The darker side of being a doctor

Friends in medicine often mention the constant emotional drain from dealing with suffering and death. Takes a serious toll.

Healthcare is the last industry that should be privatized. It should be for the public good rather than for the profit of few.

• panick21_ · 21 hours ago

  By that logic all food production and distribution should not be privatized because is should be for the public good rather then the profit of the few. There are are arguments to be made about private or public but that logic makes no sense. Some system that have many private aspects outperform other public systems and the other way around. And even in a public system many people will profit as many of the companies that are your suppliers are still for profit.

  • dwb · 20 hours ago

    > By that logic all food production and distribution should not be privatized because is should be for the public good rather then the profit of the few. Sounds like good logic to me, at least for essentials!

    • panick21_ · 20 hours ago

      If you want to make the argument that anything that is essential should be publicly owned you can make that argument. But I would suggest if you want to make that argument 'nobody should make profit' shouldn't be the relevant argument. The argument should be 'this is how we can solve X problem efficiently'.

      • ourmandave · 20 hours ago

        Universal healthcare solves the problem. The US is #1 in science and tech, but spends the most with worse outcomes in general healthcare than other peer countries by far.

        • furytrader · 19 hours ago

          But it doesn't solve the problem. Does it sound like the nationalized healthcare in Australia is going well? How about Canada? The NHS in Great Britain? Why would it be any different here?

          • ourmandave · 19 hours ago

            I don't know anything about those countries healthcare problems. Hospital bills causing bankruptcy. Deciding between meds or food. Donation jars at gas station checkouts begging for money to pay for a child's cancer treatment. Putting off preventative care because of endless co-pays. Out-of-network providers being a thing I have to worry. Those problems I do know.

          • yodel_few · 19 hours ago

            Those countries DO have better healthcare outcomes than the US. You are so ignorant. The US is #1 in developed countries for infant and maternal mortality. Americans die from preventable and treatable causes at much higher rates than residents of peer countries, alongside a life expectancy of 79, or two to four years lower than the average for OECD countries. We spend 18% of our GDP on healthcare, NEARLY DOUBLE the average of other peer countries. The number one cause of bankruptcy is medical debt. When will the American people wake up and realize their private healthcare model only benefits the rich that are able to afford the care.

            • sickofparadox · 19 hours ago

              >The US is #1 in developed countries for infant mortality. This is only because the United States is unique in its huge amount of preterm babies, which some other developed countries do not even count within their infant mortality statistics. If we had the same average infant gestation length as Sweden, we would be tied for fourth best with France and Portugal, which considering how obese we are is pretty impressive. If we had that and adopted more restrictive reporting categories like Poland or the Netherlands, we could very well be reporting as the lowest.

              • ourmandave · 18 hours ago

                And depending on your insurance coverage, having a preterm baby in the US can bankrupt you.

            • nradov · 17 hours ago

              You can cherry pick particular metrics to make the US healthcare system work better or worse than other countries. The US does badly on infant and maternal issues, but that's largely caused by social and lifestyle problems unrelated to healthcare. On the other hand we're at or near the top in 5-year survival rates for most forms of cancer. Medical debt is not the number one cause of bankruptcy so you're simply wrong there. Most consumers who file for bankruptcy have some medical debt but the most common cause is a sudden loss of income (like losing their job). When consumers don't have enough cash to make ends meet they prioritize paying for food, housing, and transportation, and stop paying medical bills. Thus the medical debts tend to accumulate but this didn't really cause the bankruptcy. I do support measures to reduce healthcare costs and improve access for patients but let's be clear about what's actually happening.

              • ourmandave · 15 hours ago

                It's a double whammy in the US. Lose your income (job), lose your insurance. Lose your job from injury and you're well and truly screwed.

                • nradov · 15 hours ago

                  Right, having employer-sponsored health coverage as the default is a terrible system. It causes so many misaligned incentives.

            • panick21_ · 53 minutes ago

              Its amazing to me how Americans (and others) act as if there are only 2 things in the world the US (private) system and public system that apparently everybody else on the planet has. The US system is neither fully private nor are those other systems fully public. Its a false binary people use so they don't have to actually engage in the details of how different systems operate. Nobody is arguing that the US has a good or 'the right' system. And nobody should argue that the British NHS (or systems like it) is some amazing magical place that gets everything right. > When will the American people wake up and realize their private healthcare model only benefits the rich that are able to afford the care. And yet one of the countries wit the lowest spending % of GDP on healthcare with very good outcomes has a system that has a lot of private aspects.

      • dwb · 18 hours ago

        Okay: it’s obviously inefficient for some people to collect profit on essential services where competition is meaningless. That money should be going to improving the service for all, or paying the workers better, or ideally both. It would be more efficient to collectively organise food, shelter, healthcare, and other natural monopolies. Market competition can be for non-essentials where some inefficiency is acceptable.

        • robocat · 12 hours ago

          You seem to think "efficiency" is the issue. No. The issue is that there is an almost unlimited demand for healthcare. That is true regardless of capitalism or marxism or whateverism you believe is the right answer. Avoiding talking about money: it is easy to see the underlying issue of how should we balance a doctor's lifetime versus patients' needs versus the businesses that ultimately pay tax for it all. We have public healthcare in New Zealand (a huge percentage of our economy is run by our government - almost socialist). Here we restrict healthcare by waitlists, beaurocracy, and other tricks. It mostly works, but the nurses that I know give too much, and are flaming out. Meanwhile I've done the dirty boring capitalist work of bringing in overseas income to pay for our beautiful services, and I've reached my personal limit of balancing working harder versus gaining extra income (for myself and my government). I'm taxed at a demotivating rate. There's fuck all respect for being the guy bringing in the bacon to the country. I get to look forward to being treated like a boomer in a few years. I love kumbayaa political beliefs, but not when I'm the donkey.

          • dwb · 12 hours ago

            You’re talking at cross purposes here, there’s nothing “kumbaya” about what I’m saying. We all have to work hard for the stuff in this world and that would be the case whatever the economic system, for the foreseeable future. I just don’t want the result of that hard work to be hoarded by the bosses, that’s all.

            • robocat · 6 hours ago

              The point is that I'm in a country that is closer to what you said you wanted (compared against the USA). The vast majority of healthcare here is not profit oriented but instead is run by the NZ govt. The purpose of most business is money, and few people would choose to be a boss without the financial winnings. I had the opportunity to roll the dice with everything: because fortunately I'm in a country that still has a backstop. However the boss payout result is quite simply not worth the risk; because the median return for a startup is $0. Remaining an employee would have been a more sensible decision. Other people like you complain, and I accept that is part of the deal I chose. I am smart enough to have had the choice of alternative lifestyle paths like teaching or being an artist. Meanwhile, I'm literally the guy paying for our social welfare and health system because I'm an export earner. Obviously the NZ economy deserves its return on its investment in me and our business environment. But if you want to imply someone is greedy, then look at yourself or at your government.

              • dwb · 2 hours ago

                There wouldn’t be half the complaints if we didn’t see the wealth disparity that we do, or the horror that is the US healthcare system. If you are running a respectable business that pays your employees fairly, has as good working conditions as you can, isn’t profiting from some fully privatised necessity, and pays its taxes, while it may not be my idea of utopia, you’re not the target of my ire.

    • nradov · 17 hours ago

      Public ownership of food production always results in famines. https://en.wikipedia.org/wiki/Holodomor

      • dwb · 15 hours ago

        Saying “always” and then pointing to a single event doesn’t make sense.

        • nradov · 14 hours ago

          https://en.wikipedia.org/wiki/Kazakh_famine_of_1930%E2%80%93... https://www.hrw.org/reports/2006/northkorea0506/1.htm https://www.ebsco.com/research-starters/history/great-leap-f...

          • dwb · 13 hours ago

            You don’t have to read very far into each of these to see that the historical conditions in each are very different to any first-world country right now.

            • nradov · 13 hours ago

              You don't seem to understand the cause and effect here. Adopting collectivist economic central planning would be an effective way to turn prosperous first-world countries into third-world shitholes.

              • dwb · 12 hours ago

                None of the countries you’ve cited were prosperous first-world countries before the events described. And I didn’t necessarily advocate for central planning in the same way that Stalin or Mao directed it. I don’t pretend to be an expert in such things, but fundamentally I think we can do a lot better than how we organise things now, and that profit for natural monopolies is stupid. If you think that naturally entails famine, I think you have a sad lack of hope and imagination.

  • juiceland · 20 hours ago

    I mean the US gives enormous subsidies to farmers for food production, and Walmart receives somewhere around $27 billion a year in SNAP from customers. So in that sense, both of these are essentially public to some degree

    • panick21_ · 51 minutes ago

      The subsidies are not 'enormous' vs the total value of all food consumption or production. There is a huge difference also between subsidizing demand with private supply and providing supply. Exactly the debate that is relevant in healthcare as well. A system can do both, or neither or a combination of the two.

  • yodel_few · 20 hours ago

    This is terrible reasoning. Food is, in general, very accessible, cheap, and elastic (People's food decisions are easily changed depending on the price). Healthcare in America is not accessible, extremely expensive, and inelastic. We have not had a famine in the developed world in quite a long time, but the healthcare crises continues. The fact remains clear: The number one cause of bankruptcy is medical debt. Healthcare is the only service that is life and death, where the money paid by the patient is completely inelastic. I'm not saying doctors shouldn't be paid well. But what is really clear is that while the rich pay for premium concierge VIP treatment, the poor are regularly turned away for treatment they can't afford. You health insurance here is tied to your job. Lose your job? Pay $2000/month for COBRA or you don't deserve to have healthcare. Don't act like public healthcare, expanding access to primary care physicians, and reducing medical administrative bloat is some economic degeneration headed for the sickle and hammer. I'm tired of pretending Ayn Rand style libertarianism capitalism is the perfect solution that has worked for everything including healthcare.

    • panick21_ · 1 hour ago

      > Healthcare in America is not accessible, extremely expensive, and inelastic. Did I somehow make the argument that the US has a good health care system? I must have missed that. > Healthcare is the only service that is life and death, where the money paid by the patient is completely inelastic. Most healthcare spending isn't actually 'life and death' either. And even if it in the medium term is 'life and death' only a very small amount of health care is an emergency where you can not potentially consider different options. Just as most time when you are going to the store its not 'life and death'. But still if don't do anything eventually you will starve. > The fact remains clear: The number one cause of bankruptcy is medical debt. My goal would be to achieve the best overall healthcare outcomes at reasonable cost. That's at least the first stab at a definition, I'm sure we could come up with a better criteria. If you increase payroll taxes as much as a fully public system would required, you would just have more people default on their houses and cars instead. Because there is no world, no matter how many billionaires you disown, that you can implement a universal system without massive increases of income taxes. Again I'm not even arguing that a universal system is bad or wrong thing to aim for. The argument that I actually made was that 'some people make profit' isn't actually a good argument against any system. > Don't act like public healthcare, expanding access to primary care physicians, and reducing medical administrative bloat is some economic degeneration headed for the sickle and hammer. I'm tired of pretending Ayn Rand style libertarianism capitalism is the perfect solution that has worked for everything including healthcare. You are literally just ranting about shit I have never argued. I guess I must have trigger something.

  • lkey · 19 hours ago

    The government already subsidizes private overproduction on US farmland. USAID was, at its heart, a farm subsidy. And it should be said that most 'small' farmers in the US are millionaire scions and shouldn't need subsidies to make a profit in most parts of the US (we have abundant natural resources). More than half of all calories produced in the US are not even for human consumption. And globally enough calories to feed every human on earth are lost to inefficiency each year. We can all benefit from a better system of distribution and production without getting lost in the magical thinking of a public/private false dichotomy.

    • panick21_ · 52 minutes ago

      Subsidies account for a very small % of either production or consumption of food. Not sure why you are making an argument about food subsidizes to me, I have not argued in favor of them. > More than half of all calories produced in the US are not even for human consumption. Most of those go threw animals and are then consumed by humans. There is a lost factor there but saying its not for human consumption misses the point I would say. For Chicken, Pork and fish the lost factor is pretty small.

• xadhominemx · 20 hours ago

  The doctor who killed himself was an Australian man living and working in Australia. Australia has public, universal healthcare.

  • nradov · 17 hours ago

    Not exactly. The Australian system is mixed public/private and many physicians work at for-profit organizations. While Australia does have some level of universal coverage it's a two-tier system where people who can afford it pay for private insurance to obtain better care.

• dash2 · 19 hours ago

  You realise this is an Australian doctor writing?

>You might ask, why can’t you work less? It’s not as easy as that. If I decide to work less, who is going to cover the hospital? If the hospital aren’t employing other doctors, we can’t allow patients to go uncovered. I accept the fact that I have a duty of care to be on call. Yes, you can allow patients to go uncovered. This hero mentality is what leads the bosses to not properly staff and the politicians to not properly fund in the first place. It is not an individual’s responsibility to correct a societal failure by hurting themselves.

• Ensorceled · 21 hours ago

  We saw this during the COVID crisis: declare nurses and doctors "heroes" and then it's ok that they burn out, get PTSD or die due to lack of PPE because "that's just what heroes do"

I remember some friends working in intensive care during the pandemic, I'll never forget their facial expressions after these 24hr shifts... I really wish someone would come up with a better way to do this

• throw39304938 · 21 hours ago

  There is no better way to do this. Perhaps all doctors should be on suicide watch and under psychiatric supervision.

• bryanlarsen · 21 hours ago

  And that's the main reason why lock downs extended so far later than they should have. Our hospitals run at 120% during normal times; during abnormal times they're stretched to the breaking point. Our small local hospital had two nurse suicides during the pandemic. Not early in the pandemic, but well after vaccines were available.

  • khalic · 21 hours ago

    I'm sorry to hear that... this thing really took away a lot of good people...

  • throw39304938 · 21 hours ago

    Covid kills people even today! We should have a lockdows every winter! Those nurses saved many people! It was worth it!

    • Schlagbohrer · 19 hours ago

      Our societies should have expanded their healthcare capacity afterwards and maintained it to a high standard, but unfortunately it sounds like the political classes continue to treat healthcare as a cost centre that they can starve or pull money from for other projects.

Wow. > I had worked in a hospital network that covered 4 campuses and drove 500kms a week when covering these sites. I had worked in a hospital where I didn’t get home for days at a time, sleeping overnight in hospital quarters, outpatient clinic benches and in my car. As a patient, I'd like the person performing surgery on me to be well-rested! It gets worse: > I used to be able to arrange the operating list because I know that some operations take longer than others. But now, the bookings office determine that that all my tonsillectomies take 14 minutes because that’s the average time recorded on the computer. The moment I scrub in, the timer starts. The moment I unscrub timer stops. Click. Click. Click. Because the theatre bookings does not take into account the interpreter time, pre-med period or transfer to ICU, the list is running late. The nurse in charge is breathing down my neck to finish on time. And yet somehow that 14 minute tonsillectomy gets billed at ~$10,000. This seems to me like a system that has been hyperoptimized in a way that grinds down the participants.

• askonomm · 21 hours ago

  Sounds like just about every other system in modern capitalism.

  • joenot443 · 21 hours ago

    Really? This funny limbo seems pretty specific to American healthcare, which is a fairly unique and admittedly fascinating study in the intersection of politics and capitalism. You don't perceive that system to be different from grocery stores, auto manufacturing, Nvidia, or lemonade stands? They're all very different in my mind, I'm surprised you see them as identical.

    • lotsofpulp · 21 hours ago

      I assumed the linked article was written by a non American, given the use of kilometers and anecdote of a Brisbane doctor committing suicide. Although the whole website has 1 post and there’s a prominent advertising link to some doctor book that then links to herbal stuff, so not sure if the whole thing is fake to advertise books.

      • simonw · 21 hours ago

        Huh, you're right! This is by an Australian doctor: https://ericlevi.com/ - "Paediatric & Adult Specialist Otolaryngologist, Ear Nose & Throat, Head & Neck Surgeon" in Melbourne.

    • alt227 · 19 hours ago

      The doctor who wrote the article is Australian, not American.

(speaking from US): The reality is we need more doctors. A lot more. There's no solution other than training a lot, lot, lot, lot more doctors. Their salaries need to be lower, training needs to be cheaper and faster, and we need a lot more of them.

• ossicones · 21 hours ago

  The American Medical Association would sooner let the whole thing burn than allow that to happen

  • askari01 · 21 hours ago

    sooner or later whole world(west) is going to hire more doc at lower(not as high as it is right now) salary from East(asia). they might lower the barrier to entry. same would happen in medicine the causes are inflation, economic conditions and poor health system.

    • dh2022 · 19 hours ago

      I think the system will burn down before AMA would allow any US States to import a massive amount of doctors from anywhere in the world. Which maybe is better for the rest of the world - they get to keep their doctors.

      • nradov · 18 hours ago

        Several US states have already changed licensing rules to make it easier for foreign medical graduates and internationally trained physicians to practice medicine here. The system hasn't burned down yet. https://www.fsmb.org/siteassets/advocacy/policies/states-wit...

  • joenot443 · 21 hours ago

    This is the bottleneck, right? I hear people say "we need more doctors" all the time. It would seem to me, the people deciding how many new doctors we train per year, are doctors. Their pay is proportionate to their scarcity, if we had 5x as many doctors, existing doctors would make far less. Imagine if existing software engineers got to decide how many juniors entered our profession each year. I think things would look very, very different.

    • sebastiansm7 · 21 hours ago

      Now that senior engineers can utilize an LLM as his junior, the job market its deciding that don't need too many juniors.

    • Gareth321 · 19 hours ago

      We have created a society in which the tail wags the dog. We have deferred so much control to institutions like the AMA that we have forgotten how to govern. Our politicians wring their hands and wax lyrical about the intractability of issues while they hold all the power to affect change. I think it's time we stop allowing institutions to rule. We elect our leaders to lead. They need to start fucking leading, or people are going to start voting for some radical alternatives.

      • nradov · 18 hours ago

        The AMA has no control over this. While they do advocate for training more doctors they don't have authority over medical school admissions or residency program funding or anything like that. https://savegme.org/ One area where we can perhaps legitimately criticize the AMA is for their lobbying state governments to limit the scope of practice for lower licensed PA/NP clinicians. While some of their concerns about care quality and patient safety might be legitimate, the reality is that we're not going to have enough primary care doctors to ensure adequate patient access. Some of that work has to be delegated down.

        • Gareth321 · 3 hours ago

          > The AMA has no control over this. While they do advocate for training more doctors they don't have authority over medical school admissions or residency program funding or anything like that. I feel I made this distinction very clear in my comment, so I'm surprised to see you repeat it. I make it clear that it is our elected officials which hold the power, *but who have deferred that power to institutions like the AMA.* For example, the AMA and Association of American Medical Colleges jointly sponsor the Liaison Committee on Medical Education (LCME), which accredits US MD programmes. LCME accreditation is extremely consequential because most state licensing boards require graduation from an LCME-accredited US programme, and LCME accreditation establishes eligibility for the USMLE and ACGME residency programmes. This gives the accreditation system considerable influence over expansion. LCME standards require a school to admit only as many students as its resources can support, including faculty, facilities and clinical training capacity. Schools must also notify the LCME when class-size increases exceed specified thresholds, currently a cumulative increase of 10% or 15 students, whichever is smaller, relative to the class size at the previous full accreditation survey.

    • estearum · 19 hours ago

      No, the AMA has been lobbying for more residency slots for decades. Congress decides how many slots get funded and they have been way too slow to fund them.

    • HDThoreaun · 15 hours ago

      Congress decides how many doctors are trained each year. Residencies lose money so they rely on federal subsidies, Congress has limited the number of residency slots that get funded and that’s the number of doctors that get trained each year. Medical schools can’t expand without residency funding expansion.

  • sarchertech · 21 hours ago

    The bottleneck is funding for residents and the AMA has been lobbying for more resident slots for nearly 30 years.

    • RussianBot9580 · 20 hours ago

      In the SF Bay Area there's a town called Milpitas. There's a gigantic island next to it made of garbage. A government funded study has been running for over 10 years now trying to determine why Milpitas smells. They have not yet been successful. You see, succeeding means getting funding withdrawn from the study.

      • estearum · 19 hours ago

        Irrelevant

• khalic · 21 hours ago

  I'm not sure about the salaries. Vocation-motivated people are already doing it. The rest needs a good reason to put their entire life, quite literally, into one single purpose. It's one of those professions that requires a complete dedication of free time, youth, health, mind, etc.

  • pajamasam · 21 hours ago

    If there are more doctors, it would require less of each one's time though.

    • khalic · 21 hours ago

      Yes it would, but the sacrifices start at the university already, that part is incompressible I'm afraid

      • groestl · 21 hours ago

        And there's certain constraints related to patient's safety which have an impact (i.e. less handovers, longer shifts)

      • hibikir · 21 hours ago

        If you look across countries, you realize that a lot of the sacrifices are part of the pipeline, but not necessarily key to good outcomes. Just like the grueling hours at certain residencies. It's like claiming that one needs to cram hours upon hours of leetcode practice to be a quality software developer. It might be necessary for some companies to hire you, but that's to meet a filter that is less and less predictive over time, not an actual performance requirement.

      • killerstorm · 20 hours ago

        Education system was set up in XIX century. It's not clear how much of it is necessary in XXI century. Back in the day religious books were copied by scribes educated in a monastic tradition. Now printers can print them in a completely godless manner but the result isn't any worse.

    • nradov · 18 hours ago

      Nope. There is effectively infinite demand for physician services. If we had more doctors that wouldn't reduce the workload on individual doctors. The actual solution to reducing demands on their time would be through reducing the administrative workload which contributes nothing to patient care. Much of that could be automated or delegated or not done at all. The time demands also differ widely between specialties. You can't really be a part-time neurosurgeon. But we see a lot of doctors in other specialties like pediatrics, internal medicine, radiology, and emergency care downshifting to part-time schedules after they have established careers.

  • kolla · 21 hours ago

    It does not require more than your standard 8-17. Know tons of doctors that work the same hours as I do and spend their free time the way I do.

    • khalic · 21 hours ago

      so... you didn't read the article?

• seb1204 · 21 hours ago

  Would you say that people also need to be more responsible to be healthy themselves? Reducing pressure on the system and freeing capacity. E.g. healthy lifestyle to reduce diabetes.

  • panick21_ · 21 hours ago

    Of course people need to take some responsibility, but reality is most people live in a society and do as the society does. You can minimally change people with some financial intensives but the effect of that is pretty limited and its hard to implement. You have to create a healthy system, that takes social engineering and government cooperating on a general plan. And in the US such a thing is basically not possible, even if they wanted to do it. Ideally your transportation, agricultural, educational policies should all work together to produce healthy population. But this simply isn't the case. But it will not 'reduce pressure' in a practical way, because such changes purely private or public take decades to work themselves threw the population.

  • Forgeties79 · 21 hours ago

    Well let’s start with insurance actually acknowledging preventative care as a worthwhile investment. We have a system that incentivizes waiting until emergency care is necessary and that comes with massive cons. I can’t even get basic foot stuff covered, they won’t care until my feet and knees land me under “disability,” so people like me - but unlike me they can’t afford to spend hundreds more a year on special inserts and shoes - just keep doing what they’re doing until they’re hurt. People go to the grocery store and marketing teams are trying to sell them “vitamin water” which is neither of those things, so they have to do tons of research and pay constant attention to literally every food they buy. Then when they get hurt they can’t afford to go to a doctor and the insurance that is sucking up huge amount amounts of their annual pay doesn’t pay for it either. Meanwhile we have a US administration that is telling everybody, a population that is incredibly predisposed to heart disease already, to go eat more red meat. Also, they have spent a decade telling people that vaccines are shady and maybe they shouldn’t get them. How much damage have we done to preventative care with that one? I could go on and on, I’m barely covering the breadth and depth of this problem. We can’t just call it “personal responsibility” or whatever

    • nradov · 18 hours ago

      Insurance is already required to cover preventive care services which are justified by a clear cost-benefit analysis at no cost to the patient. The list of those services should probably be expanded but in many cases we lack scientific and economic data to justify to more research is needed. https://www.healthcare.gov/coverage/preventive-care-benefits...

      • Forgeties79 · 17 hours ago

        > Insurance is already required to cover preventive care services which are justified by a clear cost-benefit analysis at no cost to the patient. I am clearly not saying they literally don’t cover any preventative care. I think most people agree that insurance companies’ idea of what is “justified” is far too narrow. What is “clear” is also often very opaque. That’s the issue I’m pointing to. US health insurance is a terrible experience. And who cares if the analysis costs me nothing? Why is that something I should be grateful for?

        • nradov · 17 hours ago

          Most people don't understand the system well enough to even have an informed opinion on the subject. Commercial insurance companies get a lot of criticism for denying claims or prior authorization requests, and some of that criticism is well deserved due to errors or artificial friction. But for the most part they make very few decisions about what care is justified. At a first level the federal government publishes a set of medically unlikely edits used to deny claims when procedure codes don't align with diagnosis codes. It's used by Medicare, and most Medicaid agencies and commercial health plans have also adopted it. https://www.cms.gov/medicare/coding-billing/national-correct... At the next level most commercial health plans have adopted clinical care guidelines published by vendors like MCG. These vendors take publications from specialist medical societies and codify them to determine what's medically justified and set step therapy requirements. https://www.mcg.com/solutions/care-guidelines/ At the final level, providers can appeal denials to human nurses and doctors who do case review at insurance companies (peer-to-peer). In a huge healthcare system there are always patients with unique needs who don't fit the pattern in published care guidelines. Dealing with those appeals is a major administrative burden and often badly managed on both sides of the adversarial interaction. Most US-based HN users are on commercial self-funded group health plans sponsored by their employers. The Affordable Care Act (ACA / Obamacare) establishes a baseline for what's covered but ultimately the decisions are made by employer HR departments. Insurance companies would be happy to offer custom health plans that paid every claim at 100% with zero denials or prior authorization requirements; it would mean less work and higher profits for them. But no employer wants to pay for that so the insurance companies take measures to hold down costs.

• rolisz · 21 hours ago

  Are you sure you can find that many more doctors? That they'll be any good? Speaking from Romania: here medicine is prestigious. So many parents push their kids towards medicine. There's a glut of newly minted doctors every year, but rumour has it that the quality drops every year. Sure, they pass the exams and residency and what not, but... They're just not into medicine as much. Do you want to get treated by such a person? This year I had to go to a neurologist. I went to one locally, they dismissed me in 5 minutes, told me to take some vitamins basically. Went to another one in a much bigger city, they talked to me for an hour, ordered a ton of tests. Would it help if we get a lot more of the first kind of doctors?

  • postalcoder · 21 hours ago

    We do have qualified people to do the work of doctors, and they're called nurses. But arbitrary lines are drawn between what they can do and what doctors can do, just to maintain the existing salary structure.

    • prh8 · 20 hours ago

      The medical training involved for nurses and physicians is absolutely not equivalent

      • uurrnn · 20 hours ago

        There are APPS as well that have more training than nurses.

    • b38484848 · 20 hours ago

      lol lmao even

    • wl · 20 hours ago

      If nurses are to do more of the work of physicians, nursing education needs to drastically change. Nurses are mostly taught the how of nursing and not the why of medicine. If you look at the curricula of DNP programs, which are often touted as a way to get nurses practicing with lots of autonomy in places where they are short on physicians, they're heavy on nonsense nursing theory and light on things that actually matter like pathophysiology and pharmacology. We actually do have a better model in the form of physician assistants. They're taught the same kinds of things physicians are taught, just in less depth.

      • ACCount39 · 19 hours ago

        That is the kind of thing makes me wonder how much of "things that actually matter like pathophysiology and pharmacology" can be factored out into the automation land now. AI isn't perfect, but even loosely scaffolded generalist systems show promise in the field of medicine now. And the alternative isn't some hypothetical "perfect healthcare" - the status quo is often closer to "nurses running near the limits of their competence" or "physicians stretched thin almost to the breaking point". The fundamental problem of healthcare is that it struggles to scale. The need for well educated, well paid professionals is inescapable. Or, was inescapable? We might be at the point where this can start changing.

        • leereeves · 17 hours ago

          > That is the kind of thing makes me wonder how much of "things that actually matter like pathophysiology and pharmacology" can be factored out into the automation land now. I would say not much. AI is still often wrong and a clinician needs to know when the LLM is saying something crazy. I think AI has the most promise for increasing the productivity of well trained professionals, not replacing them (or their training) entirely.

          • ACCount39 · 16 hours ago

            Human clinicians are also "often wrong", for a given definition of "often". "Get a second opinion" didn't originate with AI. Are AIs wrong more often or less often? Would the healthcare get better or worse if the "first opinion" was AI more often than not? "Increasing the productivity" and "replacing them" is two sides of the same coin. If a human can do five times the work, because AI does most of the work and the human performs "exception handling"? You need less humans. And healthcare, historically, is almost always human-constrained. That's why you get insane wait times and overworked clinicians. Most other inputs scale more readily than human expertise. Thus the impetus to figure out where "human expertise" can be substituted for that of a scalable machine system - and what would be the best ways to implement that.

            • leereeves · 12 hours ago

              I was replying to "how much of 'things that actually matter like pathophysiology and pharmacology' can be factored out into the automation land" I'd argue they aren't being factored into automation land if they're still the responsibility of a human expert, even if there are fewer more productive human experts. (Though I do think AI will have a role in pathophysiology and pharmacology, initially catching errors, and probably some day taking responsibility, but not soon.)

    • nkrisc · 19 hours ago

      Yep. I haven’t seen an actual MD in quite some time. Instead my general care provider is a Nurse Practitioner and he’s been handling all my routine healthcare needs.

  • TeMPOraL · 21 hours ago

    Hate to be cynical, but going by the stories a doctor in my personal circles tells me, "talked to me for an hour, ordered a ton of tests" could be more about billing the national healthcare fund for many tests, that may not be most useful, but carry best margins for the facility. In my country, there's a big feud between cardiologists and radiologists right now, big enough to be a regular topic in national media. Inside sources tell me it has nothing to do with quality of care, and is entirely about the march of technology allowing radiologists to perform some diagnostics that previously required cardiological procedures, and those procedures happened to be the major funding source for the cardiology departments.

    • estearum · 19 hours ago

      Which is why we need more doctors trained more cheaply who are earning less money. They have far too much labor power currently for a role that increasingly can be fulfilled by a pure “technician” style expertise.

      • nradov · 13 hours ago

        You're describing Physician Assistants and Nurse Practitioners.

    • tastyfreeze · 18 hours ago

      Radiology and imaging gets that treatment everywhere. They are treated as a photography service for doctors and only doctors can diagnose.

      • TeMPOraL · 18 hours ago

        Yes, but it's erupting now that it killed a golden goose for the "real doctors", and the problem here is not along the doctor/technician lines (radiology has doctors too), but along the specialty/hospital department divide , because those are effectively separate business units.

  • adrianN · 21 hours ago

    I'd like not to have to wait for three months to see a doctor to prescribe me the routine treatment for my routine illness, so yes, more mediocre doctors would be good for me. It would also unburden the doctors who are "really into medicine" so that they could spend their time on more difficult cases.

  • lolakutty · 21 hours ago

    Yea, that is what is going to happen. Earlier you just need to find a doctor and they were probably good. Now you have to take your luck with many till you find a good one (if you are still alive by then).. I don't know why people think that they can mass produce competence..

    • vladms · 19 hours ago

      You can mass produce anything, but it has a cost. I have the impression that some people imagine that you can produce now 10x more doctors at the same cost that you were producing one doctor 10 years ago. Mostly because some tasks (even programming) got many times "more efficient" I feel people transfer to easy to other topics. Even worse, education expenditure is decreasing for many countries! (see some examples: https://ourworldindata.org/grapher/education-spending?tab=li... )

    • nradov · 18 hours ago

      There have always been a lot of incompetent and even dangerous doctors. It's just that patients weren't aware of this and tended to trust their doctor even when the actual care quality was terrible.

  • expedition32 · 21 hours ago

    Ah yes and when doctors give everyone expensive tests because the patients are a bunch of drama queens who think they know better because they have a doctorate in Google the costs go up.

  • cbg0 · 21 hours ago

    This is another one of those "kids these days" thing based on nothing but vibes. https://www.science.org/doi/10.1126/sciadv.aav5916 I'll give you some N=1 sample on older doctors since I'm also from Romania: a lot of these older doctors haven't opened a book in a very long time and are still using older practices instead of providing their patients with the latest and most effective treatments available because they're too lazy and/or prestigious to go and learn new things. Would you say that they "into medicine"? > Would it help if we get a lot more of the first kind of doctors? It would certainly help hypochondriacs a lot. Ordering "a ton of tests" needs to have some basis behind it, and doing it just to make the patient "feel seen" is not a great way to do your profession. People being dismissed quickly also happens in the US quite a lot, sometimes with disastrous results though it's not incredibly common, it's typically labeled under "diagnostic error" https://qualitysafety.bmj.com/content/23/9/727.long

  • account42 · 21 hours ago

    > Would it help if we get a lot more of the first kind of doctors? Hard to tell when you don't let us know which of those doctors ended up solving the issues that made you seek a doctor. Dismissive doctors are bad but so are those that waste your time and risk complications from unnecessary invasive tests.

  • elil17 · 21 hours ago

    You get the same problems in the US with the attitudes of doctors. In the US, medical school is extremely expensive (like $400,000 expensive). There are many people who are excellent doctors who are just priced out of the profession. If we could make medical school less expensive (by subsidizing it and by reducing the amount of instruction), we would probably get many more excellent doctors.

    • sarchertech · 21 hours ago

      Essentially no one pays for medical school outright. They take out loans. Those loans aren’t credit based. People aren’t priced out of being doctors.

      • intrasight · 21 hours ago

        They are priced out earlier - when they can't get the academic credentials to pass the medical school gatekeeping.

        • sarchertech · 15 hours ago

          You mean they can’t get an undergraduate degree. That’s a different problem.

      • wl · 20 hours ago

        Half a million in debt is scary. Especially if you have any doubts that you can match and make it through residency at the end. It's even scarier if you come from a family making $50k/yr.

        • sarchertech · 15 hours ago

          I’m sure there are some people who are put off by that but The average med school debt is half that and only 30% of borrowers end up owning $300k or more. Fewer than 1% of us med school graduates never find a slot. And that includes people who start families, move into industry etc and voluntarily leave. The bottleneck is residency slots not med school slots.

      • Herrum · 19 hours ago

        Don't they have to back these gigantic loans? That might deter people from going to medical school out of fear they're not gonna have what it takes and drop out halfway with huge debt.

        • sarchertech · 15 hours ago

          Very few people make it into med school who can’t make through. Also the bottleneck is residency slots, so even if this is the case, it wouldn’t change anything.

      • tossstone · 18 hours ago

        Loans need to be repaid. I have many physician friends who graduated from medical school with 500k-750k in student loan debt (including debt from undergrad which compounded during medical school) with a combination of federal student aid as well as private loans anywhere from 8-10%. After graduating medical school, they completed 3-5 year residency programs earning somewhere in the ballpark of $50k-$60k salary. This is in an expensive northeast US market where such a salary barely covers basic living expenses, and as such their debt continued to compound. After completing residencies, they earn $175k-$200k salary which is about average for this area as an attending physician in their specialties (primary care related specialties like Family Medicine). You do the math: over a 10 year repayment period with compound interest, their education cost them MILLIONS and they'll be well into their 40s before they start saving a dime for retirement. The cost and scarcity of medical education is extremely punitive to doctors and prices out many would-be great physicians. Many I know who have gone through this ended up regretting it due to the enormous financial burden they are saddled with for many years after becoming an attending. Maybe folks believe these professions should be reserved to those who inherit great amounts of generational wealth.

        • sarchertech · 15 hours ago

          My wife and most of our friends are physicians and I don’t know anyone with $750k in debt. The average debt is a little over $200k. Only 30% of graduates have over $300k in debt and they are considered high debt graduates. Family Medicine salaries are above $200k in every state in the nation for full time doctors. None of the doctors I know come from families with generational wealth. Here is the nationwide average for resident salaries by year and its higher in higher cost of living areas. Program year 1—$68,166. Program year 2—$70,499. Program year 3—$73,301. Program year 4—$77,593. Program year 5—$81,807. Program year 6—$84,744. Program year 7—$89,187. Program year 8—$94,215. Your entire picture is inaccurate.

          • tossstone · 12 hours ago

            If "only" 30% of graduates are graduating with over $300k in debt, that means that of the 30,000 graduates that graduate from both allopathic and osteopathic programs each year [1] there are almost 9,000 physicians that are high debt graduates. At high interest rates, that debt can easily grow by hundreds of thousands of dollars while you complete a residency program. The resident salaries that you listed are an average taken across all specialties. Family Medicine is the lowest paid specialty with 2026 PGY-1 salaries at $58,500 (representing an increase of over 15% since 2021) [2] That is simply not enough to pay the cost of living in a state like Massachusetts where the median household income is more than double that [3] and the average rent in Boston metro is almost $40,000 annually [4]. Not only can you not afford to pay down your student loan debt, you are extremely likely to accrue additional consumer debt on things like credits cards or vehicles. My main point is that training to become a doctor carries so much financial risk that it selects against folks from poor socioeconomic backgrounds that would otherwise make great physicians. In 2018 the AAMC published a study showing that 51% of medical school matriculants were from families in the top quintile for family income [5] and if I were a betting man, I'd guess that proportion has only increased. 1. https://www.kff.org/state-health-policy-data/state-indicator... 2. https://www.inspiraadvantage.com/blog/how-much-do-medical-re... 3. https://fred.stlouisfed.org/series/MEHOINUSMAA672N 4. https://www.zillow.com/rental-manager/market-trends/boston-m... 5. https://www.aamc.org/media/9596/download

            • sarchertech · 5 hours ago

              > At high interest rates, that debt can easily grow by hundreds of thousands of dollars while you complete a residency program. Sure. But that’s not what you said. You said you had many fiends that graduated med school with $500k-$750k in debt. I think you were lying or your definition of many was highly exaggerated. > That is simply not enough to pay the cost of living in a state like Massachusetts $58k is the national average. Not the average in a high cost of living area like Massachusetts. > My main point is that training to become a doctor carries so much financial risk that it selects against folks from poor socioeconomic backgrounds that would otherwise make great physicians. There is almost zero financial risk. Eventual graduation rate is 96%. Eventual match rate is around 99%. Are there doctors that could have make more money going into finance sure. Are there doctors who are financially ruined, not meaningfully. >In 2018 the AAMC published a study showing that 51% of medical school matriculants were from families in the top quintile for family income 1. Doctors kids are more likely to become doctors. 2. High income is correlated with intelligence and intelligence is partially heritable. 3. Kids from high income families are more likely to have extended family and friends who are editors who encourage them to become doctors. 4. Med school requires college and college and children from income families are much more likely to have college degrees. 5. Medical school entrance is competitive and high income kids are much more likely to go to better colleges. 6. High income kids are much more likely to have higher grades in college because they don’t have to work. 7. High income kids are much more likely to go to better high schools which impacts what college they get into and how well they do there. The list goes on and on. The cost of medical school is so far down that list.

              • tossstone · 5 hours ago

                I don’t think accusations of lying add anything productive to the conversation, but thanks. We have different circles of friends with different financial circumstances and that’s OK. There are plenty of stories if you would care to read more: https://www.reddit.com/r/whitecoatinvestor/comments/1jayeai/... Residency match rates for American graduates from American MD or DO programs are more like 93%. Also worth considering that thousands of Americans go abroad for medical school due to limited seats in the US. For American IMGs the match rate is only 70%. If you dig into things a little bit further, it’s actually worse than that because the figures do not include applicants who did not submit a rank list because they did not receive any interviews. I agree that the vast majority are able to match into a residency program, but I certainly would not consider that “almost zero financial risk” https://www.nrmp.org/about/news/2026/03/nrmp-releases-result...

    • fusslo · 20 hours ago

      I'd love to vote for loan forgiveness for anyone who successfully qualifies and practices as a doctor We have the Public Service Loan Forgiveness program where qualifying public servants pay 10 years of their loans and the rest is forgiven tax free. Removing financial stress from doctors seems like a public good most people could get behind

      • nradov · 18 hours ago

        Several US states have programs which pay off medical school loans for physicians who practice in under served rural areas.

    • nradov · 18 hours ago

      There are some schools which now offer combined BS/MD programs which cut up to two years off of the total education time. We should expand those. https://students-residents.aamc.org/medical-school-admission...

  • juujian · 21 hours ago

    Maybe I would rather be treated by such a doctor with time on their hands than a burned out brilliant doctor?

  • 1980phipsi · 21 hours ago

    "Are you sure you can find that many more doctors? That they'll be any good? Speaking from Romania: ..." The prior post was specifically talking about the US. (I assure you, arrogant dismissive doctors are also a thing in the US) In the US, there are a number of things that artificially increase the barriers to becoming a doctor. 1) You typically need a four year college degree to apply to medical school 2) Medical schools are accredited by the AMA, which is controlled by doctors. The AMA makes it very difficult to start a new MD-granting medical school. 3) Medical school in the US is very competitive to get in. They are likely turning away a lot of people who could complete the degree. 4) Since 1997, the federal government has a fixed number of Medicare (Medicare is a federal health insurance program for people over 65) supported residency positions. That number was basically flat for 25 years. We lost about 20% per capita of doctors being trained with support from this program. The caveat to this is that the total number of residents per capita has increased over time, particularly the past 15 years or so. My understanding is that they are less likely to be fully funded, so they spend more money getting trained, and then have higher students loans (on average graduating with debt above 200k going back to the late 2000s) that they need to pay off, so they charge more. And you can add to this that it can be very difficult to be a doctor in another country and come to the US to practice here.

    • TuringNYC · 20 hours ago

      I totally dont by the "no medicare funds for training". A doctor will see you for 10min (perhaps another 10min prep) and bill $1000. If you doubt this, just check your EOB statements from the insurance company or check your deductible history. The entire salary for the resident can be earned back in 3-4 days. You still have 360 days left to pay back admin overhead, facility overhead, supplies, etc. That is earned back in the next several weeks. After that, the next ~300 days of the year are profit. In states with balance billing, the doctor can set any price and bill you for the remaining figure with a balance bill. In NY and NJ these can be thousands or tens of thousands. If you dont pay, it goes to collection and the provider still gets 10 to 15 cents on the dollar. So no...the $75k annual salary of a resident is not a barrier to training more doctors according to any math i'm seeing. What am I missing? What seems more likely is that supply is artificially constrained to increase scarcity and prices.

      • b38484848 · 20 hours ago

        It is not in the interest of the members of a cartel to add new members. What's so hard to understand? Anyone here should be familiar with the ""sAfEtY"" argument at this point.

      • Calavar · 20 hours ago

        > What am I missing? Several things. First, private practice docs see patients with very good employer provided insurance, but residents are largely seeing patients that private practices wont see - patients who are far too medically complex to fit into a 10 minute slot and who also have particularly stingy insurance. So as opposed to a private practice doc who is seeing 30 patients per day and billing an a average of $250 to $300 per patient (certainly not $1000 - that is unrealistic in my experience), a resident is seeing more like 10 to 15 patients per day (30 minute slots) and billing less than $100 per patient. Second, residents have to be supervised. You have not included the salary of the physicians supervising them in your calculation. Third, and I have mentioned this many times before on HN, training is limited by chiefly by the number of training sites that can offer quality training. For example, most hospitals will not see a single case of Guillan-Barre in a single year. Would you want to be treated by a nuerologist who trained at such a hospital? This is why neurology training is generally limited to places with a high volume of neurologic cases that would be considered rare at the average hospital, and these hospitals can only accommodate so many residents. Even for general medicine, you probably do not want to be treated by a doctor who trained at a hospital where any case that passed a certain complexity was transferred out to a bigger center.

    • macNchz · 19 hours ago

      On top of these, a few things with the training process also jump out to me from a "can we attract smart and motivated people to this work" point of view: the sheer cost of medical school that creates an imperative for high pay down the line, coupled with a real chance that you can wind up without a residency match but still owe all that money for school, and in particular the grueling nature of the residency system, currently capped at only 80 hours/week since 2003, because people were working >100 and making mistakes. There are arguments that these are factors that filter out the people who are not sufficiently motivated, but it's hard for me to imagine there aren't a lot of bright young people who might be interested in medicine, but see one of the various paths that exist today to making doctor-level money with only an undergraduate degree and in an environment that doesn't require a working schedule that actively harms your health.

      • nradov · 18 hours ago

        Yep, it's a huge risk. If a student enters medical school and realizes halfway through that they don't want to be a doctor then they're still stuck with a huge debt and no way to pay it off. It's not like undergraduate education where you can fairly easily switch majors from chemistry to mathematics or whatever.

  • Aeolun · 20 hours ago

    > Would it help if we get a lot more of the first kind of doctors? Depends? Did the tests actually find anything, or did they just make you feel better? I had a talk with my GP about this at some point, and he more or less told me that he can just say "Go home, rest, come back in two weeks if it doesn't get better.", and 95% of the time that'll be exactly what is necessary. The hard part of his job is figuring out which of the visits are those 5%.

  • rudolftheone · 18 hours ago

    So you're saying limiting the number of doctors work better? Speaking from Poland, we see the same outcome: doctors rushing patients out after 5 minutes. The reasons may be different, though: since COVID, many doctors here have, in my view, become more arrogant and focused on money. Over the past few months, an uproar over doctors’ pay has swept through Polish social media. Reports have emerged of doctors billing for overlapping work under multiple contracts. In one case, a doctor’s records showed 72 hours of work in a single day! Meanwhile, the Polish Chamber of Physicians and Dentists (NIL) continues to defend caps on medical school admissions, adding fuel to the national debate.

  • M95D · 13 hours ago

    I work in a med lab in Romania. I'm doing some of that "ton of tests" your doctor ordered. 99.9% is money wasted - your money I bet.

• simianwords · 21 hours ago

  > Their salaries need to be lower, training needs to be cheaper and faster, and we need a lot more of them. We need to reduce the requirements to be a doctor. I think general ability is way way way more important than the specialisation. I don't think the speciality that doctors spend money and time on add that much value..

  • azan_ · 21 hours ago

    > I think general ability is way way way more important than the specialisation. I don't think the speciality that doctors spend money and time on add that much value.. And why do you think that? I'm a doctor and I disagree completely - the medicine nowadays is so advanced, that it's impossible to keep up with advances without specialising yourself in narrow area.

    • simianwords · 21 hours ago

      That's interesting because it is exactly for the reason you give "impossible to keep up" that I think general ability is crucial.

      • azan_ · 19 hours ago

        Please read what I said again - it’s impossible to keep up unless you specialize. It’s really bad tactic to cut something out of context where context is literally in the same sentence.

        • simianwords · 16 hours ago

          Can you please read again? If the pace moves so fast that you can't keep up, it is even more reason to hire for general ability. What made you think that "things are moving really fast" is an argument for hiring specialists? Doctors smh.. Please at least show an attempt to understand what is said.

          • azan_ · 16 hours ago

            > If the pace moves so fast that you can't keep up, it is even more reason to hire for general ability. I can keep up with my specialized field, but I can’t keep up with entire medicine because it’s too broad. It’s clearly a case where specialization is important. I’m not the one that has problems with understanding here.

    • sebmellen · 19 hours ago

      I say this as a tech person married to a physician. Hacker News is a very bad place to discuss medicine because most of the readers and writers are tech people who just don't have exposure to medicine in depth. It would be the same as someone from Hacker News going to read a medical forum where people are discussing AI, and the takes would feel similarly juvenile and uninformed, simply due to lack of exposure. You are right, of course… but unfortunately I don't think it's worth arguing too much here.

      • jeuue · 18 hours ago

        He’s a deluded fool that keeps commenting on things way out of his expertise and for which he has zero experience of. He’s polluting this damn place. Many of his posts tend to be down voted for a reason.

• 7952 · 21 hours ago

  I don't think Dr salaries are even that high a percent of healthcare spending. Although, maybe better work life balance, lower salary escalation and less debt would help everyone.

  • sarchertech · 21 hours ago

    It’s 8%.

• balderdash · 21 hours ago

  Agree - one sensible start would be to at least hybridize the European model where students are a whole lot closer to getting there medical degree as an undergraduate.

  • sarchertech · 20 hours ago

    In most countries that do this training is longer which that total training time is only 1-2 years shorter. So you’re doing a few things. 1. Moving more training from cheaper colleges to more expensive medical schools. 2. Moving the filter from undergrad to medical school 3. There is no national curriculum in US high schools, so essentially the first 2 years is getting everyone on the same footing. Removing this without changing high school, puts students at poor high schools at an even greater disadvantage.

    • nradov · 18 hours ago

      There are some schools which now offer combined BS/MD programs which cut up to two years off of the total education time. We should expand those. https://students-residents.aamc.org/medical-school-admission...

      • sarchertech · 15 hours ago

        Many of the programs you listed don’t cut any time off. They’re just a special pipeline program that can help you get into med school. Of the ones that do save time, most cut 1 year off not 2. And they do it by having students take more than a full time load during undergrad. It’s essentially the same thing as taking an extra class or 2 every semester so you can finish undergrad in 3 years instead of 4. I randomly sample 15 of the programs listed there and 14 were 8 year programs. Only 1 had an optional 7 year program (if you were willing to take more than full time load or go to school in summmer). And there were no 6 year programs.

• mococa · 21 hours ago

  In brazil, we imported doctors from Cuba

• lolakutty · 21 hours ago

  > The reality is we need more doctors. A lot more. No, the reality is we should be more healthy, so we need less doctors.

  • killingtime74 · 21 hours ago

    While you're at it why not no crime so there's no police. Nothing dangerous so no firemen. Nobody throws anything away, so no need for factories. Peace on earth, so no soldiers.

  • layer8 · 21 hours ago

    I think you’re not sufficiently taking into account the demographic trajectory of age distribution [0], and the lag induced by the length of the human lifespan on health improvements. For the next few decades, more doctors will be needed. [0] https://www.calculatedriskblog.com/2013/08/us-population-dis...

  • victorbjorklund · 20 hours ago

    We don't need firemen. Just don't start fires.

    • lolakutty · 19 hours ago

      That is a good analogy. Let us consider that there is a growing number of fire events in the recent years. Instead of finding out what is causing it, and fixing it we are asking for more firemen....

• zsoltkacsandi · 21 hours ago

  > The reality is we need more doctors. A lot more. I think building a better prevention layer is more important. Don't get me wrong, I agree that we need more doctors (and nurses, and physios, and dietetists, and ...), but it is much easier to scale a good prevention system than the number of workers in healthcare.

  • lotsofpulp · 18 hours ago

    Do you have a plan on preventing the effects of aging, such as mutations in DNA and wear and tear?

    • zsoltkacsandi · 16 hours ago

      Prevention is not about age related diseases, but early onset cancer, diabetes, high blood pressure caused by alcohol and tobacco use, unhealthy diet, and sedentary lifestyle. A significant amount of cases could be prevented before they need medical intervention (and put burden on the medical system). There are several researches about this, the number of people with type 2 diabetes doubled in the past decades. This is why some healthcare systems reward for example doing 10.000 steps a day with lower insurance fees. They recognized they save a huge amount of money if they get people to move.

  • nradov · 17 hours ago

    Widespread use of GLP-1 agonist drugs will prove to be the most effective prevention layer. I absolutely support people living healthier lifestyles in order to delay the onset of the chronic diseases that drive the majority of medical care demand. But on a population basis, attempts at lifestyle interventions have been broadly ineffective. A lot of the chronic disease burden including type-2 diabetes, hypertension, heart failure, MSK, etc is downstream of obesity so if GLP-1 drugs can cause a lot of people to lose weight then we might see some real improvements within a decade. To be clear I'm not suggesting that everyone should be on GLP-1 drugs, and it's obviously better to maintain a healthy lifestyle and body composition without those drugs. But for people who can't or won't do that on their own the drugs seem to work pretty well. There's also promising evidence that they cause reduction in alcoholism and other substance abuse disorders.

• gww · 21 hours ago

  I think one issue is that the admissions for medicine are getting harder and harder. In many places you practically need a 4.0.GPA, volunteer work, great mcat scores, research experience, sometimes a post grad degree like an MSc and PhD etc. This selects for highly competitive and intense personalities that are not always suited for every medicine specialty. Most of them don't want to go into family medicine and pediatrics because it's more work, less money, less prestige etc. The friends I had who wanted to go into family medicine couldn't because of the admission requirements. Their only alternative was to have family money to pay for medical school in places like Ireland. Edit: I should have mentioned that pediatrics and family medicine represent a large proportion of available residency spots each year and are rarely full.

• Forgeties79 · 21 hours ago

  General practitioners make something like 150k on average in the US. Specialists tend to make a lot more (upwards of double) and also tend to skew perceptions of doctors’ pay. You could argue specialists should make less but considering how long it takes to become a doctor, how much work it takes to get there, how long you’re putting off real earning potential, school debt, etc., I do not consider 150k overpaid. From a more practical angle, I don’t know how you could possibly find more doctors by lowering their earning potential.

  • chromatin · 21 hours ago

    > From a more practical angle, I don’t know how you could possibly find more doctors by lowering their earning potential. You certainly could if you were willing to accept people who are terrible at being a physician. The notion that you can just throw more warm bodies at the problem is ludicrous

    • hibikir · 20 hours ago

      Other countries have double, even triple the number of physicians per capita. They also pay them a lot less. Are they all less competent? Are US filtering requirements actually all that predictive of future performance? Can we, say, see that MCAT scores really line up well with clinical performance? Because it's easy to be selective, but not so easy for the selectivity to be predictive of actual quality, especially when you are being selective before training starts.

      • victorbjorklund · 20 hours ago

        But those countries also pay less in a lot of other fields as well. Developers make less in those countries than they make in the US.

      • folkrav · 19 hours ago

        I would be surprised if wages in most of those countries were not lower overall, not just for doctors.

  • Calavar · 20 hours ago

    General practitioners make more like 250k on average. 150k for general practitioners working in academics, but not overall.

    • boelboel · 17 hours ago

      They can make a lot more than 250K in less attractive places as well. But I believe the current cohorts of med students are more 'worldly' and in it for the money than in the past. They'll take getting paid 100K less so they can stay in a nice city and take another 50K less to work part time.

• Palomides · 21 hours ago

  there is another solution that will be (and is) actually happening: diffusion of doctor responsibilities to other less regulated/trained workers sucks but that's incentives for ya

• torben-friis · 21 hours ago

  The author: "Doctors are caught in a web of business, no longer a noble vocation. The altruism of young doctors have been replaced by the shackles of efficiency, productivity and key performance indicators." The answer: here's some key performance indicator we can improve. Sigh.

• baxtr · 21 hours ago

  If you want more doctors you need to find out what’s holding people back to become doctors. I have no idea what this might be.

  • mzmzmzm · 21 hours ago

    Speculating, but it could be a spiral where the shortage places more responsibilities on existing doctors, making the field less appealing to potential doctors. For too many people no amount of income compensates for a difficult lifestyle (we see this with air traffic control). If this were the case it would be productive to redesign medical systems to unburden doctors, but the current for-profit, scarcity-oriented system (in the US anyway) seems calibrated to squeeze everyone.

• chromatin · 21 hours ago

  > Their salaries need to be lower, training needs to be cheaper and faster, and we need a lot more of them. The quality of the average physician is already so low I am not sure what you are hoping to accomplish with lower salaries and faster training. Doctoring isn't a matter of more warm bodies

  • hibikir · 21 hours ago

    Most countries get good results with shorter training and much lower salaries. And, just like most other US university degrees, the majority of the filtering is done on entrance, not on training. So it's not that we are evaluating the best doctor, but the best diligent people that get great scores in the MCAT. Whether that actually lines up well with being a good doctor is not all that clear.

    • sebmellen · 20 hours ago

      Here’s an excerpt from a study of more than 1m physicians: > “Better examination performance was linked to improved adherence to mammography screening recommendations, appropriate prescribing practices, improved care of patients with diabetes, lower patient morbidity and mortality, fewer complaints to regulatory bodies, and lower malpractice payments. The association was observed across examination formats and medical specialties.” https://academic.oup.com/academicmedicine/article-abstract/1... Unfortunately, it’s very clear.

  • killerstorm · 21 hours ago

    It's low because there's no competition. MDs are like medieval guild: once you're in, you're set for life. Restrictive regulations are lobbied by MD associations, which limit competition.

    • dguest · 20 hours ago

      It's an old joke: Q: What do you call the worst student to be admitted to medical school? A: Doctor.

      • nradov · 18 hours ago

        Ha ha, but the joke is kind of wrong. While anyone with an MD degree is entitled to the honorific "doctor" that doesn't mean they can legally practice medicine. Becoming a licensed physician generally requires completing a residency program, and the worst students sometimes fail to get matched to the limited number of residency slots.

        • dguest · 15 hours ago

          Yes it's a joke, but to quote some numbers in the US: something like 93% of the US graduates matched to a residency program [1], although the numbers were a lot lower for international students applying for US residency. So if you're talking about US medical students, you have to be in the bottom 10% to flunk out. The attrition for lawyers is higher, neither has anything on PhDs where the number of "practicing" doctors drops off constantly during and after the degree, and only really levels off when O(10%) of them land faculty jobs. [1]: https://www.ama-assn.org/medical-students/preparing-residenc...

      • chromatin · 10 hours ago

        I can think of at least one person who failed out of my medical school class

    • chromatin · 10 hours ago

      An alternative hypothesis is that it's low because our most talented kids know they can make a ton more in finance and tech

• meken · 21 hours ago

  > There's no solution other than training a lot, lot, lot, lot more doctors. Seems like having doctors emigrate from other countries would work as well.

  • layer8 · 21 hours ago

    It might not work for the other countries.

  • sebmellen · 20 hours ago

    Then you end up with students from places like Nepal and Pakistan, where cheating is so rampant that you can't really evaluate the quality of your medical student or applicant. Even standardized exams like the USMLE/STEP series have been gamed. You also end up with significant cultural mismatch. I don't believe this is a good solution.

  • slices · 19 hours ago

    anecdote alert: had a family member treated by a foreign doctor last year, and received advice from that doc that was both 1) highly dangerous, 2) bare minimum 20 years out of date. Inconceivable that a domestically-trained doc would have made the same mistake.

• killerstorm · 21 hours ago

  Probably better solution is to upskill nurses + AI to do handle all the simpler tasks like prescribing standard treatments, etc. There's already a concept of mid-level practitioner which can be expanded. There's basically no need for GP to be a doctor.

  • sebmellen · 19 hours ago

    This is so hilariously false and completely inverted that it shocks me that people not in medicine can believe it. Out of respect for you as a fellow intelligent HN commenter — you are deeply misinformed, and I would urge you to reconsider your perspectives on this. Every study shows that utilization of APPs and nurse practitioners Leads to decreased quality of care and a significant increase in utilization of other healthcare resources, like the emergency department and imaging, that better-trained physicians don't need. Less-trained providers misdiagnose cancers, refer patients to the wrong specialists, overprescribe antibiotics, and generally cost the system significantly more in overall health load than if we had better-paid general practitioners. There is an argument that not enough physicians go into general practice, which is true, but it's because subspecialties are in such high demand that they're generally better paid. The unfortunate fix is that we need to find a way to better compensate primary care, even though Medicare physician reimbursement rates continually decline and our health insurance system is not well structured to support this kind of primary care model. I've left a few links below if you'd like to read them: General burden of NPs higher than physicians even with lower appointment cost: https://static1.squarespace.com/static/615326dd2c363f1e2a5c8... Skin cancer misdiagnosis: https://www.ovid.com/journals/jaderm/abstract/10.1001/jamade... Antibiotics overprescribed: https://pmc.ncbi.nlm.nih.gov/articles/PMC5047413/

    • killerstorm · 17 hours ago

      There are several papers demonstrating AI is at least as good at diagnostics as fully qualified doctors. So why would NP + AI be worse? AI should compensate for the lack of knowledge. And I'm not saying NP + ChatGPT - it should be properly calibrated system which would defer to a 'proper doctor' in more complex cases.

      • sebmellen · 17 hours ago

        > AI is at least as good at diagnostics as fully qualified doctors If the prompt is an expert-written board question! Not so with inferior prompts [0]. Critically, you need deep medical knowledge to interact correctly with the agent. What you're asking is basically: "If we take someone out of a three month dev bootcamp, and have them prompt Claude, why can't they be as good as a four year CS grad?" I doubt that you would feel similarly about expertise in your own field. [0]: https://www.nature.com/articles/s41746-026-02428-5.pdf

        • killerstorm · 17 hours ago

          There have been a huge progress in AI reasoning in the past 2 years. GPT-4o mentioned in the article would struggle with high-school math problems, OTOH GPT-6 can solve problems beyond capability of professional mathematicians. I'd wager GPT-6 would not depend on high-quality prompts, although it might still be good to get a trained person to enter information and do a sanity check.

          • sebmellen · 16 hours ago

            Yes, point taken. I am well aware of the intelligence explosion and I am very AI pilled. But the core problem still exists based on the clarity of the prompt and the prompter. Seeing my wife's depth of intuition and expertise as a physician, compared to my comparatively caveman-like prompts when asking for health advice, there's a massive delta in accuracy. Have you ever had a significant health issue and tried to get help from a model? Even something like GPT 6 Pro? The firehose and confusion you will generate trying to figure out answers are far less helpful than having directed interaction with a physician.

            • sebmellen · 7 hours ago

              Following up on this because I've been thinking about why this is. I believe a big part of it is just that the intuitive parts of medicine are learned essentially by internship and therefore are not well encoded into the models. Unlike software, where you can have deterministic output that the models can train on, medical outputs are very fluid and dynamic. What works well in a paper, even though we claim to do evidence-based medicine, may be very far from what a "good" physician does in practice. The issue is that the AI is at best what's in papers and medical records, which often forgoes the core thing that might lead a physician to uncover something or take a different approach with the patient.

• SirFatty · 21 hours ago

  "There's no solution other than training" Not true.. according to most around here, it will be AI and robots all the way.

• sleepyguy · 21 hours ago

  The reality is we need a lot more than just more doctors.The entire system needs to be revamped.

• sarchertech · 20 hours ago

  We already have a system for cheaper doctors. It’s called physicians assistants and nurse practitioners. They are essentially exactly what’s you’re talking about. They make less and they have less training.

  • xadhominemx · 20 hours ago

    Exactly! I suspect the parent commenter does not interact much with the US healthcare system.

  • halJordan · 12 hours ago

    The over reliance on PAs and NPs are very much a part of the problem.

    • sarchertech · 6 hours ago

      Sure it is. But a less well trained cheaper doctor looks almost exactly like a PA.

• qmmmur · 20 hours ago

  Nah you just need to unfuck your insurance system. It’s fine in other places without watering down the quality of medical professionals.

• sebmellen · 20 hours ago

  For a lot of specialties, we just don't have enough caseload to train doctors well enough. There is this meme that there's a cap on residency positions, which is the main limiter, but caseload is a significant limiter as well, especially for anything procedural or less knowledge-based.

• Gareth321 · 19 hours ago

  > (speaking from US): The reality is we need more doctors. A lot more. [Doctors only spend around 18% of their time with patients in the U.S.]( https://pubmed.ncbi.nlm.nih.gov/40500897/ ) The rest is spent on administration. I respectfully contend that the bigger issue is not the number of doctors per patient (though I admit that it could be a contributing factors), but rather that successive bureaucracy and compliance and laws and insurance requirements and policies have resulted in a system which forces doctors away from patients and towards ass covering. Remove the bureaucracy and you instantly have 5x as many doctors, effectively. Add more doctors to the machine and the machine will only find more creative ways to waste their time and talents.

  • estearum · 19 hours ago

    Re-engineer the entire US system or train more doctors… > Remove the bureaucracy and you instantly have 5x as many doctors, effectively. Add more doctors to the machine and the machine will only find more creative ways to waste their time and talents. That’s a huge leap and not at all evidenced by your comment. I’m all for simplifying all these administrative stuff. But no, that will not solve the fact that we have way more people who are way sicker and fewer doctors for them.

  • nradov · 19 hours ago

    Yes, that's true to an extent. Some administrative tasks can really only be done by the attending physician. Ultimately they're the ones taking legal accountability. But other tasks can be automated or shifted to cheaper employees or not done at all. The problem is that many health system managers and administrators treat physician time as an unlimited free resource and impose all sorts of extra burdens on them. This is one of the factors driving physicians to burn out and leave the profession, further exacerbating the shortage.

• nradov · 19 hours ago

  True, but the other side of that is a lot of primary care will be taken over by lower licensed PA/NP. We can't possibly train enough new physicians to meet the demand imposed by an aging population. It doesn't take a real doctor to deal with routine scrapes and sniffles.

• matheusmoreira · 19 hours ago

  Why do you think you're going to get more doctors by paying less?

• yilomap · 18 hours ago

  I am willing. I just need someone to fund med school for me. If you won't do that you can't be that desperate :)

• strideashort · 18 hours ago

  AI. We need AI, period. At least as first line docs. But what the author describes - fuck no, this is absolute unsustainable madness. Race to the bottom. I’d rather fix plumbing at my own pace.

In the same vein: there’s the fantastic book This is Going to Hurt: Secret Diaries of a Junior Doctor by Adam Kay