Hacker News Reader

Comment by lekanwang | Hacker News Reader

The AMA chooses who can be a doctor, who can train doctors, who can practice any kind of medicine, has extremely strong pricing power over the entire healthcare system via the RUC (https://en.wikipedia.org/wiki/Specialty_Society_Relative_Val...), advocates on behalf of doctors whether or not you agree, and much more, all under a guise of "non-profit advocacy for public health." They are a racket -- we would do well to have a rogue upstart competing licensing body.

View on HN

Most of what is stated is simply not true. I am a physician, not a member of the AMA. They have absolutely no role in the selection of medical students, training of physicians, or their licensing. I have no particular love for the AMA. But lets keep the criticisms accurate.

The AMA lobbied in the 90s to limit federally funded residency slots. This served to restrict supply of doctors because medical schools base acceptance on available residency slots. The AMA has pushed for more funding of residency slots in more recent times, but their lobbying behavior in the 90s clearly shows they have an interest in controlling the supply of doctors.

The AMA was founded to get control of the "snake oil salesman" problem in the 1800s, and their stated method was lobbying to get licensing laws passed in every state. Controlling who gets to be a doctor was unambiguously the central function of the organization. Along the way, they were no doubt approached with a lot of other suggestions about how they could help and once they outlived their original purpose, have carried on as a zombie improving their ability to profit from all the little suggestions they got along the way.

To (mis-)quote Eric Hoffer, “Every great cause starts off as a movement, turns into a business, and ends up as a racket.”

Is that misquoting? I think that's almost verbatim the quote.

I believe the AMA is responsible for accreditation of medical schools. Without accreditation, they can't make doctors, thus the AMA controls the supply of doctors.

^ Yeah that's directionally accurate. The AMA is one of the two funders of LCME, the accrediting agency of medical schools for MDs (outside of the med school trade association itself). While they do not run medical schools, they have enormous power over training standards, who should be a physician, how medicine should be practiced, and who shouldn't practice. As an example, they lobby pretty regularly against the expansion of the role of RNs/NPs (https://www.ama-assn.org/press-center/ama-statements/ama-sta...). Much of this derives originally from the Flexner Report which created the current system of US medical education, which is still based on old sensibilities that physicians should be professional gentlemen and "proper" (and perhaps fueled by cocaine -- no seriously, google "halstead cocaine").

I am not a physician, but I have been in the guts of healthcare for quite a while, and the AMA continues to pop up as the man behind the curtain surprisingly often.

They're all connected in some capacity, but AMA does not accredit medical schools.

* LCME accredits M.D. Schools

* D.O. Schools have their own accreditation (not sure what it is)

* AAMC runs the racket of "MATCH" to appoint graduating medical students to programs (and strip most of their rights as employees).

* ACGME accredits Residency Programs.

The ABA pretty much does the same for their profession and I would not double many of such organizations is the same. Why dock just one, we need to get them all.

The ABA does not do anywhere near as good a job of protecting their market. There are far more law school slots each year, and that's reflected in salaries for lawyers, a huge portion of which are well under $100k/year.

> The AMA chooses who can be a doctor, who can train doctors, who can practice any kind of medicine

The majority of doctors are not AMA members. The oft-cited claim that they choose who can be a doctor or how many people get to be doctors is also a myth.

There are a lot of criticisms of the AMA, but these two are not really factual in basis.

You're correct that they do not choose who can be a doctor.

You're incorrect in that they are the primary force and loudest voice restricting the number of residency slots in the US. You cannot practice medicine without matching into a residency program, whether you have an MD/DO or not.

> You're incorrect in that they are the primary force and loudest voice restricting the number of residency slots in the US.

They are not, and haven't been for at least something like 20 years, which is when they publicly came out in favor of increasing the number of residency slots.

They are a racket -- we would do well to have a rogue upstart competing licensing body.

And programmers think that they are too intelligent and have too much variation in productivity to form any sort of professional organisation, or “union”, you could call it.

Doctors don’t worry about ageism or offshoring or being stabbed in the back by their peers or managers.

Unions work, there's no question in my mind about that. Just look at macroeconomic stats from the 40s to 70s. All that inflation took pretty much all the wealth from capital owners and handed it over to workers.

However, most software people are clearly in the capital owners category (despite still having salaries), so maybe it is justified to keep the status quo.

You can be both a wage earner and a capital owner. 401K or just a standard discount brokerage account are easy paths to that. I don't know why this is always presented as two sides with no overlap.

The point is you can say goodbye to the S&P500 performance if unions become as popular as in the post-FDR era. You'll experience low to negative real performance for decades.

Find old Warren Buffett shareholder letters or opinion pieces from those times if you want a capitalist's point of view, the guy has been around forever and has seen this particular story play out. Also, he's still for greater wealth redistribution, but that's just his personal political opinion.

That might be true in the FAANG/bay area world, but there was a time when nearly all of my social circle was "software people" and none of them were in any way in the capital owners category.

I’d actually argue that they don’t work, and that comes from someone who is pro-labor but has worked in union shops. Unions are intended to give a voice to the voiceless but in my experience they end up promoting a toxic culture that is counterproductive to everything. Management is unhappy not because of wages but because production drops and every incentive is now to do the bare minimum. Employees are unhappy because they’re not rewarded for hard work and instead rewarded for tenure. I’ve seen so many shit employees fired for blatantly disregarding safety practices but were then brought back by the union with back pay. Support staff is unhappy because they are caught in the middle of a culture war when all they want to do is be productive. And the culture goes to shit because both sides are constantly at war with each other. The only people “happy” with the union were the old timers at the top and they hated the company and hated working there but they were trapped there because no other job will have the same perks. I worked closely with the people on the shop floor and they hated both sides, and one stands out in my mind because he preferred the underpaid and overworked Foxconn factory to his current gig in the unionized factory.

If you want to argue about economic trends from the 40s to 70s I can go down that road too. Those unions aren’t around because they clearly weren’t competitive. A great example is the truckers unions that controlled pricing thanks to heavy lobbying and regulation. Those truckers were very well paid and made a very comfortable living but the high costs meant transportation of goods was incredibly expensive. Deregulation in the 70s opened that industry to competition, rates plummeted and now truck driving is more competitive than ever which has enabled other businesses that depend on transportation to be more productive than ever.

Oh, I didn't mean to imply they work in the sense that they result in better allocation of resources. That I do not know. It's probably a balance problem, for example modern Germany has strong unions and does not experience much shit show because of that. I just meant they're effective at redirecting the capital from capital owners to workers.

Also, yes, the 70s took it over the edge and then we've had 80s, 90s, 00s, 10s all very capital friendly. What will the 20s show? Again, no idea.

This is important to remember when "planning your stock market returns" - do include the 40s-70s period in your analysis! Things are sometimes very very different.

A developer union/guild system probably would build off of professional engineer certifications which exist for other fields of engineering (predominantly civil because of interactions with regulators). So if you don't have a 4-year degree from an appropriate institution and mentorship (or don't pass the appropriate exams), you're going to have some lower-status tech status. But, yes, would absolutely check the boxes for someone like myself--who admittedly isn't in a position to care any longer.

Offshoring maybe, but I think pretty much anyone in a corporatized career worries about those others. I know for certain that doctors have no shortage of office politics.

I know for certain that doctors have no shortage of office politics.

No 40- or 50-something doctor worries he or she is going to be sidelined by a 20-something with a cool new style of surgery that’s getting loads of retweets and stars on Medhub. He or she is senior and respected because experience is valued. A lot of people are going to feel the cold wind of ageism and wish they hadn’t been so eager to stab their older coworkers in the back for the sake of which JavaScript framework was hot this week.

> He or she is senior and respected because experience is valued.

Medicine is not the field we should be modeling our value of experience on. If you've been there 1 year longer, your opinion is more valued. Not because you're more knowledgeable, but because you happened to have graduated residency one year sooner. Medicine is about as far away from meritocracy as you can get while still somewhat feigning support for it.

Should we be trusting the experienced folks that say mainframes are fine and editing the DOM directly with jQuery is good enough? I mean zipping up binaries and dropping them on a share is just as good as GitHub, right?

Ageism is an excuse for being uncompromising and unwilling to accept that someone younger than you might have a good idea or know something you don't.

Do you think that older doctors insist on using obsolete surgical techniques or less effective medications? Or older lawyers reference laws that have already been repealed?

Ageism is an excuse for being uncompromising and unwilling to accept that someone younger than you might have a good idea or know something you don't.

They might do, sure. But you’ll hit ageism eventually and see younger people reinventing a wheel that you too reinvented.

Obsolete? Probably not. Indicated in outdated literature but contraindicated in current literature? Absolutely. I am old enough to have experienced it, and haven't. I'm also not against doing things differently than I did in the past. I've worked with 30 year olds who were completely unwilling to compromise, and folks in their 60s who were. I don't know anyone who would rather work with the former over the later because of age.

Reply on news.ycombinator.com