This weekly roundup thread is intended for all culture war posts. 'Culture war' is vaguely defined, but it basically means controversial issues that fall along set tribal lines. Arguments over culture war issues generate a lot of heat and little light, and few deeply entrenched people ever change their minds. This thread is for voicing opinions and analyzing the state of the discussion while trying to optimize for light over heat.
Optimistically, we think that engaging with people you disagree with is worth your time, and so is being nice! Pessimistically, there are many dynamics that can lead discussions on Culture War topics to become unproductive. There's a human tendency to divide along tribal lines, praising your ingroup and vilifying your outgroup - and if you think you find it easy to criticize your ingroup, then it may be that your outgroup is not who you think it is. Extremists with opposing positions can feed off each other, highlighting each other's worst points to justify their own angry rhetoric, which becomes in turn a new example of bad behavior for the other side to highlight.
We would like to avoid these negative dynamics. Accordingly, we ask that you do not use this thread for waging the Culture War. Examples of waging the Culture War:
-
Shaming.
-
Attempting to 'build consensus' or enforce ideological conformity.
-
Making sweeping generalizations to vilify a group you dislike.
-
Recruiting for a cause.
-
Posting links that could be summarized as 'Boo outgroup!' Basically, if your content is 'Can you believe what Those People did this week?' then you should either refrain from posting, or do some very patient work to contextualize and/or steel-man the relevant viewpoint.
In general, you should argue to understand, not to win. This thread is not territory to be claimed by one group or another; indeed, the aim is to have many different viewpoints represented here. Thus, we also ask that you follow some guidelines:
-
Speak plainly. Avoid sarcasm and mockery. When disagreeing with someone, state your objections explicitly.
-
Be as precise and charitable as you can. Don't paraphrase unflatteringly.
-
Don't imply that someone said something they did not say, even if you think it follows from what they said.
-
Write like everyone is reading and you want them to be included in the discussion.
On an ad hoc basis, the mods will try to compile a list of the best posts/comments from the previous week, posted in Quality Contribution threads and archived at /r/TheThread. You may nominate a comment for this list by clicking on 'report' at the bottom of the post and typing 'Actually a quality contribution' as the report reason.
Jump in the discussion.
No email address required.
Notes -
Conversation has been slow here. I feel like the standards have increased to the point where people are afraid to post (except of course for bad faith posters who don't care).
So, let me try a post that's more of a conversation starter and less of a PhD thesis.
According to Bernie Sanders, it costs about $5 to make a monthly dose of Ozempic, the blockbuster-weight loss drug. Americans pay about $1000/month. Canadians pay $155. Germans pay $59.
The stock of the company which makes the drug, Novo Nordisk, has doubled since the beginning of 2023. (I considered buying in 2022 but didn't because I thought I was already too late 💀) It now has a market cap of nearly $600 billion, making it the most valuable company in Europe.
I assume that if companies were forced to charge the same price in U.S. as they do in Europe, the global pharma industry would become insolvent.
So why is the United States paying for > 100% of global pharma research? And how can we fix the glitch?
The entire US medical system is fucked. Higher drug costs are a substantial input cost, but another huge one is the AMA.
The steps for fixing US healthcare are actually pretty simple:
Smash the AMA cartel by allowing unlimited immigration of doctors trained in Canada, UK, Australia, NZ and Ireland without any licensing requirements, re-doing residency etc. Allow doctors from other Northern European (not southern) countries if they pass a tough English written and oral exam that requires fluency. This will lower US doctors’ salaries (currently 300% or more of what they are in Europe) by half, to a more reasonable rate where surgeons are respectable PMC but not making a million dollars a year solely because the AMA lobbies to restrict residency places. Doctors should be paid $120-300k a year at the cap, with the high figure for the most elite surgeons in tough specialties. Why is the American middle class paying for anesthesiologists to make $700k a year when their equivalents in European countries that are almost as rich are paid like $150k? There are almost a million doctors in America, this overpaying adds up.
Handle drug pricing centrally. Insurers pay a price negotiated by a trade association chartered for that purpose and which represents all US insurers (including the state for the VA etc), exempt from the usual rules around cartels. The trade association negotiates as a bloc and can therefore refuse to accept pricing that is any more than a basket of comparable countries (eg rest of Anglosphere) + 20% (at most). Pharma companies will essentially be forced to comply, since there is no other major wealthy market that would possibly pay more than the US. The reason manufacturers can charge so much is that (much as with doctor pay) so much of the cost is offloaded onto third parties (eg employers for most health insurance) in a way that causes huge economic drag but which is often not immediately visible.
Because they graduate with $300k+ in school debt? Doctor salaries are a part of artificially constrained supply, yes, but becoming a doctor in the US requires you take on enormous financial risk.
A decade on from completing undergrad, folks in medical-adjacent fields are still underwater on pretty high interest student loans. Long term they're massively overpaid, but the people who somehow don't pass exams or don't get into medical school are fucked.
$300k in debt isn't that huge when the median physician pay is $350k - at 6% interest and 40% taxes it drops your take-home from $210k to $192k.
The much larger cost for doctors is the opportunity cost of going to medical school and one or more residencies. The median doctor graduates from medical school at age 30 and then still has years of residency(ies) to go. Making peanuts for a decade+ after college for the types of driven/conscientious/smart people who go to medical school is an enormous opportunity cost, dwarfing the literal debt (e.g. discount rate of 5%, forgone earnings of $100k per year, for 10 years = $1.26m at the end.
It's not really an "enormous financial risk". The 6-year graduation rate from medical school is 96%, and virtually all of them find a residency. That is, an admission offer from a medical school is as close to a "golden ticket" as you can get in life. The only risk is whatever time you invest in getting in to medical school beyond undergrad - a risk that, for most people, is 0-4 years.
Finally, re people being underwater. This can happen, but it usually stems from specific decisions - i.e. spending many years trying to get into medical school, switching specialties late in the game, refusing to give up on a very selective specialty, choosing to do academic medicine in a high cost-of-living area, etc.
More options
Context Copy link
Surely a $300k debt isn't very high for a doctor who can easily bring in that much annually?
More options
Context Copy link
There are many, many fucked up things about the American medical system, as has been pointed out by others in this thread, but the silver (well, maybe aluminum) lining here is that the massive debt incurred by a medical education does incentivize graduates to monetize their skills, instead of just treating the MD as a vanity/MRS degree.
Unfortunately, as someone pointed out downthread, "monetizing their skills" these days increasingly means going into tech or pharma, rather than actually, y'know, treating patients.
This is a really important point in my mind, you can argue that doctors aren't the smartest people in the world but by the time you get into late training you've demonstrated that you are among the hardest working (24-36 hour shifts, 80+ hour weeks for some specialties) and best at stupid box checking.
More options
Context Copy link
More options
Context Copy link
More options
Context Copy link
Pretty much everything you've said about the doctor side of things is wrong and much of it borders on malpractice. Frustratingly, I've corrected you on some of the clear matters of fact in the past and you've refused to update, so I guess this is more for the benefit of others who may be looking.
-Physician salaries are not responsible for high healthcare costs. They are a low percentage of healthcare costs. 8.6%. Half physician salaries (which nobody is suggesting and would collapse the system anyway) and you would barely make a dent in cost. Data: Stanford (SIEPR).
-Anesthesiologists do not make 700K a year. The average salary of a gas attending in the northeast is 380k. Data: MGMA survey (granted the one I have is a few years out of date).
--Can a gas attending make that much? Probably not in a desirable geographic area but if they want to work 2x full time or take a lot of weekend/holiday call they can get close. Maybe in L.A. if they do celebrity work, pain management or something like that? The ones I know who crack that level make the money off of owning something, patents, or something else of that nature, not working.
--On a more editorial note, why does gas make $$$? Gas is like being a pilot, most of the time it doesn't look like you are doing something outside of take off or landing but you get paid for the hopefully rare emergencies. Additionally procedural work reimburses well in the U.S. for historical reasons. Fix that problem if you want.
-The average physician salary is 350,000 in 2023. Not far off from Cim's range. Data: 2023 Mescape reports.
-Over half of doctors are in the "low paying" specialties where it's not uncommon for your salary to be under 200k (IM, FM, Peds, Psych). Depending on where you work and what you do you may be able to go over 500k but that's pretty much 95% percentile and involves shady cash only practice or working exclusively night shifts in Arkansas.
-No specialty makes over 800k without it being "fair." What do I mean by that? To make that much you are doing something like cash practice plastic surgery for wealthy people in LA, own and run a business (unrelated or related), have patents/high level consulting work, work 350 days a year (yeah people do do this), or are a neurosurgeon (egregiously long training, work hours, stress, and competency requirements).
-Doctors. Do. Not. Make. Millions. A. Year.
-The federal government is in charge of residency spots. However, state governments and private companies can and do make their own residency spots. We've had a bunch of recent scandals about this as the residents have been critically undereducated and frequently unhireable outside the system that trained them (specifically: HCA in Florida). Turns out medical education is complicated and you cannot just increase spots this is most true in surgical specialities which have small number of highly trained doctors, but also represent most of the specialties making the most money.
-The AMA is not a cartel. Most physicians hate the AMA and have for decades, as they've been lobbying for depressed physician salaries in the form of increased midlevel involvement (which is to the benefit of end career physicians at the expense of everyone else).
Their's a lot more to say here on things like "docs in Europe get paid less because their training is shorter and they don't have hundreds of thousands of dollars in debt" or "training quality if much higher outside the U.S., even in wealthy western countries" but this has gone on long enough.
Cim you have to reevaluate your level of knowledge on this topic because (among other things) you said "doctors should be paid $120-300k a year at the cap, with the high figure for the most elite surgeons in tough specialties" is very close to the system we already got.
Additionally doctor's wages in real terms have been decreasing for over 30 years while costs (including med school tuition) have been skyrocketing. It's driving a lot of people you want in medicine out of medicine. Just 68% of medical school graduates at Stanford went on to residency (with the majority of the rest going into tech or business instead). And that stat was in 2011, can't imagine how much worse it is now.
This is not true. Doctors in the UK have comparable training length to doctors in the US.
The amount of debt US doctors are saddled with has nothing to do with how much they should be paid in a free market. Expensive medical school is a whole another problem entirely and the way to fix it is not by increasing doctor wages, it's by controlling costs, including subsidising doctor training (as the UK does).
Most European countries have 6 years of combined med school and undergrad (see: Germany) vs. 4 years of undergrad + 4 years of med school in the U.S. these days 1-2 gap years is also common, with 3-5 being uncommon but not rare (for things like PHD, MPH, MBA).
The amount of debt is important because it is relevant to the level of pushback you get for changes, and the fact that if you cut salaries by half and allow limitless importing of doctors then you will have pretty much zero people applying to med school in the U.S. overnight (and that would be the rational response). People still interested will do PA/NP school instead.
Do also keep in mind the quality difference which is real but is frequently not acknowledged.
The 4 years of undergrad could be in a variety of subjects and aren’t really comparable to the first few years of training in countries where med school begins at 18.
More options
Context Copy link
We have 6 years of combined med school and undergrad here in the UK (3 years undergrad + 3 years clinical training), but that doesn't mean that when you're done with those 6 years you can start working as a doctor. After those 6 years you have to do another 2 years "foundation training" which brings it up to 8 years. Even than that's not enough, becuase after those 8 years you have to do mandatory "specialist training" which is 3 years for GPs and 5-8 years if you want to do a speciality (and are good enough to get in).
At a minimum to become a fully qualified and independent doctor it takes 11 years and at the most it takes 16 years. That's not dissimilar to the US.
Do keep in mind that the UK does its own thing and doesn't map well to the process in the U.S. (or other western countries).
At an extreme example if you want to be an electrophysiologist in the U.S. you'll be doing a minimum of 16-18 years of training after high school, with many looking at 22 years. During 8 of those years you will be working 60-80 hours a week with some programs closer to 100 hours a week. Even if the years are the same you are doing twice* as much work during each year (is that sane? No. But it is).
All the while you are dealing with an average student loan debt of around 250k, with that number not counting interest or all the rich kids (who are admittedly a fair chunk) with zero debt.
If you want anybody in the U.S. at all to do that you need to offer them a pretty big carrot. And you do want them to do that - we've seen the outcome disparity between U.S. MDs and other populations (most notably of late, midlevels).
AND.
Lower quality doctors (or doctor replacement) increase overall healthcare cost due to increased unnecessary testing. Very well documented at this point.
You need to change the regulatory and malpractice environment first if you want any of this to work, which nobody seems to be interested in doing, and if you did things would cost less without coming for MD salaries at all.
*these days 1.5 times the work is much more common and realistic but that's still a fuck huge disparity.
I think you’re discussing a few separate issues:
“Debt loads are too high to pay less.” Agree in part, the solution is to subsidize medical school costs such that medical students pay no more than the average STEM degree haver who goes on to a well-but-not-exceptionally-highly paid job.
“No talent will go into the profession”. Plenty of smart people are going to continue to want to be doctors for a salary of $120-300k a year. Are you going to get the 99.9th percentile people who want a guaranteed path to being moderately rich? No, but the question here is ‘do we need them?’. Is it really so bad if doctors are 95th percentile people instead of 99th percentile? I don’t think so, I think there are plenty of moderately smart people happy to do this job for $200k a year if trained. And healing people is high status vs. sales or finance or other professions people consider a little dirty. That boosts demand to be a doctor too, in the same way that many smart people want to be journalists or diplomats even though they get paid badly.
“Residency sucks”. Again, completely agreed. Doctors shouldn’t have to work 100 hour weeks during training. That’s an issue for hospitals and people who manage residency programs to solve, ideally with the help of residents. On the other hand, a lot of doctors have a ladder-pulling mentality and think that because they went through it, the kids of today have to do so too.
“Midlevels are taking our jerbs”. Again, I agree that this is a problem and I sympathize with doctors who see poorly-trained midlevels hurt patients and waste time and money. But they don’t seem to understand that mid levels are a consequence of desperation on the part of other elements of the healthcare system (ie the hospital managers who have to try and balance budgets) because doctors are paid so much money. In other systems, doctors might be paid 60-80% more than nurses. In the US (excluding rare examples of temp/travel nurses etc), specialist doctors and surgeons often make 300% more than baseline unspecialized nurses; this naturally leads to the creation and proliferation of midlevel roles. If doctor pay was halved and there were many more doctors in the US, hospitals would obviously hire them instead of CRNAs and specialized NPs etc.
Actually, if the AMA really cared about solving the midlevel problem, they’d provide a simplified pathway for CRNAs and NPs to become physicians, with guaranteed residency at their current hospital (if they pass whatever assessment required) and negotiate some kind of federal support for any dependants during the study process.
Right now it takes like 10-12 years for a competent CRNA to become an anesthesiologist, even if they can already do much of the job. Surely you can see how ridiculous it is - do you REALLY think it takes 10+ years to teach a good CRNA to do an anesthesiologist’s job?
On 1), don’t multiple other countries subsidize medical school, and all of those countries have in common medical school working very differently from the US? Specifically, things like a shorter overall path, strictly meritocratic admissions with no fudge factors at all, etc, etc.
Obviously if the US declared medschool free for anyone who could get in, there’d be all sorts of problems. For one, medical schools would admit thousands of people who spend immense amounts of money to never graduate(or graduate into incompetence). No doubt right wing Twitter would find someone literally named Shaniqua who’s getting paid to take organic chemistry again after failing it three times, but the problem is actually deeper than that- students who never graduate are now a money printer for medical schools. Currently there’s some incentive but actually doing this pretty much requires the federal government to pay for every medical student’s books and classes and also give them all living stipends. That changes things.
More options
Context Copy link
That's all stuff which is much amenable to discussion and debate (even if we disagree) but these are unrelated to my problem with your post which was the gross factual inaccuracies.
It's several orders of magnitude more common for a doctor to start making 250K a year at age 32 with a half million dollars in debt than it is for a doctor to be making over 750k a year, which nearly zero are doing through clinical duties alone.
Your comment, much as I loathe to use this term, is misinformation.
"What is the right amount of money for a doctor to make" is a reasonable question but it's functionally entirely unrelated to healthcare costs in America.
More options
Context Copy link
More options
Context Copy link
More options
Context Copy link
More options
Context Copy link
More options
Context Copy link
I don't think that's true. You can't decouple a party's costs (in this case, school) from the prices they charge (i.e. wages) because the costs are a significant part of the price one is willing to accept in the marketplace. If you lower the cost to be a doctor, people will more readily accept lower wages because they're still doing OK for themselves. And if you lower wages without lowering costs, one would expect to see fewer doctors out there as young people decide to go down different (more lucrative) career paths.
More options
Context Copy link
More options
Context Copy link
More options
Context Copy link
Why should doctors need to be able to prove they can speak English to be allowed to work in the US? The point of medical licensing is to make sure that doctors know what they're doing, something that is not easily verified by patients. But patients can tell immediately if a doctor speaks English. If he can't, no one is actually going to be harmed by it and he may still be able to help patients who speak some other language.
If insurers in the US negotiated a lower price for drugs, that would kill the incentive to develop new drugs.
More options
Context Copy link
This would be so nice. I have lots of medic friends who studied alongside me at an elite university and now are doing shitty training years in the NHS only to be rewarded with a crap £60k job at the end of it all. These are highly competent people I would not hesitate to say are better than the 90th percentile doctor in the US. But for whatever reason they can't go over to work in the US and now are striking to get paid more than a derisory amount for a role which requires almost a decade of post school graduation training. Having a minimal friction market for doctors with the US will not only fix their problems but also force the rest of the developed world to pay doctors a wage commensurate with the effort it takes to become one.
More options
Context Copy link
Just make it more free in the most straightforward of terms and everything will fix itself.
More options
Context Copy link
No the answer is to stop gate keeping drugs by requiring a doctor to write a prescription for all of them.
This is the most obvious and correct thing to do. My health insurer would save 500-1000 dollars a year if this were permitted
More options
Context Copy link
Tylenol would not be approved as an over the counter drug if discovered today because of how easy it is to kill yourself accidentally (or intentionally) with it.
The average person has no idea how badly many drugs can interact with each other, recreational substances, and with medical comorbidities.
And that's ignoring other problems like the people who would give themselves antibiotics for viral infections etc.
Yes, but anyone who, say, completes and undergrad economics major should be capable of using a computer to check for negative drug interactions. Let them prescribe drugs after passing some test.
People fuck this up constantly. Educated people. Smart people. People believe in antibiotic stewardship until they have a cold and demand antibiotics "just in case." People take medications and are told "no really tell me if you start supplements or something really bad could happen" and then something really bad happens. People are told "don't eat before your expensive, time sensitive, maybe life saving surgery" and then they eat. Sometimes they die because they eat and we can't do surgery.
See front page of meddit today for a discussion on colonoscopies.
People can't be trusted to do a good job of this, and that includes health care professionals (including doctors). Thus the waves of verification.
More options
Context Copy link
More options
Context Copy link
More options
Context Copy link
The problem is that just letting people get drugs as they like means that if they're the one in ten thousand who gets the rare but really severe reaction, who ends up getting the blame?
It's risky enough with prescriptions and people taking medication they're not sure of, or there are interactions with drugs they already are prescribed, or the doctor was careless about checking are they safe to take this drug. I've been prescribed things that gave me (fortunately) low side-effects and now have it on record that I can't take X or Y medication. Without some system of doctors and prescriptions, how are you going to manage this?
Simple, the person who took the drug without a prescription. This is no different to how if you park in an open parking lot you have to bear the risk of someone breaking in and stealing your shit.
You really think that's going to happen? "Oh my bad, my mom or brother or kid took that drug and suffered a severe side-effect, their fault for being too dumb to read the label"?
No, it will be Something Must Be Done and they'll sue the government and the drug manufacturer and the hospital and anywhere else they can think of: yes this is legal but someone else is to blame!
Yeah, it doesn't matter how blindingly obvious you make the risks. A lot of people will say they're OK with the risk right up until they lose a roll, at which point they are mad and want something to be done.
Yes, and it is the responsibility of the systems established by society to make sure nothing is done in response to such tantrums. It's fine if they sue, as long as they lose and have to pay the court costs.
More options
Context Copy link
More options
Context Copy link
More options
Context Copy link
That attitude leads to things like the opioid crisis where the rest of society is left cleaning up the mess left behind by people making questionable decisions.
A huge chunk of healthcare costs these days are associated with lifestyle related problems. That's going to get worse if you have 100k people fuck up their kidneys and need dialysis.
Negative externalities are a thing.
More options
Context Copy link
More options
Context Copy link
More options
Context Copy link
More options
Context Copy link
More options
Context Copy link
More options
Context Copy link