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Comment by barmstrong | Hacker News Reader

This is true. Part of the reason doctors have high salaries (and healthcare costs are high) is that the AMA issues licences and creates scarcity. In this sense, they perform a similar function to a union.

It does seem like an outdated way to see if a doctor is good or not. I'd personally find a recommendation from a friend or a bunch of positive reviews on yelp a lot more convincing than the mere fact they have a license to practice. It's pretty likely hospital administrators and others would be able to determine which doctors were good without a licensing practice (just like we find good programmers without licensing), and they have strong incentives to do so.

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I'd personally find a recommendation from a friend

You would, but so would a bunch of stupid people with stupid friends. I think licensing doctors falls into the same category as mandatory school attendance, i.e., stopping people from hurting ourselves so they don't drag us down with them. To think we worry about doctors following decades-old traditions instead of evidence-based medicine, or being influenced by drug companies. Those are good worries to have! It could be a lot worse. Everyone knows you're supposed to see a doctor when you need medical care, got to take your kids to the doctor when they're sick, etc. That magic word "doctor" results in people actually getting competent medical care instead of going to a faith healer or an herbalist, which is what they'd do if anyone could call themselves a doctor and people had to discriminate for themselves.

Let people screw themselves all they want if it doesn't screw me, but we should take some measures to make sure people get more competent medical care than they would be able to choose for themselves, just like we force them to educate their kids instead of putting them to work full-time when they're eight.

Mandatory schooling has nothing to do with ensuring education and everything to do with ensuring dogma and a uniform and compliant citizenry. You need only look at the flag salute and the various rituals that have nothing to do with education to see it. Education is not mandatory, only schooling.

If mandatory schooling was about education then why can't parents take their education dollar to any certified provider?

If mandatory schooling was about education then why can't parents take their education dollar to any certified provider?

They can, in the U.S. They can send their kids to a private school or even school them at home, provided they meet certain requirements.

If you live in a free state in the US, you can take your children wheresoever you so please.

Wait, are there states of the US where private schools don't exist? I didn't know this.

Uhhh-huh. So if that's the case why do they waste so much time teaching you science and mathematics and ancient history and foreign languages and so forth when they could just be having four-hour flag-salutin' sessions?

Not everything needs to be a vast conspiracy, y'know. Some things are slightly screwy despite the best of intentions.

There are a couple encouraging signs in medicine. First, a lot of doctors advertise that they're board-certified. That's a voluntary, private certification that attests to the doctor's competence and has more rigorous requirements than state licenses do. Without licensure, there's every reason to think that private certifications would take on even more importance.

Second, the market is steadily routing around physician's monopoly on the practice of medicine. There's sverything from questionable stuff like acupuncture and chiropractic to nurses and PAs doing things that only doctors used to be allowed to do (e.g. prescriptions, minor procedures), and those trends seem to be accelerating.

Are nurses and PAs licensed?

Yes, and they're lobbying state governments to be allowed to do more.

> I'd personally find a recommendation from a friend

Plenty of people already use that method. And a lot of them go to see homeopaths and chiropractors based on that. Can you image what would happen to those people if they had to use recommendations from friends when they had actual medical problems that require actual doctors?

Just last month one of my friends with a debilitating back condition that forced her to spend many days in bed was told by medical doctors that she needed surgery to get rid of the pain. On the advice of friends, she went to a chiropractor and got immediate relief. The chiropractor solved her problem without surgery. Medical doctors have their place, but so do other healers.

But, there is going to be pressure on those that make the judgments. What happens when someone figures out how to game the doctor rating system? I'm just very risk averse when it comes to surgery (and I want my doctors to be vetted by experts in their field, as well as my social circle).

And you're absolutely right to be risk averse. That's why if you needed major surgery, you'd go to a reputable hospital and not to some clinic above a grocery store.

The hospital in this case is a middle man, and their role is vouching for the doctors they hire. When you buy a propane tank at Home Depot, the reason it doesn't blow up is that Home Depot's reputation depends on selling non-explodey propane tanks. When you buy meat at Whole Foods, why are you sure it's not rotten? Because the government checked that specific steak, or because you know Whole Foods wouldn't sell you rotten meat? Similarly, the reason people go to reputable hospitals is precisely because they know they can trust those places to hire competent staff.

While this isn't your central point, I'm pretty sure the reason Home Depot's propane tanks don't explode is not that Home Depot is concerned for their reputation and therefore takes all necessary measures required to avoid a rather infrequent problem, but that propane tanks and their handling are, in fact, regulated by government, and that those regulations codify best practices for infrequent events.

A purely free-market, reputation-based system of behavior works well for frequent events, but fails miserably for infrequent events, and that's why regulations are necessary.

In other words, and more snarkily, the assumption that Home Depot hires competent staff is probably not sufficient to protect you from explosion.

The government does regulate the safety of things like propane tanks, but major retailers, Home Depot included, usually have merchandise quality standards well above what the government mandates. That's suggestive (though not conclusive, I'll admit) that it's Home Depot, and not government safety standards, that keep you safe when you shop at Home Depot.

Home Depot doesn't have to train their staff to inspect propane tanks, they only have to make sure they buy from a supplier who provides good propane tanks. But of course, since propane explosions can easily hurt bystanders, and "Fred's Discount Mailorder Propane" doesn't necessarily have as many incentives to ensure safety, so in this case I would say regulation is a good thing.

But there are cases where dangerous things aren't regulated by the government and it still works out pretty well, like roller coaster rides. In that case insurance companies actually play a big role in disseminating industry best practices.

In cases where companies produce danger for people other than their customers we shouldn't expect them to necessarily be responsible without government oversight - like with pollution. And in something like a hospital where people tend to die even when the hospital does everything right I wouldn't expect people to be able to differentiate between good and bad hospitals well enough - and the evidence I've seen is that people don't currently choose hospitals based on how good they are even with the government publishing statistics on the matter. I can easily imagine that in a totally unlicenced market the problem would be worse.

To play devil's advocate, the people that have to fear getting food posioning the most are those least able to afford Whole Foods.

Are you really gonna rely on a bunch of reviews on yelp to tell you which doctors are competent? I don't even trust yelp reviews to tell me which restaurant to go to. Everything seems to have 3.8 stars...

You're completely wrong.

"The average physician's net income declined 7 percent from 1995 to 2003, after adjusting for inflation, while incomes of lawyers and other professionals rose by 7 percent during the period."

http://www.nytimes.com/2006/06/22/business/22doctors.html

"...none of this really matters, because doctors' salaries aren't a large enough chunk of health care spending in the United States to make a difference. According to Reinhardt, doctors' net take-home pay (that is, income minus expenses) amounts to only about 10 percent of overall health care spending. So if you cut that by 10 percent in the name of cost savings, you'd only save about $26 billion. That's a drop in the ocean compared with overhead for insurance companies, billing expenses for doctors' offices, and advertising for drug companies. The real savings in health care will come from these expenses."

http://www.slate.com/id/2227965/

The rest of your comment is incorrect as well. The AMA does not license physicians, state governments do. Many physicians don't even belong to the AMA. The AMA lobbies for physicians, but it's not in any way like a union (not that there's anything wrong with unions).

Resident physicians in particular would probably lead better lives if in fact there were something like a union to limit hospitals and training programs that have traditionally worked these young physicians upwards of 100 hours a week for what amounts to minimum wage. Resident physician hours and primary care doc hours are still onerous, and most are paying education debut averaging $150,000.

Physicians can practice without any involvement with a hospital, and many do. In any event, the idea of using hospital CEOs or CFOs to determine "good" doctors is about as misguided as asking British Petroleum to determine "safe" drilling engineers.

There is a reason for (some) licensing. We tried the adolescent libertarian fantasy of letting the "free market" drive things like medical training and licensure back in the early days of the 20th century. You could characterize the vast majority of medical education in that era as training in quackery, before people like Abraham Flexner got involved:

http://www.npr.org/templates/story/story.php?storyId=9366625...

You're completely wrong. "The average physician's net income declined 7 percent from 1995 to 2003, after adjusting for inflation, while incomes of lawyers and other professionals rose by 7 percent during the period." http://www.nytimes.com/2006/06/22/business/22doctors.html "...none of this really matters, because doctors' salaries aren't a large enough chunk of health care spending in the United States to make a difference. According to Reinhardt, doctors' net take-home pay (that is, income minus expenses) amounts to only about 10 percent of overall health care spending. So if you cut that by 10 percent in the name of cost savings, you'd only save about $26 billion. That's a drop in the ocean compared with overhead for insurance companies, billing expenses for doctors' offices, and advertising for drug companies. The real savings in health care will come from these expenses." http://www.slate.com/id/2227965/

Interesting data, but the question is if licensing scarcity increase salaries than without. The salary decrease in 1995 to 2003 doesn't tell us anything other than.....net income decrease.

Would it be possible that AMA effectively limits licensing rate through their lobbying?

Interesting data, but not enough details to support your statement. We need more details on what kind of reforms were made, privately or governmental.

Logjam's comments on the Flexner repor are widely accepted to be true. If you're not familiar with it, it's worth reading the wikipedia article on the subject. Pre-Flexner, it was a dangerous, anything-goes world.

I am not disputing Flexner's report at all. I am asking Logjams to provide me with a list of reforms, private and governmental.

The AMA is totally a guild and its primary mission is to limit the number of people able to practice of medicine, thereby driving up doctors' salaries. They don't need to organize as a formal union because the federal government actively sets the number of doctors in the U.S., so they can manipulate public policy instead.

I can tell you first-hand that AMA lobbied hard to reduce the number of medical school slots in America, there actually was an AMA-backed federal program in the mid-1990s that paid schools for the lost revenue from being forced to admit fewer students! The AMA also works to prevent nurses and midwives and the like from performing simple medicine and competing with doctors.

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