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Your last point isn't correct.

While that is the result I think emphasizing that it isn't made easier is important.

Electricians need to install high voltage wires that are safe in the home for untrained individuals for potentially a century.

Plumbers need to install water tight pipes that can withstand significant pressure without leaking (which can be difficult to detect and very quickly devastating damage wise)

Doctors are expected to be able to catch nearly any disease in their specialty based on an honest consultation.

Lawyers need to know a phenomenal amount of information to meaningfully know what o research when it comes to prepping for court cases.

All of these jobs are hard to prepare for and their is value to everyone else that you can prove you actually prepared.

The problem is the incentives for encouraging more people to prepare are backwards (those supporting the newbies benefit from fewer of them) which causes no real help to be given and the labor shortages.

But it isn't made up boundaries just to benefit existing members.

>The problem is the incentives for encouraging more people to prepare are backwards (those supporting the newbies benefit from fewer of them) which causes no real help to be given and the labor shortages.

>But it isn't made up boundaries just to benefit existing members.

I would argue that it largely is just made up boundaries to benefit existing members. That is to say, regulatory capture has increased the barriers so far that any benefit from additional quality of service is far outweighed by the increased scarcity.

It doesn't matter if you have the best doctors and electricians in the world, if they are so few and expensive that the public does not have access to them.

The fundamental problem is that is both easy and popular to error on the side of "caution", creating increasingly stringent licensing requirements. These benefit established interests and sound attractive to the public.

I don't disagree but I like to distinguish between "there shouldn't be barriers" and "there should be fewer barriers" and the verbiage I responded to felt like the former.

I don’t think you can reasonably draw a comparison from medicine to home electrics and plumbing.

My dad was a plumber and I’m preparing to pass the certification that permits me to work on home electrics. They are, to be blunt, easy. An average person can pick up most of it in a couple of months. Electrics and gas plumbing carry a certification requirement because an error can kill someone, but it’s easier than passing a driving test.

Obviously, there are higher tiers of those trades that require a lot more training, but even those aren’t really comparable to the level of knowledge and study needed to become a qualified doctor, let alone a consultant.

In the UK, shortages of tradespeople are less to do with the difficulty of training, or lack of course capacity, and more to do with people really just not wanting to do the job, for various reasons.

Medicine has more barriers to entry at least partly because we’ve decided to erect them. Doctors learn all kinds of things outside their direct specialty that they don’t really need to know, but nobody inside the system has an incentive to streamline medical education or to encourage more and earlier specialization.

For example, we force most doctors to take a 4 year degree before medicine (sometimes pre-med, but often an arts or non-biological science degree). Wasting 4 years of a future doctor’s prime career on an expensive and often irrelevant screening program is extremely wasteful for society as a whole.

> Wasting 4 years of a future doctor’s prime career on an expensive and often irrelevant screening program is extremely wasteful for society as a whole

I have a cousin who's doing his residency right now and he has an interesting take on this.

You don't want to have a 21 year old in a cancer ward directly treating patients. They may lack the personal skills and life experience needed to convey empathy. In addition, they will not be taken seriously by patients due to their youth.

He is speaking from experience as someone who is doing his residency at a slightly younger age than average.

> You don't want to have a 21 year old in a cancer ward directly treating patients. They may lack the personal skills and life experience needed to convey empathy. In addition, they will not be taken seriously by patients due to their youth.

I just don't buy this take.

You don't let the junior engineer wild in production. You place guardrails around them until they learn and prove themselves as capable. The exact same thing can be done in medicine.

There isn't enough staff to manage teaching AND medical care at hospitals.

Shadowing/Interning is already done in your MD program.

In Engineering, you will generally have 1 engineer paired with 1 intern/NCG. In a hospital setting that is an unrealistic ratio given the relative lack of staffing.

Add to that liability related issues because unlike CS, you as a medical professional can be held legally liable. This of course leads to high malpractice insurance rates subsidized by the hospital, who then in turn also need to show insurers that they are doing the needful.

> There isn't enough staff to manage teaching AND medical care at hospitals.

The complaint "we can't spend the time to train new employees" isn't specific to the medical field, but the solution is the same: they can't afford NOT to, and the lack of staff is proof of it.

The last plan ended in the failure we're at now (no staff available to train new staff). The best time for staff to start training more staff was before they ran out of staff. The next best time is now.

The rub is that lack of staff isn't what prevents this, nor is even lack of staff time. It's a conscious, short-term-focused decision by hospitals to focus efforts outwards on making more money, rather than inwards on training or changing the status quo. And honestly, the long-term herculean task of changing the existing resident system seems, in my opinion, out of scope and fantastical for the average hospital.

Residency positions are not paid for by hospitals. They're paid for and allocated by the federal government.

That is also correct, the task of changing the system just seems out of scope for any given hospital.

Maybe if a sufficient number of hospital systems were sufficiently motivated to sufficiently lobby the government for change. I don't know what that would take.

Residents unionizing is a good start.

> You don't let the junior engineer wild in production. You place guardrails around them until they learn and prove themselves as capable. The exact same thing can be done in medicine.

You mean like a residency?

A residency is direct care of a patient. MDs already have internships and shadowing during their degree.

Residents provide direct care under supervision and have many guardrails, as the comment I was replying to stated.

Clinical clerkship is not an internship, interns are first year residents. Shadowing does not teach you medicine.

Residency is one form of that. A form with extreme labor restrictions and no ability to move jobs.

Yes, the system as designed by a cocaine addict[1] is broken. Residency is still necessary in principle. In a specialty program one only starts to become competent in PGY4.

It's a difficult problem to fix, I finished my residency training in Canada where we don't have ACGME protections in place and while it was far more abusive than US programs (where I currently work) it certainly made us very competent at the end, better than I am seeing in the average US trainee I supervise.

I'm not sure what the solution is to be honest. Competency is almost entirely driven by clinical volumes and exposure, you don't train to handle the 90% of normal cases but the 9% that are challenging and the 1% that's incredibly complex. If you're not working long hours (or spending many more years in training) chances are you won't get that exposure.

With that said one could argue with the current expectation that everyone does 1-2 fellowships we're already training longer.

[1]https://en.wikipedia.org/wiki/William_Stewart_Halsted

Practically the whole world educates doctors with a 6-year program straight out of high school, out of which 6 years are relevant to medical education, instead of the 8 years in the US, out of which 4 are barely relevant to medical education.

"Doctors are expected to be able to catch nearly any disease in their specialty based on an honest consultation."

From my experience they don't. If you have any problem off the beaten path you may spend years and multiple doctors to figure out what's going on.

That makes more sense. I interpreted the "catch" quote to mean that doctors are expected to literally come down with any contagious disease within their specialty.

I agree that happens, my point is about the intersection of speciality and expected.

Aka it doesn't always happen but that is the goal.

Honestly disease diagnosis is the one area I could see AI being super helpful in which might lower this burden from extreme memorization to facilitating collecting data for analysis and being a guard on false positives.

Agree about AI. It would be way more patient and take its time to talk to the patient than doctors have these days.

AI has had the opposite effect on false positives. Statistically, most patients aren't (that) sick and don't have zebras.

Taking radiology as an example (because that's my specialty) ~90% of studies are normal and some types (e.g. CT for pulmonary embolism, CT for transient ischemic attack/vertigo) are closer to 98-99% normal.

Every diagnostic AI application I've seen implemented as of 2023 that merely replicates the work of a human has done nothing but increase false positives.

The extreme class imbalance makes this a non-trivial problem.

I've heard a quip from my wife, "When you hear hoofbeats behind you, don't expect to see a zebra." Essentially, you need to know that booth horses and zebras make hoofbeats, but zebras are rare (in the US). It'd be foolish to look for a zebra until you've ruled out the possibility of a horse.

In fact, it even has a wikipedia page: https://en.wikipedia.org/wiki/Zebra_(medicine)

> Plumbers need to install water tight pipes that can withstand significant pressure without leaking (which can be difficult to detect and very quickly devastating damage wise)

There is no shortage whatsoever of licensed plumbers who will do incompetent work. Fortunately there is a decent collection of companies making excellent plumbing products that are quite robust.

Current personal favorite failure modes:

Use of inappropriate water-insoluble flux. This usually doesn’t cause a leak, at least not quickly. It is, however, disgusting (petroleum crud and not-very-good salts being released slowly over months to years in cold water pipes) and is a code violation.

Use of copper in boiler condensate pipes.

Use of essentially arbitrary mixes of pipe tape and pipe dope.

Overtightening of plastic threaded connections.

Incorrect combinations of tapered threaded fittings and gasketed straight threaded fittings.

I once moved into a house and had a plumber come out to connect the fridge to the water (there was some custom work that needed to be done).

There was a plastic line there already and that line hadn't been used in atleast a year (previous tenants kept their fridge in the garage). I remember asking the plumber if we should replace that plastic line and he said no, I even told him it hadn't been used in over a year.

A week or so after he did this work I'm walking through my living room and my socks are getting wet. At first I couldn't figure out what was going on until I realized that line had split (as I expected it to) and was leaking, said leak having moved into the living room where it was making the wood floors damp.

To this day I don't understand why that plumber thought that would be ok when I, as a complete layman, understood what happens to plastic lines that go unused for that long (they dry and crack).

What kind of plastic line? I've used a decent amount of name brand LLDPE tubing, and I've never seen it fail or even appear to degrade.

I have had issues with compression connectors at the ends (they don't like to be too loose or too tight), and I've seen plenty of failures of the really crappy washers that get used in "female compression" connectors.

I'm not a plumber so I couldn't say, but clearly it did degrade :)

There can be more schooling and training in engineering.

After undergrad, master’s, PhD, a postdoc or two, one would still make low income. After that, there is a never ending path where one has to constantly chase ever changing technologies. The older you get, the harder it will be to keep up and remain employed.

In medical science, you finish the residency (roughly equivalent to 1-2 postdoc in engineering), and you start to practice. Already, income is OK in residency. The older you get, the better!

The income is most assuredly not okay in residency, or for that matter, fellowship. Most U.S. residencies and fellowships range from $60-$70K a year, basically the U.S. median income, and on a per hour basis is terrible.

To make it worse many of the big name institutions one would aspire to train in (e.g. 10 of the US News top 20 hospitals) are in expensive metros where you don't cross the "low-income line" until the third year of residency.

All the while spending 60-80 hours a week on clinical service and 5-10 hours on research and education so you can maybe get a job somewhere not remote when you're done.

> I just want to point out that - you landed (probably more random than intentional) into arguably the best career in the history of labor.

I don't disagree. However, I certainly am not a top earner in the industry. Much of my career has been remote. My income is not out of line with most STEM fields. The main benefit for me was the ability to work remotely, moving with my wife to various small towns/cities.

Keep in mind, my wife had almost 10 years of med school and residency to start her career. I was making income the whole time. That's essentially a $1M difference 10 years into careers. It takes a while to overcome that gap.

-----

> I think the particular problem with the medical industry is... it's particular detrimental to society to be overworking doctors to the bone and it not really paying off for them until they're in their 50s.

Yep. There's also a huge personal burden of carrying that non-dischargable debt. If residency doesn't work out for some reason, you're in a huge hole.

We know many physicians who say they wouldn't do it again if they had know how shitty the journey would be.

Problems are doctors are unlikely to "help" with, and are highly likely to make matters much, much worse.

Also, contrary to popular opinion, there's little stigma or awareness of "bad doctoring", for a number of systemic reasons.

So you have someone who doesn't give a fuck about anything, certainly not your situation, not listening to you, and trying to prevent you from receiving medical treatment.

This doesn't look so necessary to me. I know there will still be medical experts and surgeons and so forth, but much of this medical infrastructure doesn't benefit the average citizen (I know there's an argument that it does or for a change in perspective, but that's a whole different can of worms.

Similar to policing, if you think of the typical way you interact with the medical system, you start to realize there's very little in there to help you. 99.99% of the infrastructure is built to benefit powerful people with tons of money; helping you is an after thought.

What happens when you're a victim of crime? Turns out there's very little in place to help. Oh, someone is actively trying to murder you? well give us a call after it happens and maybe we'll investigate.

How many of us have experienced something like this? I'm not saying there's no reason for the arrangement, but we should stop trying to pretend these people are looking out for the public.

I know people may be tempted to chime in regarding some situation a police officer or doctor helped you. I'm not saying you're wrong, just explaining why some people are asking questions; if you honestly think about it, your naive assumptions about safety and health will be shattered.

A doctor, in many ways, arguably has a patients WORST interests at heart, in a similar manor to a police officer, in it's interaction with the public. They have, as their most important responsibilities, to detect certain things, and take actions to hurt the person.

This is priority #1, virtually everything else comes after. This is an important observation, is not obvious, and should cause us to reconsider these institutions.

Perhaps a more diplomatic to phrase what I perceive as your thought there is that a good doctor or policeman is actually in some respects often acting that way regardless of the system -- they would've tried to help people as much as they could anyway. Meanwhile a bad or apathetic doctor, policeman, etc. will tend to receive little friction for it while you have to fight uphill to get basic care, all while being milked of as much of your money as possible and still having to wait unbearably long for useful treatment.

Likewise, there's such a range of outcomes, and when it's involving chronic diseases combined with an apathetic or bad doctor, you can be stuck realizing you've wasted months with no resolution (not even getting into any potential costs) only to now have to start all over again potentially several more times just for a sliver of hope that you'll find a doctor who's caring and competent enough to finally help you out. So sitting on the receiving end feels like being bled dry by people who couldn't care less about your suffering or if you die, so long as you keep paying them, with little realistic recourse other than accepting that you got burned and moving on.

In any case, just my two cents from what I think seems like a somewhat related view but with a different "spin".

The point is that the "bad or apathetic" doctor doesn't exist; It's not distinct. This is just default.

People are treated based on convenience to the doctor and their moral judgements. EVERYTHING in medicine works the opposite from the propaganda. I've been convinced it's part of a trope.

Any time a profession tries to convince you it's not something (eg. do know harm, treat regardless of morality, ect.), it is ALWAYS because they were doing exactly that, people correctly detected it, and now they're doing damage control.

>to artificially reduce the work force to benefit current workers at the cost of future workers

is that really the purpose? or is it that an entire industry has been built on top of the trades, and that industry does whatever to continue to grow?

> We're all gonna need medical help some day...

95% of health is being proactive about your health: food, fitness, sleep, dentist, etcetera.

I wonder how much doctoring is due to negligence of a healthy lifestyle, or perhaps chronic choices (addictive substances like alcohol, shift-work).

> But we're all going to have severe medical problems at some point.

Which often are untreatable - and the doctoring is regularly prophylactic. Hip-replacements are an obvious outlier.

> 95% of health is being proactive about your health: food, fitness, sleep, dentist, etcetera.

Maybe 70%? Genetics play a huge role. You will likely need a doctor if your family has a long history of cancer.

> 95% of health is being proactive about your health: food, fitness, sleep, dentist, etcetera.

You're young, aren't you?

The percentage is significant, but nowhere near 95%.

I'm middle-aged.

I might be over-estimating the percentage. I might also be over-estimating how much we can affect diabetes, weight, fitness, addiction.

I can say that the chronic health problems of my peer-group often appear to be self-inflicted.

Of my dead acquantances there are maybe a few groups: (1) health problems caused by childhoods of poverty, (2) health problems that we haven't solved yet which the medical system helps little, (3) suicides, (4) crashes/accidents, and (5) health problems caused by smoking, drinking and drugs (e.g. HepC).

Also acquaintances with chronic conditions often don't follow medical advice anyway e.g. diabetic friends that abuse their bodies. Or people told to quit drinking or smoking that do not stop.

I'm not saying it is easy. I am saying I know plenty of acquantances that have made difficult choices to improve their lifestyle choices (presuming cause not correlation), and others that have not made positive changes.

Context: I'm in New Zealand, so healthcare is mostly free and of reasonable quality. We have lots of immigrants so I have some exposure to people from other (often adjacent) cultures.

I had rectal cancer at age 40. There were no indications that my lifestyle caused or contributed to it. I rarely drank, didn't do drugs, etc etc. I might have had a genetic predisposition, but who knows, cancer is a complex thing. If I didn't have insurance, my medical bills would have easily been over $800K. So enough with your BS statistics that you pulled out of your ass.

Obviously many people get critically ill for no reason, totally without apparent casualty.

https://bowelcancernz.org.nz/about-bowel-cancer/early-detect... says about prevention: While no cancer is completely preventable, a healthy diet and regular exercise can lower your risk of bowel cancer. Numerous studies have indicated that a diet too rich in red meat and processed foods can heighten the risk of bowel cancer. However I would guess the percentage amount you can lower your risk by is below 1%. Across all health outcomes, healthy food choices and a daily walk can have a large effect overall.

It seems to me a hell of a lot of our healthcare funding goes towards people that make no preventative effort towards health. I have friends and acquittances with chronic conditions due to alcohol (diabetes, excessive obesity, gout, Korsikov's, accidents), smoking (emphysema, cancers), severely damaged joints (impact sports, car accidents), drugs (hepC, OD, teeth, accidents and worse).

Personally I eat "risky" foods , occasionally I drink excessively, I heartily enjoy high risk sports and activities, and I definitely don't exercise enough. I am not trying to preach: my point is many close their eyes to known risks.

I certainly am not blaming your cancer on your lifestyle. I sincerely hope the best for remission.

> I didn't have insurance, $800k

I'm in New Zealand and our taxes pay for reasonable quality cancer care for all - probably not $800k worth often. The sticker price for the US insurance system is often grossly[1] overstated (for reasons). I've seen our healthcare system mostly work (and I've seen some failures too).

[1] e.g. Hospital billed $100K, insurance negotiated to about $20K. The actual doctor only got $2-3K. https://news.ycombinator.com/item?id=37977337

I have multiple problems with this comment

> 95% of health is being proactive about your health: food, fitness, sleep, dentist, etcetera.

This is a statistic pulled out of nowhere.

>> But we're all going to have severe medical problems at some point.

>Which often are untreatable - and the doctoring is regularly prophylactic. Hip-replacements are an obvious outlier.

Again this is pulled out of nowhere. All types of joint replacement, stents and heart surgery are major procedures which are common and not prophylactic. Prostate cancer surgery has an 85% success rate in eradication where I live, and no, I didn't get it from bad lifestyle choices.