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Comment by lesam | Hacker News Reader

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.

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> 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.

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