesn't seem to be any problem for various art schools that award university degrees, so there doesn't appear to be any fundamental limit to that.
If the answer is that we have to make massive changes to the entire structure of higher education in the US (and secondary education, too, since most high schools graduate in June), then that isn't really an answer. Not having to pay tuition will also encourage more people to go to medical school, as is the case where you are. I agree with you generally, but I don't think that it's feasible to suggest we overhaul our entire educational system.
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Let me back up and reiterate - the culture in the vast majority of undergraduate and graduate programs and types of program in the U.S. is that they have a holistic admission process that requires candidates to do a variety of things beyond just take a test and excel at it.
It's water. We don't do that here. And importantly - wokeness has made this orders of magnitudes worse.
You want that to change you have to reorganize the way education is done in the U.S. top to bottom, that's a big change and med schools aren't going to lead it.
Students, parents, the government - everyone expects extracurriculars and other holistic admission processes to be the lay of the land.
You are saying "well stop playing basketball, just play football instead." That is a ....big project.
Now as an adjacent matter I do believe the holistic admission process is in many ways better, but that's a separate thing.
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A great argument for moving undergrad or trade school back four years too.
Or more succinctly:
The amount of resource investment in a medical student (and later resident) is immense, like millions of dollars of physical stuff (like cadavers) and valuable time (not just lecture style teaching but academic physicians taken away from care provision to do education) and infrastructure. Not to mention the cost in tuition.
Once started you are locked in and if you leave at any time you leave with nothing. In the case of BS/MD programs if you drop out from difficulty you often end up without even an undergrad degree.
Even cutting undergrad out training time is 4+(3-7)+(0-???).
This isn't really comparable.
And all of that to say nothing of the Western values of general education and such that you get out of a regular degree.
Okay, so let's reduce the investment by $100k-$200k (average cost of undergrad degree).
True for every degree program.
Totally irrelevant, retention for GE material is near zero.
Talking to you on this topic is remarkable because you seem totally convinced that everything in medicine is exempt from fundamental economic laws like supply and demand, it's impossible to change anything that touches doctors without making things worse (pay no attention to the other western countries that train MDs out of high school despite the allegedly ruinous cost of this and the other countries being much poorer than the US), and this margin is too small to contain a description of anything that can actually be done.
I'd argue that other elite degree programs tend to have the ability to easily transfer credits to similar lines of work. If you can't crack Actuary you're still likely capable of landing as an accountant or data scientist or whatever with minimal disruption. Then you can still make a decent living.
Comparatively there's not really a ton of paths for a partial Doctor. I know in Australia a major university offered an undergraduate qualification in medicine that still required you to go through screening to get into Masters/actual practice pathway and people who couldn't clear that hurdle tended to have to go do an entirely diffeentg degree
If getting a BA before an MD is so great, people will do it anyway. The argument that med schools are doing this for the benefit of the students is bewildering.
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Medical school is totally different structurally than undergrad, and smart kids can struggle with academically rigorous programs, since high school success doesn't necessarily correlate with success in college. If being a doctor means committing at 18 to an expensive, academically rigorous, and time-consuming program that if they wash out effectively means starting college over again, I'm not sure enough will take the deal to meaningfully increase the number of doctors. At least in rigorous undergrad majors you spend most of the first two years taking core courses so if you struggle with college math then maybe engineering isn't right for you but at least you have your math credits complete.
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This is really just an example of the more general very common phenomenon where Americans (and yes, it's specifically Americans who do this) will treat their current system as an unchangeable law of nature when presented with "why don't you do X like this large group of countries?" instead of actually engaging with the question.
It's a strangely pervasive attitude that I've noticed it time and again ever since I first got internet access 30 years ago (first when it came to internet access and then mobile plans).
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I did not say that it is impossible to change anything without making things worse.
Also large swathes of medical care do not follow the laws of supply and demand due to things like inelasticity.
And also - medical school and residency need to be two separate buckets with two separate applications. One without the other does not work and has the potential to be worse than useless. This differs from most professional training.
Sure, but it is your uniform response to every proposal.
I'm not sure how you would have heard about "elasticity" without realizing that we talk about the "elasticity of supply or demand" and that it's a fundamental part of how supply and demand determine a market clearing price. To say that inelasticity means that supply and demand doesn't apply is to completely misunderstand Econ 101 level topics.
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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?
I don't think number of patients seen is a very robust metric, even if it's not useless. You also need to keep in mind that multiple med students or doctors in training can review the same person, even if they aren't handling the actual treatment. It's quite common for us to be to be asked to come up with a treatment plan in parallel, compare it to what our seniors did, and then have a discussion on the pros and cons of various approaches.
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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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