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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.
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?
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.
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