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Comment by seibelj | Hacker News Reader

Even worse is that some states have legally mandated monopolies that prevent competition from opening up. See this doctor who has to fight in court to allow his clinic to offer MRI's https://www.vox.com/policy-and-politics/2018/7/31/17629526/m...

New medical schools must be allowed by the American Medical Association, artificially capping the number of doctors minted. This is why it's so difficult to get into medical school - the supply of spaces is constrained, unlike law school, where there is a spot for everyone who applies.

Dentists in Maine vehemently opposed allowing dental hygienists with a special kind of license to fill cavities without needing a full DMD. https://www.washingtonpost.com/politics/the-unexpected-polit...

If we want to fix the medical and legal professions, and by fix I mean make it cheaper, we need to remove the warped incentives caused by the government that prevent natural competition from fixing the issues.

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New medical schools have been established. The AMA doesn't cap the number of doctors minted. The actual cap is imposed by the number of residency slots that the government funds.

Residency slots don't have to be funded by the government.

I mean, it's reasonable to expect hospitals left to their own devices to fund the most profitable number of slots, so government is left to do the sensible thing for society in general, but health care providers have lots and lots of the money.

I think a tiny revenue tax would be a good way to fund slots. And structural incentives to host programs.

A waste of resources. The cost of training a doctor in the US is in the 100k's. Doctors outside the US get trained dirt cheap.

If you want to lower physician cost, make a doctor visa. Within 2 years you will be oversupplied.

I agree. I don't know why Bill Gates, Bezos, Buffet and the rest of them don't fund residency spots... at least for 15 years. It would make a big difference in reducing costs. It's also easy to do.. just endow a medical school or hospital or something..

I see what you're saying there, but I'm not positive artificially capping the number of doctors minted is a terrible idea. Don't we want to make sure only the best and brightest end up being doctors? If there's a spot for everyone who applies to med school, wouldn't that leave us with far more incompetent doctors?

There should probably be more doctors, but it doesn't seem wise to lower the bar too far down.

This is the same broken logic as people who think they need to go to the "world's best X doctor" for care. That inevitably leads to sub-standard care because everyone is trying to go to the same person for a service and getting rushed in and rushed out. Most of us don't need the best doctor at X in the world to perform our services. It's like thinking you need James Gosling or John Carmack to write the code for your small business website.

By that logic, we should artificially cap everything. Why allow just anyone to be a programmer? Don't we only want the best programmers to write our software?

Any entrepreneur should be able to open up a licensed medical school. Anyone who graduates should be able to get certified as an MD. This is how markets should work - not capping doctors on the hope that we get "better" ones.

Also, I have seen some awful doctors, so I'm not sure the system is working.

Anyone who meets accreditation requirements can open a new medical school. The actual bottleneck in producing new physicians is downstream of medical schools in the residency system. Every year there are students who graduate with an MD degree but can't find a residency position.

I know so very little about how all this stuff works, that's really interesting, I've not heard that before.

I don't think we have to think of it as a binary opinion. The Association of American Medical Colleges (AAMC) realizes that the supply of doctors is an issue - but anyone can already start a medical school (California Northstate, for example).

And to address your point about "awful doctors", people are also starting to realize the shortcomings of the previous system - filtering too heavily on test scores/grades, for example, meant that many medical schools churned out graduates with great test scores but relatively poor interpersonal skills (which is a travesty since you're dealing with people all day) for a while. Nothing is changing overnight, of course, so the jury is still out in how things will be in the next few decades.

I would have much prefer having 30 minutes of time from an average doctor than 5 minutes of time from a great one.

Also we could quadruple the number of doctors we let in every year, and and we'd still only be letting in really smart hard working people.

And it's about choice, if you want to spend $400 to see the best of the best for 5 minutes go for it. But there are plenty of people who'd rather see a cheaper doctor for longer, even if there mcat scores weren't great or they got a B once in college.

Lastly a major chunk of what doctors do is pretty routine. Hey you have a soar throat, let's do a strep test, it's positive, here's an antibiotic. Or you say you have problems being happy, here take an ssri. Oh that one didn't work, let's try another one.

I suspect that is what is meant by "artificial", in "artificial cap". The idea is that we train fewer people than we could without a drop in quality (and further, make it difficult for already trained people from elsewhere to practice.

This is almost certainly true, and the incentives for physicians, medical schools, and banks are difficult to re-align.

"The idea is that we train fewer people than we could without a drop in quality"

That's a great point! That sums up my point much better than I did.

Shouldn't anyone who passes through the training be considered qualified? If training is expensive then you no doubt want to prevent people from starting if you don't think they're likely to finish, but the metric there should obviously be a bar on absolute student quality, not rank. It should also be measured -- confidence intervals, correlation between input metrics and output performance etc.

I bet the marginal student in terms of acceptance is more than likely great doctor material, and I bet it doesn't drop off sharply right past them.

> Don't we want to make sure only the best and brightest end up being doctors?

No, you want people free to choose. If you want to go to the best and brightest, pay the best and brightest, and allow the others to get cost-effective care.

How would we measure that? How can we even measure that now in any kind of reliable way? Even you've been sick, or had a family member that's been sick, you know it's not easy. Plus, very few people can afford to pick and choose. I have no good answers.

Sure you can. Primary care is shifting to PAs and NPs who bill the same, but make about half.

I believe that the core issue is that in public policy, people think healthcare like NASA rocket science and it's more like car-repairs.

A good rule of thumb is: if you are using legalities to define economics, you are on the wrong path.

No. You want people who are able to pass the STEP exams, complete an ACGME residency, and become Board Certified to end up becoming doctors. That is the only metric we should be using and, as it stands, there are significantly more people capable of overcoming those hurdles than the US currently allows the opportunity.

The reality is the "bar" ensures most people in medical and dental schools come from upper middle and upper class families.

It works to deter not those who are more than capable, but those that cannot incur huge costs to get into medical school. That includes volunteer time, extracurriculars, going on "mission trips" in undergrad to volunteer to help in medical clinics abroad, very expensive application costs (if you aren't in the 0.1% academically you NEED to apply to a lot of schools), paying to travel for medical school interviews, etc. Not to mention the opportunity costs of doing these things instead of working a paying job.

It doesn't end there. I have twice this year hosted friends from out-of-state that came to my city to interview for fellowships. Even after completing a residency most (all?) hospitals and medical groups will not pay for your travel to interview with them. One of these friends told me he is paying ~10k in travel costs to interview across the country for a fellowship position...thankfully he has a trust fund. I believe he faced similar costs when applying for residency.

It is insane. And that's just one aspect of medical education that deters otherwise great people.

If Cuba can figure out how to output a huge number of successful physicians (to the point that they placed them in other countries) there's no reason America can't other than apathy.

For the last few years, my medical care has been administered by a PA or a nurse...All the facilities around me are like that. 1 doctor for a few PA/nurses. I don't have major medical problems (that I know of...). But I'd rather have more medical professionals that studied for 8 years, than those who studied 2. If they aren't smart enough to be doctors, let the schooling weed them out.

I've had the same experience, but my complaint is that the services I'm going to them for don't require the services of a doctor at all. Most of the time, I am just going to get a prescription for something that I know I need, that for idiotic reasons I'm not allowed to just buy off the shelf.

Most of the time, I don't need Dr House. I need a warm body with a prescription pad. Occasionally a tailor, if I've sliced myself up.

That is a perfectly reasonable preference, but that the insurance system with unclear price differentiations makes difficult. You can make a copay larger for one and then people exert they preferences cost-effectively.

This actually would be my preference. I keep going to the same office because I have minor issues and the location is convenient for me. But one day I would prefer to see a doctor. Till that day, I should pay less for a "doctor's visit".

And actually, because I have a high deductible plan....I'm not paying a simple copay, but rather the full bill.

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