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Nah, I am fond of you, even though I agree we have our disagreements. I can't even be mad at the AMA, they're not responsible for my med school being subpar and lazy.
I was just in a very bad place yesterday, largely to do with the fact that I work in the UK, where I ended up at precisely because I'm still not eligible for the USMLE. That makes the whole situation somewhere between academic and painful to engage with, what difference does it make what I think?
(This standard, applied fairly, would preclude most engagement on this platform. I will cop guilty to mild hypocrisy.)
For what it's worth, I think American doctors are world class, only closely rivaled by places like Singapore or other very rich First World countries. The UK is far more uneven, even if I regularly meet doctors who are both better than me and are at a level I would consider well past competent. India? All I can say is that there are plenty of doctors who are world-class, and I know many who would easily fit in in the US. And a lot of idiots who would find a way to kill a cadaver.
Where am I in the grand scheme of things? Idk. My confidence is shot in many ways, but I think the objective evidence, at least from exam results, is that I am above average with respect to my peers in India or the UK. I am not a senior physician, so I suppose that is good enough. I can handle most things in psychiatry, at least if I have time, Google and ChatGPT to help me. I absolutely can match my bosses if I have those tools at hand, which I do have in most scenarios that aren't academic assessments.
However, the medical training pipeline in the US is a bad joke. Mandatory pre-med? What the absolute flying fuck. I don't need my surgeon to have read Seneca in order to harvest my appendix. Even harder stuff like chemistry or microbiology is a waste of time, the syllabus covers everything we need to know. There is very good reason that the rest of the world doesn't do this.
Then there's the fact that the sheer explosion in mid-levels is because of the doctor shortage. I think that, in objective terms, there is nothing wrong with making tradeoffs between quality and availability. Otherwise we could have only the single most talented med student per year become a doctor, and have them train for 50 years so they can handle their own geriatric care right before the next candidate takes them off for MAID.
If you can't legally do that, since the quality of medical training is sacrosanct, then the system will try very hard to route around doctors. I have no reason to think the US has found the global optimum, and I think you guys are too strict. Obviously, I wouldn't endorse any measures that dilute physician wages to the point nobody bothers, but that is very unlikely to happen anyway.
If you float a bill that says: all global physicians who come from a very specific med school in India, have practiced in the UK, are at least six feet tall and right-handed, are welcome to enter the US? It would have my vote. But I am obviously biased.
Anyway, you needed up coaxing me into a more substantial reply than intended, so I hope both you and @DirtyWaterHotDog are happy. Still not everything I have to say, or could say, but it's something.
I think it's important to keep in mind (and this applies to the AI side of things also) that the U.S. is a weird country and that weirdness has benefits and costs.
One of the things that pops up is that the number of demands on U.S. physicians extends beyond beyond academic medical knowledge, this is one of the reasons that individuals with perfectly excellent medical knowledge sometimes don't survive the retraining process.
Doctors here have to survive the vagaries of our legal system, malpractice environment, U.S. patients (who are...different) and other factors. This requires both higher standards of behavior and other standards of behavior.
Much of this I would happily get rid of, but that's not usually the targets complainers want to go for. Tort reform would solve a lot of problems.
With respect to the physician shortage, it mostly isn't real.* If you live in a reasonably sized area you can get a PCP. You may need to look around, and you may have to establish care before you get sick. But the problem is that U.S. patients are demanding and don't want to think ahead and want instant gratification. If you live outside of a major area you may not be able to find a doctor but that's because of the allocation problem. Midlevels don't fix the allocation problem because they also don't want to move to those areas and then don't.
For specialists the situation is more complicated, some of them can't be replaced by midlevels, cant really increase training amounts, others have had shortages get worsened by midlevels (like cardiologists getting over consulted, same for neurology and some others). Others like psychiatry have a situation where people just stopped taking insurance and do cash pay because its more lucrative leading to a phantom shortage.
*Strong disconnect between the feel people have about this and the actual numbers.
I can't really argue against you, can I? It's been like 25 years and change since I was in the States, and would have been like 6 months if my visa didn't bounce. Perhaps American patients genuinely are more demanding and entitled, I can promise you I have seen more than my fair share of demanding and entitled patients in the UK (while the NHS is free, a doctor is not considered that different to a bus driver). I have seen demographic disasters/marvels that have simultaneously made me lose hope in humanity and rekindled my optimism for medical progress. Like seriously, how the fuck are some of these people still alive?
However, I am confident that there is a severe physician shortage when you leave urbanity. Several states, from memory including Texas and Mississippi, have quite recently massively relaxed the requirements for foreign doctors to come and practice as long as they go to underserved areas. They don't even need to have cleared the whole USMLE, let alone have completed a residency. You bet I follow that kind of stuff like my life depends on it, in a very meaningful sense, it does.
The fact that this happens at all, let alone in like 3 or 4 states (could be more) is suggestive of something. Of course the typical doctor wants to be in the Big City and will fight to go there. In India or the UK, where doctors are more abundant, the sheer competition will force some of them to take up less than ideal appointments, albeit not at major loss to earning potential.
I've worked in for-profit systems, in not-for-profit setups, and plenty in between. I would be rather surprised if the US was qualitatively different and not merely quantitatively so. I would happily take the hassle of insurance and the extra medicolegal liability if I could double or triple my income. I'll take the risk of getting shot or knifed. You guys have it very good, by global terms, at least when done with residency.
This is not really an argument that we should let every dude with half a frontal lobe practice medicine, or that doctors should be paid worse. But I think you heavily discount the risk posed by AI, both present and future. I have had senior doctors, family and otherwise, try and flummox recent versions of ChatGPT. They can't pimp it. It will out-pimp them. It's not going to do surgery for you today, or even next year, but many branches of our profession do not rely on procedural skills to make a living (I say, while crying that I have to do cannulations, catheterization or conduct ECGs because our nurses are useless).
With respect to AI, I'm sure it will get it done eventually, and I am sure it has tremendous pressure to do the job.
AI can do simple fact recall, it struggles much more to deal with a patient who tells you he fell and can't move his leg at all when really it's he won't move his leg due to pain. The AI will probably assume a neurologic deficit and trigger a work-up for that. A physician will poke the patient and see him move and assume traumatic injury. Someone needs to get clean data to give to the AI for outsourcing to work (for now).
And yes some states are doing alternative paths to practice, this is exploding in popularity and it's a solution to the allocation problem. It may even be a good one, it seems ineffective so far though because people can't get malpractice coverage or privileges without actual training - the liability risk is too high.
I am sorry to say this, but you are woefully underestimating the ability of AI.
I threw your hypothetical into ChatGPT, the paid version, and even before it finished thinking (it's doing a lot of thinking, and it all seems relevant) it immediately noted:
Emphasis added.
In the full workup, it mentions:
Seriously, try this for yourself. Get a paid subscription and try and find a clinical scenario where the evidence you have provided has a definitive answer, which the AI is unable to diagnose even after the same amount of effort a human clinician would devote.
Here's the full conversation, if you want to take a look:
https://chatgpt.com/share/69be7d62-ad60-800b-a335-bf527ee5168e
AI can't do a lot of clinical work, because it lacks hands. But it can borrow someone else, say an NP or PA or just a nurse. And then it can do things that would otherwise take a human doctor.
I don't want to undermine our profession, but you have to understand that I value probity over professional solidarity, at least if challenged. When I do disclose how close we are to replacement, it's where it doesn't matter, I don't want to lose my job either, but I can rarely bring myself to mislead when I genuinely believe otherwise. I'm not accusing you of being misleading, by any means, but consider this example a data point that you're not considering how scarily good LLMs can be. We can take this to DMs if you prefer.
No I get they can do fancy things, but translating those in a real environment is HARD. We will get there eventually, but we can't get self-driving cars approved because of the liability and failures - medicine has just has much cost pressure to do so but as much contrary pressures (if not more because of people's demand for a person).
We also have a side game where LLMs are killing skills and knowledge development by outsourcing thinking (ex: in note writing). That will be a separate problem.
It's 2026, the US has Waymos in Phoenix, SF, LA and slightly more limited availability in Austin, Atlanta, Miami, Dallas, Houston...
That is a lot of of people (50 to 60 million people nominally served). And that is today.
It's one thing to say self-driving isn't going to happen when they're puttering around in a DARPA course and knocking over half the cones. A whole different kettle of fish today, when a good fraction of your country can step out and order one through Uber.
It's like claiming we can't land humans on the moon after we have manned spaceflight and rovers on the surface. While we have hundreds of billions of dollars (or pretty much all the positive growth in the US stock market) and thousands of the world's smartest people, some of them drawing literal billion dollar salaries working diligently to make it happen, as is the case with AI.
I would not bet against it. Maybe it's more academic for you, you've probably had a decently long and well-remunerated career. On the other hand, I face a very real threat of being deported after outliving my welcome and then coming home to a ship that is simultaneously on fire and sinking. Oh well, at least I can probably make it through my psych residency before things get that bad, the ladder is rapidly ascending beneath me every time I look down. We can argue about timelines, it might take 5 years. It might take 10. It won't take 20, I'm confident of that much, and I really put a lot of thought into this.
I wish I am wrong, and you are right. But if wishing were horses, I'd have made PETA very mad by making a living life raft to the States already.
Sure self-driving cars are getting there, but they aren't fully in use yet, and the legal tests aren't all the way there yet.
AI may in fact replace everyone at some point, doctors have more physical work, patient interaction work, need to be a liability sponge, and so on than most other white collar work.
Yes the financial pressure to replace us is higher, but by the time they come for us in a serious way everyone else is gone too. Especially in psychiatry - you should have some safety there. More likely is an intractable increase in volume due to AI assistance.
In any case, even the finance people who love this shit are starting to push back against the way our economy is overweighted.
LLMs might just end up getting dropped as a boondoggle before they apply to too many use cases.
All fair points, but you have to consider that I'm pricing them in. I think that the regulatory and legal hurdles associated with replacing human doctors will buy us anywhere from 1-5 years once automation-induced unemployment has really taken off it. It's already started, but I'm talking >25% of the population being laid off and unable to find a job that pays nearly as well.
Even if it "merely" augment humans, the elasticity of demand in medicine is not literally infinite. A world where 90% of the doctors are laid off while 10% supervise mid-levels and oversee LLMs (both as troubleshooters and liability sponges) is almost as bad as 100% of us being laid off.
Once a large fraction of the population is unemployed and baying for relief, how long do you think governments can hold out and keep doctors on a pedestal? The AMA is not all-powerful either. It's even worse in the UK, the NHS is floundering, and Rishi Sunak wanted to keep us uppity doctors in check by replacing us with AI and midlevels years ago. They couldn't pull it off then, but it is an increasingly real possibility now. The very fact that doctors are rare and expensive in the US makes you excellent targets. You can't hold out forever. Once a single country or even a state bites the bullet, and succeeds (or doesn't crash and burn), there's going to be a domino effect.
Hell, even places where doctors are more abundant and cheaper aren't safe, mostly because AI is even cheaper and because they're poor countries without the luxury of swallowing as many systemic inefficiencies as the US system can tolerate. The relevant comparison is the delta in pay between the next lower rung of the ladder + a ChatGPT subscription vs a human doctor (or drastically fewer human doctors). That is a very large financial attractor, and barriers are not airtight or as robust as either of us would like.
Anyway, give it 5 more years and we'll see who's right. It's not like I think that being correct about this will change the trajectory of my life, I can only try and lessen the blow.
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