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Comment by dantheman | Hacker News Reader

Remember the AMA successfully lobbied to reduce the number of residencies and thus the number of doctors in the 90s.

We need to open up the medical profession to competition and allow the # of doctors to meet the demand.

This! It's crazy how infrequently the stranglehold the AMA has on limiting the number of doctors is mentioned when we talk about the cost of medical care in the US. It's like we allow a single institution to create an artificial shortage of something and then act surprised when the cost of that thing goes through the roof.

Well, here's a couple of points. Ultimately, the decision of how many residency slots to fund comes down to Congress. Here's an older article that discuss how the cost of residency slots is covered, but it's essentially covered by Medicare:

https://economix.blogs.nytimes.com/2013/12/17/how-medicare-s...

Now, hospitals could just fund additional slots directly, but they don't. That's a problem as well. Over the years, there have been several bills introduced to increase this number. Here's an article about efforts in 2013 and 2015:

https://www.the-hospitalist.org/hospitalist/article/122261/h...

Here's another one for this year:

https://www.aha.org/news/headline/2019-03-14-bill-add-15000-...

Generally speaking, they don't pass for a variety of reasons of which the AMA is only one.

I think it helps to understand that there's a large, complicated system that depends on this artificial supply limit and dismantling only a single section would not fix the rest. Universities make a huge amount of money with the tuition they charge medical students, which is much higher than for other degrees. They can charge this knowing that these students can absorb the debt using their future earnings, which are dependent on this limited supply. Mortgage companies have special home loans for physicians because they know this artificial supply and nature of physician contracts means that their money is nearly guaranteed. I could go on, but there many, many industries that depend on this system.

Again, I don't agree with this, but I think it helps to understand that it's not just the AMA who has a vested interest in keeping the status quo. Every industry who benefits from this system has interest in keeping it the same and actively lobby for it. Further, fixing this shortage problem necessarily means finding fixes for all of the other industries that depend on this money.

On top of this, even if we eliminate the soft cap on residency slots, it's not necessarily going to fix the problem with supply. The primary issue isn't lack of physicians, it's lack of family medicine physicians who want to work outside of large markets. While it depends on specialty, big markets like D.C., Seattle, and Denver can be very, very difficult for a physician to find a job. In fact, I know many physicians who live in these cities and then work remotely a week or two a month in a small town in a different state doing locums. They're paid a premium for such work and they enjoy it, but they'd never want to live in these places. Unless you want to force physicians to work in these markets, that problem doesn't change.

To be fair to the AMA, they submitted a support letter for the 2019 bill - https://www.ama-assn.org/education/gme-funding/how-gme-fundi... . Do you have evidence of them arguing against the 2013, 2015, or 2017 versions?

I'm sorry. I am incorrect and it was more a comment based on the lobbying efforts during the 1990s when the AMA lobbied for the cap. Thanks for the clarification.

I think this is the key, so much of of the problems physicians face were created by physician and their own lobbying. American Physicians are paid more then other countries by a lot [1] in large part because of high educational requirements that were supported by physicians. Resident burn out is awful, but the people pushing them to work insane hours aren't the hospital administrators, but older physicians who have the attitude that they went through it too. It's really hard for a physician from another country to immigrate to the US and practice, restrictions supported by, you guessed it, physicians!

If you really want to lower physician burn out and decrease health costs we need to increase the supply of physicians in this country, and you'll have to fight the existing physicians to do it.

[1] https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2010....

American software developers also get paid multiples of their non-us counterparts. Same with many other professions.

Except there is no organization limiting the number of software developers. In fact, I can't think of another field out there with so many free resources for one to educate and prove themselves a capable programmer.

Nurses make more in the us, then most doctors outside the us. There is a shortage of people in general in the usa, and we have the INS artificially limiting immigration for everyone.

As mentioned it's way easier for software developers to immigrate to the US, and there is no organization limiting the number of software engineers trained into the profession every year. There is an additional confounder in that the biggest and highest paying software companies are all located in the US and exporting products throughout the world, which is not how it works with physicians.

Also don’t forget about resistance to becoming employees, but then complaining about the protections/advantages afforded to employees.

While the AMA is guilty of limiting the number of doctors before, they have reversed their position are are now actively lobbying for more funding of residency slots.

https://www.ama-assn.org/press-center/press-releases/ama-fun...

Yep, everyone seems to ignore that the AMA operates like a cartel. Hippocratic Oath my ass.

An analysis of the Hippocratic Oath and its application in the modern day will turn up the same results as any other ethical standard. Selectively applied on criteria that would rarely be tolerated if openly stated, requiring unstated assumptions to avoid internal contradiction, and powerless to change human behavior as those who commit to upholding it will do so only for interpretations in their own image. While I do admit my view of ethics as a whole is quite cynical, I think one only needs to consider how many ethically bound actors have caused significant harm with unquestionably wrong actions to see that such cynicism has solid foundations.

In short, we should treat doctors no different than any other human in regards to how they operate and how to protect society from bad actors. One practical example is that doctors should follow the same rules and others with regards to child safety such as ensure a child is always accompanied by two unrelated adults and that patients and their parents should be willing to seek second opinions on anything a doctor does that they do not feel comfortable with.

As for the issue at hand, we should not assume doctors will behave more benevolently than any other industry with regards to self regulation and rent seeking(-esque) behavior.

Also to clarify, there are many selfish doctors who do their best to help others. I'm not questioning our doubting that. I'm speaking of groups in general and not of every single member.

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