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Comment by daoboy | Hacker News Reader

"In 1997 federal funding for residencies was capped, forcing hospitals to either limit programmes or shoulder some of the financial burden of training their doctors. Some spots have been added back, but not nearly enough. Many potential doctors are being left behind. “Not everyone who would be willing to go through that training and could do it successfully is being allowed to,” says Professor Gottlieb, the economist."

I regularly hear it is the AMA that is creating an artificial shortage, but this seems to indicate that the logjam is at the level of residency funding.

Does anyone have a good insight or data about this?

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It is the same issue.

The AMA has lobbied to limit federal funding for medical residency. This is the bottleneck.

The fundamental problem is that the US government should not be in the business of funding residencies to begin with. That should the on the hospitals.

Right now the problem is that no hospitals want pay the 150k cost for residency when there is the option for the federal government or another hospital to pay it. It basically leads to a tragedy of the commons/prisoners dilemma, where all the hospitals defect and try to fight for limited grants.

This article has some general details: https://thesheriffofsodium.com/2022/02/04/how-much-are-resid....

Do you have evidence of this lobbying? It does not stand to reason, since care provided by residents is quite cheap to hospitals from the perspective of labor.

Hospitals have no obligation to hire the residents they produce, so an optimal behavior would seem to be training many residents and not hiring them.

>It does not stand to reason, since care provided by residents is quite cheap to hospitals from the perspective of labor.

The AMA represents doctors, not hospitals, and doctors benefit from scarcity. Hospitals benefit from residency grants, existing doctors do not.

>Do you have evidence of this lobbying?

Here is a source [1]

>Hospitals have no obligation to hire the residents they produce, so an optimal behavior would seem to be training many residents and not hiring them.

Optimal only if they can make money from the residents. Due to the bizarre natures of US medical reimbursement, resident physicians do not bill for their services [2]. While they may provide value in other ways, they are viewed as cost on the balance sheet. This is further complicated by the fact that hospitals dont want to bear this cost if they can get a grant, or simply hire a doctor away from another hospital. Getting rid of the grants would be a step in the right direction.

https://blog.petrieflom.law.harvard.edu/2022/03/15/ama-scope...

https://thesheriffofsodium.com/2022/02/04/how-much-are-resid....

Residents are not fully qualified physicians, so it does make sense that they cannot bill for their work.

Further, residents, by and large, are paid for by Medicare.

> While they may provide value in other ways, they are viewed as cost on the balance sheet.

Are you saying that replacing residents with physicians would be more advantageous to hospitals? I don't have a sense of the numbers or billing processes involved

no, Im saying if it costs 200k to train a physician, They should include that in the cost of their in what they charge for their licensed physicians. It is basically how it works in every other job in the world that requires on the job training or licensing.

I again don’t have a sense of how this works, but the activities performed by a resident are overseen by a qualified doctor. Eventually, the residents are able to supervise other residents and only consult the qualified doctor for important matters.

This would seem to increase the potential productivity of a hospital. So I am confused by why you say residents are a cost on balance sheets (again, considering that their pay comes from Medicare/Medicaid)

Hospitals claim that residents take more work than they do, and that hospitals would loose somewhere between 75-100k/year on each resident if the federal governments didn't pay them. I think this is likely bullshit, but if if it is true, that still doesnt mean the government paying for residents is a good solution. Employers take a loss all the time to train worker in other industries, and there are many ways for them to recoup their losses.

> Residents are not fully qualified physicians, so it does make sense that they cannot bill for their work.

Residents are actually more qualified than many other "mid level" professions aka Medical Providers.

Would I rather see a resident, or a nurse practicioner? The resident of course, because he/she actually completed medical school, whereas an NP may have a nursing oriented (no emphasis on diagnosis) masters or terminal degree.

It's interesting how truth can disappear over time. They were out and proud about it back then.

Here: https://www.washingtonpost.com/archive/politics/1997/03/09/r...

> Last week a powerful coalition of medical groups, including the American Medical Association and the Association of American Medical Colleges -- the umbrella group for medical schools -- proposed their own plan. Their idea is to limit residency slots financed by Medicare to the number needed for the 17,000 annual graduates of U.S. medical schools.

There's other things like this that folks say "Well, where's the evidence?" and the truth is that the evidence was all around us back then. Now that people have changed their minds on this stuff, it's harder to find as the perpetrators go quiet about it. And you have to search the past which isn't that easy.

I'm sure the pandemic response will be similarly rewritten, especially the business about telling people masks don't work because they wanted to make sure that average people won't take masks that they wanted to keep for healthcare people. That's being rewritten in front of me to say "Oh there's no evidence that masks ever worked and that's why they said that".

Where's the evidence? Well, in many cases, it was everywhere. Truth casts a small shadow on time. The motivated sceptic stands purely in the light.

This is a difficult issue - if we accept the statements on their face (and I don't have enough information to accept or reject the statements), it seems that there was waste by hospitals that were doing just what I mentioned, soliciting residents that were not needed.

From the article: "But why should hospitals be interested in this when, under current law, they automatically get sizable government subsidies for training residents who as part of their education take care of many of the hospitals' patients, work long hours and collect meager salaries?"

If this issue were to arise again in today's political climate, I imagine there would be a redistribution of seats away from in-demand specialties to primary care.

Yeah, this is one of those things you had to be there for. When you're just reading a picture from history, and that's the only insight you have into it, you're going to get a particular view of it. It can't be helped, especially if one is searching for evidence to support one's own beliefs.

I find myself reading comments like this in disbelief (or assuming the author is not in good faith responding), as if there can be any doubt where political lobbying is possible that there doesnt exist a tremendous apparatus to exploit it.

Yes, here it is. With citations:

https://blog.petrieflom.law.harvard.edu/2022/03/15/ama-scope....

You can look up things for yourself, you know

My understanding is that at least at one point in the past the AMA lobbied either for the cap or to not fix the problem. Also inversely speaking, you don't really hear much about the AMA lobbying to -fix- the problem and given the frequency of this theory, you would think they would publicise it more.

There is also the weird thing where, my understanding is that the hospitals can 'sell' the slots to each other and strangely they can fetch more than the funding in question.

But really, so much of the medical residency industrial complex reminds me of a hazing ritual in and of itself.

The program was started by a guy hopped up on cocaine the whole time, that's why the hours alone suck:

"William Stewart Halsted developed a novel residency training program at Johns Hopkins Hospital that, with some modifications, became the model for surgical and medical residency training in North America. While performing anesthesia research early in his career, Halsted became addicted to cocaine and morphine" https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7828946/#:~:tex....

>reminds me of a hazing ritual in and of itself

It's absolutely abusive and I cannot believe there's never been more of a push around patient advocacy. It's bad enough for the residents working 100 hours a week and getting fits of sleep in a shitty spare hospital room they share with multiple other residents. It's even worse for the patients receiving care from a tired, overworked resident.

There has been a push back, and hours are now capped well below 100 hours (maybe 60 hours a week now?) with limits on duration of shifts, also. When I trained the cap was 80 hours/week with a limit of 30 hours in a row.

The cap is still 80 hours/week. I'm not sure about the consecutive hour limit. It's at least 24 hours. That doesn't stop the residents I know from frequently having duty hour violations. In one case I know a resident had his hours manipulated by admin to under report them.

Where? I still see/hear of residents in the states working 80+. Many pulling 20-24 hours a day for 3 or more days a week, then additional coverage beyond that.

There is theoretically a cap, but my wife (a doctor) knows many peers who either:

* Been made clear in no uncertain terms (mafia style) that they were never to log more than the regulated hours, regardless of actual hours worked.

* Weird things started to happen if they did log more than the required hours.

And yet in my few experiences, the residents are actually the ones that will talk to you and tell you what is going on. As opposed to the super important Attendings who you only see when it's time to talk about things with legal repercussions like pulling the plug.

Residency funding, and the fact that even fully trained foreign doctors have to redo residency to practice here.

An American can marry a foreign doctor with 10 years experience, get their spouse a green card and everything, and they still can't work as a doctor without redoing residency like a fresh graduate.

That depends on the state. Some states such as Tennessee now offer more flexible options for foreign trained doctors to practice there.

https://www.medscape.com/viewarticle/993693

Globalism for thee, protectionism for me.

That's not an example of globalism hypocrisy

Bring in foreign programmer: here's dozens of laws and programs to make that easy.

Bring in foreign doctor: here's dozens of laws and programs to make that hard.

Bring in foreign low skill labor: Laws? No human is illegal!

Coding, farming and medicine have different stakes (in general). It makes sense to be pickier with the last than the first two.

Millions are protected to die simply due to lack of access to medical care. The doctors would have to be actively malicious to be worse than the alternative of no doctor.

> doctors would have to be actively malicious to be worse than the alternative of no doctor

There is so much low-hanging fruit to pick before we create a two-class medical system.

Also, “millions” is hyperbole. It’s tens of thousands a year [1]. Two million or so in a lifetime. But half as many as from alcohol [2].

[1] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2323087/

[2] https://www.cdc.gov/nchs/fastats/leading-causes-of-death.htm

> From link: although some studies stated that people aged 25 to 64 were 25% more likely to die if they lacked health insurance, the risk of death was probably higher because uninsured people are less healthy than insured people.

The interesting point is that the early deaths are mostly due to selection - people that can't get insurance are more likely to die early e.g. lifestyle choices. Giving them access to the medical system might not help as much as we might hope.

> Upthread: willcipriano said: Millions are pro[j]ected to die simply due to lack of access to medical care.

No. The risk of death is 100%. People can die earlier than otherwise due to lack of medical access - or better said we can delay death but it usually gets harder and harder to delay as we accumulate chronic health conditions. And some people avoid chronic conditions better than others.

Aside: Meanwhile the richer your country, the more you can take the best doctors and nurses from the poorer countries. New Zealand trains a lot of great doctors and nurses for the USA. And we take a lot from other countries too.

Feel free to at any point in the last twenty years. It wasn't done so now drastic action is required to save lives.

> now drastic action is required to save lives

You realise it’s this sort of rhetoric that inhibits moderate progress? If I wanted to kill a residency expansion proposal, and a lawmaker were saying we should let doctors trained in the worst medical systems in the world treat poor Americans, I would run that framing on billboards.

I've been hearing that for twenty years. #ForceTheVote most recently. Drug reimportation under Trump. The public option with Obama. It's never the right time.

> been hearing that for twenty years

That extremist policy positions backfire? Yes. Because it’s consistently true. See: defund the police and abortion.

What you’re suggesting is lower impact and still more radical than a public option or drug price regulation.

If it's extremist to say "hey we shouldn't spend at least twice as much for healthcare for no reason" then burn it all to ashes, nothing of value remains.

You are precisely correct - this is not an AMA issue. Funding for this is tied to Medicare/Medicaid and thus a political issue that does not turn based on what the AMA may request. In searching for the below table, it seems that there is some effort to use funds from other sources to pay for targeted slots[1]

1. https://www.aha.org/news/headline/2023-07-27-hhs-awards-15-g...

Here's a breakdown for funding for one year in the recent past: https://www.ncbi.nlm.nih.gov/books/NBK248024/table/tab_3-1/?...

A former roommate of mine was a doctor in residency. They were paying him peanuts and grinding as much work out of him as they could. I think this was maybe 5 years ago and he was at 65k or so in a major metro in the US.

So if you're a hospital, and you can get cheap doctors in residency who basically need to work whatever workload you give them, why wouldn't they hire as many of them as they could? I figure the limiting factor should be their ability to manage them, not federal funding. They are paying pennies on the dollar for doctor labor that they are NOT giving patients a discount on.

Residencies all lose money. That's why they're subsidized. My family member is a chair of a residency and the business analysts are constantly trying to close it because it takes time away from the doctors and doesn't provide anything to the bottom line.

My partner did a second residency. Medicare doesn't fund second residencies, so she had to get an unfunded spot. At least with her second residency, they have those unfunded spots precisely because they're profitable. Maybe it's not all programs, but certainly some of them are profitable.

You figure wrong. Hospitals require residents to do a lot of work, but they can't bill Medicare/Medicaid or private insurers for much of that work. Hospitals can't afford to just hire more.

Residents are still doing work. The notion that they should be federally-funded, rather than just getting paid for doing that work directly through the proceeds of whatever patients get charged for that work, seems dubious to me. I'd also be skeptical of a claim that available slots are more of a limiter compared to the fact that propective physicians are looking at 4 years of post-graduate education followed by 3-9 years of working 100 hour weeks for $30-40k a year before they can get licensed.

I once considered becoming a doctor when I was still a teen, and I'm quite confident I could have gotten into medical school and qualified for a residency somewhere, but it was the decade of hazing while being paid like a ranch hand that dissuaded me.

This has led to is a rise in PAs and ARNPs for primary care, and scary things like CRNAs asking MDs for sign offs without a supervising anesthesiologist.

Is there a reason other than fear to think that CRNAs are ineffective at their jobs?

Not quite the question-- the real question is why would they be effective at the jobs of others? Doctors have 10-15 years of training, there's a reason for that.

They need a supervising physician, which should be an anesthesiologist. Surgical MDs do not have the same qualifications to sign off on their orders. The liability with CRNAs flows to the supervising physician, so most MDs tend to be very uncomfortable working with only CRNAs.

Here's a recent report from the Congressional Research Service about this that provides a very detailed summary of how this works: https://crsreports.congress.gov/product/pdf/IF/IF10960

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