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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.

>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.

> 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 :)

"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.

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)

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.

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.

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

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.