[HN Gopher] Why doctors in America earn so much
___________________________________________________________________
Why doctors in America earn so much
Author : bookofjoe
Score : 181 points
Date : 2023-11-01 14:38 UTC (8 hours ago)
(HTM) web link (www.economist.com)
(TXT) w3m dump (www.economist.com)
| bookofjoe wrote:
| https://archive.ph/6VVzh
| FrameworkFred wrote:
| only a robot would click that button so many times
| bookofjoe wrote:
| https://youtu.be/uc6f_2nPSX8?si=uPuu2D-3exVf4aBG
| daoboy wrote:
| "In 1997 federal funding for residencies was capped, forcing
| hospitals to either limit programmes or shoulder some of the
| financial burden of training their doctors. Some spots have been
| added back, but not nearly enough. Many potential doctors are
| being left behind. "Not everyone who would be willing to go
| through that training and could do it successfully is being
| allowed to," says Professor Gottlieb, the economist."
|
| I regularly hear it is the AMA that is creating an artificial
| shortage, but this seems to indicate that the logjam is at the
| level of residency funding.
|
| Does anyone have a good insight or data about this?
| candiddevmike wrote:
| This has led to is a rise in PAs and ARNPs for primary care,
| and scary things like CRNAs asking MDs for sign offs without a
| supervising anesthesiologist.
| Empact wrote:
| Is there a reason other than fear to think that CRNAs are
| ineffective at their jobs?
| candiddevmike wrote:
| They need a supervising physician, which should be an
| anesthesiologist. Surgical MDs do not have the same
| qualifications to sign off on their orders. The liability
| with CRNAs flows to the supervising physician, so most MDs
| tend to be very uncomfortable working with only CRNAs.
| prh8 wrote:
| Not quite the question-- the real question is why would
| they be effective at the jobs of others? Doctors have 10-15
| years of training, there's a reason for that.
| whaleofatw2022 wrote:
| My understanding is that at least at one point in the past the
| AMA lobbied either for the cap or to not fix the problem. Also
| inversely speaking, you don't really hear much about the AMA
| lobbying to -fix- the problem and given the frequency of this
| theory, you would think they would publicise it more.
|
| There is also the weird thing where, my understanding is that
| the hospitals can 'sell' the slots to each other and strangely
| they can fetch more than the funding in question.
|
| But really, so much of the medical residency industrial complex
| reminds me of a hazing ritual in and of itself.
| 303uru wrote:
| >reminds me of a hazing ritual in and of itself
|
| It's absolutely abusive and I cannot believe there's never
| been more of a push around patient advocacy. It's bad enough
| for the residents working 100 hours a week and getting fits
| of sleep in a shitty spare hospital room they share with
| multiple other residents. It's even worse for the patients
| receiving care from a tired, overworked resident.
| phren0logy wrote:
| There has been a push back, and hours are now capped well
| below 100 hours (maybe 60 hours a week now?) with limits on
| duration of shifts, also. When I trained the cap was 80
| hours/week with a limit of 30 hours in a row.
| 303uru wrote:
| Where? I still see/hear of residents in the states
| working 80+. Many pulling 20-24 hours a day for 3 or more
| days a week, then additional coverage beyond that.
| cpburns2009 wrote:
| The cap is still 80 hours/week. I'm not sure about the
| consecutive hour limit. It's at least 24 hours. That
| doesn't stop the residents I know from frequently having
| duty hour violations. In one case I know a resident had
| his hours manipulated by admin to under report them.
| mindslight wrote:
| And yet in my few experiences, the residents are actually
| the ones that will talk to you and tell you what is going
| on. As opposed to the super important Attendings who you
| only see when it's time to talk about things with legal
| repercussions like pulling the plug.
| downrightmike wrote:
| The program was started by a guy hopped up on cocaine the
| whole time, that's why the hours alone suck:
|
| "William Stewart Halsted developed a novel residency training
| program at Johns Hopkins Hospital that, with some
| modifications, became the model for surgical and medical
| residency training in North America. While performing
| anesthesia research early in his career, Halsted became
| addicted to cocaine and morphine" https://www.ncbi.nlm.nih.go
| v/pmc/articles/PMC7828946/#:~:tex....
| klipt wrote:
| Residency funding, and the fact that even fully trained foreign
| doctors have to redo residency to practice here.
|
| An American can marry a foreign doctor with 10 years
| experience, get their spouse a green card and everything, and
| they still can't work as a doctor without redoing residency
| like a fresh graduate.
| willcipriano wrote:
| Globalism for thee, protectionism for me.
| moron4hire wrote:
| That's not an example of globalism hypocrisy
| willcipriano wrote:
| Bring in foreign programmer: here's dozens of laws and
| programs to make that easy.
|
| Bring in foreign doctor: here's dozens of laws and
| programs to make that hard.
|
| Bring in foreign low skill labor: Laws? No human is
| illegal!
| JumpCrisscross wrote:
| Coding, farming and medicine have different stakes (in
| general). It makes sense to be pickier with the last than
| the first two.
| willcipriano wrote:
| Millions are protected to die simply due to lack of
| access to medical care. The doctors would have to be
| actively malicious to be worse than the alternative of no
| doctor.
| JumpCrisscross wrote:
| > _doctors would have to be actively malicious to be
| worse than the alternative of no doctor_
|
| There is so much low-hanging fruit to pick before we
| create a two-class medical system.
|
| Also, "millions" is hyperbole. It's tens of thousands a
| year [1]. Two million or so in a lifetime. But half as
| many as from alcohol [2].
|
| [1] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2323087/
|
| [2] https://www.cdc.gov/nchs/fastats/leading-causes-of-
| death.htm
| willcipriano wrote:
| Feel free to at any point in the last twenty years. It
| wasn't done so now drastic action is required to save
| lives.
| JumpCrisscross wrote:
| > _now drastic action is required to save lives_
|
| You realise it's this sort of rhetoric that inhibits
| moderate progress? If I wanted to kill a residency
| expansion proposal, and a lawmaker were saying we should
| let doctors trained in the worst medical systems in the
| world treat poor Americans, I would run that framing on
| billboards.
| willcipriano wrote:
| I've been hearing that for twenty years. #ForceTheVote
| most recently. Drug reimportation under Trump. The public
| option with Obama. It's never the right time.
| JumpCrisscross wrote:
| > _been hearing that for twenty years_
|
| That extremist policy positions backfire? Yes. Because
| it's consistently true. See: defund the police and
| abortion.
|
| What you're suggesting is lower impact and still more
| radical than a public option or drug price regulation.
| willcipriano wrote:
| If it's extremist to say "hey we shouldn't spend at least
| twice as much for healthcare for no reason" then burn it
| all to ashes, nothing of value remains.
| robocat wrote:
| > From link: although some studies stated that people
| aged 25 to 64 were 25% more likely to die if they lacked
| health insurance, the risk of death was probably higher
| because uninsured people are less healthy than insured
| people.
|
| The interesting point is that the early deaths are mostly
| due to selection - people that can't get insurance are
| more likely to die early e.g. lifestyle choices. Giving
| them access to the medical system might not help as much
| as we might hope.
|
| > Upthread: willcipriano said: Millions are pro[j]ected
| to die simply due to lack of access to medical care.
|
| No. The risk of death is 100%. People can die earlier
| than otherwise due to lack of medical access - or better
| said we can delay death but it usually gets harder and
| harder to delay as we accumulate chronic health
| conditions. And some people avoid chronic conditions
| better than others.
|
| Aside: Meanwhile the richer your country, the more you
| can take the best doctors and nurses from the poorer
| countries. New Zealand trains a lot of great doctors and
| nurses for the USA. And we take a lot from other
| countries too.
| nradov wrote:
| That depends on the state. Some states such as Tennessee now
| offer more flexible options for foreign trained doctors to
| practice there.
|
| https://www.medscape.com/viewarticle/993693
| dublinben wrote:
| Here's a recent report from the Congressional Research Service
| about this that provides a very detailed summary of how this
| works: https://crsreports.congress.gov/product/pdf/IF/IF10960
| ejstronge wrote:
| You are precisely correct - this is not an AMA issue. Funding
| for this is tied to Medicare/Medicaid and thus a political
| issue that does not turn based on what the AMA may request. In
| searching for the below table, it seems that there is some
| effort to use funds from other sources to pay for targeted
| slots[1]
|
| 1. https://www.aha.org/news/headline/2023-07-27-hhs-
| awards-15-g...
|
| Here's a breakdown for funding for one year in the recent past:
| https://www.ncbi.nlm.nih.gov/books/NBK248024/table/tab_3-1/?...
| wombat-man wrote:
| A former roommate of mine was a doctor in residency. They were
| paying him peanuts and grinding as much work out of him as they
| could. I think this was maybe 5 years ago and he was at 65k or
| so in a major metro in the US.
|
| So if you're a hospital, and you can get cheap doctors in
| residency who basically need to work whatever workload you give
| them, why wouldn't they hire as many of them as they could? I
| figure the limiting factor should be their ability to manage
| them, not federal funding. They are paying pennies on the
| dollar for doctor labor that they are NOT giving patients a
| discount on.
| nradov wrote:
| You figure wrong. Hospitals require residents to do a lot of
| work, but they can't bill Medicare/Medicaid or private
| insurers for much of that work. Hospitals can't afford to
| just hire more.
| HDThoreaun wrote:
| Residencies all lose money. That's why they're subsidized. My
| family member is a chair of a residency and the business
| analysts are constantly trying to close it because it takes
| time away from the doctors and doesn't provide anything to
| the bottom line.
| wl wrote:
| My partner did a second residency. Medicare doesn't fund
| second residencies, so she had to get an unfunded spot. At
| least with her second residency, they have those unfunded
| spots precisely because they're profitable. Maybe it's not
| all programs, but certainly some of them are profitable.
| s1artibartfast wrote:
| It is the same issue.
|
| The AMA has lobbied to limit federal funding for medical
| residency. This is the bottleneck.
|
| The fundamental problem is that the US government should not be
| in the business of funding residencies to begin with. That
| should the on the hospitals.
|
| Right now the problem is that no hospitals want pay the 150k
| cost for residency when there is the option for the federal
| government or another hospital to pay it. It basically leads to
| a tragedy of the commons/prisoners dilemma, where all the
| hospitals defect and try to fight for limited grants.
|
| This article has some general details:
| https://thesheriffofsodium.com/2022/02/04/how-much-are-
| resid....
| ejstronge wrote:
| Do you have evidence of this lobbying? It does not stand to
| reason, since care provided by residents is quite cheap to
| hospitals from the perspective of labor.
|
| Hospitals have no obligation to hire the residents they
| produce, so an optimal behavior would seem to be training
| many residents and not hiring them.
| renewiltord wrote:
| It's interesting how truth can disappear over time. They
| were out and proud about it back then.
|
| Here: https://www.washingtonpost.com/archive/politics/1997/
| 03/09/r...
|
| > _Last week a powerful coalition of medical groups,
| including the American Medical Association and the
| Association of American Medical Colleges -- the umbrella
| group for medical schools -- proposed their own plan. Their
| idea is to limit residency slots financed by Medicare to
| the number needed for the 17,000 annual graduates of U.S.
| medical schools._
|
| There's other things like this that folks say "Well,
| where's the evidence?" and the truth is that the evidence
| was all around us back then. Now that people have changed
| their minds on this stuff, it's harder to find as the
| perpetrators go quiet about it. And you have to search the
| past which isn't that easy.
|
| I'm sure the pandemic response will be similarly rewritten,
| especially the business about telling people masks don't
| work because they wanted to make sure that average people
| won't take masks that they wanted to keep for healthcare
| people. That's being rewritten in front of me to say "Oh
| there's no evidence that masks ever worked and that's why
| they said that".
|
| Where's the evidence? Well, in many cases, it was
| everywhere. Truth casts a small shadow on time. The
| motivated sceptic stands purely in the light.
| ejstronge wrote:
| This is a difficult issue - if we accept the statements
| on their face (and I don't have enough information to
| accept or reject the statements), it seems that there was
| waste by hospitals that were doing just what I mentioned,
| soliciting residents that were not needed.
|
| From the article: "But why should hospitals be interested
| in this when, under current law, they automatically get
| sizable government subsidies for training residents who
| as part of their education take care of many of the
| hospitals' patients, work long hours and collect meager
| salaries?"
|
| If this issue were to arise again in today's political
| climate, I imagine there would be a redistribution of
| seats away from in-demand specialties to primary care.
| renewiltord wrote:
| Yeah, this is one of those things you had to be there
| for. When you're just reading a picture from history, and
| that's the only insight you have into it, you're going to
| get a particular view of it. It can't be helped,
| especially if one is searching for evidence to support
| one's own beliefs.
| s1artibartfast wrote:
| >It does not stand to reason, since care provided by
| residents is quite cheap to hospitals from the perspective
| of labor.
|
| The AMA represents doctors, not hospitals, and doctors
| benefit from scarcity. Hospitals benefit from residency
| grants, existing doctors do not.
|
| >Do you have evidence of this lobbying?
|
| Here is a source [1]
|
| >Hospitals have no obligation to hire the residents they
| produce, so an optimal behavior would seem to be training
| many residents and not hiring them.
|
| Optimal only if they can make money from the residents. Due
| to the bizarre natures of US medical reimbursement,
| resident physicians do not bill for their services [2].
| While they may provide value in other ways, they are viewed
| as cost on the balance sheet. This is further complicated
| by the fact that hospitals dont want to bear this cost if
| they can get a grant, or simply hire a doctor away from
| another hospital. Getting rid of the grants would be a step
| in the right direction.
|
| https://blog.petrieflom.law.harvard.edu/2022/03/15/ama-
| scope...
|
| https://thesheriffofsodium.com/2022/02/04/how-much-are-
| resid....
| RALaBarge wrote:
| I find myself reading comments like this in disbelief (or
| assuming the author is not in good faith responding), as if
| there can be any doubt where political lobbying is possible
| that there doesnt exist a tremendous apparatus to exploit
| it.
| light_hue_1 wrote:
| Yes, here it is. With citations:
|
| https://blog.petrieflom.law.harvard.edu/2022/03/15/ama-
| scope....
| asdfman123 wrote:
| You can look up things for yourself, you know
| nonameiguess wrote:
| Residents are still doing work. The notion that they should be
| federally-funded, rather than just getting paid for doing that
| work directly through the proceeds of whatever patients get
| charged for that work, seems dubious to me. I'd also be
| skeptical of a claim that available slots are _more_ of a
| limiter compared to the fact that propective physicians are
| looking at 4 years of post-graduate education followed by 3-9
| years of working 100 hour weeks for $30-40k a year before they
| can get licensed.
|
| I once considered becoming a doctor when I was still a teen,
| and I'm quite confident I could have gotten into medical school
| and qualified for a residency _somewhere_ , but it was the
| decade of hazing while being paid like a ranch hand that
| dissuaded me.
| mytailorisrich wrote:
| Entry to medical school is also extremely competitive in Western
| Europe and there are also limits on number of places in some
| countries. And there are shortages of doctors as well.
|
| I don't think that's key.
|
| In Europe healthcare tends to be socialised and heavily regulated
| so that I would argue that average salaries are kept
| "artificially" low.
|
| Medical services are highly valued by society for obvious
| reasons, and the level of required training is extremely high. If
| the market was left to its own devices I have little doubt that
| doctors in Europe would earn much more than they do now. Of
| course that does not mean that healthcare would be better on
| average, in fact most likely the opposite, but the question is
| about doctors' income.
| titanomachy wrote:
| It's not as competitive. I had classmates who were rejected by
| every Canadian and US medical school and ended up going to
| Ireland or France instead. (The one who went to France was a
| French national. The ones who went to Ireland were not Irish.)
| mytailorisrich wrote:
| Article says:
|
| > _Lots of people want to train as doctors: over 85,000
| people take the medical-college admission test each year, and
| more than half of all medical-school applicants are rejected_
|
| But I believe that this means applications with a Bachelor
| degree.
|
| In France, the system is different. Students go to 1st year
| medical school after highschool where there is a massive
| selection with limited number of places to get to 2nd year.
| Only 15-25% of students get to 2nd year, taking into account
| that only good students will attend 1st year to start with.
|
| In the UK admission rate in 1st year (afte highschool) is
| about 15%, again taking into account that those who are not
| straight-As students probably don't bother applying to start
| with.
|
| This does not sound less competitive. If your French
| classmate had a bachelor degree but went back to 1st year in
| France that might have given him an advantage over students
| fresh out of highschool.
|
| In any case, according to the article it is the shortage of
| qualified profesisonals that should ultimately impact
| salaries, and there are shortages. But, again, salaries tend
| to be in effect regulated one way of another, which I think
| has much more of an impact.
| Jensson wrote:
| > Entry to medical school is also extremely competitive in
| Western Europe and there are also limits on number of places in
| some countries. And there are shortages of doctors as well.
|
| USA has much less doctors per capita than Europe though, so the
| problem isn't the same. It would be nice to have more doctors
| in Europe, but in USA it is a critical problem.
| mytailorisrich wrote:
| Maybe so but the point is that in Europe if the number of
| doctors per capita dropped salaries would not go up, that
| would require a political decision. But since admissions are
| already ultra competitive there would be no need to attract
| even more candidates, rather they would try to lower the bar
| or 'import' more foreign doctors where possible. So that's
| why salaries in Europe are lower than in the US.
|
| Conversely, I am not convinced that more doctors in the US
| would lead to a big drop in earnings assuming the market
| there is 'freer' than in Europe. It's a rich country and
| healthcare is very valuable with high barriers to entry in
| any case.
| SkyPuncher wrote:
| There is absolutely a shortage of doctors. AMA is unwilling to
| fix this and instead rely on a system that drives many to
| suicide.
|
| My wife is a doctor. I'm a software engineer. While she now makes
| more than I do, it took nearly 10 years. That whole time, we were
| racking up tuition/debt on tuition. Residency was demanding and
| severely underpaid.
|
| Based on our math, we'll be 25 to 30 years into our careers
| before her medical education with have a better ROI than my
| career choice. I didn't even push for top-dollar jobs.
|
| In other word, medical training had a huge opportunity cost. Even
| if you solve the bottleneck of residency placement, salaries need
| to offset the insane burden of training.
| kevmo wrote:
| America needs tuition-free state universities and trade
| schools. Full-stop. We're encountering endless problems,
| sending our entire economy (and living standards) out of whack,
| because we don't.
| xyzelement wrote:
| Who pays for tuition free universities and trade schools?
| jLaForest wrote:
| The same people that pay for tuition free primary
| education....
| bequanna wrote:
| Local taxpayers/property owners?
|
| That model doesn't really work to fund higher education.
| The public won't accept doubling or tripling their
| property tax.
| WkndTriathlete wrote:
| > That model doesn't really work to fund higher
| education. The public won't accept doubling or tripling
| their property tax.
|
| [citation needed]
|
| And I can give you a citation _against_. In my local
| municipality the tax base is roughly $1.5 billion. The
| annual expenditures for the local vo-tech school for that
| municipality is $30 million. If all of the state and
| tuition funding for the vo-tech school suddenly vanished
| the property owners would see a rise of ... wait for it
| ... a grand total of 2%. Certainly a far cry from the
| doubling or tripling you suggested.
|
| Amortizing the tuition across all public post-secondary
| institutions in the state via income and property tax
| bases of the entire state would likely be somewhere in
| the neighborhood of 1-2% total every year. Based on that
| analysis it seems monumentally stupid to NOT publicly
| fund post-secondary education.
|
| Ditch the NCAA sports programs and it probably gets
| cheaper. The whole sales pitch for sports is that
| scholarships provide a pathway for some students to go to
| college that otherwise could not afford it. Get rid of
| tuition and suddenly that reason goes away, too.
| bequanna wrote:
| Colleges/Universities absolutely do not need more
| money...they need more accountability.
|
| I'm not arguing with your numbers, I guess my point is
| that I don't think taxpayers will accept a huge "freebie"
| for one group which results in their taxes going up. The
| optics are terrible.
| BeetleB wrote:
| In reality (and historically), it's the state taxes and
| not property taxes.
|
| Still, if I had 2 kids, doubling my property tax would be
| cheaper for me than my paying for their tuition at
| current rates.
| nordsieck wrote:
| > The same people that pay for tuition free primary
| education....
|
| Are you suggesting that people should be locked to the
| school in their district? Because that's the way primary
| education works.
| sophacles wrote:
| They aren't locked in. That's the one provided for free.
| It doesn't seem to stop private schools and homeschooling
| at all.
| antoniuschan99 wrote:
| Public community colleges primarily attract and accept
| students from the local community and are usually
| supported by local tax revenue - from Wikipedia.
| neaden wrote:
| Public universities are generally run by the state, not a
| local government so sure, free in state tuition sounds
| reasonable.
| hotnfresh wrote:
| This question is important and needs to be asked because
| nobody's already solved this problem. We'd be moving into
| uncharted territory.
| stronglikedan wrote:
| If they were free, more people would take advantage of
| them, potentially earning more, bumping them into higher
| tax brackets, where their taxes would be used to fund
| tuition free education, and the cycle would continue.
| stonemetal12 wrote:
| Who pays for them in Germany? In Germany, universities are
| free for everyone even foreigners.
|
| Since GP says State Universities I would assume the State
| they were in would, through whatever tax policy they like.
| rayiner wrote:
| In Germany, taxes are 39.5% of GDP. In the US, they are
| 26.6% of GDP. There's no realistic proposal that has ever
| been advanced, not even from the Bernie/AOC/Warren types,
| on how to raise the extra $2.8 trillion annually that
| would be required. Elizabeth Warren's proposed wealth tax
| wouldn't even raise that much money over a _decade_ ,
| much less annually.
| MisterBastahrd wrote:
| We literally had tuition free universities and trade
| schools for decades until desegregation. I'll let you
| figure out what happened after that.
| bequanna wrote:
| This sounds like less accountability when fixing the problem
| requires more.
|
| America needs to stop letting their University systems bloat
| everything unrelated to actual education and research.
| ethbr1 wrote:
| Agreed. American universities need a two-pronged fix.
|
| - Implement ACA-style budget efficiency minimums
|
| This much of tuition must be spent on direct-teaching
| expenses. Only this much may be spent on everything else.
| Otherwise the university in ineligible for _any_ federal
| educational assistance grant /loan.
|
| - Increase funding via increased state contributions to
| public universities (returning to historical averages), to
| lower tuition costs
| readthenotes1 wrote:
| Full-stop? Hardly. Who would gatekeep so that universities
| and trade schools aren't just continuing the babysitting in
| high school?
| chmod775 wrote:
| Sounds like the system is basically set up to enrich loan
| companies, and to a lesser degree universities.
|
| Who is lobbying for this system to be improved? Because almost
| certainly loan companies and universities are lobbying against
| that.
| HDThoreaun wrote:
| Medical schools absolutely want to expand, they make tons of
| money and have many applicants who are qualified and willing
| to pay. The problem is there aren't enough residency seats.
| If there were more med school grads without expanding
| residences many competent graduates would go unmatched.
| naveen99 wrote:
| In the us, there are almost 3 residency spots for every 2
| us medical students.
| endisneigh wrote:
| Source?
| naveen99 wrote:
| https://www.nrmp.org/about/news/2023/05/nrmp-releases-
| the-20...
| endisneigh wrote:
| This is overall not per speciality and doesn't include
| overall people who did not apply, the article even says
| itself it's a all time match high.
|
| Look no further: https://www.nrmp.org/wp-
| content/uploads/2023/03/Match-Rates-...
| naveen99 wrote:
| The person i was responding to said that residency spots
| are the bottle neck, and not medical school spots. While
| residency spots have not kept pace with population growth
| also, the medical student spots are a much worse bottle
| neck. Specialties have their own periodic undersupply and
| oversupply, but that was not the topic of discussion in
| the post i was responding to.
|
| Now, I don't know how you would ever include people who
| don't apply. I mean there are 5 million americans of age
| every year, so i guess that's a denominator.
|
| what's a all time match high ? The number of spots and
| students ? Yeah, so ? The concern was that the number
| isn't high enough, and where the bottleneck is.
|
| The real answer to why doctors in america earn so much,
| is that everyone in america earns so much. If you compare
| doctor to median salaries in the us, vs. doctor to median
| salaries in europe, maybe its not so different ?
| buildbot wrote:
| Right, but then half of all med students apply only to
| derm residency or other lucrative and competitive field
| with nice hours, leaving us in the situation we are in
| now where 18% of all emergency med department residencies
| went unmatched: https://www.aliem.com/mismatch-unfilled-
| emergency-medicine-r...
| naveen99 wrote:
| Emergency med has decent flexibility in terms of hours.
| The problem was Covid and remote work reduced infections
| and accidents and heart attacks, and they lost turf to
| physician assistants manning urgent care centers.
| buildbot wrote:
| Not during residency, and I have not idea what the second
| part has to do with the match going underfilled. Are you
| saying med students saw this phenomena and decided
| emergency med was best left to PAs, and did not apply to
| match?
|
| What I heard was emergency departments suffered brutally
| during covid, and that has had a chilling effect on
| anyone wanting to go into it. The med students matching
| now were all rotating through departments during covid.
| naveen99 wrote:
| yes, there are periodic oversupply and undersupply of
| various medical specialties (just like oil, labor, money,
| real estate agents), and medical students do react and
| choose accordingly. ER was hot for a while, and radiology
| was not so hot for a few years after 2008. Now
| surprisingly radiology has held up despite AI fears,
| because of baby boomers starting to get cancer, and ER is
| down, because private equity went nuts investing in
| urgent care centers before covid.
| rayiner wrote:
| What "loan companies?" For more than a decade, medical school
| loans have been provided directly by the federal government.
| nradov wrote:
| Why are you expecting the AMA to fix this? The primary
| bottleneck on producing more physicians today is lack of
| residency program slots. Every year some doctors graduate from
| medical school but are unable to practice medicine because they
| can't get matched to a residency program. The AMA has been
| lobbying Congress to increase Medicare funding for those
| programs.
|
| https://savegme.org/
| eppp wrote:
| Why on earth would medicare have anything to do with
| residency spots to start with? Why wouldn't the hospitals use
| this as an apprenticeship program and pay the residents and
| charge appropriately for their services?
| ethbr1 wrote:
| Because hospitals generally don't have the funding (in the
| case of rural or urban trauma barely balancing the books)
| or inclination (in the case if wealthy suburb, managed
| facilities trying to maximize profit by running minimal
| staff) to do this.
|
| Ergo, like education in general, it's funded from the
| federal government.
| s1artibartfast wrote:
| If hospitals don't have the revenue, they should charge
| the cost of services to balance their books.
|
| I think government involvement in the residency program
| is problematic distortion, causing hospitals to chase a
| scarce resource instead of working to expand the supply
| pipeline.
| ethbr1 wrote:
| Among other laws, there's the EMTALA that prevents
| charging the cost of services.
|
| https://en.m.wikipedia.org/wiki/Emergency_Medical_Treatme
| nt_...
| nradov wrote:
| This is not a free market and you won't accomplish
| anything by telling hospitals what they "should" do.
| Prices are largely fixed by Medicare/Medicaid
| reimbursement rates. Whenever prices are fixed, shortages
| are pretty much inevitable.
|
| Relying on Medicare to pay for residency programs isn't
| an ideal situation. But the reality is that there are no
| other major players in the system with both the money and
| incentive to cover those costs. That won't change without
| a complete restructuring of the entire system, and
| achieving the political consensus to do that will be
| extremely difficult.
|
| If you have a few million dollars to spare then feel free
| to donate it to your local teaching hospital. They'll be
| happy to take your money to expand their residency
| program. There is an opportunity for philanthropists to
| do some real good in reducing the physician shortage.
| s1artibartfast wrote:
| I dont think I agree. Medicare/medicaid rates change
| constantly. The cost of retaining physicians is part of
| cost of providing healthcare, so there is no reason to
| carve it out. Hospitals have a natural incentive to have
| doctors on staff. The only reason they dont have
| incentive today is because there is someone else taking
| on the cost.
|
| I would argue that it is easier and more _realistic_ to
| simply include it in the price than expect congress
| accurately predict future demand, and continually pass
| legislation to that effect. We dont need a congressional
| act to subsidize hospital janitors- Somehow hospitals
| figure out how to include them in their operational
| expenses because they need them.
|
| Furthermore, it wouldnt break the bank of most of these
| hospitals. Take one of the largest teaching hospitals in
| the world, Cleveland clinic, with 2000 residents. at
| typical resident grant of 100k, that is 200 million. The
| Cleavland clinic annual revenue is >13 Billion.
| nradov wrote:
| That is not a realistic or sensible proposal. Only a
| subset of hospitals do graduate medical education. If
| teaching hospitals raised their prices to cover the
| overhead of residency programs then that would put them
| at a competitive disadvantage relative to hospitals that
| don't train residents at all. In order to keep residency
| programs financially sustainable there has to be a
| separate revenue source.
|
| Cleveland Clinic is a non-profit. Their total revenue is
| irrelevant. If you'd like them to spend an extra $200M on
| their residency program then they would have to spend
| less on other stuff. Take a look at their financial
| statements and then you can tell them exactly where they
| ought to cut back in order to fund your proposal. Please
| be specific.
|
| https://my.clevelandclinic.org/about/overview/financial-
| info...
| ethbr1 wrote:
| > _We dont need a congressional act to subsidize hospital
| janitors- Somehow hospitals figure out how to include
| them in their operational expenses because they need
| them._
|
| Observation that the lead/training time for additional
| hospital janitors is a couple weeks.
|
| An additional resident takes 4+4=8 years.
| TuringNYC wrote:
| You just need to look at an EoB statement to realize the
| sheer volume of revenues earned by Residents (thought not
| retained by residents). They are huge profit centers for
| the medical system with millions in earned revenue
| annually.
|
| Medicare does not need to pay for residents, they are
| massively net positive revenue. The AMA boards create
| artificial scarcity and "medicare" is the boogeyman word.
| ethbr1 wrote:
| But if those residents were paid by hospitals, they
| wouldn't be huge profit centers.
|
| Or, to put it another way, if hospitals have difficulty
| balancing the books _with_ free resident labor, adding
| additional paid residents wouldn 't necessarily fix the
| financial problem in most hospitals.
| ceejayoz wrote:
| Medicare pays for the residency spots.
|
| https://www.cms.gov/medicare/payment/prospective-payment-
| sys...
|
| https://crsreports.congress.gov/product/pdf/IF/IF10960
| nradov wrote:
| There are a lot of bizarre path dependence issues and
| misaligned financial incentives in the US healthcare
| system. Most teaching hospitals are non-profits, often run
| by university systems or governments. Those hospitals get
| much of their revenue from Medicare/Medicaid. Reimbursement
| rates are fixed and hospitals have no ability to raise
| prices to cover increased training expenses. So, the only
| solution has been to get separate GME funding from
| Medicare.
|
| There are other GME funding sources such as private
| charitable foundations but still the majority of the money
| comes from Medicare.
| HDThoreaun wrote:
| Residencies lose money, so they're reliant on federal
| subsidies.
| ska wrote:
| > Residencies lose money,
|
| Do they though? Or is that mostly creative accounting.
| I've heard claims in both directions but like anything in
| medical billing in the US, it's all pretty murky.
| SkyPuncher wrote:
| The general impression is that AMA is basically giving lip
| service to that goal. In public, that may be their goal. In
| private, it's certainly not happening.
|
| Most states are begging for more qualified providers. Many
| are looking to mid-levels to fill the gaps. If the AMA were
| serious, they'd be working with all of these states to fill
| those gaps with physicians.
| nradov wrote:
| The primary bottleneck today is caused by lack of residency
| slots. The AMA isn't doing anything to prevent states from
| putting more money into residency programs. In fact they
| are actively encouraging it.
|
| https://www.ama-assn.org/education/gme-funding
|
| And if you think they're saying something else in private
| then let's see proof. This is not a place for baseless
| conspiracy theories.
| alistairSH wrote:
| Not that long ago (through at least 1997), the AMA was doing
| the opposite. They were instrumental (but not alone) in
| creating the shortage.
| onlyrealcuzzo wrote:
| > Based on our math, we'll be 25 to 30 years into our careers
| before her medical education with have a better ROI than my
| career choice. I didn't even push for top-dollar jobs.
|
| I just want to point out that - you landed (probably more
| random than intentional) into arguably the best career in the
| history of labor.
|
| Compare a doctor to almost anything beside an engineer - and it
| won't seem so terrible.
|
| Most people that have been in engineering for >10 years got
| into it because it's what they liked doing - and then it just
| so happened to be ridiculously lucrative and not require you to
| go into hundreds of thousands of debt to get trained to do the
| job (medical, lawyer, etc).
|
| Even most trades (electrical, plumping, beauty, the taxi
| medallion system, etc) are designed similar to the medical
| industry - and require ever more schooling (debt, opportunity
| cost) to get the job - to artificially reduce the work force to
| benefit current workers at the cost of future workers and
| everybody who uses those services.
|
| I think the particular problem with the medical industry is...
| it's particular detrimental to society to be overworking
| doctors to the bone and it not really paying off for them until
| they're in their 50s.
|
| We're all gonna need medical help some day...
|
| Maybe we can do our own plumping and cut our own hair and be
| good law abiding citizens and not need a lawyer. But we're all
| going to have severe medical problems at some point.
| Guvante wrote:
| Your last point isn't correct.
|
| While that is the result I think emphasizing that it isn't
| made easier is important.
|
| Electricians need to install high voltage wires that are safe
| in the home for untrained individuals for potentially a
| century.
|
| Plumbers need to install water tight pipes that can withstand
| significant pressure without leaking (which can be difficult
| to detect and very quickly devastating damage wise)
|
| Doctors are expected to be able to catch nearly any disease
| in their specialty based on an honest consultation.
|
| Lawyers need to know a phenomenal amount of information to
| meaningfully know what o research when it comes to prepping
| for court cases.
|
| All of these jobs are hard to prepare for and their is value
| to everyone else that you can prove you actually prepared.
|
| The problem is the incentives for encouraging more people to
| prepare are backwards (those supporting the newbies benefit
| from fewer of them) which causes no real help to be given and
| the labor shortages.
|
| But it isn't made up boundaries just to benefit existing
| members.
| s1artibartfast wrote:
| >The problem is the incentives for encouraging more people
| to prepare are backwards (those supporting the newbies
| benefit from fewer of them) which causes no real help to be
| given and the labor shortages.
|
| >But it isn't made up boundaries just to benefit existing
| members.
|
| I would argue that it largely is just made up boundaries to
| benefit existing members. That is to say, regulatory
| capture has increased the barriers so far that any benefit
| from additional quality of service is far outweighed by the
| increased scarcity.
|
| It doesn't matter if you have the best doctors and
| electricians in the world, if they are so few and expensive
| that the public does not have access to them.
|
| The fundamental problem is that is both easy and popular to
| error on the side of "caution", creating increasingly
| stringent licensing requirements. These benefit established
| interests and sound attractive to the public.
| cameronh90 wrote:
| I don't think you can reasonably draw a comparison from
| medicine to home electrics and plumbing.
|
| My dad was a plumber and I'm preparing to pass the
| certification that permits me to work on home electrics.
| They are, to be blunt, easy. An average person can pick up
| most of it in a couple of months. Electrics and gas
| plumbing carry a certification requirement because an error
| can kill someone, but it's easier than passing a driving
| test.
|
| Obviously, there are higher tiers of those trades that
| require a lot more training, but even those aren't really
| comparable to the level of knowledge and study needed to
| become a qualified doctor, let alone a consultant.
|
| In the UK, shortages of tradespeople are less to do with
| the difficulty of training, or lack of course capacity, and
| more to do with people really just not wanting to do the
| job, for various reasons.
| lesam wrote:
| Medicine has more barriers to entry at least partly
| because we've decided to erect them. Doctors learn all
| kinds of things outside their direct specialty that they
| don't really need to know, but nobody inside the system
| has an incentive to streamline medical education or to
| encourage more and earlier specialization.
|
| For example, we force most doctors to take a 4 year
| degree before medicine (sometimes pre-med, but often an
| arts or non-biological science degree). Wasting 4 years
| of a future doctor's prime career on an expensive and
| often irrelevant screening program is extremely wasteful
| for society as a whole.
| rqtwteye wrote:
| "Doctors are expected to be able to catch nearly any
| disease in their specialty based on an honest
| consultation."
|
| From my experience they don't. If you have any problem off
| the beaten path you may spend years and multiple doctors to
| figure out what's going on.
| anonymouskimmer wrote:
| That makes more sense. I interpreted the "catch" quote to
| mean that doctors are expected to literally come down
| with any _contagious_ disease within their specialty.
| amluto wrote:
| > Plumbers need to install water tight pipes that can
| withstand significant pressure without leaking (which can
| be difficult to detect and very quickly devastating damage
| wise)
|
| There is no shortage whatsoever of licensed plumbers who
| will do incompetent work. Fortunately there is a decent
| collection of companies making excellent plumbing products
| that are quite robust.
|
| Current personal favorite failure modes:
|
| Use of inappropriate water-insoluble flux. This usually
| doesn't cause a leak, at least not quickly. It is, however,
| disgusting (petroleum crud and not-very-good salts being
| released slowly over months to years in cold water pipes)
| and is a code violation.
|
| Use of copper in boiler condensate pipes.
|
| Use of essentially arbitrary mixes of pipe tape and pipe
| dope.
|
| Overtightening of plastic threaded connections.
|
| Incorrect combinations of tapered threaded fittings and
| gasketed straight threaded fittings.
| P_I_Staker wrote:
| Problems are doctors are unlikely to "help" with, and are
| highly likely to make matters much, much worse.
|
| Also, contrary to popular opinion, there's little stigma or
| awareness of "bad doctoring", for a number of systemic
| reasons.
|
| So you have someone who doesn't give a fuck about anything,
| certainly not your situation, not listening to you, and
| trying to prevent you from receiving medical treatment.
|
| This doesn't look so necessary to me. I know there will still
| be medical experts and surgeons and so forth, but much of
| this medical infrastructure doesn't benefit the average
| citizen (I know there's an argument that it does or for a
| change in perspective, but that's a whole different can of
| worms.
|
| Similar to policing, if you think of the typical way you
| interact with the medical system, you start to realize
| there's very little in there to help you. 99.99% of the
| infrastructure is built to benefit powerful people with tons
| of money; helping you is an after thought.
|
| What happens when you're a victim of crime? Turns out there's
| very little in place to help. Oh, someone is actively trying
| to murder you? well give us a call after it happens and maybe
| we'll investigate.
|
| How many of us have experienced something like this? I'm not
| saying there's no reason for the arrangement, but we should
| stop trying to pretend these people are looking out for the
| public.
|
| I know people may be tempted to chime in regarding some
| situation a police officer or doctor helped you. I'm not
| saying you're wrong, just explaining why some people are
| asking questions; if you honestly think about it, your naive
| assumptions about safety and health will be shattered.
|
| A doctor, in many ways, arguably has a patients WORST
| interests at heart, in a similar manor to a police officer,
| in it's interaction with the public. They have, as their most
| important responsibilities, to detect certain things, and
| take actions to hurt the person.
|
| This is priority #1, virtually everything else comes after.
| This is an important observation, is not obvious, and should
| cause us to reconsider these institutions.
| burnerburnito wrote:
| Perhaps a more diplomatic to phrase what I perceive as your
| thought there is that a good doctor or policeman is
| actually in some respects often acting that way
| _regardless_ of the system -- they would 've tried to help
| people as much as they could anyway. Meanwhile a _bad_ or
| _apathetic_ doctor, policeman, etc. will tend to receive
| little friction for it while you have to fight uphill to
| get basic care, all while being milked of as much of your
| money as possible and still having to wait unbearably long
| for useful treatment.
|
| Likewise, there's such a range of outcomes, and when it's
| involving chronic diseases combined with an apathetic or
| bad doctor, you can be stuck realizing you've wasted months
| with no resolution (not even getting into any potential
| costs) only to now have to start all over again potentially
| several more times just for a sliver of hope that you'll
| find a doctor who's caring and competent enough to finally
| help you out. So sitting on the receiving end feels like
| being bled dry by people who couldn't care less about your
| suffering or if you die, so long as you keep paying them,
| with little realistic recourse other than accepting that
| you got burned and moving on.
|
| In any case, just my two cents from what I think seems like
| a somewhat related view but with a different "spin".
| dylan604 wrote:
| >to artificially reduce the work force to benefit current
| workers at the cost of future workers
|
| is that really the purpose? or is it that an entire industry
| has been built on top of the trades, and that industry does
| whatever to continue to grow?
| aborsy wrote:
| There can be more schooling and training in engineering.
|
| After undergrad, master's, PhD, a postdoc or two, one would
| still make low income. After that, there is a never ending
| path where one has to constantly chase ever changing
| technologies. The older you get, the harder it will be to
| keep up and remain employed.
|
| In medical science, you finish the residency (roughly
| equivalent to 1-2 postdoc in engineering), and you start to
| practice. Already, income is OK in residency. The older you
| get, the better!
| robocat wrote:
| > We're all gonna need medical help some day...
|
| 95% of health is being proactive about your health: food,
| fitness, sleep, dentist, etcetera.
|
| I wonder how much doctoring is due to negligence of a healthy
| lifestyle, or perhaps chronic choices (addictive substances
| like alcohol, shift-work).
|
| > But we're all going to have severe medical problems at some
| point.
|
| Which often are untreatable - and the doctoring is regularly
| prophylactic. Hip-replacements are an obvious outlier.
| Capricorn2481 wrote:
| > 95% of health is being proactive about your health: food,
| fitness, sleep, dentist, etcetera.
|
| Maybe 70%? Genetics play a huge role. You will likely need
| a doctor if your family has a long history of cancer.
| BeetleB wrote:
| > 95% of health is being proactive about your health: food,
| fitness, sleep, dentist, etcetera.
|
| You're young, aren't you?
|
| The percentage is significant, but nowhere near 95%.
| robocat wrote:
| I'm middle-aged.
|
| I might be over-estimating the percentage. I might also
| be over-estimating how much we can affect diabetes,
| weight, fitness, addiction.
|
| I can say that the chronic health problems of my peer-
| group often appear to be self-inflicted.
|
| Of my dead acquantances there are maybe a few groups: (1)
| health problems caused by childhoods of poverty, (2)
| health problems that we haven't solved yet which the
| medical system helps little, (3) suicides, (4)
| crashes/accidents, and (5) health problems caused by
| smoking, drinking and drugs (e.g. HepC).
|
| Also acquaintances with chronic conditions often don't
| follow medical advice anyway e.g. diabetic friends that
| abuse their bodies. Or people told to quit drinking or
| smoking that do not stop.
|
| I'm not saying it is easy. I am saying I know plenty of
| acquantances that have made difficult choices to improve
| their lifestyle choices (presuming cause not
| correlation), and others that have not made positive
| changes.
|
| Context: I'm in New Zealand, so healthcare is mostly free
| and of reasonable quality. We have lots of immigrants so
| I have some exposure to people from other (often
| adjacent) cultures.
| greedo wrote:
| I had rectal cancer at age 40. There were no indications
| that my lifestyle caused or contributed to it. I rarely
| drank, didn't do drugs, etc etc. I might have had a genetic
| predisposition, but who knows, cancer is a complex thing.
| If I didn't have insurance, my medical bills would have
| easily been over $800K. So enough with your BS statistics
| that you pulled out of your ass.
| readthenotes1 wrote:
| Based on the workload of medical students and residents, I do
| not believe that even if the AMA relaxed the standards for
| entry that unless they relaxed the standards for exit we would
| have more doctors.
|
| And by workload, I don't mean just hours on the job, I mean
| amount of material to learn. It is overwhelming to most
| HPsquared wrote:
| Is it all really necessary? As an outsider it looks like
| letting the perfect be the enemy of the good. That, or it's
| just tradition / an elaborate hazing ritual.
|
| I don't see how the ability to work long hours is necessary
| to heal the sick. They don't train airline pilots like this,
| or nuclear plant operators. What's so special about doctors?
| nostromo wrote:
| Similarly, my husband is a commercial pilot and is now starting
| to make more money than me in tech after his 10+ years of
| underpaid work and a high student loan debt load.
|
| But, here's the deal: he's basically going to make top dollar
| until he's 65. Meanwhile, I'll likely be seen as a dinosaur in
| tech by that age and will be lucky to find work at all.
|
| I imagine your wife will be seen the same way. She can
| comfortably work until retirement age, in an profession that
| sees experience as a positive thing, while you might be a
| pariah before you know it.
|
| Yes, we make good money when we're young in tech. But we age
| out much more quickly due to the bias common in our industry.
| mrits wrote:
| If you were bringing in a competitive salary in tech for the
| last 20 years you don't even need to work anymore. So there
| is that..
| hotnfresh wrote:
| BLS says US median programmer salary in the US was just
| under $100,000 last year.
|
| 20 years of a normal US tech salary won't let you retire. A
| top-few-percent one, maybe.
| mrits wrote:
| That was a competitive salary when I started in 2005.
| hotnfresh wrote:
| Well, it'd also represent a raise for about 50% of
| programmers in 2022.
|
| [EDIT] Further:
|
| "The lowest 10 percent earned less than $54,310, and the
| highest 10 percent earned more than $157,690." (in 2022,
| still).
|
| The ones who can retire in 20 years are making (ballpark)
| top-5%-of-field wages most or all of that time.
|
| [EDIT EDIT] I didn't pick the best category for this, but
| the numbers only skew up 25ish % for the most-relevant
| one. Not a single BLS computer job category has a median
| particularly close to "retire in 20 years at this income"
| money. FAANG, finance, and a small segment of the startup
| market that's in that same category--yeah. Almost all the
| rest? No.
| dboreham wrote:
| They classified people we don't think of as programmers
| as programmers. Classic job stats mistake.
| hotnfresh wrote:
| Ok, sure, that's one category and some of the others do
| have a higher median. Some of what we think of as
| "programmers" or "developers" will actually land in other
| categories, and also some we don't, will too.
|
| https://www.bls.gov/ooh/computer-and-information-
| technology/...
|
| But still, even the top-median category, "Computer and
| Information Research Scientists", doesn't have "retire in
| 20 years" median wages.
| polyomino wrote:
| What's the distribution of experience though? In a fast
| growing field, most will be early in career, which will
| push this metric down relative to established fields with
| little growth.
| hotnfresh wrote:
| The question's whether 20 years of a "competitive" tech
| salary is enough money to retire.
|
| I think one must have a very-skewed, bubble-bound
| definition of "competitive" for that to be plausibly
| true. Programming jobs don't pay enough to grant easy-
| mode early retirement for _most_ of our field--even in
| the US.
| woobar wrote:
| First, Computer Programmer is a strange occupation.
| According to BLS there are just 147K positions in the US.
|
| Instead I'd suggest looking at Software Developers (1.5M
| positions) with median income at $127K.
|
| Second, by definition median is not a competitive salary.
| I'd think top 25% of devs are getting competitive salary.
| Which is $161K [1]
|
| 20 years of savings at 30% of income will get you $2M.
| Which is not a fat retirement, but still doable.
|
| [1] https://www.bls.gov/oes/current/oes151252.htm#nat
| hotnfresh wrote:
| > Second, by definition median is not a competitive
| salary.
|
| Yes, it is. For the field as a whole? Yes, it absolutely
| is. For _specific segments of it_? No. Some of those are
| higher. And others are lower.
|
| > 20 years of savings at 30% of income will get you $2M.
| Which is not a fat retirement, but still doable.
|
| Healthcare complicates early retirement _badly_ in the
| US. Retire at (say) 45 with only $2m in the bank and you
| are... gambling. To put it mildly. Even if you live
| reasonably frugally.
| rootusrootus wrote:
| > Healthcare complicates early retirement badly in the
| US. Retire at (say) 45 with only $2m in the bank and you
| are... gambling. To put it mildly. Even if you live
| reasonably frugally.
|
| 100% this. I'm almost 50, and as I look towards
| retirement, I think I should try to find a cushy job
| that'll last me to 65 without causing too much stress,
| because until you qualify for Medicare it's really hard
| to afford health insurance premiums unless you're
| fashionably wealthy.
| manzanarama wrote:
| Really, what is a good ballpark for a family of 4? Is it
| like 5k a month?
| woobar wrote:
| I do not agree. If someone said "bringing regular salary
| in tech" I'd agree that median should be used.
| "Competitive" means we are talking about higher
| percentile within the field.
|
| > Healthcare complicates early retirement
|
| You don't have to stay in the US when retired. With 4%
| SWR one will be getting $80K/year. Which is more than
| median household income in the US and majority of the
| other countries. I am not advocating retiring at 45 with
| $2M, I am just saying it is not _that_ crazy.
| ryandrake wrote:
| I've always considered "competitive" to be a signal of
| "as close as possible to our average competitor". It
| doesn't mean good or high. When a job offer says
| "competitive salary", it's not a good sign. I assume they
| mean around average, maybe a little bit below average. If
| the job offer was offering a significantly great salary,
| the company would boast about it as more than
| "competitive."
| FireBeyond wrote:
| It is also not going to be the easiest, emigrating to a
| country with a robust healthcare and social safety net as
| a retiree in your 40s.
| randomdata wrote:
| The median income is ~$30,000. That means you have
| ~$70,000 to invest each year. If we assume a 5% rate of
| return, you'll have ~$2MM after 20 years. At the same
| rate, that will continue to provide you $100,000 each
| year in retirement. Bad luck can happen, but generally
| speaking retirement should have been quite easy with that
| kind of income.
| adra wrote:
| I love your optimism. Some may be able to live off
| software at 30k/yr making 100/yr "somewhere", but not
| most places. My rent started at around 40% of my take
| home and adding taxes alone, my pay rate was well under
| this 70% fantasy which doesn't even begin to address any
| other "incidental" living expenses like food, transport,
| children, elderly, school loans, etc......
| hotnfresh wrote:
| Median topped $40k in 2022.
|
| The (just under) $100k is pre-tax.
|
| You won't get much social security when you hit
| "retirement age" if you retire after only 20 years of
| working at that level of income, so you'll need more
| savings at that age than others do.
|
| $100k/yr is a 5% withdrawal rate on $2 million, which
| might be a "safe" rate at normal retirement age
| (debatable) but is risky as hell if you start doing it at
| 45 and don't plan to die in your 60s.
|
| If you've been saving that aggressively (as
| cash/investments), you won't own your own house, or at
| least, you definitely won't be anywhere near paying it
| off. That significantly raises your costs in retirement.
|
| You have significant risk from healthcare costs until you
| hit medicare age (and even then...). You're probably
| looking at $5k-10k a year in premiums (individual) at age
| 45+, and still five figures of _annual_ risk exposure
| despite already paying that much.
|
| Retiring on $2m at 45 would be very likely to end in
| failure, even as an individual supporting only yourself.
| irrational wrote:
| What is a competitive salary? Do you mean the small
| fraction of programmers that work for FAANG companies? Or
| do you mean the more normal salaries the vast majority of
| programmers make at non-FAANG companies?
|
| I've worked for the past 20 years and am as far from not
| needing to work anymore as my first day. Well, that isn't
| strictly true, but my 401k only has about 33-50% of what it
| needs for me to retire. I have no savings beyond that.
| mrits wrote:
| I didn't realize anyone could go to medical school.
| dmoy wrote:
| Maybe a little overly sarcastic, but there's a real point
| there:
|
| Not everyone can get into med school (~5% acceptance
| rate?), but even more disturbingly some people get out of
| med school with tons of debt, and then either fail their
| step 2 or don't pass quickly enough to get a residency.
| Or fail boards after residency. Then you're in a really
| shitty position, with hundreds of thousands of debt but
| no ability to practice medicine.
| squigglingAvia wrote:
| Thing is which med school you'll go will determine your
| debt load. Not all med schools charge the same rate.
| johnmaguire wrote:
| And also your board exams success rate!
| sokoloff wrote:
| That depends exclusively on your savings rate (which
| dictates your years-needed-to-retire):
| https://www.mrmoneymustache.com/2012/01/13/the-shockingly-
| si...
|
| Most people aren't saving ~43% of their take-home pay, no
| matter how much they earn.
| encoderer wrote:
| I'm 41 and I totally understand this sentiment. A silver
| lining is that the tech industry is just so much larger now
| than it was when we started, a trend I think will continue,
| and there are now tons of jobs where it's really helpful to
| also be a developer. Some examples:
|
| Developer and marketer/technical writer - selling to other
| devs is a giant business now and it often takes devs to make
| that content.
|
| Developer and SRE - we live in the world of huge scaled our
| saas businesses where there are always support issues too
| advanced to be handled by non-devs
|
| Developer and project manager - everybody has worked with
| non-dev project managers and it's usually terrible.
|
| Developer and people manager - there are so many more eng
| manager roles than there used to be, and moving to the
| management side is a well worn path now.
|
| Developer and product manager - you have to develop a lot of
| new skills but in this role a past life as a developer can
| give you super powers.
|
| That said, I moved first into people management and then into
| running a small software company which sort of demands a
| little bit of all of those skills
| okdood64 wrote:
| > Developer and SRE
|
| I'd say these are pretty interchangeable in one's career if
| they wanted to. The others not so much.
| morelisp wrote:
| If you're 20+ years experience and not any good as _at
| least_ a project manager, I think your core skills are
| also pretty suspect.
| pipes wrote:
| You mean your core tech skills will be suspect if you
| aren't a decent project manager? Well that's a depressing
| thought. Though in my experience so far we have dedicated
| project managers. But maybe you are right.
| Terr_ wrote:
| > I'm 41 and I totally understand this sentiment. A silver
| lining is that the tech industry is just so much larger now
| than it was when we started
|
| I'd also point out that if people forget the growth-aspect,
| they will overestimate the problem of ageism in the
| industry.
|
| Yes, there aren't that many grizzled 60-year-old
| programmers today... but much of that is because 40 years
| ago there were only a handful of 20-year-old programmers
| _to start with_.
|
| Even if advancing age turned people into happy rockstars,
| they'd still be outnumbered today just because there are
| more jobs.
| ipqk wrote:
| And a good chunk of them probably hit it big at some
| point and retired early. I know so many software
| engineers my age (40s) that are effectively retired
| already.
| bcrosby95 wrote:
| Yep. Most of my friends work as software engineers and
| we're in our 40s. And most of them have/could retire if
| they wanted to.
|
| One was working at Google and got shit for taking time
| off when he planned it 6 months out. He quit and decided
| to retire early instead of putting up with it. He's 42.
| Terr_ wrote:
| I don't, but then again I didn't focus on maintaining job
| application loops against multiple giganto companies
| every single year...
| BurningFrog wrote:
| As a 63 year old programmer, I can confirm the industry
| used to be _much_ smaller.
|
| A lot of people my age also retired because they had too
| much money to work :)
| mixmastamyk wrote:
| Managers have to be youthful as well these days.
| pcthrowaway wrote:
| I'm almost 40, never made good money... this makes me sad
| lnsru wrote:
| Join the club. I did good money once with tiny startup
| exit. Salary is just enough to pay for food, mortgage and
| vacations.
| llsf wrote:
| I am almost 50, and my partner (ophthalmologist) always
| made more than me as developer, and architect. But to be
| fair, I only worked for small startups in the Bay, and
| startups that did not make big. Not complaining, but a bit
| worried for the next decade though. Especially as I am
| super busy at work, so much that I cannot spend time on
| programming anymore.
| dboreham wrote:
| Until AI is flying planes...
| bdamm wrote:
| I could not feel comfortable as a passenger on a commercial
| airliner without a human on board that could take over and
| fly the plane manually. There are all kinds of failure
| scenarios where a computer, AI or not, would get confused.
| Even just the specter of malware is enough for me to expect
| a human being, that values their own life, is able to take
| over.
| AussieWog93 wrote:
| >Even just the specter of malware is enough for me to
| expect a human being, that values their own life, is able
| to take over.
|
| I'd be more concerned abouta human going insane than
| malware.
|
| I'd imagine they're mostly fly by wire anyway, so a virus
| could theoretically just disable the human input.
| bdamm wrote:
| Airbus designs are substantially fly by wire, although
| supposedly with an isolated control system. Boeing
| designs are isolated electro-hydraulic.
|
| There's a big difference between isolating a single
| control link vs an entire control system comprising of,
| at least, a corpus database and all the supporting code
| that streams inputs and actuates outputs.
| saghm wrote:
| > I could not feel comfortable as a passenger on a
| commercial airliner without a human on board that could
| take over and fly the plane manually. There are all kinds
| of failure scenarios where a computer, AI or not, would
| get confused.
|
| "Person there just in case to take over in the rare case
| of emergencies" might not be as well paid as "person
| who's responsible for the plane at all times". Plus, if
| you're concerned about malware, you'll probably want a
| person still involved in vetting the code outputted by
| some hypothetical AI, so there would still be at least
| some engineering jobs.
| almostnormal wrote:
| The person to fly in case of an emergency will require
| the same kind of currency as a person flying all the
| time. The person flying all the time will be much more
| capable than the person watching the plane fly, and
| acquiring experience only in specific training.
| MattSayar wrote:
| I largely agree with you, however auto-pilot has existed
| for decades. I don't foresee AI taking over the cockpit
| anytime soon, but a compromise is likely. Perhaps it'll
| allow for copilots with less overall experience than
| copilots today.
| nostromo wrote:
| Given how good ChatGPT is at coding, I'd bet on software
| development being radically disrupted before we're boarding
| planes with zero pilots.
| silisili wrote:
| I don't think we'll ever be at zero pilots. But one pilot
| instead of 2(or more) would nearly halve the pilot
| market, no?
| civilitty wrote:
| We're facing a really bad pilot shortage right now, even
| in the fun jobs like flying fighter jets for the Air
| Force. That change would allow more plains to fly, I
| doubt it'd hurt the market for pilots - salaries which
| are already depressed because the airlines have been able
| to get away with it.
| nradov wrote:
| The complaints I have heard from military pilots are that
| shortages are caused mainly by toxic leadership and
| unattractive career path options. Combat pilots don't
| appreciate taking orders from careerists or "shoe
| clerks". And they don't want to get stuck in staff or
| management assignments for years just because the service
| needs a warm body to fill a slot. Plus the day-to-day
| administrative workload is high even when they're not
| flying. So, a lot of them in the O-3 to O-5 range just
| get burnt out and quit. Air Force leadership could fix
| those retention problems if they actually wanted to, and
| it wouldn't even be very expensive.
| mortenjorck wrote:
| The economics won't make sense any time in the foreseeable
| future. Pilots are a small fraction of the total cost of a
| flight, making the upfront cost to automate the extremely
| edge-case-laden final 10% of safety-critical operations
| they oversee a non-starter for now.
|
| We'll have terrible Roomba boxes replacing flight
| attendants long before anything replaces pilots.
| adgjlsfhk1 wrote:
| they're a pretty big fraction for shorter range
| flights/smaller planes (somewhere around 10%?), and more
| importantly they are a cause of cascading delays. often
| major delay problems happen because the flight before was
| delayed requiring the pilots to stop working and you now
| need to reschedule all your pilots leading to more
| problems. pilots are more of a problem than flight
| attendants because there are more attendants, so you can
| more easily have a few in reserve.
| nradov wrote:
| Flying the airplane is the easy part. The hard bit is
| responding to equipment failures and other emergencies.
| There is no way to predict all of the possible failure
| modes, nor do we have AI that can figure out how to manage
| unexpected problems in real time. That technology is likely
| at least several decades away.
|
| There is also a sensing issue. If aircraft sensors fail
| then they might feed the AI faulty data. And sensor
| redundancy or fault detection logic can't necessarily cope
| with that. Whereas experienced human pilots have a pretty
| good record of using their organic senses to handle such
| failures safely.
| borkt wrote:
| I hope you're correct but the very realistic possibility of
| SPO (single Pilot Operations) is what pushed myself - and
| many others like me - away from the career. The current pilot
| shortage was by design, as the airlines were well aware of
| the issue and had many ways to avoid it. I'm still of the
| mind the current shortage (and short term plans to mitigate
| it) are just to hold them over long enough to end the current
| 2-pilot system and bring the standard to single pilot
| operations
| freedomben wrote:
| Wouldn't that require FAA complicity? And do you think
| pilot unions would allow it? Do they have power to stop it?
| laserlight wrote:
| > he's basically going to make top dollar until he's 65
|
| There's no such guarantee in any of the professions.
| SoftTalker wrote:
| True but it's likely, unless fully-autonomous commercial
| airliners are developed. There's a shortage of pilots as
| well, and unlike most other careers, they _have_ to retire
| at 65 (or maybe younger?).
| sokoloff wrote:
| They're one failed First Class Medical exam away from
| losing it.
| rvba wrote:
| Even if autonomous aircraft are developed, will the "old"
| planes be converted? Could they be converted without tons
| of changes? Sounds unlikely.
| patall wrote:
| Doesn't necessarily matter when its rich countries (or
| their carriers) that buy the new planes and out of a
| sudden, pilots have the choice of flying for an
| indonesian island hopper or not at all.
| esafak wrote:
| Especially with machine learning engineers automating lines
| of work away :)
| rstuart4133 wrote:
| > But, here's the deal: he's basically going to make top
| dollar until he's 65. Meanwhile, I'll likely be seen as a
| dinosaur in tech by that age and will be lucky to find work
| at all.
|
| Errr, I'm 64, generally get a title like "senior programmer",
| and have switched jobs a few times recently and didn't have a
| day out of work. I expect to be going for a few years yet -
| in fact I expect your husband will be forced into retirement,
| whereas I will chose my time.
|
| Moreover, I have quite a few software engineering friends or
| about the same age. It's the same for them. Some are still
| working, some not. But in every case it's been their choice,
| they weren't forced into it by the industry.
| silisili wrote:
| Thanks for posting. It's something that concerns me as I
| head into my 40's, so it's really nice to read anecdotes
| from folks showing there are opportunities for those
| getting up there in age.
| manzanarama wrote:
| Maybe I am naive but I don't get this age vibe really. I do
| backend java distributed system stuff for a large company. A
| lot of my peers and managers are "older" 40s and 50s with
| kids. A lot of the work is high collaborative and design
| focused. Maybe I am just in a bubble of an aging tech stack
| but it does seem like we are always using "new" (at least
| different) databases, caching, and network layers to stay
| somewhat current.
|
| Its hard to imagine that 5,10,15 years of distributed systems
| and system design experience and knowledge along with domain
| knowledge and social skills will be all of a sudden be so
| irrelevant that it is worth phasing all of us "old guys" out
| for someone who happened to learn the newest programming
| language straight out of school.
|
| We are constantly expected to learn the new stuff and will
| just a project assigned with a mandate "okay this is to be
| done in spring boot, using this DB, this HTTP layer, etc...
| toomuchtodo wrote:
| It's still unfortunately common, because there are always
| young workers in the pipeline.
|
| HP: https://news.ycombinator.com/item?id=38043552 ("It took
| seven years but over-40s fired by HP win $18M settlement")
|
| IBM: https://www.diversityjobs.com/career-advice/team-
| building/ho... (Control-f "Sources")
|
| https://features.propublica.org/ibm/ibm-age-
| discrimination-a... ("ProPublica: Cutting 'Old Heads' at
| IBM")
|
| https://www.forbes.com/sites/jackkelly/2023/02/17/prior-
| agei... ("Prior Ageism Allegations At Google, Facebook And
| IBM Raise Concerns About Older Workers Being Targeted For
| Termination")
|
| https://news.ycombinator.com/item?id=14932680 ("HN: Ageism
| is forcing many to look outside Silicon Valley")
|
| https://www.orangecountyemploymentlawyersblog.com/dfeh-90-a
| g... ("DFEH: 90 Age Discrimination Complaints Filed Against
| Tech Firms Since 2012")
| simonbarker87 wrote:
| It's the bubble of very online people and start up culture
| who think tech people age out at 40. I know plenty of devs
| in theirs 50s, after that they just take early retirement
| since they've earned enough.
|
| Most devs aren't terminally online, they treat coding as a
| job not a lifestyle and for them it's just like any other
| industry - so you don't hear from them.
|
| Also, some devs retire into SQL and DBA like work since you
| can basically make yourself unfireable if you want to coast
| out the last decade of your career.
| deepsun wrote:
| > ... to coast out the last decade of your career.
|
| Here right now the age vibe is coming from ;) It's not
| like a doctor can coast it out (or maybe I'm also naive).
|
| (I'm an employer as of now)
| dools wrote:
| I don't think it's the case that experience is generally
| useless, but you need far fewer experienced people like
| this than you do cannon fodder to advance the front line a
| couple of centimetres.
|
| There are people earning good scratch well into their
| "golden years" in the tech sector, but the demand for them
| is much weaker.
| atleastoptimal wrote:
| Here's the thing. There won't be "tech work" or any kind of
| work in 5 years due to AGI.
|
| In fact any long term plans at this point seem silly. AI is
| going to make all human labor irrelevant.
| dghlsakjg wrote:
| Your husband is also in the position where any mental issue
| and a lot of physical health issues will force an early
| retirement.
|
| And if he wants to make the big bucks, there are not that
| many companies to work for (~10 mainline carriers in the US
| at the moment), and the seniority rules suck.
| SystemOut wrote:
| I think the ageism thing is not as big of an issue anymore.
| Yes, you will see it in startups that are run by 20somethings
| but I'm in my early 50s and haven't had any problem staying
| employed or getting offers.
|
| If you stagnate skills wise or stop trying to grow/evolve
| your abilities then you definitely will have issues but
| that's true in many industries, not just ours.
| Racing0461 wrote:
| I wouldnt be so sure. aviation is ripe for automation (and
| planes can even land on its own now.). I can see airline
| companies pushing for only 1 pilot in the cockpit.
| bsder wrote:
| > Meanwhile, I'll likely be seen as a dinosaur in tech by
| that age and will be lucky to find work at all.
|
| I disagree. Go to some technical meetups.
|
| At practically all of them I have seen people offering jobs
| to both juniors and greybeards. The biggest problem everybody
| is having right now is _connecting_. The garbage in the
| middle is clogging everything up. So, everybody is going back
| to the old tried and true, the weak social network of in-
| person acquaintances.
|
| Yeah, you have to not suck and you have to keep your skills
| up-to-date. But, that's true whether you are 20 or 60.
| JoshTko wrote:
| We don't have a shortage. We have too much regulation by AMA
| limiting number of doctors.
| anonporridge wrote:
| Just because the shortage is intentionally engineered doesn't
| make it not a shortage.
| winrid wrote:
| She has better job security than you, however.
| tenpies wrote:
| And career longevity. A 40 year old developer is "old". At 50
| you're ancient.
|
| A 40 year old doctor is insanely young. A doctor in his late
| 60s can easily be in their prime, especially in some practice
| areas or research. Provided they are okay health-wise, even
| an 80 year old doctor can still be working, especially if
| they have a strong team. They'll probably be in a mentorship
| role or a more laid-back practice, but they'll still be
| earning a meaningful income and having a very real impact on
| their patients.
|
| And generally speaking, doctors in the West live longer than
| the general population, so that longevity is better as well.
| strikelaserclaw wrote:
| Who knows if software engineers will be paid the same in the
| future but doctors will most likely have a strong "moat" till
| the day they die. Software engineers lucked out in this era not
| because they are smarter / harder working than people like
| mechanical engineers but they just chose a profession that
| naturally scales, and scaling is really how you can make a lot
| money.
| dylan604 wrote:
| eventually, the cost of a team of software engineers will be
| the monthly fee to chatGPT
| mianos wrote:
| Maybe, but how longs is eventually? I love GPT, use it
| every day but it is pretty flawed. 10 years?
| dylan604 wrote:
| who knew what chatGPT was 2 years ago? things are moving
| fast, and gaining speed. will they plateau before getting
| to being ubiquitously useful?
| rgifford wrote:
| LLMs have been around since the 50s. Chomsky has plenty
| to say on them [1]. It's not half as rosy as the current
| hype cycle.
|
| 1. https://www.nytimes.com/2023/03/08/opinion/noam-
| chomsky-chat...
| rgifford wrote:
| The machine building itself is end game. At that point
| you're suggesting singularity. I don't see how any
| profession survives that.
|
| There's so much hype around AI right now, it's absolutely
| unhinged. Yes, we have semi-conversational AI. Yes, image
| detection is pretty good. It's all supervised.
|
| Can we please touch grass?
| anonporridge wrote:
| At that point, the same will likely be true of most
| doctors, with DoctorGPTs making most of the cognitive
| decisions and a team of lower knowledge technicians and
| nurses doing most of the hands on work.
|
| Other than surgeons, a ton of what we would traditionally
| think of as doctoring has already been abstracted away and
| work specialized and divvied up to technicians, with MDs
| pulling strings in the background.
| ShamelessC wrote:
| > they just chose a profession that naturally scales, and
| scaling is really how you can make a lot money.
|
| They chose a profession that appears to scale to investors.
| When software _actually_ scales rather than being a subpar
| substitute for an existing mechanism is when the people
| involved were indeed smarter and worked much harder
| (typically).
| anon115 wrote:
| i dont get ageism in tech at all if anything i would hire the
| most experienced programmers tf would i hire a less experienced
| person.
| nytesky wrote:
| Ageism in tech is based on the premise if you aren't already
| a multimillionaire dabbling in angel investing by 30, you
| don't have the "it" (ambition, skill, etc) to really
| contribute at a high level, and a young programmer can do
| similar work but be more familiar with latest tools and langs
| mianos wrote:
| While true, in my experience, many much more experienced
| developers can do a lot of things the less experienced ones
| think they can.
|
| What about the people who did make a lot of money but like
| to work and create things?
| ska wrote:
| > salaries need to offset the insane burden of training
|
| A cycle here is that student loans rise with expected earnings
| and banks are fairly open ended about it, institutions happy to
| justify the use of the cash.
|
| Salaries wouldn't need to be nearly as high if you didn't walk
| out of residency with 200k+ [medical school ] debt at a point
| that is effectively mid-career. As a society we'd probably be
| better off if the both the median salary and median debt was
| much lower. I've also seen the "guarantee" of a high salary
| later lead many young doctors and med students to be foolish
| with money, as "eh, what's a little more debt" is easy to fall
| into.
|
| It's also part of the driver to overspecialization, more
| available GP's and fewer people reliant on emergency visits
| would obviously improve the system, but the economics and QOL
| for a general practice keep getting harder.
|
| Residency bottleneck and the high barrier for foreign trained
| mid-career people are the two other areas for potentially major
| impact.
| HPsquared wrote:
| The question is, does it really cost 200k to train each
| doctor? Surely the main input is the student's own time and
| effort, which isn't even included.
| ska wrote:
| I wasn't wording things clearly. The 200k is just the
| median residual debt from medical school alone. People
| don't tend to pay it off much during residency years
| though, since residency pay is relatively low (50-70k).
| Lots of them acquire extra personal debt during residency.
| Doctors aren't typically considered "trained" until after
| residency.
| benhurmarcel wrote:
| You're making the comparison with software engineering in the
| US which is one of the biggest outliers in terms of income.
| kulahan wrote:
| I have no source for it, but I read once that (GP) doctors make
| less than software devs on average, simply because devs get
| that decade head-start with much less debt. It makes sense.
|
| This is such a hard problem to fix. I doubt anyone is
| interested in hearing any solutions that involve worse-trained
| doctors, or longer training schedules, or massive pay increases
| for what are viewed as some of the highest-paid people in the
| nation. There is a lot of talk about opening up medical care
| for more people - which, naturally, means there will be a surge
| in demand. I can only imagine this would exacerbate the
| problem. It feels like we're running out of time to fix this.
| raverbashing wrote:
| Yeah, for real, the whole residency/shifts they are submitted
| into are borderline abusive, and I don't think any other
| profession accepts their professionals going though this
|
| It's basically a firm of hazing
| codegeek wrote:
| And not to mention that doctors usually have no work life
| balance. I have many doctors in my family/friends here in the
| US and most of them have no time for anything including
| weeknights and weekends. It is crazy.
| atleastoptimal wrote:
| Most of my friends who became doctors have rich parents. The
| ones without rich parents funnily enough dated software
| engineers who were the main breadwinners during their med
| school/residency.
| asdfman123 wrote:
| I know a guy who accrued $400k+ of med school debt and dropped
| out last quarter. Insane system. I didn't even consider
| medicine, despite being a top science student, because of the
| stress.
|
| And god forbid you think you can handle it at 18 years old and
| then being stuck on the medical track for... decades.
| nextworddev wrote:
| Why did he decide to do so, if I may ask?
| asdfman123 wrote:
| I didn't know him well enough to ask
| aborsy wrote:
| That's a year of their salary. The salary/debt ratio in
| engineering is lower.
| asdfman123 wrote:
| But it's not a year of salary for a med school dropout.
| gist wrote:
| > Based on our math, we'll be 25 to 30 years into our careers
| before her medical education with have a better ROI than my
| career choice. I didn't even push for top-dollar jobs.
|
| This has quite frankly zero relevance to anything. The analysis
| depends on what you her husband does (I mean seriously how does
| that prove a point at all) and your choice and abilities
| (totally arbitrary based on a host of factors especially given
| the tech scene over the last decade.
|
| I mean ROI? So someone makes a career decision by comparing to
| what their partner makes or what ROI is?
|
| > AMA is unwilling to fix this
|
| This has to do with residency slots and residency slots are
| determined by how many hospitals can accept residents. Now you
| can say AMA is a roadblock to that but there are a slew of
| other roadblocks in addition (if true not sure it is) to having
| more residency slots.
|
| You can think idealistically that you can re-imagine the whole
| system but massive change in something entrenched like that
| (where lives matter) most likely is not practical.
| matheusmoreira wrote:
| On the other hand, you want doctors to be well rewarded because
| it's a high stress, high work hours, high responsibility, high
| liability, high effort and high opportunity cost profession. If
| it doesn't pay well, very few people are going to bust ass in
| medical school and residency for 10 years to do it.
|
| In my country the government flooded the market with doctors
| and the results weren't pretty to say the least.
| demondemidi wrote:
| Really helps to come from money so that you don't have that
| huge college debt to crawl out from under.
| 0xB31B1B wrote:
| Black pill for me: the doctors that are paid extremely well
| (surgeons, complex specialties) are doing work that is extremely
| challenging and realistically only a tiny amount of people are
| able to do. Increasing med school and residency slots wouldn't
| impact these specialties because the gating is due to innate
| qualities like IQ/drive/etc. The people who are currently
| excluded from these job roles are intentionally excluded due to a
| lack of these qualities and it is good.
| hibikir wrote:
| The US has fewer residency seats per capita than almost anyone
| else in the civilized world. Are American students less capable
| than everywhere else? Are Europeans dying in droves because
| getting into med school is marginally easier?
|
| Looking at health outcomes in other countries, your argument
| just doesn't hold
| 0xB31B1B wrote:
| It's not residency slots that gate complex specialties it's
| fellowship slots. At the end of residency, a "general
| surgeon" can do common and basic things like appendectomies.
| Those that go on to do organ transplants, complex cancer
| cases, etc do a fellowship that is another 1-3 years of
| training in a further sub field. We don't need more
| internists or family med doctors, most of that caseload can
| be handled by NPs and PAs. Family med MDs make maybe
| 160k/year, they are not high earning.
| light_hue_1 wrote:
| > Family med MDs make maybe 160k/year, they are not high
| earning
|
| The mean wage is 224k/year.
| https://www.bls.gov/oes/current/oes291215.htm Definitely
| high earning.
|
| > We don't need more internists or family med doctors, most
| of that caseload can be handled by NPs and PAs.
|
| Ok. When someone in your family dies from horrible
| substandard care from an NP, we'll talk. I don't let anyone
| in my family deal be under the care of an NP, I've seen
| them make far too many serious mistakes.
| some_random wrote:
| The obvious question I have then is why you think the current
| system is selecting exactly the right number of surgeons? How
| do you know the next 10% of potential surgeons who don't make
| it under the current system wouldn't have the IQ/drive/etc to
| be high quality, effective surgeons?
| 0xB31B1B wrote:
| Fellowships are the last 1-3 year stint of training for
| specialist docs. There are unfilled training slots in
| competitive/complex fellowships in many disciplines. The
| fellowships are choosing not to train because they don't have
| qualified applicants.
| 11101010001100 wrote:
| You are describing a bias in terms of expected traits of a
| doctor. You can imagine (and attempt to measure) that there are
| a good number of people who share these traits who are not
| doctors and a good number of doctors who do not share these
| traits.
| 0xB31B1B wrote:
| Yes. The 3 dominant features are (1) income and (2) ability,
| (3) alternative opportunities. Highly specialized doctors in
| the US get paid a lot because they have great alternatives
| because they are some of the smartest and most driven people
| alive. If we increase the number of training slots, that
| doesn't increase then number of qualified applicants to train
| because we are already at an equilibrium where marginal slots
| are unfilled in competitive fields. If we want to increase
| the number of qualified doctors we need to increase training
| slots AND increase pay for these docs. This will move some of
| the top talent pool from drug discovery/finance/law/software
| back to medicine. Will a law partner become a top surgeon
| ever? No. Will a highly capable 18 year old who is choosing
| their path be more likely to take the "highly compensated
| surgeon" route over the "highly compensated finance worker"
| route? Yes. Some of the best folks I know in the field have
| previously worked in business services/legal routes before
| settling on medicine relatively late in their career.
| yibg wrote:
| Lots of things stated as fact that isn't necessarily
| supported. How do you know they are the smartest and most
| driven people alive? How do you know we are at equilibrium?
| I open up 100 spots and pick a terrible qualifying criteria
| I can still have a shortage of "qualified candidates" but
| it doesn't mean there aren't qualified candidates, it just
| means I have a shitty filter.
| closeparen wrote:
| "Drive" in terms of motivation to do medicine specifically and
| nothing else, sure. But plenty of people who could succeed in
| medicine choose fields like tech instead due to work-life
| balance. Medicine could potentially attract this talent if it
| were willing to split its classic 24-hour shifts among two or
| three doctors instead of only one.
| wing-_-nuts wrote:
| I always find it funny when people say that we'd have less
| doctors under 'socialized medicine'. This article clearly shows
| that other countries have more doctors per capita. Not only that,
| but by and large those doctors are _happier_ working under that
| system than our doctors are working under ours
|
| https://image.slideserve.com/488686/physician-satisfaction-w...
|
| My guess is that not dealing with a mercurial insurance
| industrial complex that tries to constantly deny medically
| necessary treatment to your patients makes your day to day work
| more enjoyable.
| EricRiese wrote:
| Cuba is out here with probably the most socialist system and
| the most doctors per capita.
| wing-_-nuts wrote:
| When I use the word 'socialized medicine' I'm referring to a
| system of universal healthcare, not communist
| authoritarianism. It irritates me to no end that the two are
| conflated.
| neaden wrote:
| For the sake of clarity I think reserving the term
| socialized medicine for situations where the government is
| the one providing service such as in the UK and not when
| the government is providing funding such as Canada. There
| is also universal healthcare systems like Singapore that
| still provide a strong private component.
| dukeyukey wrote:
| Although even that's contentious - in the UK GPs,
| pharmacies, dentists, and most other frontline medical
| jobs are privately owned and run. Only really hospitals
| are government-operated, and even then there are private
| hospitals, insurance, and healthcare.
| buzzert wrote:
| I believe it's because "universal healthcare" is so non-
| political, it's basically meaningless in the context of
| this conversation. Universal healthcare just means
| "everyone has access to healthcare". Well, 92.1%[0] of
| Americans have health insurance, and close to 100% of
| Californians have health insurance with a public option[1].
| The city of San Francisco even adds coverage[2] on top of
| what California and federal programs can offer, which
| basically means everyone has access to healthcare, even
| those 400% over the federal poverty line. Oh, and there are
| more people in the state of California than all of Canada,
| which is especially interesting when Canada's system enters
| the debate.
|
| [0]: https://www.census.gov/library/publications/2023/demo/
| p60-28...
|
| [1]: https://www.coveredca.com/health/medi-cal/
|
| [2]: https://healthysanfrancisco.org/
| neaden wrote:
| Cuba is a weird case though where doctors are essentially one
| of their most important exports where they send them to other
| countries, primarily in Latin America.
| NoMoreNicksLeft wrote:
| Cuba leases theirs into medical slavery. Not sure that's a
| model we want to imitate.
| bequanna wrote:
| Socialized medicine has nothing to do with this problem.
|
| You can squarely place the blame on the AMA who (proudly)
| lobbied for years to cap Federal funding for medical Dr
| education and residency.
| throwaway5752 wrote:
| This article is political and can and should be ignored. Being a
| doctor is extremely difficult, and pays about as much as a
| sinecured, pseudo-academic "economist" who sells analysis and
| lightly dressed up op-eds in the Economist to the highest bidder.
| These articles get picked up by people who are predisposed
| towards the argument it is making because they have had a bad
| health care experience or want to take someone else down. It pits
| patients against doctors, when the real money is being made by
| the hospital systems and insurers who add little value but have
| massive influence over policy (much more than AMA).
|
| The AMA should stop opposing single payer, though. That is the
| key difference in the US health system and other national health
| systems with better outcomes.
|
| also: just look at the section of the Economist it is in: _United
| States | Medicine's gilded age_ - very professional.
|
| also: What percentage of the total healthcare costs in the US are
| attributed to physician salaries? That is the theoretical maximum
| improvement to the cost of care delivery, if you dropped it to
| zero. And is that net or gross take home? Is the data before or
| after paying malpractice insurance of administrators to navigate
| the intentional bureaucracy created by providers?
| wife_is_md wrote:
| Spot on
| throwaway5752 wrote:
| Thanks. I'm arguing against the HN group think on this one,
| clearly. The antipathy to the medical profession here is odd
| and also a little gross, because it comes off as professional
| insecurity or jealousy. Most of what people say here about
| salaries could easily be said about most software development
| position and will be, probably in the same section of The
| Economist, before you know it.
| s1artibartfast wrote:
| Being a doctor is difficult, and doctors should earn a market
| clearing income. However, the market supply is excessively
| constrained by legal licensing requirements which exceed the
| public's best interest. There is a point where improving the
| education or quality of doctors is a net negative, because
| having a less competent doctor is still better than having no
| doctor at all.
|
| Of course the AMA looks out for the benefit of its own members,
| which benefit from scarcity, as is reasonable. It is up to the
| public and their legislators to act in their own interest to
| increase supply of medical professionals (which is counter to
| the interests of existing medical practitioners)
| ejstronge wrote:
| I'm not an expert on this topic, but the article confuses a
| handful of issues that should be separated.
|
| There is a limit on the number of seats in US medical schools
| _but this does not affect the number of new practicing physicians
| in the US directly_. Thus the article 's discussion of MD
| matriculations and of DO programs should be ignored.
|
| The article correctly states that all physicians must complete
| residency programs. The US Medicare and Medicaid programs fund
| the vast majority of residency slots. Residency slots
| preferentially are awarded to US medical graduates (i.e., new
| MDs) but they are available to any graduate of an accredited MD
| program. Thus, if a bottleneck exists, it exists here.
|
| However, hospitals can - and do - use other funds to train
| medical graduates in their residency programs. I do not know the
| thinking about how many such slots a residency program operates,
| but this would have been a far more interesting area for the
| article to examine.
| gcapu wrote:
| The AMA issue is not new. In "capitalism and freedom" 1962,
| Milton Friedman wrote that it will turn into a cartel, then it
| did.
| NickC25 wrote:
| Was going to say exactly what you said. The whole approach the
| AMA takes seems very much in-line with cartel behavior. Through
| lobbying and other similar actions, their behavior is quite
| similar to OPEC and Latin American drug traffickers.
|
| They have their own interests to protect, and those interests
| aren't 100% aligned with the medical needs of the American
| population at large, nor with doctors struggling to make ends
| meet after taking on a ton of debt to go to med school.
|
| Is it any wonder that those who enter med school (or residency)
| with a deep sense of altruism get burned out rather quickly? I
| think not.
| s1artibartfast wrote:
| The fault is not with the AMA, which can be expected to act in
| it's own interest. The fault is with the capitulation of
| government institutions which enable regulatory capture at the
| expense of the general public.
| zone411 wrote:
| One of the worst requirements is mandating that medical students
| spend four years getting their bachelor's degree before entering
| med school. Realistically, the essential prerequisites for med
| school could be covered in two years. This would allow graduates
| to start their careers younger and with less debt.
| thmsths wrote:
| The "bachelor for everything even if it has no direct
| correlation with the work" mentality is a real plague. It's
| causing issues with airline pilots too. From what I understand
| the FAA does NOT mandate it, they "only" ask that you get a PPL
| and 1500 hours of flight to get your ATP and then you can work
| for an airline. But airlines want to hire college educated
| people for some reason...
| nradov wrote:
| Yes, and some US medical colleges are doing exactly that with
| combined baccalaureate/MD programs.
|
| https://www.aamc.org/news/combined-bachelor-s-and-md-program...
| epivosism wrote:
| Yes. Other countries don't do this - you go directly from HS to
| a 6 year medical school. It not just saves time, but increases
| your useful career length by over 10%, probably more if we
| weigh age-effectiveness.
|
| Plus it would let many more people do MD-related jobs like
| medical researcher.
| bell-cot wrote:
| Reality Check [FAIL] - Both from many things I've heard & read
| over the years, and some quick web searches just now - it sure
| looks like "American doctor" earnings vary _vastly_ depending on
| the doctor 's specialty. With the GP's and similar "keep 'em
| healthy" specialties often paid ~3X less than the MD's who get to
| bill lots of cool, expensive "procedures".
|
| (The frequent blindness of The Economist to such critical basic
| facts was ~80% of why I cancelled my print subscription.)
| albertgt wrote:
| We need more doctors, physician assistants, nurse practitioners.
| Most are burning out and overworked. I have overheard a business
| conversation in which one person said, "the only way to solve
| this is to make doctors work more hours" ... I do not think that
| is the solution either.
| mithr wrote:
| There are just so many factors in play, and many statements in
| this articles can spawn their own large-scale discussions.
|
| > More than 100m people today live in an area without enough
| primary-care doctors
|
| I have several friends who are primary care doctors, and their
| patient panels are 2000-3000 people. That is an absurd number of
| people, and requires a ton of work on their part, leading to poor
| work/life balance. Being a primary care physician is becoming
| more difficult and less attractive, even for people who otherwise
| would be really interested in being generalists and building the
| kinds of relationships that come with being a PC.
|
| > the problem is particularly bad in rural areas
|
| Generally, highly-educated people tend to live in urban areas
| (there are many sources that track this trend). In addition,
| rural areas tend to imply private practices (because there aren't
| as many large hospitals in those places), and private practices
| are even harder to work at -- whereas a hospital has an entire
| department dedicated to billing and dealing with the myriad
| insurance types their patients have, private practices have to
| mostly manage on their own with minimal staff. This winds up
| taking a ton of their time, and is a major reason some folks I
| know have not gone that route.
|
| > As the baby-boomers age the need for medical care rises and the
| doctors among them retire
|
| This may be a "usual suspect", but it is a real one.
|
| > it takes 10-15 years after arriving at university to become a
| doctor in America
|
| IMO, this alone largely answers the question in the title. While
| training, physicians don't generally earn a lot of money
| (relatively, and especially since many of them train in large
| hospitals, which are based in large cities, which have higher
| costs of living). The expected reward for spending a 10-15 years
| of your life studying and working hard, long hours, in schools
| and then residency programs that are short-staffed and have
| multi-day shifts, must be high enough to justify the cost, even
| for those that go into it with a very idealistic mindset.
| Ericson2314 wrote:
| Either the AMA will reform, or super nurses will do everything.
|
| Ideal outcome is accelerated MD for nurses as continuing
| education. Not having this is plain classist af.
| Ericson2314 wrote:
| https://en.wikipedia.org/wiki/Mustang_(military_officer) the
| military is unsurprisingly miles ahead on this
| Vaslo wrote:
| Medicine has thrived on limiting its intake of Doctors in the
| same way law has not. The legal profession went the way of
| opening Law Schools all over the place whereas medical schools
| are far and few between. Obviously medical schools are much more
| expensive to open, but having organizations that limit opening
| those schools also helps.
|
| Medical schools are so far and few between that it is one of the
| rare places students seek admission in the Caribbean and Latin
| America to get certified with the hope of clobbering their USMLE
| exams and getting into a good residency program to make up for
| it.
|
| The fact that someone can have 2 points lower on the MCAT and not
| qualify for a good medical school tells you how messed up the
| priorities are.
| musha68k wrote:
| Paywalled article but I'm wondering if the stat for Canada's
| "Doctors per 1000 people" is actually lower due to emigration?
| jschveibinz wrote:
| Becoming a doctor through service in the armed forces is a
| legitimate alternative path in the U.S.:
|
| https://veteran.com/military-doctor/
|
| Wouldn't it be great if this program were expanded to include
| "civilian service," as in "rural community and inner city"
| assignments? e.g. psychiatry?
|
| Oh wait, there are programs for this, as well /s:
|
| https://www.usphs.gov/students/
|
| https://www.ruralhealthinfo.org/topics/scholarships-loans-lo...
|
| Other options: nurse practitioner, social worker, physician
| assistant, nurse anesthetist, etc.
|
| Bottom line: if a teen wants to be a doctor or healthcare
| provider, there are many paths to getting there. It's a lot of
| hard work and it takes the right person to do it. Good luck and
| thank you to all of you considering this career choice-it's your
| gift to humanity.
|
| And you deserve to be paid well!
| BarryMilo wrote:
| So you're saying if poor people want quality education, they
| ned to join the army? And you don't see how that's a problem?
| bartkappenburg wrote:
| A couple of comments here are touching on the fact that being a
| doctor is hard in terms of that the profession is very difficult
| (IQ-wise), competitive and challenging.
|
| I tend to disagree. There is a very strong halo effect which I
| just kind of 'hate'. Let me explain.
|
| Here in the Netherlands we have a numerus fixus (about 500 spots
| each year on each university). Getting in is part luck and part
| skill. The skill required is to show eagerness and motivation in
| an interview with a commitee. That's the hard part.
|
| Once in, you are very unlikely to drop out. The drop out rates
| are extremely low compared to other studies. The education is
| very long and intense: this is very needed, you need to be highly
| trained.
|
| If you compare the academic level to other studies, it's quite
| moderate. Basically, it's a very pratical education with a lot of
| "hands on" in 6-8 years (and more if you specialize). For the
| dutch: people jokingly say that we need to rebrand the education
| to HBO-G.
|
| I have a friend who started out in Economics, finished the study
| with a degree with honours and decided to follow his dream to
| become a doctor. He said: the education was so easy compared to
| economics, it was a total joke. Mind you: the level of education
| for doctor is very good in the NL compared to othet countries.
|
| Now, in the NL we have a quite good health care system and still
| the doctors make an extremely good living. I have friends who are
| 40- and live in an 1 million+ house, drive a porsche and do
| luxury vacations three times a year.
|
| And I think it's fine: you are highly trained, you work shit and
| long hours and have an very very big responsibility.
|
| But is it a difficult and challenging job? I disagree, you are a
| highly trained production employee doing 95% on experience
| because you did this a 1000+ times before.
|
| The elephant in the room is, with the rising care costs here in
| NL, is this still viable? Earning high 6 figures while the system
| is under pressure? Also: why is the gap between doctors and
| nurses so big? Is that fair?
|
| (Sorry for my rant :-))
| pcthrowaway wrote:
| > But is it a difficult and challenging job? I disagree, you
| are a highly trained production employee doing 95% on
| experience because you did this a 1000+ times before.
|
| Unlike software, where you don't even need an education to get
| started, but you'll be expected to learn a different framework
| every year
| strikelaserclaw wrote:
| To me the defining trait of doctors is their persistence not iq
| (although some doctors have an ample degree of both). You
| really really have to want to become a doctor.
| benreesman wrote:
| I like the Economist in general but I press the back button when
| the instant they start shilling for wealth inequality.
|
| It's called "anchoring".
|
| 350k a year was a _ton_ of money that bought you home ownership,
| supporting a family, saving for retirement, and some if not all
| of the finer things even in a desirable geography.
|
| 15-25 years ago.
|
| 350k is _relatively_ a ton of money compared to dystopian
| nightmare of constant insecurity at the median.
|
| 350k is a _damned sight_ better than typical household income,
| take home is $19,319.25, which is _very_ comfortable but not
| "lavish" for a childless bachelor with no debt most anywhere.
|
| But throw in funding your 401k, ~18k, _renting_ a single-family
| home in a desirable geo in a neighborhood you'd park your car on
| the street: ~13k, couple of car payments
| /reg/insurance/maintenance, ~11.5k, 4 decent mobile phone plans,
| decent internet, utilities: 10.5k, couple of grand in student
| loans: maybe like ~8k, a year's worth of school clothes and
| supplies, replace a piece of furniture or two or a TV that craps
| out, a laptop or iPad or whatever someone broke or lost or was
| stolen because they're kids, and the long tail of "major
| expenses" that you never see coming amortized over a year: ~7k,
| fund college savings for two public universities: ~5k, healthy
| groceries you don't have to ruthlessly optimize and the
| occasional dinner out with your partner: ~3.5k, save up a robust
| emergency fund and then build a portfolio that will let you
| retire before 70 with a life expectancy pushing 90: zero. Hope
| you're not passionate about any hobbies that cost money and never
| want to go on vacation.
|
| You did a STEM-heavy undergrad, passed the MCAT, did years of
| extremely technical advanced degree education, took years off
| your life pulling crazy hours in a residency, built a practice.
| You're among the most highly educated and indispensable members
| of society.
|
| And your "lavish" profligate conspicuous consumption is living in
| California, sending your kids to public universities, and
| retiring ever?
|
| No, it's the median that's barbaric, not a modestly comfortable
| middle-class lifestyle you worked your ass of for that was pretty
| mundane for educated folks even a few decades ago.
| P_I_Staker wrote:
| I'm guessing you make close to 350k or over it. 80k a year is a
| ton of money. It's not so great in the bay area, but in the
| vast majority of the country, and even in the bay area it's
| life changing money.
|
| It covers a lot. I'm sick of reading defenses of people making
| 250k+ acting like they're in the poor house. I get families are
| expensive, but lifestyles have inflated to such an absurd
| degree.
|
| I've been on both sides of this argument, but it's so
| frustrating. I def agree with the median sucking, however I
| know plenty of people IN the median that feel differently.
|
| It's so strange to hear all this doom and gloom from people
| like me. I get that we don't have all the luxeries we were
| promised. In the 90s it would have been $90-150k and you would
| have a vacation house. These were really prosperous times if
| you were in the middle class.
|
| I get that we've experienced a bit of a "darth vader I changed
| the deal moment". There seems to be more expenses and we're
| getting less out of the deal (though more in some other ways).
| All that said, you're comparing against very prosperous people
| who were getting a pretty good deal.
| Manuel_D wrote:
| > 350k is a damned sight better than typical household income
|
| This is an absolutely baffling statement. Median income in the
| USA is $76,000:
|
| https://www.census.gov/library/publications/2023/demo/p60-27...
|
| Perhaps it makes more sense if you limited this comparison to
| top-20 college graduates that could realistically work for top
| law firms or tech companies. But $350K is still not remotely a
| slight better than the typical household income.
| svachalek wrote:
| "damned sight" means "a whole lot" not "slight"
| rendang wrote:
| "sight better", not "slight better". Not sure if you made a
| typo or misread the post you're replying to
| tunesmith wrote:
| People are gonna bash for complaining about 350k, but you're
| directionally right; the system is fucked up. The question is
| whether people can expect a reasonable retirement by working
| within the system. I think you can make the same argument just
| by comparing the median income with median expenses, and then
| actually seeing: can those people max out their 401k's? Do they
| even have 401k's? Can they max out their Roth's? If they do,
| what will they have when they retire? Is it enough?
|
| I would bet that in those sorts of scenarios, we're further
| away from "enough" than we used to be.
| trgn wrote:
| The numbers dont jibe with reality. Yes, 80k (or whatever the
| median is) feels low, but people are constantly - in reality
| - retiring, vacationing, sending their kids to school, buying
| cars, eating out, ... on that income.
|
| There's a huge disconnect, I don't know where it stems from.
| The average/median american is not living in destitution, at
| the brink of collapse.
|
| The fact that 350k feels low, is, I don't know, weird
| (although, like you, I understand that directionally it
| _feels_ about right).
| tunesmith wrote:
| I met with a fee-only fiduciary financial planner a while
| back. This was after several years of making income that I
| knew was above average, even somewhat above average in
| tech. We plotted out our expenses (which aren't
| exorbitant), plugged in our account balances, talked about
| wanting to retire maybe in our mid-late 50s rather than 65.
| Mind you, this is me maxing out 401k and Roth almost every
| year, and saving excess into a taxable "retirement" account
| as well. We answer a bunch more advanced questions, they
| press the button that runs all the Monte Carlo scenarios,
| and the result was... we were basically on target. We
| weren't on the road to fuck-you money, but we were on a
| road to be able to retire in the desired timeframe and meet
| our current expenses, maybe with a couple of vacations per
| year added on top.
|
| And I can't explain the emotional reaction I had. Like, I
| was relieved and proud that I had done a good job saving,
| but... I also knew that I was _far_ above average in income
| and saving, and even with that was only "on target" rather
| than exceeding. I eventually spluttered out my words to the
| financial planner, asking about all the other people out
| there that make less and aren't in a position to see
| financial planners, and with a sad look on his face, he
| simply said:
|
| "It is going to change society."
| trgn wrote:
| It's scary. But are families really now more poor than
| ever, that unlike today/before nobody will be able to
| retire?
|
| I think there's a huge difference in baseline cost. A lot
| of people on high incomes have huge spending jumps, that
| most just don't. e.g. the vacation is international, the
| house is twice as big, or in the "good" neighborhood, the
| car is big, the school is private, the kids have trusts,
| ...
|
| At all that up, and yeah, 350k is barely enough. Take all
| that away, and 80k is solid.
|
| > "It is going to change society."
|
| socialism (we'll take from thee) or fascism (don't you
| dare take from me). America is in for a rough ride if
| he's right.
| tunesmith wrote:
| I think I'm also a bit sensitized because my partner is a
| medical social worker and regularly comes across the
| people that don't retire. People that can retire don't
| tend to hear about the experiences of the people that
| don't. It's a long slog of scrambling to survive and earn
| while physically able, cutting expenses, cutting them
| more, qualifying for aid, getting into medical
| difficulties, spending down, qualifying for medicaid, and
| then... well, it's a journey that a lot of people would
| wave off as a normal way to live and die. Big question:
| does that happen to people who made median income? More
| than before?
| ZephyrBlu wrote:
| Exactly, with this topic it's impossible to have a
| calibrated discussion because everyone has a different
| baseline.
|
| Agree that "you need a lot more money" feels
| directionally correct, but at the same time complaining
| about $350k is dumb. At that level of income it's
| entirely down to your lifestyle choices.
|
| A lot of things people spending money on feels like
| status signalling. "I make $x, therefore I need to look
| like I made $x". Cars, private school, massive house,
| yearly international vacations, etc all feel over the top
| to me. If you want to have it all, yes it costs a shit
| ton.
| closeparen wrote:
| If the income is contingent on showing up to work in a
| high-cost region, I don't think we can explain away the
| payment/interest/taxes/insurance on a modest, reasonably
| located home in that region as "lifestyle choice."
| closeparen wrote:
| The median American lives in exurban Dayton, OH or
| something. Living somewhere with growing industry and
| career prospects is a completely different thing.
|
| The typical homeowner in a coastal metro doesn't have a
| massive income, but does have a million plus in home
| equity. You as a young adult will need dramatically more
| labor income to reach the same lifestyle on ~$0 wealth. You
| will even need more labor income than they had capital
| gains, because high-end labor is taxed much more heavily
| (~40% effective) than capital gains on primary residence
| ($500k exemption then ~20%).
| trgn wrote:
| I don't disagree. Come to think of it, Dave Chapelle
| lives in exurban Dayton. Must not be too shabby.
| strikelaserclaw wrote:
| doctors can move to any low col city and make similar amounts
| to living in CA (which is certainly not available to software
| engineers wanting to make the big bucks), not to mention a lot
| of them marry high income spouses as well. Just a FYI, i don't
| believe wealth inequality really stems from the people making
| 350-700k working jobs, it really stems from the minority of
| people / corporations who seem to own a ton of capital.
| vel0city wrote:
| After tax takehome for a married $350k income in California
| would be $230k/yr.
|
| Your list of expenses totaled to $58,500.
|
| What happened to the other $171,500/yr??
| yibg wrote:
| The cost numbers make no sense without a denominator. Take home
| looks like per month, 401l per year. Rental, per ..? 13k per
| month for rent is insane, per year is super cheap.
| charles_f wrote:
| It's interesting that the argument I've heard most often for the
| American healthcare model is the quick access to doctors and
| specialists.
|
| When you consider that there are less doctors per people in the
| US compared to some countries where healthcare is partially or
| entirely public, it's quite revealing how this result is
| achieved: by decreasing the population who can offer one. So that
| if you were re-adjusting the graph to the population with
| insurance or sufficient needs, the US would probably be higher
| than the rest.
|
| I don't know how you can argue to yourself that limiting access
| to health care is better because now _some_ people can get what
| they want faster (because others can 't get what they need at
| all).
| sjkoelle wrote:
| regulatory capture in action
| neonate wrote:
| https://web.archive.org/web/20231101143856/https://www.econo...
| sfc32 wrote:
| > The profession is lavishly paid: $350,000 is the average salary
| according to a recent paper
|
| Plenty of people in tech getting TC like this.
| strikelaserclaw wrote:
| Is this really true? Define plenty of people. An average doctor
| in America would probably make much more than an average
| software engineer. If you are comparing the top 10% of software
| engineers, then we should probably compare them the top 10% of
| doctors (who probably make close to a million dollars).
| game_the0ry wrote:
| At the top tech companies, yes. [1]
|
| That would be standard TC for a senior level engineer. But
| not at at a typical fortune 500, bank, or any other
| traditional type company that does not have tech as their
| main strategic business offering.
|
| [1] https://www.levels.fyi/
| strikelaserclaw wrote:
| yes but comparing the top x percent of software engineers
| to the "average doctor" seems a bit misleading.
| ipnon wrote:
| This is the average salary of all kinds of doctors in all parts
| of the United States. A relatively subpar doctor in South
| Dakota makes as much as a highly skilled engineer in one of the
| largest corporations in the world. Silicon Valley is not the
| exemplary of the nation's software engineering industry, many
| of us are making much meeker TC than $350,000.
| rqtwteye wrote:
| Plenty of doctors make >1,000,000.
| Merad wrote:
| Median TC for SWE in the US is $170k according to levels.fyi.
| strikelaserclaw wrote:
| keep in mind, normal swe don't even know levels.fyi exists so
| the self reporting is done by people who probably know what
| leet code is (which means they know the "game" to some
| extent).
| wly_cdgr wrote:
| It is weird, because aside from surgeons, dentists, ER docs,
| paramedics, and nurses, the work they do is trivial/clerical
| shortrounddev2 wrote:
| The US often prides itself on its world renowned universities,
| but this is usually due to the prestige of its research arms. In
| terms of actual education, the US school system is quite
| inefficient compared to other developed nations. What takes some
| countries 16 years takes the US 18-22. We spend a lot of time
| focusing on trivia and irrelevant courses for the sake of a
| "rounded" education, though retention is low and most people
| willfully forget anything they learned that doesn't have any use
| in their day to day lives
| swatcoder wrote:
| We think of doctors as healers because that's the traditional
| role they grew out of. But with the institutionalization of
| medicine in the 20th century, they became accessory bureaucrats.
| Their job is to approve or deny access to institutional services,
| per institutional policy, and they go through many years of
| learning how to do that. Their pay is scaled with the cost of the
| institutional services they safeguard, those costs in some
| markets being obscene and arguably corrupt.
|
| But people still need genuine healers for everyday ills, and so
| we see the institution move towards restoring that role to those
| with a less critical role in the institution, like nurses,
| pharmacists, physical therapists, etc
| anoxor wrote:
| fwiw, I'm a fan of this hot take.
| sf_rob wrote:
| From my experience as both a patient and a spouse to a general
| practitioner the opposite is generally true. Doctors are
| grossly unaware of both costs to patients and insurance
| eligibility of procedures. They push for the solution that they
| believe will resolve the issue with the best health outcomes
| while minimizing their own risks of lawsuits without
| considering other factors. Next, a faceless bureaucracy on both
| the medical and medical insurance side of things (few of whom
| are medical doctors) will slowly spin into motion to maximize
| profit and minimize costs, all while you have very little
| recourse/leverage/knowledge to fight the outcome.
|
| I will grant you that in some specialties and smaller private
| practices what you describing is probably true.
| swatcoder wrote:
| Of course doctors are often committed to the wellness of
| their patients, but I'd argue that the point of their
| extensive training is to help them align "best health
| outcomes while minimizing their own risks" with very specific
| institutional understandings of what that looks like. And
| that's what their pay is ultimately based on. They need to
| make the correct decisions, per the AMA/government/etc, about
| very expensive things and with minimal supervision. And it
| needs to authentically feel like it's for a good reason.
|
| But when it comes to the broad swath of everyday ills,
| someone with far less alignment training and who therefore
| hasn't been entrusted with the "MRI approved" stamp can often
| do a perfectly comparable job of taking care of people.
| That's what most practical medical care demands and it's what
| US doctors are now too overqualified and overpaid to
| provided.
| waffle_ss wrote:
| It's really an indictment of how far HN has fallen to
| Redditification* that you see this kind of low-brow ignorance
| so prevalently and so often.
|
| Yes, the greedy doctors who are lucky to get a couple hours
| of medical coding training when they start practicing and get
| needled constantly by their billing department for
| underbilling actually have "years of learning" in how to
| screw over their patients.
|
| Maybe they mean the man-years of time wasted arguing with
| insurance companies, shuffling around medications and care
| plans to please them, evenings and weekends spent in the EHR
| finishing up patient notes (because there's no time to get
| them done during the working day with 20 minute visits) and
| correcting and signing off on patient care for the PAs and
| NPs (cold-heartedly taking 100% of the malpractice risk
| burden for the nurses who _actually care_ about "healing").
|
| I'd encourage people this far gone on the deep end of
| visualizing physicians as hand-rubbing greed machines to
| spend a day actually shadowing one. Because you are very
| ignorant about how they spend their time and the amount of
| effort they put into caring for patients _in spite of_
| continual soul-crushing roadblocks put in their path.
|
| * Yeah I know it's against site rules to say but I don't care
| it's true
| swatcoder wrote:
| I don't get the vitriol or where you assume I see doctors
| as "greedy" or determined to "screw over their patients". I
| assume you've read a lot of stuff here that gets under your
| skin, and that my post somehow reminds you of those. But
| you read a lot of things into it that I didn't write and
| wouldn't write.
|
| Doctors are brilliant individuals and often deeply invested
| in patient care. Many if not most of them pursued the
| career because they wanted to be healers. But as you
| beautifully describe, a lot of their actual job is now
| committed to navigating endless bureaucracy because they
| are the only people who have been institutionally blessed
| to do so. Given that many of them do care so much about
| patients on a personal level, and pursued the field for
| that reason, it's tragic that paperwork takes so much away
| from their opportunity to do so.
|
| My perspective even goes so far as to argue that their pay
| isn't a product of greed at all, but simply a necessary
| outcome of institutionally mediated medical goods, of which
| they've been tasked as front-line guardian, being grossly
| expensive. Reduce the cost of what they control access to,
| as we see in non-US health care markets, and their pay
| naturally reduces.
|
| In lieu of that, the US solution is to cleave out the
| responsibilities that don't require 8+ years of education
| and residency to get right and allow them to be dispensed
| by others.
|
| There's no indictment of doctors here, friend. None at all.
| It's all just mechanisms in a system much much bigger than
| them, and these mechanisms (as you describe!) frustrate
| them at least as much as anyone else.
| ska wrote:
| The perhaps more informative framing is: Why do doctors in
| America earn so much more than their peers in other countries
| (i.e., those with roughly equivalent systems).
|
| Pulling on that thread is pretty interesting in how broad it
| goes. I'm certain I don't understand it well and the experts are
| pretty argumentative also.
| xyzelement wrote:
| A bit orthogonal to the article, the answer to why someone makes
| "so much" or "so little" boils down to how badly people need that
| work done and how many people can do it. IE, supply and demand.
|
| Consider a doctor or even a plumber. When you have a problem that
| needs one, that problem is usually important and urgent, and it's
| not a job you can "afford" to be poorly done by an amateur. So
| you end up paying a lot to get it done quickly by someone from a
| small pool of qualified providers.
|
| On the flip side of that is something like a barista. My 3 year
| old has figured out how to operate the Keurig and while obviously
| a high-end barista can make a way better coffee, the second-best
| and "nearly free" option is totally acceptable, putting a hard
| ceiling on how much a barista can make. That option doesn't exist
| for doctors and plumbers so they make a lot.
| NoMoreNicksLeft wrote:
| I've seen more than a few $100,000 bills for surgeries.
|
| The fee paid to the surgeon is something like 2-4% on the ones
| I've seen. So, a few grand to save someone's life. I don't
| think they're paid so much at all. What they are paid seems
| more than earned to me. We might instead ask why so little of
| the money paid for procedures seems to be paid to the doctors,
| and so much to the medical bureaucracy.
|
| Most of what people complain about isn't the plumber charging
| $500 to fix plumbing, so to speak, but why the Plumbing Center
| adds another $40,000 to the bill and itemizes things like "$50
| Miscellaneous Paper Towels".
| gcapu wrote:
| There are insane controls on supply. It's not a free market.
| Everyone has to choose a Ferrari treatment or not go to the
| doctor. There's no budget option.
| Invictus0 wrote:
| Something like 25% of healthcare visits are now done by
| nurses and PAs. https://hms.harvard.edu/news/fourth-us-
| health-visits-now-del...
| gcapu wrote:
| That doesn't mean we have a market. I was billed $1000 for
| en ECG for example. I wouldn't have paid for it. It's a
| simple procedure that doesn't require a genius or advanced
| equipment. I'd rather an immigrant with a foreign degree
| look at it for $80 than a licensed American doctor for
| $1000. I'm not allowed to do so. I can't choose the quality
| of care I get.
| kulahan wrote:
| >There's no budget option
|
| What do you say to things like shopping around using newly-
| transparented prices, telehealth, minute/community clinic
| visits, and nurse help lines?
| digdugdirk wrote:
| That isn't actually a thing. Those prices aren't
| transparent, and there's no guarantee that an up-front
| price quote will be the price you're actually billed for.
| derbOac wrote:
| I think the "how many people can do it" part is where things go
| astray. "Can" can mean "are capable of doing it" or it can mean
| "allowed to do it" and those are conflated under the current
| system.
|
| Plumbing is maybe a good example, in the sense that if I own a
| home and feel comfortable with something, I can do whatever
| repairs I want. I could hire my friend John Smith to do it if I
| trusted him. The limit is the inherent risk I take, and knowing
| that if I screw something up, I could cause problems that cause
| problems to me. There are code issues, but that gets
| complicated and is orthogonal to the issue of who does the work
| that meets code.
|
| In healthcare though, even if you are entirely capable of doing
| something yourself, you are not able to legally. If there's a
| medication that you have been taking your entire life, and has
| been deemed safe in the primary scientific literature, you are
| still not able to just go buy it from the pharmacy without a
| prescription. If you want help or advice with the medication,
| you also can't just go to a provider that you want. You can't
| take the drug yourself, under the advice of the pharmacist for
| example -- even though the pharmacist often knows more about
| drugs than an average physician -- and you can't take it from a
| different type of provider that you trust more, for whatever
| reason.
| NotSammyHagar wrote:
| Often high pay is related to competition in hiring or
| demand/need by the employer, but not always. In my town like in
| many others they have lots of help wanted signs. All they need
| to do it pay more and they'd have a much better chance of
| hiring people. They just don't want to pay that much. Starbucks
| apparently pays over $20/hr starting, and they have benefits if
| you work enough (something like >20hrs/week) but they seem to
| manipulate people's work hours so they don't work enough. And
| they are evil union busters, but that's another issue.
|
| The are significant structural reasons behind pay. Teachers
| can't be paid more because they are govt jobs and the govt
| almost always doesn't do that. So programmers in govt are
| underpaid too, and they can't raise rates. Or they raise them a
| little but they don't have anything like market rates.
|
| The pay of real estate agents, where each side commonly gets 3%
| of the sale price (shared usually with your firm) is a
| rediculuous cartel that needs to be destroyed. In my city avg
| home price is over a million, so the seller/buyer each pay a
| 30k commission for a few hours work? That high pay comes from a
| cartel.
|
| Some people are paid high amounts because that's the
| expectation. Parity with other jobs might be a support for high
| pay, but maybe not. I'm skeptical of this argument applied to
| doctors. I had more years of college than a doctor plus medical
| school plus a year or two of hospital / internship. I used to
| be paid less than them by a large margin, probably I make more
| than most now. It's market rates. Am I doing more important
| things for society than teachers in my town? (where they can't
| find enough and now they recruit parents to be subs because
| they don't pay enough for that either). What I'm doing is
| useful but probably not more important than public school
| teachers.
| bmitc wrote:
| I feel terrible for my doctors, especially my vetenarians and
| primary care providers. They just seem so exhausted every time I
| meet them. And many doctors book out weeks if not months, which
| tells you how insanely busy they are and showcases a lack of
| doctors.
| derbOac wrote:
| Salaries are a red herring. So are the number of physicians per
| se. We don't have a physician shortage per se, we have a provider
| shortage, and more generally, we have a healthcare provision
| shortage.
|
| What you really want to know is, if you deregulated healthcare in
| general, and removed a lot of the medical licensing restrictions
| around care provision, what would be the expected decrease in
| healthcare costs? What if you increased care access?
|
| For example, let's say you dramatically opened access to large
| classes of drugs that are basically safe, and made various
| procedures and medicines available through, say, pharmacists or
| psychologists, or created opportunities for different provider
| models that don't exist now. What would be the expected decrease
| in cost, both in absolute dollar amounts and in "intangibles"
| such as time?
|
| For me the problem is this hierarchical view of healthcare
| provision, where we assume a physician is omnicient and
| omniskilled in all areas of medicine, more so than other types of
| providers who specialize more, and the only safe training path is
| bachelors -> MD -> residency.
|
| I don't buy the safety argument either because having practicing
| power so concentrated in one professional group also leads to
| safety problems. Those highly skilled and trained physicians
| didn't save us from things like the fentanyl crisis, even though
| it was literally their job under the current paradigm. If someone
| was really concerned about safety regulation, you would regulate
| on a skill basis, not on a degree basis.
|
| There a whole host of problems in US healthcare, including
| increasing consolidation of healthcare companies, healthcare
| management and administration, and so forth. But I do think a
| hierarchical provider model characterized by intense regulatory
| capture is a big, nonignorable part of it.
| Eumenes wrote:
| > For many Americans, the doctor shortage has already arrived.
| More than 100m people today live in an area without enough
| primary-care doctors (the problem is particularly bad in rural
| areas). For mental health things are even worse: half of
| Americans live in an area with a shortage of mental-health
| professionals.
|
| I agree with many of the points made here (doctors aren't
| overpaid, schooling is too long, etc) but how about addressing
| how many people constantly believe they need to see a doctor. How
| much time in the doctors office is actually necessary? There are
| probably more hypochondriacs today than ever before and I know
| many IRL. I've gone to the doctor probably less than 5 times in
| my adult life, but I have friends my age (late 30s) who go dozens
| of times per year, and don't have chronic issues! Some people
| suggesting a single payer system would fix this but I see it the
| opposite, just like in Canada, our system will be flooded for
| people seeking care for every single thing.
| shakil wrote:
| The single biggest factor is the cost of medical education. Once
| a person spends a fortune getting their degree, it creates a
| gated community that works to preserve its privileges, deny entry
| to other cheaper alternatives, and keep prices high across the
| eco-system.
|
| You will see this in any field that transacts with high value
| goods: real-estate, enterprise software, weapons of war,
| investment bankers handling M&A ... the higher the cost of the
| product, the more the people dealing in it feel entitled to
| charge for their services.
| ignite2 wrote:
| I seem to recall a study that showed, per hour worked to get into
| medicine, that being a physician did not pay particularly well.
|
| Consider opportunity costs for all those hours spent studying.
| Salary, in isolation, is not a sufficient measure.
| FigurativeVoid wrote:
| I'm a bit of a radical on this, but we should basically remove
| traditional college from the whole medical school pipeline. When
| I think of my friends that went to med school, they all took the
| MCAT after two years of school. That seems like a great
| indication that the last two years aren't important[1]. Two years
| of fundamental sciences, and then right into med school.
|
| Also, we have some many people that _want to be doctors._ We
| should let them all start medical school, and let them get weeded
| out from there.
|
| [1] the caveat here is research. But MD/PhD fits far better into
| the traditional college pipeline.
| gniv wrote:
| In Europe you go to medical school immediately after high
| school, but it takes longer, so ends up similar to what you're
| proposing I think.
| FigurativeVoid wrote:
| I think that they have a much harder high school process, but
| yes
| anonporridge wrote:
| That's not a radical proposal.
|
| The US and Canada are globally unique in requiring a 4 year
| bachelors before 4 more years of med school. Every other OECD
| country has a single 5-6 year program available straight out of
| high school.
|
| https://www.niskanencenter.org/the-case-for-shortening-medic...
| ejstronge wrote:
| Other nations have longer post-graduate training
| requirements, sometimes including compulsory national
| service. For many specialties, a US high school grad will be
| fully qualified before her UK peer
| kkylin wrote:
| There are nuances here the article misses. For one thing, pay
| disparity between specialties is huge -- compare a radiologist to
| a pediatrician, for example. In part this is because we have an
| insurance system that rewards (monetarily) people who perform
| procedures compared to those who don't.
| orangepurple wrote:
| What is the best place outside the country for Americans to get
| good healthcare? I have heard about Algodones, Mexico
| ugh123 wrote:
| 1/4 of all hospital visits are delivered by non-physicians [1]
|
| That number should rise with reduced regulation and sentiments
| toward what affordable healthcare means.
|
| In the meantime, AI offers promise to assist both physicians and
| non-physicians.
|
| Should our goal be to replace most hospital general checkups,
| triage, oncology, select emergency room visits, and a number of
| other medical fields with a _non-physician who is trained to use
| specialized AI technology to deliver with a patient together_.
|
| YES.
|
| [1] https://hms.harvard.edu/news/fourth-us-health-visits-now-
| del...
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