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Comment by jimbob45 | Hacker News Reader

I agree that the US has less physicians and I agree that their proposed solution would work to quickly train/hire more physicians. However, the article failed to show a relationship between number of physicians and quality of health outcomes in countries that would prove that this is a problem worth solving.

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That's because those data are already available elsewhere and also well known. In addition to lack of insurance, lack of access to primary care physicians means that the first time the medical systems sees a patient is in the ER. This is staggeringly inefficient. Add to this the fact that case managers are not physicians, and you wind up in a situation where there is often no one who actually has a general understanding of a patient's overall medical situation.

> the article failed to show a relationship between number of physicians and quality of health outcomes in countries that would prove that this is a problem worth solving.

Anecdotally it absolutely is. Finding an appointment for even the most basic level of care is impossible. If you’re sick, if the level of care you receive today or after a week or two is the same and the outcomes are the same, for me as a patient, it matters if I can suffer a few days less. I cannot count the number of times I’ve just had to “wait it out”. This is absolutely dangerous because sometimes, even the smallest of the things like “a sniffle” can become life threatening if not treated on time.

If you don't mind sharing, where are you living that finding a primary care appointment is impossible? During my recent battle with covid, I was able to get appointments with specialists in several fields in about 1 week or less, which I think was pretty reasonable. At the time I was living in Long Island, close to the Stony Brook University which I think makes the area a big hub for doctors.

I had a minor dislocation in my shoulder. It took me 1 month to finally see an orthopaedic doctor and a couple more weeks before I could meet a physical therapist. Guess what, my pain was nearly all gone by that point.

This is in Boston, one of the US medical meccas.

How many doctors offices did you reach out to? Did you try to find one on zocdoc?

Only my primary care. It was a pretty major center in terms of associated doctors.

The idea that someone would have to keep calling different doctors offices to find one that would take me is just as absurd as needing to wait 1 month.

It really isn't, and Zocdoc solves this problem. Calling an office hardly takes 2 minutes; why wouldn't you shop around? By contrast your approach is "I've tried nothing and I'm all out of options".

Isn't the whole point of a primary care that a doctor chooses a 'limited' number of patients for whom they can make themselves available ?

I usually keep myself open to any doctor in my primary care location, outside the one person I see on a regular basis.

I don't see why you'd want to see a different doctor every time, if that means making sure insurances are sorted out, transferring all my media reports over to the new practice and building a new rapport with that doctor.

I went to urgent care when I had a bursitis and tendonitis two years ago. Two days later I was in with a PT. How you approach it will impact how quickly you can be seen.

I live in California. It took me 2 months of calling people to finally get someone who was accepting new patients to be my PCP within an hour commute(I had to pay for one medical membership). Getting ANY dermatologist appointment is 1 month out, getting a good dermatologist appointment was 3 months out (involved a lot of time calling them up again and again). My wife is undergoing mental health crisis, it took us two weeks of just basically calling everyone on the insurance phone book to finally get an appointment 1 week out. My PCP appointments usually take at least 1 week out at all times. When I needed a gastroenterologist for a “mystery pain” in the stomach, it took me 1 month of suffering before I could see them (if you’re dying call 911, else suffer), my CT scan appointment took a week and me constantly having to call them up to expedite it.

Basically the point being if you’re dying call 911 else wait at least a week to see someone. I as a person who has no medical degree should not be making that call. I should have access to someone who can make that call (without bankrupting myself). Even in third world countries you can see doctors the same day. It’s appalling you can’t in the greatest country in the world.

Baltimore MD, nobody I know has a PCP who they can actually see when they are sick -- like you can't get an appointment within 2 months. PCP's give you useless annual wellness checks, if you're actually sick or have another medical problem, you have to go to an Urgent Care where you see someone who is probably comptent to decide if you should go to an ER in order not to die, and that's about it.

We need a different kind of system for medical care. It has to be more like the dentist if we ever want to reduce costs on this side of the triangle. The MD should only see patients when absolutely necessary, the rest of the time a RN or CNA is completely fine. By having lower levels provide most of the care, we can change the economics and actually provide more care to people who don't get it now.

A lot of this is of our own making. Trying to get into a dermatologist for a skin condition is really hard. They are all booked up on cosmetic customers that pay more and increase profits. We want urgent cares on every corner because it is more convenient to our schedule than scheduling with our primary. All this duplication of facilities and staffing have consequences. Care from lower level staff is coming more and more rapidly, it is the only way to somewhat limit costs against the bloat on the other side. For that, we really need reference based pricing but don't forget that one person's waste is another person's salary.

> The MD should only see patients when absolutely necessary, the rest of the time a RN or CNA is completely fine

Today there are nurse practitioners with a four year undergrad in Nursing, 2-3 years of experience in hospital, and a 3 year full time masters degree (where fall and winter are spent in classroom and the summer term in the field). We are rapidly approaching the years of (relevant) schooling of an MD in family medicine...

This would be more believable position if nurse practitioners have ever been able to demonstrate equivalent medical knowledge to physicians, but when the best trained NPs were given the chance to take a watered down version of Step 3 which has a 97% MD pass rate with 1-3 weeks of casual studying, only 40% passed. The reality is an equivalent number of years does not equate the quality and rigor of the family medicine which is argueably one of the hardest specialties. This is notwithstanding the explosion of NP diploma mills with classes on lobbying and health care disparities who take any applicant with a pulse.

> but when the best trained NPs were given the chance to take a watered down version of Step 3 which has a 97% MD pass rate with 1-3 weeks of casual studying, only 40% passed.

Citation needed?

> This is notwithstanding the explosion of NP diploma mills

There's no standardization yet for NPs. I've seen short, one year programs as well as 3+ years ones. That's indeed an issue they must tackle.

There are also other confounders, for example, the mass entry of women into the medical education system at the same time: they tend to seek part-time employment arrangements, so it takes some 1.x 2020 doctors to replace each 1970 doctor. Women as physicians are wonderful, wouldn't have it any other way, the point is the confounder wasn't accounted for.

> they tend to seek part-time employment arrangements

Do you have a source for that?

"Tend to seek" is too strong of wording, but "seek part time employment at a significantly higher rate" is on target.

E.g., the most recent source I can find is a 2019 survey:

> Women physicians were significantly more likely to report not working full-time than men physicians (40 of 177 [22.6%] vs 6 of 167 [3.6%]; odds ratio [OR], 7.83; 95% CI, 3.22-19.04)

https://jamanetwork.com/journals/jamanetworkopen/fullarticle...

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