Comment by rcarr | Hacker News Reader

Comment by rcarr | Hacker News Reader

Supposedly it never used to be this nuts. It mainly came about because of one cokehead surgeon at John Hopkins who got in charge of the training program because of his "increased productivity" and basically started forcing these insane work weeks on everyone. See here:

https://en.wikipedia.org/wiki/William_Stewart_Halsted

The concluding line of this report[1] is absolutely amazing in that the authors still won't even recognise that he was abusive towards his trainees. After discussing his lifetime coke habit and how his "eager and enthusiastic students" would pick up his slack (e.g that he had conditioned to work ungodly hours for his approval) they write (emphasis mine):

*While we are not condemning Halsted*, we are suggesting that if one carefully analyzes and critiques the motivation for the structure of the Halsted surgical residency, his addiction was a major influencing factor.

Either way, any person who can pass the entrance exams should be allowed to train as a doctor or surgeon. The fact that we have artificial caps on the numbers, yet surgeons are routinely working 100 hour weeks is an absolute joke. Everyone's health suffers - both surgeon and the patient. The "wages will come down" argument is an absolute joke - at the end of the day, if there's one thing people will pay a high price for, it's "to stay alive". And if there's a second thing people will pay for, it's "to not be in pain".

[1] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7828946/

> The "wages will come down" argument is an absolute joke - at the end of the day, if there's one thing people will pay a high price for, it's "to stay alive".

Good argument for universal public health care.

It’s absolutely dumb to have number of surgeons trained or number of patients undergoing surgery be a function of supply and demand. Enough surgeons should be trained to attend the population and it should be a normal career with normal working hours and a steady salary like any other.

> Good argument for universal public health care.

Doesn't always work out well. I was just in Canada and the evening news was filled with stories that the wonderful "free medical" system was shipping patients down to the US for surgery. I hope they got a good rate on bulk deal.

it works for all industrialized nations... but us.

the question is how much do we want to waste and how many should die?

If supply and demand don't set the number of surgeons, then who does?

Currently, the American Medical Association limits the number of new doctors being trained in medical school. The AMA judges this to be enough to attend to the population. The long working hours, high wages, and continuing shortage of doctors is direct evidence that their judgement is questionable.

The equilibrium found between supply and demand implies the existence of "excess demand." For some, myself included, the choice between excess demand and efficient markets leans heavily toward reducing excess demand, despite it being less effecient.

> If supply and demand don't set the number of surgeons, then who does?

Public policy. Have public education and graduate X number of doctors every year no matter what.

Free market doesn’t work well for essential services. Lobbying will artificially restrict supply to make more money at everyone else’s detriment. Demand for health is unbounded and any patient will value life over capital, so without forcing oversupply it will be exploitative.

If there is an organization which is arbitrarily limiting supply, it is not accurate to call it the "free market".

Graduating X doctors per year seems like a much worse solution than allowing to graduate however many are willing to learn.

There's no point in graduating more doctors per year if there are no residency program slots for them. We already have some students every year who graduate with an MD degree but are unable to practice because they can't obtain the necessary post-graduate training. We need to address that bottleneck first.

So instead of having one surgen work 100 hours, a novel concept might be 3 at 33.3 hours?

Surgeons have to complete the same amount of training regardless of how many hours they end up working per week after training. There is just no practical way to train three times as many surgeons: the teaching hospitals have nowhere near enough capacity.

In japan, they have large teaching hospitals where patients get treatment from several doctors, effectively free of charge, because you're paired with one senior doctor and several training doctors.

US teaching hospitals already have multiple residents delivering patient care under the supervision of an attending physician.

> no residency program slots for them

which is an artificial limitation. More positions can be generated easily, since there's a high demand for medical care and the costs currently are high to obtain medical care.

Until those residency programs have doctors sitting idle and twiddle their thumbs, the lack of position is just artificial in order to make it more competitive.

You appear to have a misunderstanding of the motivations and incentives here. The limit on residency program slots is not to make them more competitive but rather to hold down Federal government Medicare spending. If you want to help solve the problem then please ask your members of Congress to increase Medicare funding for residency programs.

https://savegme.org/

> if there is an organization which is arbitrarily limiting supply, it is not accurate to call it the "free market".

Free market is like communism: when it doesn’t work we can complain it wasn’t the true thing.

You can contrast it with the sciences

There's a joke that grad school and med school are polar opposites - med school is hard to get into and easy to get out of, while a PhD is easy to start and hard to finish

Being a postdoc sucks, and you have to be pretty willing to do something radically different than what you did as a student - but it isn't the end of the world.

I can't see a situation where it makes health in the US worse overall to increase the number of students.

You're confused. Scandinavia has the same organizations that limit the number of doctors trained in the same way.

I think the people in the bread lines in the USSR may have disagreed.

You can go ask the people on the bread lines what they think today. There are 34 million people living with food insecurity in the US alone. A triumph of efficient resource allocation!

Nice, "food insecurity", sounds like a weasel wording of "definitely have food, hence the obesity epidemic, but not securely".

The USSR was very efficient at resource allocation. Those who "needed" the resources the most got it. Of the resources that existed, that is.

Socialists would love this system to return, as, in their narcissism, they consider it inevitable that they'll be chosen among those who "need" it.

The AMA has no power to limit the number of medical school slots. The actual limit is imposed by federal Medicare program funding for residency slots. The AMA has been actively lobbying Congress to increase those.

https://savegme.org/

You should really take 5 minutes to do some basic fact checking before making false accusations.

Can private funding fund residency training positions, sidestepping Congressional appropriations?

Sure, there is already some limited private funding for residency slots. If you have a few million dollars to spare you could probably endow a new slot at a teaching hospital. But in general the organizations that actually have a lot of money don't consider this a top priority.

It's almost like governance was handed over to a private organization, not elected by the people

Unions are fine on the us it seems, provided they are branded as an association

> The "wages will come down" argument is an absolute joke - at the end of the day, if there's one thing people will pay a high price for, it's "to stay alive". And if there's a second thing people will pay for, it's "to not be in pain"

Demand for surgery is inelastic instantaneously. That does mean it’s also induced, i.e. more surgeons will generate more surgeries. Supply and demand will still apply.

Supply and demand will apply, but there's both a massive internal backlog (at least in the UK) as well as a massive backlog internationally. Globally, the population is still growing so the demand for essential medical treatment is only going to increase for the immediately foreseeable future. And that's just essential treatment. Rightly or wrongly, demand for non-essential treatment like cosmetic surgery and probably, as technology marches onwards, performance enhancing surgery is only increasing. For example, if we created enhanced ligaments that perform better than natural ones, it's not a stretch to imagine competitive athletes having surgery to replace them. I don't think wage protection is a valid reason not to be training surgeons who have the aptitude to do it.

If we could create (and safely implant) artificial ligaments that are even close to human ligaments that would be amazing for anyone with ligament injuries. Once you damage a ligament it never regrows, and current artificial ligaments don't last very long and can cause other health issues. At least for UCL rupture, the current state of the art surgery (Tommy John surgery) involves taking a ligament from some other part of the body and replacing the damaged ligament, which is obviously a major surgery and still doesn't work nearly as well as the original ligament.

> Demand for surgery is inelastic instantaneously

This is not true, a lot (most?) surgery is elective and can be delayed or avoided altogether

Only emergency surgery is instantaneously inelastic

If more people can get the surgery they need, faster, then I see that as a positive

Also, not all doctors work as surgeons or need to perform surgery. Ideally we will also train a lot more of other specialties that can help people prevent surgery

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