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belltaco

The decades long wait times for green cards for immigrant doctors is also hurting health care in rural America.

https://money.cnn.com/2018/06/08/news/economy/immigrant-doct...

https://www.wusa9.com/article/news/local/maryland/communitie...

https://time.com/5299488/international-medical-graduates/

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I believe the American Medical Association (AMA) lobbying congress to shut down medical schools and artificially limit residencies and thus the supply of doctors is a much bigger factor.

A lot of people who are capable and motivated to be doctors for good reasons are shut out because doctors don't want there to be more doctors who will serve to limit their wage growth.

Why go through the costly process of training a physician, when in most healthcare a midlevel practitioner would provide appropriate evaluation and treatment? Also it seems that not all stakeholders in medicine are into restricting physician training[1]. (I come into the discussion with a physician’s perspective.)

[1] https://www.modernhealthcare.com/article/20140730/NEWS/30730...

We should go through the process of training more physicians, because every day in the USA many people are harmed, up to death, due to there not being enough physicians.

We need more midlevels too, I agree, though midlevels are not allowed to do everything doctors can do and are required to have many things approved by a doctor as well. So to increase midlevels would naturally require an increase in physicians.

I come to this from the perspective of someone being harmed by the way it is right now and I don't like being harmed.

I don’t mean to underestimate what you’re going through and those in similar situations, but consider the significant harm being done by unnecessary procedures and medications which add no value to a patient’s life. A lot of it is being done by a glut of avaricious physicians in metropolitan areas, particularly those with large elderly populations. Witness end-of-life care with its outrageous in-hospital costs, which again adds little to the quality of someone’s life. This is one of the great scandals in U.S. healthcare.

Edit: For whatever reason, I was downvoted on this comment. I’m truly curious to know why. Is it too alarmist? Is it betrayal of my colleagues from someone in the trenches of our inefficient healthcare? Am I just restating the well known? Is it believable? Here is an article which should stimulate continuing discussion[1]. As far as I know, this hasn’t changed. I’m not sure how increasing the amount of medical school graduates and residency spots will deal with the issue described.

[1] https://www.propublica.org/article/unnecessary-medical-care-...

> I don’t mean to underestimate what you’re going through and those in similar situations, but consider the significant harm being done by unnecessary procedures and medications which add no value to a patient’s life. A lot of it is being done by a glut of avaricious physicians in metropolitan areas, particularly those with large elderly populations. Witness end-of-life care with its outrageous in-hospital costs, which again adds little to the quality of someone’s life. This is one of the great scandals in U.S. healthcare.

I wasn't one of the downvoters (and in fact didn't read this comment until after your edit), but I think part of the issue people might have had with it is that it does across as a bit dismissive of GP's complaints. Yes, you've also correctly identified a problem that's tangentially related to the one under discussion, but you haven't given any insight to why that solving that problem will have any effect in what people were already discussing. It's sort of like jumping into a discussion about people starving due to inadequate food supplies and saying "Yeah, but what about people dying from eating food that should have been recalled due to contamination?" Both issues are about food, but there's no apparent context for the sudden shift in topic.

You’re right. I appreciate your comment. I allowed my own frustration with the obvious problems around me to cloud my comments. Here, hoping to clarify my original argument: Adding healthcare services by producing more physicians, costly in training and by their later contribution through a perverse incentive system, does not appear to be the simple answer. In addition, is there a physician shortage [1] or not [2]? I recommended more midlevel providers, who are capable of handling a vast majority of medical problems. To suggest that only professionals with years of training and paid an exorbitant rate can do this, is not to understand what physicians do or midlevel providers’ capability. It is another way of buying into the self-serving mantra promulgated by medical boards and organizations: Only a doctor knows and, furthermore, needs to be board certified.

Depending on the state, multiple nurse practitioners and physician assistants can be supervised remotely by one physician. Add telemedicine and other online tools to this partnership and you’ve got a pretty robust team able to care for a much larger population than one physician could. A zillion other tweaks to the system, and all of a sudden efficiency starts to make an impact. But some artificial barriers must be broken in the process (e.g., coordinated information dissemination between health professionals).

[1] https://www.aamc.org/news-insights/press-releases/new-findin...

[2] https://www.ncbi.nlm.nih.gov/pubmed/26177529

Edit: For now and the near future, there are procedures that only physicians can perform (e.g., surgery mostly). This is not true in most general medical care and even in specialized care.

That is an issue, but I don't think preventing the training of physicians will help. If anything it shows our training is inadequate.

Because Americans all think they deserve attention from someone that fits their personal image of what a doctor should be—-in terms of race, gender, age and personality. Someone who is in the top .001% of intelligence and with twenty years of training. All to spend hours listening to them complain about their cold or achey knees. And they don’t want to have to wait. Also, they don’t think they should have to pay anything for it.

Instead of acknowledging the impossibility of their desires they jump from villain to villain and magical silver bullet to magical silver bullet. The politicians of course don’t tell them they are being childish, but instead indulge their fantasies.

Why do you think the ability to shop around for a physician something so crucial to preserve in any reform? What does that have to do with outcomes?

That's not all bad though. I don't want to wait to see a doctor and I don't want to pay for it either. What's surprising about that?

Hell, I don't want to pay for anything but I acknowledge that people need to eat so I'm quite happy to have that payment be from my tax dollars.

You need wage growth. It’s half million dollars in schooling and deferred wages.

Applications to medical schools suggest the contrary.

Do you have sources for this? I see this claim a lot on HN.

https://www.washingtonexaminer.com/thanks-to-doctors-there-a...

I also like this 45 minute lecture Milton Friedman gave to physicians telling them how they were making healthcare worse due to this type of lobbying by their representatives. https://www.youtube.com/watch?v=rWlk9HreE7U

Your source is an opinion article in an outlet deemed right-biased and of mixed factual reporting.

https://mediabiasfactcheck.com/washington-examiner/

"In the early 1900s, the AMA lobbied lawmakers to shut down many medical schools."

That's over 100 years ago. No information is provided as to which schools, or what the AMA's reasoning was behind their decision.

Likewise, lobbying to reduce residencies occurred over 20 years ago. The actual reductions were implemented by a Republican Congress and the Clinton administration.

"At the time, they argued there was an impending 'glut' of physicians. It is more likely they were, again, trying to protect their high wages."

Needless to say, that latter assertion is not in any way supported by documentation.

Friend married a Russian cardiac surgeon, one with 20 years of experience, brilliant woman. She was not allowed to practice in the US without years of redoing residency and entry level exams and loads of money. She ended up changing careers as it was so much bother. Patients ended up losing out on a caring and bright provider.

A DBA I worked with a couple jobs ago was a surgeon in China. He immigrated in the mid 1980s. After he was told he would have to redo his med school, he also decided it wasn't worth it and instead "learned computers".

That sucks. There's probably a situation in the future where doctors, or at least surgeons, can work remotely. Russian doctor marries US citizen, logs into VPN in Russia from USA living room, performs Surgery with Nintendo remote.

If there is already an over-supply of docs already in the country, I don't see how an influx of foreign doctors helps anyone.

That is a feature, not a bug.

Why would a well-paid, highly regulated profession allow people to come into their turf and undercut them?

Not saying this is a GOOD thing. Merely pointing out that the system is working as intended.

There is no "undercutting" in health care. Vast majority of services are already priced out by insurance companies, there just aren't enough people to do all of them.

>...there just aren't enough people to do all of them.

which factors into the economics of prices negotiated between providers and insurance companies.

If the final user is losing, it's a bug.

At least in the IT world, there are lots of contractors sold on their certifications who end up being complete frauds. I'd like there to be some sort of way to prove your merit especially when you have people's lives in your hands.

In my experience being at the receiving end of many arrogant and unprofessional "doctors", having that medical license is far from proof of anything. If anything, the licensing requirement functions as little else than yet another barrier to competition, which ultimately harms the patients.

Have you ever thought about the fact that the issuing of green card to immigrant doctors is really hurting other countries? Other countries need doctors as much as America, there's a huge brain drain when green card is issued for immigrant doctors. BTW, I'm not saying that I'm for it or against it. I also want to point that that giving a migrant doctor green card is not guarantee that they can practice in the US. Passing the board and getting certified is really difficult and there are tons of doctors that come to the US with hope of practicing and end up driving a cab, becoming a nurse or doing some sort of odd jobs.

That's not America's concern. We're looking for the best and the brightest.

There are plenty of highly qualified Americans who do not get accepted into medical school each year. We need to make the AMA stop preventing medical school class sizes from increasing

Some smart business in a foreign country should start providing tele-medicine to the US for reasonable prices.

We could send blood work overseas cheaper than the piracy prices of labcorp, for that matter.

They could explain it legally as "not medical advice" to skirt any FDA laws, but provide world class health care in reality.

It's a business model that could really work. The "skirt America's dumb self-inflicted crap" business model.

That would be illegal because they would need to be licensed as doctors in the state of the patient, nothing to do with the FDA. https://www.ruralhealthinfo.org/toolkits/telehealth/1/barrie...

More likely, it would need to be legal in the country of the provider, and they would need to be out of reach of the US justice system, would seems doable in principle.

Sure - but it's hard to stay out of reach of the US justice system while staying easily accessible to patients by live video and internet payment in a low-cost-of-living area.

Is the green card attached with the rule, that you need to work umin rural area? Otherwise those people would just do what everyone would do. Work in a big city / hospital etc..

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