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> They're treating these young doctors like it's Hell Week in a fraternity, and the main excuse you'll get from the AMA is because that's what they (the older doctors) did so all of this fanfare is a right of passage towards full membership (attending physician) which unlocks all of these riches to justify sacrificing your youth for.

For the sake of nipping generational warfare in the bud...

My father runs a oncology fellowship. There are laws that prevent them from doing to our generation what was done to them. In addition, they don't want was done to them to be done to us. It doesn't benefit patients, increases drop out rates, and (especially in my father's field) drastically increases suicide risk and physician counseling costs. My father is currently 67, working 80 hours per week. He's not protected by those laws so he ends up covering for those hours that no longer fit the old formula, which means he did it both as a youth and in his 50s and 60s. There is a ton to crucify their generation for, but I really don't think this one is it.

> What I'm trying to get at is this feels like the kind of thing a propaganda outlet would do to give you a false enemy to hate

Once you account for hours worked, time spent in the workforce, and debt accumulated to achieve their income, a doctor will only have a 10-20% boost in lifetime earnings compared to a UPS driver. People seem to conflate income and wealth, which is a TERRIBLE fallacy to fall into. For some personal numbers, my father's income is double mine. Once you've adjusted for the those aspects I mentioned above, I'll have earned 80% more than him in my career.

> Once you account for hours worked, time spent in the workforce, and debt accumulated to achieve their income, a doctor will only have a 10-20% boost in lifetime earnings compared to a UPS driver.

Do you have any reference to back that up? Not doubting it. Just curious.

This is a fairly old source, but it demonstrates the concept.

http://www.er-doctor.com/doctor_income.html

In case people don't bother reading it in depth, here is one of it's updated links:

https://www.linkedin.com/pulse/70000-per-year-start-now-kevi...

I ran the numbers recently and the numbers were even more grim, but I'd need to track down all my sources again.

I just think the main point is that income is not the number to focus on. Wealth is the end result of the equation, and income is only one part of that.

I think that factoid comes from that shitty graph where the suppose that the UPS driver starts working straight at the moment they turn 18 and they will have maximum pay rate that is available for the UPS driver position.

While in reality, the average wait time to become a driver from loading is 11 years. During that time you make about $13/hr part time where the schedule can be horrible and you could work less than 15 hours a week. When you do become a driver it takes another ~2 years (on avg) to get your own route until then you are a part time worker and your hours worked will fluctuate a lot over the year. The first year is paid at 17.50-18.50/hr (~$36,000/yr @ 40 hours a week) and then goes up.

> they turn 18 and they will have maximum pay rate that is available for the UPS driver position.

That's not the assumption. It's that they receive median pay their entire career, which would be reasonable if they never left their job. Getting paid 60, 70, and 80 over a 3 year period is the same as working three years at 70 ignoring inflation and investments. That's the assumption

> While in reality, the average wait time to become a driver from loading is 11 years.

Then compare it to the countless other blue collar trade skills that don't require any educational debt. The point continues to stand unless you want to focus on the example rather than the concept.

He doesn't have a reference because it's nonsensical.

Say it takes you 15 extra years to get into the workforce over a UPS driver, that you're saddled with $400k of debt and that UPS driver is the highest compensated driver in history at $100k.

$350k over 30 years is $10,500,000 - $400k = $10.1MM

$100k over 45 years is $4.5MM

Your net earnings is >200%

You don't get it, you have to factor in the hours worked.

I did this math when I was 27 and wanted to leave programming to enter medicine. When I realized I wouldn’t come ahead financially until near retirement (and that was assuming I’d make a lot less in programming than I actually have) I decided to pass. It didn’t matter what specialty I picked except a few like plastic surgery or dermatology and there’s no guarantee of getting a residency in those. That’s also not considering that extreme hours worked in medicine and the loss of your youth. My spreadsheet also didn’t account for the fact I’m making mid-six figures in programming already at my mid thirties (!!)

Medicine is not a place to go to become rich. If you already have the brains and aptitude to overachieve in medicine you can succeed elsewhere even more greatly AND retire younger.

I would love to know what job you have in programming making $500k in your mid-30s.

Base salary is low-six figures. I work at [insert deca-unicorn here] and a lot of that comp is locked inside non-public stock (I've been here a long time), so it could go to $0... or it could be enough to retire on. That's just the nominal risk-adjusted value of my compensation. Even assuming my stock is worth $0, just my base salary puts me ahead of going into medicine. The only way going into medicine makes financial sense over programming is if you fast track your way into it from high school and end up in a lucrative specialty, and even then it doesn't come that far ahead. Given the loss of your entire youth, I'd say it comes out even at best, unless medicine is a natural passion of yours.

Rules in place by the ACGME are laughable, no one respects duty hours and a certain residency program I may or may not have participated in told us to lie about our duty hours so not to get the program in trouble. From my experience the worst offenders tend to be older attendings who do not respect duty hours and will round on your post-call day at noon meaning you have been at the hospital for 30+ hours before you can give sign out.

Why talk about reality in terms of stories and angles? Why not talk in terms of facts and truths? You speak as if it is better to blame an insurance company rather then your doctor buddies because of a narrative. Are we so weak that we can't take the truth at face value?

These are the facts: 1. Doctors the US are paid more than doctors in other countries. 2. Medical care in the US is lowest in quality among most 1st world countries.

There is a logical outcome from these two facts: The high bar required to enter medical school or residency does not produce better doctors.

The other thing that gets me is why are we attacking insurance? Obama did it. It didn't work. You know logically if health insurance companies are all so evil, a good business startup idea would be to form a company that isn't so evil and cheap. This company will of course out compete all other insurance companies, by being the first cheap and moral insurance company! What a genius idea. Sounds really similar to obamas plan of simply using the federal government to enforce some moral principles onto the whole industry.

Maybe none of this works because insurance companies are already operating on edge. To stay competitive and offer customers competitive premiums they have to screw over people asking for claims. Maybe this occurs because medical costs in the US are too high? Why are all these costs so high? Probably to payoff someones' super high salary...

Look. Every medical cost in the us from insurance to hospital bills is higher than other countries. In terms of regulation the only difference between us and other 1st world countries is the supply of doctors and the supply of medicine.

The united states places the most restrictive cartel policies on these two areas. All other problems in the medical world stem from these policies.

AFAICT, US doctors aren’t paid that much more than Australian or British doctors, yet the overall cost of health care is very different.

The article's point is they are paid more!

I realise and I have read the primary research article (https://www.healthaffairs.org/doi/abs/10.1377/hlthaff.2010.0...). I'm just saying that I don't think you can take this on face value. It's incongruous with my real-world experience.

The 24 hour shifts are there because it results in a higher standard of care for patients with life threatening and time sensitive treatment schedules. If they worked in 8 hour shifts, there would be a handoff and loss of information at each shift change that resulted in worse outcomes. It’s a fairly well studied phenomenon. My SO is in med school right now and they just changed the regs from 16 hour shifts back to 24 hour shifts.

But there would still be a loss of information after 24 hours. Improving quality means upping the shift to 96 hours. We should encourage doctors to not sleep as sleeping means loss of information.

This totally makes sense.

So it's not reasonable for a person to work 96 hours. But apparently it is reasonable for 24 hours. The goal is to minimize information loss while maximizing performance. There's a tradeoff. Apparently 24 hours is a local max in this tradeoff.

Absolutely does. And that's precisely the reason why inpatients are treated by the same doctor for as long periods as is humanely possible, i.e. usually one-week stretches on call.

It's pretty widely discussed but I don't think it's as well studied as it should be. The shift from 24 to ~16 was made without much evidence, and analyses subsequently didn't support the change.

An awareness that we need to study these decisions before making them has finally taken hold. To that end, trials are now ongoing that have randomized residency programs to the (shorter+more handoffs) vs (longer) shifts.

Patient outcomes are obviously the most important, but measures of physician wellness would be a valuable secondary outcome.

And other countries got rid of long shifts for exactly the same headline reason. Standard of care suffers if your doctor has been running hot for 24 hours and does something stupid.

I think it's possible that both things are true. The problem comes when traditionalism is in charge (as it usually is, being senior). "I had to work 48h shifts and I never killed anyone who didn't have it coming, why shouldn't they?!"

It also ignores —in the way only a doctor can— that being away from your family has both a cost on them and you. This isn't something you can just throw money at. You need numbers.

But yes, good handover procedure is essential to. However long the shift.

So I take it there is data that the reduction from 24 hours to 16 hours that occurred a while ago resulted in a lower standard of care? Can you show it to me?

As an engineer, I used to think I didn't have what it takes to work long hours. After about 5-6pm, I'd start making mistakes, and my productivity would be roughly halved. I'd occasionally come in the next day and realize I had screwed up and would spend the morning redoing the work I did after 5pm the previous day.

Then I once stayed at work late not for my project, but to help other coworkers who I thought "had what it takes". It was insightful to see they made the same number of errors that I did, and had I not been there, they would have had to redo the work the following morning as well.

This is especially true for simple, tedious work, which a lot of medicine is about (at least at the nursing level). Things like administering medications.

I'd like to know what magic they use when training doctors in their residency to avoid such errors that other industries have not been able to master.

Yes, handoffs are risky for patients. As is being tired.

What can be done to mitigate the risk of handoffs? This seems like something we can use technology to solve.

> The 24 hour shifts are there because it results in a higher standard of care for patients with life threatening and time sensitive treatment schedules. If they worked in 8 hour shifts, there would be a handoff and loss of information at each shift change that resulted in worse outcomes.

This isn't an argument that longer shifts result in better outcomes, this is an argument that the hospital's current handoff processes are insufficient, and that better handoff process would improve outcomes.

the hospital's current handoff processes are insufficient

Humans have 24h circadian rhythms that likely affect patient care due to timing of cortisol release and other cyclical bodily events... It makes sense for an attending nurse/physician to be present for that full 24h cycle to gain a holistic understanding of patient recovery during various phases of the day.

If you're handing off a patient every 12 hrs, you're going to have fewer experiential data-points to judge if their condition is improving or worsening, no matter how detailed a hand-off can be. It'd be even worse with 8h shifts. Further, if a Dr has a patient come in with a unique condition, they're not going to leave just because their 12-hr timer dings.

> to gain a holistic understanding of patient recovery during various phases of the day.

Define "holistic understanding."

Is the doctor actually sitting bedside with the patient for the entire shift? Of course not. More realistically, the doctor is coming in, making some observations, and then moves on to the next patient.

So here's an idea - couldn't you shoot video of the observation, and shoot a time-lapse video of the otherwise-lacking-direct-observation periods, and show those to the physician in the next shift? All that the attending physician has to do is vocalize his observations (of course a camera by itself can't sufficiently observe), and the hand-off physician can watch the clips just like he could read the chart. Such clips may also be accompanied by speech-to-text to produce quick summaries.

There's simply no doctor in the world who isn't privately treating a single patient who can compete with the number of experiential data-points which a computer can provide.

And those "data-points" are worthless. You're basically suggesting cooking thru a camera and expecting better outcomes because the broth is constantly monitored by a cam.

> camera

I mean... this is a thing:

https://en.wikipedia.org/wiki/Robot-assisted_surgery

It's not like the presence of cameras automatically makes medical care low-quality.

> Robot-assisted_surgery

Is based on the premiss of a smaller incision and more precise tissue manipulations leading to better outcomes. Nothing to do with a camera ;)

> presence of cameras automatically makes medical care low-quality.

Of course not. My point is that it does adds ~ nothing to the quality of care, just like cooking thru a webcam should not be expected to result in tastier meals.

Doctor’s observations are a complex synthesis of information obtained through the five senses (and not only by seeing) and “gut feeling”. They can help narrow down the diagnosis, and predict forthcoming complications. This cannot be captured by a camera.

I’ll give you an example of the “holistic understating” kirse was probably alluding to.

A 80-yo guy is admitted at 9pm for COPD exacerbation, is treated with the usual drugs, gets better. Was very anxious and well awake on arrival. You come to check back on him at 2h AM, and he seems a bit slower, and uncharacteristically relaxed. You suspect he’s getting hypercapnic, order a blood gas, and discover that he is indeed. You proceed to treat him with a BiPAP, and save the day.

If you did not see the patient before, it is very easy to interpret his sleepiness and relaxed breathing as a totally normal state for a 80-yo guy. It is indeed very easy to think he’s got better. See, he’s finally sleeping, breathing calmly, everything’s fine.

Even a family member sitting by the guy side since his admission is likely to miss the subtle signs, precisely because his observation is continuous, and the change is slight and slow. Discrete episodes of reassessment by the same qualified person is key !

"If they worked in 8 hour shifts, there would be a handoff and loss of information at each shift change that resulted in worse outcomes. It’s a fairly well studied phenomenon."

Do you have a citation for that?

Doctors have a hard time, but you can't lower US healthcare costs without lowering the salaries of those involved (which is why it is so hard). The fact of the matter is that they are high for reasons both justifiable and other less so.

Insurance companies profit margin is actually not very large on average (~11% I believe -- even worse for those in states with cost-spiraling providers post Obamacare), and while they are nobody's favorite they take a disproportionate amount of heat for what is driving up costs in healthcare.

Healthcare salaries are the bulk of the costs of the healthcare industry, just like administrative & teacher salaries are the bulk in bloated education budgets (well, outside of things like waste on things like sports programs). That's just the breaks, and its important to acknowledge they are a lobbying interest group as strong as any other (actually, one of the strongest/highest spending)

So, shortage of doctor supply (like with housing) really really has an impact. It also does not help that hospitals frequently have veto rights over other health institutions opening up on their turf. Really. Another problem is regulations that encourage consolidation of providers (see BCBS & Partners here in MA) further diminishing pricing ability (and this is additionally really bad for insurance companies, who have less leverage to fight back against high charges from fewer hospital networks)

The fact of the matter is that the US over-spends on just about every sector of the economy because the US is richer. Richer countries also disproportionately spend on healthcare of frequently marginal benefit at best.

https://www.bloomberg.com/view/articles/2017-07-20/spending-...

Not sure what the military budget has to do with this. It's a lot, but that it is bloated doesn't mean more health spending is justified or that we do not over-spend on doctors -- they aren't comparable things.

Whatever sacrifice doctors make in school is what justifies the salaries, but you also have other forces at play (largely regulatory burden, or bad regulations generally) that are causing them to drop out of being a GP in the first place as they chase higher paying spots as specialists.

All of my close friends are doctors and the toll that school and residency does on the body and mind is honestly shocking

Absolutely true: http://jakeseliger.com/2012/10/20/why-you-should-become-a-nu...

I work in healthcare and know, and went to school with many doctors. I hear this "long hours" compliant all the time. The problem is, they all seem to assume it's someone else's problem to fix. If physicians and med students want to get rid of the 24 hour shifts during residency, well they have to make that happen internally. They drive that decision, not the patients.

The whole 24hr thing seemed ridiculous to me, until I learned about the concept of continuity of care and a loved one spent a few stays in inpatient care. Now I don't really know what the answer is anymore. It sucks to be regularly handed off when you've just established some rapport with your provider and reached treatment plans, and the evidence shows it impairs outcomes.

I speculate whether we could have duos who rotate with each other, rapidly trading naps and duty & working closely together, over say a 48, 72, or 96 hour period. Barring emergencies, each gets 12 hours rest a day, and from the patient perspective they function as a tag team. But, not a healthcare professional.

In most services, the treating physician is rotating on a weekly basis. That's pretty much the most convenient/tolerable/safe period of continuous work, as long as you do not receive more than 2-3 calls per night.

Call number is dependent on the acuity of patients' condition, and the ability of the house staff (i.e. residents on site) to manage minors problems without immediately consulting the attending by phone.

Good comment. One disagreement I have is the implicit dichotomy that it's either the doctors or the insurance companies who are soaking the patients/consumers, and not both.

Both the MDs and the insurance companies are rife with a number of rotten incentives and bad actors that contribute to expensive medical care without quality commensurate with costs.

In fact, the entire policy debate over risk-based vs fee-for-service payment models is essentially the payers and providers arguing over who gets to rip you off.

You are 100% right. You can't identify a single factor that's causing high cost because all players are rotten. Insurances, doctors, hospitals, pharmaceuticals are all bad players in a system that benefits them at the expense of patients.

Part of the need for the higher pay is to accommodate the highest student debt in the world, and the highest risk of malpractice debt in the world.