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Comment by renewiltord | Hacker News Reader

Doctors are obsolete. There are too few of them and they have succeeded in stopping us from making more.

The future is we just pay the doctor tax for a few of them and we leave the majority of care to NPs. In time we can create a new category of advanced NPs to substitute for doctors. And in time, we can add more training to substitute for surgeons and specialists.

America will find that most Americans are suffering not because the care they get is bad but because they can’t get the care they need.

In time, we will discover that going to a charlatan with a shady pharma hookup and a Wikipedia page is better than dying while you wait for your doctor.

The future of health care is coming and it doesn’t look like this. All we have to do is get in front before doctors and their symbiotic hosts (hospital admin) lock down alternative paths to modern medicine.

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I concur, but it is a complicated problem. Weirdly I feel authoritarian regimes like China might actually show the path to success in Healthcare AI. This is because true success needs fast decision making/ unpopular tradeoffs that they can possibly execute better with lower regulatory barriers.

However, most studies on US healthcare point more fingers at bloated hospital admins with perverse incentives more than Doctors.

Doctors undergo a lot more and far more rigorous training than NPs, which is reflected in their efficacy.

https://pubmed.ncbi.nlm.nih.gov/32362078/

https://onlinelibrary.wiley.com/doi/full/10.1111/acem.14077

https://pubmed.ncbi.nlm.nih.gov/28734486/

https://pubmed.ncbi.nlm.nih.gov/21291293/

https://pubmed.ncbi.nlm.nih.gov/10861159/

I also wouldn’t say that doctors are symbiotic with their hospital admins — the ones I’ve worked with seemed to really dislike the admins.

Simple solution seems to be to open up a lot more residency spots and not drop the rigor/licensing/clinical experience that we currently require for doctors.

NPs are doing independent practice in some states and are charging MD rates. The issue isn't the number of doctors, it's the cost for average Joe to get treated without being charged three days of wages for a 7 minute consult.

"Advanced NPs to substitute for doctors": I suspect future you describe is one driven by a private equity race to extract profit by lowering costs NOT to provide affordable or better care for more individuals.

I pick my own treatment and medicine already for 20 years; it is not hard. If you have something you are unsure about, ask your gp for a specialist visit (that is what they do as well); otherwise, tell your doctor what to prescribe. Since 15 years, I just send the doctor office and email, they return a doc signed by the doctor and I can go to the specialist or pick up my prescription with it. GPs are not wizards; they were nice for social contact; outside that they just give you something that could work and hope it goes away; otherwise they will give you something else or send you on to a specialist. I can do that myself and an AI or crowd sourced diagnoses can do that too I believe. Doesn’t need to cost 25-50$ per consult either.

Easy to say that, harder to live it. Would you willingly choose to receive treatment from a less trained, less accurate NP? I wouldn’t, even if I had to wait longer.

Why the assumption that they're worse?

If the root cause of the problem is monopoly, then this is exactly analogous to the question of established monopolist vs startup.

"No one ever got fired for choosing <current monopolist>" is fine if you're playing it safe but many people don't have that option and find, sometimes to their surprise, that the cheaper option is also better, due to the different incentives in play.

This is an ill informed take. It’s common when someone doesn’t know what X role does from the outside to think they are interchangeable. Medical school takes candidates that are already on average much stronger than NP trainees and then trains them more rigorously. Further, the specific training pathway after medical/ nursing school is v different. NPs are trained in seeing ‘textbook’ or standard cases and a flowchart of management for them. Which is great if you are one of them. And since most people present ‘typically’ for that clinic you can use NPs to filter through people and get them seem quickly/ cheaply. However, they don’t have the toolkit to handle greater complexity that is outside the flowchart and don’t generally know how recognise when a standard flowchart approach to management shouldn’t apply.

It’s rather tough to explain in lay terms other than via analogy - you’ve basically said all software engineers should be replaced by data analysts.

No, it's like saying all programmers should be replaced by certified programmers who are all from good families and have 10 years of intense training at top schools and massive debt.

You wouldn't trust some young immigrant or a long haired hippy kid who dropped out of college and started a business in his garage to provide your tech would you? Computers are complicated, we can't let amateurs in hoodies start doing things without some central control.

NP/PA education is far less rigorous And requires far less hours than MD. Many more NP/PA schools have far more lax standards, and are probably better called diploma mills than MD schools.

It is all probabilities, and I would rather bet on an MD. At least compared to the current incarnation of NP/PA.

MD education in the US takes so long because students are required to spend four of those eight years studying something other than medicine.

Nurses actually study medicine as undergraduates before graduate NP education, so one could argue that NPs have more education in medicine.

The problem of NP/PA is not in the design or scalar length of education. It is in the credentialing. MDs have to take MCAT and step exams, which I know weed out many people. From my understanding, there is a relatively very low barrier to entry for NP/PA.

As a side note, the physician credentialing process of the US is far too long.

I doubt those exams select for skilled medical practitioners any more than leetcode interviews select for productive programmers.

In my own experience, I've seen several very good NPs and several very bad MDs.

> the physician credentialing process of the US is far too long.

Also too expensive and too abusive. It tends to select for people who are willing to put up with almost anything in exchange for the status of being an MD, not for people who are motivated to provide quality care for their patients.

NP/PA programs have entry requirements of 80-90% A’s (3.7 avg), GRE, 1000+ patient care hours and like 4% acceptance rates…

I don’t know that you can use the acceptance rate as a direct comparison to med school, you have different populations applying to each.

I remember there was a PA that did end up going to med school and took the PA boards (forget what they call it) just for kicks and ended up scoring in the 99th percentile.

What's the probability you are optimising though? That you as a rich person can get access to the artificially limited supply of <good thing>? Or that society in general gets access to <good thing>?

America has a stereotype that British people have bad teeth. They also have a stereotype that poor American "hillbillies" have even worse teeth. The stats suggest that on average the Brits have better teeth but I'd guess Dentists can make more money by moving from there to the country with the worse teeth on average and helping the Americans with good teeth have even better teeth.

> What's the probability you are optimising though?

The probably of me or my kids receiving a correct diagnosis.

To clarify, my intention was to specifically respond to

> Why the assumption that they're worse?

I have others views on healthcare credentialing on a societal scale.

Likewise: Boot camps and self-teaching are far less rigorous than CS degree programs, which I think is GP’s point.

Part of the problem with the current monopoly is that we're already assuming our choices are NPs vs MDs, as opposed to some other professional identities, with other educational paths, that don't exist because of the monopoly. It's distorted the discussion by shaping our expectations about what's possible.

In any event, med schools are now moving towards 1.5 or even 1 year of course training, there's pressure to compress background as much as possible. The difference between, say, a PA with four years of practice and a second year resident is increasingly difficult to distinguish. This is increasingly reflected in staffing demands.

I don't think the MD model is obsolete, but I do agree that the current anticompetitive system is.

That’s the wrong question. Would you rather suffer for want of a doctor or see someone else?

We already know the answer. People seek them where they can get them. WebMD. Google. Fish mox on Amazon. Self-treatment is rife.

If I had the choice I’d go to a doctor (and I always have the choice - my parents and cousins are surgeons). But I “go to the doctor” for something as mild as a contusion on my knee or the suggestion of sniffles or if I wake up with my eyes feeling a bit dry. The people who don’t have the choice don’t call the doctor when they can’t even get out of bed.

It’s about all the people without a choice.

People without any affordable alternative will, and will be the first target markets.

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