Hospitals are suddenly short of young doctors because of visa ban

While there is gate-keeping in medicine (MCAT scoring preferring English-native applicants, limited residency spots, financial costs of medical school) I would argue the residency system as it is prefers American-educated applicants versus foreign-born grads.

You can see this when looking at prestigious residency programs where the rosters are primarily filled with AMGs. In fact, highly sought after specialties such as dermatology, orthopaedics or neurosurgery tend to accept only AMGs because the number of qualified applicants usually outstrips the available residency spots. Though International Medical Graduates (IMGs) are usually academically outstanding (in my experience as an MD working alongside them) they are more likely to fill residency spots (rural, less prestigious) that AMGs don't want. Not to say that there are not IMGs in highly-sought after residency programs, it's just that their qualifications usually outstrip comparable AMG or they have other connections.

In Canada at least, foreign-trained doctors need to complete a medical degree equivalency exam and to re-do their residency. Due to the complete lack of residency spots available to them a low number of foreign trained doctors ever end up practicing medicine again after moving to Canada. It's pretty nutty.

Curious how it works in the US but I suspect it's not wildly different.

If you have a medical degree from a foreign country you take the USMLE test followed by 3 years of residency in order to get a license to practice in the US.

See https://www.usmle-courses.eu/united-states-medical-licensure...

I place enormous value on my undergrad training in chemistry before going on to med school. Impossible to prove but I do think the deeper your foundation in life sciences the better your ability to adapt to new medicines, procedures, & other advances in medicine. Speaking as a urologist.

Edit: the pre med prereqs are a good start. But I value the skills & concepts from the senior level bio/chem classes that I wouldn’t have gotten with a 6 yr track. Something also to be said for the emotional maturity that comes with 4 yrs prior to med school.

I don't understand your example. A strong knowledge of concrete is necessary to do a good job as a general contractor. I'm pretty sure the licensing exam has some questions about concrete.

Does anyone use the term "allopathic" besides naturopaths or osteopaths? If you just say "medical school" people will assume MD program.

Do AP classes require a strong lab component?

My honors chem class was in 10th grade. It barely touched on electronegativity, nor acid/base chemistry in a through way.

To expect a student to pull that experience forward two years later and integrate it with calculus to pull off organic chemistry seems non-ideal for many students.

And you really need the through physics/calculus component unless you want to wave biochem students past thermodynamics, which seems crazy to this former biochem student.

Cut the one quarter quantum mechanics class, perhaps.

I'm sorry...but "doctors in training" who "supplant _fully qualified_ MD" sounds like a step down to me?'

Hell, I generally prefer an MD to a PA...

What is the system then? Do hospitals being made out of doctors not want to do it? Is the bottle neck actually at a different stage?

So a hospital has to pay a 1M per slot - sounds surprisingly similar to NYC medallions right before Uber. Artificial scarcity.

Wait didn't you say the slots are worth a million dollars _because_ of the subsidy? But that it shouldn't be subsidized because it's profitable?

100% this. If the hospitals are desperate to increase the supply of doctors in the states (US), they can easily fund the residency spots themselves. They pay ~60-70K USD/year for each resident for three years anyway. Those residents do most of the grunt work that more senior doctors (like attendings and hospitalists) in the hospital don't want to do. In comparison, generalist attendings and hospitalists (full-blown doctors) at hospitals earn salaries in the range of 210-250K USD/year easily.

To become a full-blown doctor in the US, one has to jump too many hoops and hurdles including -- 1. maintaining 3.8+ GPA (out of 4.0 max) in undergrad while paying overpriced college tuition (which encourages students to take relatively easy course load other than the required ones like organic chemistry, biochem, a couple of basic math and physics classes, etc.); 2. pay yet another loads of money to attend med school, which is where you actually begin to learn something relatively useful; 3. volunteer unpaid at various research and/or healthcare institutions to beef up one's resume (which is only affordable/possible if you are well-connected and/or have money to volunteer); 4. pay exorbitant and unnecessary exams (each 8-9 hours long spanning sometimes 2 days for Step 3 USMLE: https://www.princetonreview.com/med-school-advice/usmle) that promotes rote learning (and you forget what you memorized ~2 months after the exam anyway); 5. pay a lot of money to apply for residency programs while footing the bill (hotels and air travels) yourself to go around the country for residency interviews; 6. spend 3 years (minimum) in residency while spending ~60+ hours per week in your first year doing the grunt work that no senior doctors want to do (e.g., night shifts/floats) 7. maybe spend another 2+ years in fellowships if you want to be a specialist

In contrast, one just need to do these in my home country to become a doctor (I know India has a very similar system to train their doctors): 1. get a high score in national standardized/matriculate exam (in my country, ~5% of top students have option to go to medical school) to get into public medical schools (there are four of them and three of them are definitely pretty good) 2. spend 5 years studying medicine (to be honest, they can cut out the first year if they want to, but it's still better than spending 4 years as undergrad in the US) 3. spend another 2 years as a rotational intern at major government hospitals (OBGYN, Surgery, Child, etc.) doing what the residents in the US system do [from what I've been told, those 2 years are certainly more demanding than the residency years in the US system] 4. take masters degree to specialize (takes ~3-4 years)

The quality of the doctors produced by these two aforementioned systems is not that different. How do I know this? My wife (foreign medical graduate) is a current medical resident at a US hospital and we have a lot of friends in the US residency programs, some of whom are foreign medical graduates. In order for them to get into these residencies as foreign graduates, they have to score on average better than their US counterparts (on top of having to work pretty hard to gain experience in the US because 99% of hospitals/medical institutions in the US don't allow volunteers/externs/interns unless one is trained from the US pipeline and is a citizen).

So the question is why is the path to becoming a doctor in the US needs to be paved with so much expenses and hurdles? Who established this path?

I'll close my long rant with what my wife recently told me after spending a year as a medical resident in the US, (I'm paraphrasing her a bit here) "I don't want to be a patient in the US hospital when I'm old. We need to go to somewhere like Singapore for treatment (she worked at a hospital in Singapore for a bit before coming to the US)."

"Let private corporations do it." - America

Such a requirement doesn't exist. 77% of residency slots are funded by the federal government. But there are slots that aren't funded by the federal government. And this makes sense because residents make residency programs money.

The doctor shortage is their intentional strategy. The fewer new doctors, the higher their pay.

They are a labor organization that's intentionally limiting supply.

I agree with this comment. US medicine has setup a long and tortuous road, which might result in extremely well qualified people (or might not), but other developed countries seem to do just fine without the hazing ritual the US required doctors to go through.

Why would you ever choose to be a doctor over an employee at a FAANG? It would be worse for your mental and physical health, and now the pay isn’t even much higher for doctors.

The theoretical person you’re describing sounds like a nurse practitioner.

The inflated requirements are a result of restricting the supply of seats, not a cause.

I think what'll happen eventually is that the doctor situation will be sidestepped and the role doing stuff like looking at patients coming in to check on a generic cough or headache will go to physician assistants and nurse practitioners. To some extent I'm already seeing it happen.

They're already kind of doing that with Nurse Practitioners. I used to have asthma, and for years I always saw a doctor. Towards the end, I rarely saw a doctor but saw a nurse practitioner instead. I strongly doubt the difference in pay was reflected in my bill.

Depends on the specialty, I would think. Pediatricians, general practice, etc. can probably have lower standards than other specialties since they are where people typically enter the medical system for treatment. If they haven't seen a malady before, they refer the patient.

However, for cardiologists, anesthesiologists, neurosurgeons, etc. you probably want a higher education standard.

Artificially increasing scarcity in a market is always a good move

The AMA regulates medical school admissions.

We could ask all other countries to stop training physicians because we can’t. Not sure that would solve the supply constraint, though.

They're treated by the hospitals that have them like taxicab shields.

Way more debt + years of residency to let that debt pile on makes earning more in the end irrelevant. And you can only really be financially free in a few specialties that pay you enough. If you become a primary care doctor, you're only making 160k a year. You can make more in areas where doctors are in short supply. That's not enough to pay off 300k in debt compounding at 7-8% a year for years before you can start paying into it, especially when you also have to pay 7500+ a year in malpractice insurance costs. You've also spent so long getting tot hat point that you're probably around 31 years old, meaning you might be starting a young family around then and cant fit everyone in a cheap studio apartment anymore.

Doctors (especially disgruntled ones) have it in their minds that they'd all be at Google or a hedge fund or white shoe consultancy making bank if they hadn't become a doctor. They consider themselves underpaid because they compare themselves to the best paid jobs out there. Of course most of them probably wouldn't make it to those levels but that inconvenient truth is ignored.

60K a year is more like a salary for a resident. My friend made approx 60k a year for 4years of residency and one year of fellow ship and then his first job paid him 250k a year. He even had an offer for approx 400K a year from an unethical private clinic which was abusing insurance so he didn't take that job. So yes, doctors in US make a ton of money compared to here in Canada.

If you're going to include long term assets then you need to include the rest of the career too. That's the way residents actually look at the problem, after all. "Doctors" do well. Residents struggle a bit in comparison, but not really that much relative to their other post-graduate-degree compatriots.

$200/300. Everyone uses income based repayment plans. It's literally impossible to make standard payment plan monthly payments on a residents salary (assuming a average debt).

Those payments don't even reach the principle though, so it's more just kicking the can down the road.

Maybe they should pay their doctors better so they don't leave.

Millions of people who emigrate every year to new countries without asking think they do.

0€. Med school is "free" as no debt for students in France. It's tough but it's "free". But some politicians are trying very hard to adopt the American model.

Say you owe 300K in med school loan. On average, a doctor in the US makes ~230-250K (even if the doctor does not have a speciality). If one lives in Los Angeles, CA with 250K/year income (in CA metropolitan areas, generalist doctors usually make more than 250K/year; it's more like 280K/year minimum), the take home pay would be ~160K. How long do you think it would take for someone to pay back the 300K loan? If one is financially responsible, it would take at most 5 years to pay it back.

So by the time one becomes a full-blown doctor at age 32 (usually in the US, it only takes ~12 years to become a generalist doctor, who specializes in Internal Medicine, from the time s/he graduates from high school), s/he is making 250K. I wish I could make something like that as a programmer, but we know that that kind of salary is reserved for people who work for FAANG and/or are at the top of their game in the software field. For doctors, that is just the starting salary.

This is all to say that I disagree that the medical debt is much of a concern for US doctors once they become one. It is the unnecessarily convoluted path, which they have to take to become a doctor, that is more of the problem.

That's a well reasoned argument, I am especially thrilled to hear one that didn't appeal to the extremes, although I don't agree that there is a direct causal relationship between supposedly low salaries and h1b.

Here's a quick experiment, click clearancejobs.com [1], as of this writing it lists 50K+ well paying jobs (high 6-figs) fully reserved for US Citizens, especially those whose antecedents can be traced. And this usually means people with surnames like Smith, Green, Johnson et al. And, this is just one website, over say a job cycle time of a few weeks. Now one can extrapolate that there are hundreds of thousands of such jobs.

Now H1b is 65K Visas a year, Let's say that 80% of H1b are fraudulent - which it is NOT, but just for the sake of argument, let's say 80% are outright fakes - this is more than offset by very high paying US citizen only jobs in on a single website, over just a few weeks!

Now salaries might not be going up as as much as some wish for, but in an economy there are many more variables than just supply & demand, that determine wages. I would also remind you tech worker salaries are already among the highest, if not the highest, salaries in any professional class. Only very specialized doctors like Neurosurgeons, plastic surgeons etc make more.

To somehow say that H1b is the root of all evil can only come from a very spoilt entitled class - dare-I-say White American Males - that has all the bountiful benefit of an economy with FULL employment, Actually FULL++ employment. And yet, they are just so fragile, entitled and selfish....

H1b is, at most, a _minor_ inconvenience to a set of very spoilt brats, used to having it their way, or throwing a tantrum otherwise. 65K jobs is not even a droplet in the ocean that's the US economy, and yet the fact that this issue gets some much coverage is a testament to the power of this very privileged group.

[1] www.clearancejobs.com

For someone fresh out of a PhD program, that was a decent base salary back in the day.

The problem is that "raise wages" alone isn't a panacea. Higher prices are a signal to stimulate higher supply. If the supply is artificially constrained that signal is useless. So I agree with the rest of your post - raise wages, but also increase supply without restrictions on employees or the types of jobs they can take.

All that does is ensure no one gets fairly compensated for 12+ hours work, and shifts the complexity down the chain to accountants as people managers try to find other ways to compensate people for their extra effort. People don't stop being sick 12 hours in.

It also unfairly hamstrings smaller practices with fewer covered professionals. Work gets offloaded from the covered individual to uncovered people in order to maximize the amount of work the covered individual can get done in that time span, or people start getting really particular about what is practicing and what isn't.

Hate to sound like a broken record with other folks in the thread, but nothing is fundamentally changing the game with that regulation, just who pays the complexity tax at any one time does.

So ball bustingly frustrating how bloody interconnected everything is while remaining so broad it's nigh-impossible to model within the confines of your own head. I say this as someone whose occupation centers around being able to very quickly jump between distinct verticals and subsystems while maintaining the capability to project the consequences of a change in one vertical through subsequently connected verticals. Everything seems to come back to a form of dynamic equilibrium where as long as you don't stare too hard the thing behaves well, but the closer you look the chaotic it becomes.

I think the trick is actually getting such regulation passed into law. The medical industry has considerable political influence; attempts to reform it will doubtlessly run into road blocks unless you manage to convince doctors that reform is necessary. That's the tough nut.

The application process is highly convoluted and not very well designed. Some people just fall through the cracks.

But yes, also a small number of people just don't have the intellectual ability to handle it, although schools do a lot of screening to minimize this. Graduation rates at schools are typically 100%, with maybe 1 person every other year failing out.

If one does not get matched and one is a citizen (or a green card holder), s/he really must have a lower than average USMLE score and/or GPA in med school. Or s/he made a mistake in shooting for too high of a program (e.g., trying to get into UPenn/JHU program when one's score isn't that good).

Foreign medical graduates who scores above 65-70th percentile have no problem getting into residency programs (I've made a comment above with more details as to how I know all this). For a green card holder, you just need to get ~60th percentile of the USMLE score (which translates to about 240+ in step 2 CK and step 3 USMLE scores).

All I wanted to say is that the bar isn't too high for a US citizen to get into a residency. That doesn't mean though that the path to get into residency is easy. It is extremely convoluted and requires a lot of persistence and planning. That's where (along the way) people fall through the cracks.