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Comment by Rinzler89 | Hacker News Reader

The understaffed healthcare system works with overworked doctors on the basis that having a tired and overworked doctor is a lot of the times better than having no doctor at all, because (s)he most likely can end up saving more lives than taking with their tired brain. If your operations have a 90% survivability rate it could still be considered a success despite those 10% they end up killing, because 90% is a lot better than 0%.

Meanwhile a tired pilot is more binary, it either can have 100% passenger survivability if things go well or 100% fatality if things go tits up, meaning the risk are too high to take chances.

It's basic game theory.

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Sorry, that is bollocks. That is the story most people believe, and makes for a convenient story for those people actually to blame. Funnily, it is also the story most doctors themselves seem to chose to believe in.

First, those are not the only choices. There is also the the option of training and hiring more doctors. 2

Probably, there is also an option of making more efficient use of doctors time, but that one is more complicated.

Most of the work of doctors is not life-saving.

I think, you see a standard problem of pushing shit down or up. Government lowers budget, pushes quotas down, which gets pushed down further until it reaches the bottom rank and file, the doctors.

They have to "do more with less" (Not limited to public sector, see Boeing), and that works for a while, until it doesn't.

> Most of the work of doctors is not life-saving.

Yes, but working out which parts are and aren't critical is the $64,000 question.

I think, that is a bit besides the point I wanted to make.

Yes, it is very hard to know a priori, what is life-saving, and what not. No, I do not wanted to suggest that the work of doctors it is not important.

The common understanding of doctors (their self-understanding included) is, that their work is very important, to the point that they exploit themselves. Or allow themselves to be "exploited".

In this forum, more commonly you have people here working on productive systems, which can empathize with the feeling the responsibility for the operations and not wanting to drop the ball.

People with that mindset think, they may safe a patient / the system, but working oneself to exhaustion won't solve those problems. And on the contrary, the exhaustion may be a contributing factor of making things worse in various ways. One directly by your actions, the other indirectly by covering up systemic problems.

Indeed. Is that weird mole just a weird mole, or is it skin cancer?

>They have to "do more with less" (Not limited to public sector, see Boeing), and that works for a while, until it doesn't.

Yes, which brings us back to the point I made about it being a numbers game. IF you start cutting back pilots sleep and planes' QA to boost profits, you'll reach the "it doesn't work" phase (planes dropping from the air killing everyone) much sooner and at a steeper rate than with overworked doctors where the decline is a lot slower and gradual hence why this issue gets ignored more easily by those in charge, because it's so slow that people keep getting used to this as the new normal.

IF a few Boeings fall from the sky, people might stop flying Boeings, but people won't stop going to the doctor just because some people get killed from malpractice (which is statistically more likely than dying in a plane crash).

It's easier for the public to recognize and be outraged about 237 dead airline passengers compared to 237 dead patients even if both are caused by overtired pilots or "providers" (I hate that word for it's vagueness).

I think having more physicians is the core thing.

The US stands out in having so few physicians per capita (per 1000 it's 3.6 in the US, here in Sweden it's 7.1, in Germany 4.5, Spain in 4.6). This has been discussed before here before, and I don't think it was controversial that a sensible solution was to simply have more physicians.

I think one major thing that the US is doing wrong with that which is not so well known is that the training starts rather late in life. Thus you get less out of the physicians you train. Here in Sweden a physician has a MSc in medicine and is ready to meet patients and be trained when he's 23, and I think this has the benefit that there's no need to overwork them.

By the time they're 30 they'll have all the experience the need without having been overworked, and not sleeping enough kills intelligence, memory, drive, all mental qualities one may have.

I think these two policies, ensuring that people graduate earlier-- removing the pre-med and having people start right away with a medicine program, and graduating in 5.5 years, that's the right approach.

Physicians would earn less, but they'd have substantially better lives. Being able to start younger also means success younger, and happier families.

This was in Australia (4.1).

Ah, thank you.

Good point, and you can turn it around: Doctors are never "finished". They could always do more to help patients. So in contrast to aviation, where there is a clear corridor of things to do, doctors have no natural upper bound on their work.

IMO this is doctors acting as enablers of a toxic administration. They need to refuse outright to not work crazy hours and force the system & administration to come to a crisis. The admins are not working those hours and thus do not feel the consequences of their actions and by enabling their bad behavior they are not getting consequences from their bosses, which are politicians and customers.

I think it's a matter of the 'tradinionalist' mindset in doctor education

most doctors will think "well, I went through a hardcore intesnse experience in medical school, therefore that's how it should be"

I'm saying they've normalized overwork as part of their specific subculture of modern medical professionals. they really believe they won't be as good doctors without this arguably abusive overwork system

it's yet another group of people who all belive in some form of the "no pain, no gain" mindset; the issue is these groups don't give nobody anything unless there's some harm or pain involved

What about the meta-game, where doctors get burnt out or suicide, and that increases pressure on the remaining doctors, in a negative feedback loop.

We should impose work limits on doctors, just like pilots.

What I don't understand:

Say I'm a doctor, and I declare I will only work my 40 hours (or however much a full time is where you are). I will literally leave when my time is up. Oh, and I don't pick up phones outside of work. Or read emails.

What will anyone else do about it? Fire me? Then they have even less doctors...

It seems to me doctors do have the power to change things, even without collectivizing. But for some reason I don't understand, it doesn't seem to work out.

They would earn less money.

> the power to change things, even without collectivizing.

Not really it's a sort of prisoner's dilemma. The one who refuses to work stupid hours gets fired and someone else has their job. If they stood together then it might work.

But there is no one waiting for their job. In most places there is a shortage of doctors.

> Not really it's a sort of prisoner's dilemma. The one who refuses to work stupid hours gets fired and someone else has their job.

Is this relevant in a profession that already doesn't have enough practitioners?

I mean, let's say there is a shortage of 100 doctors in a location that currently has 900. If you fire one, wouldn't they easily pick up one of the open 100 slots?

The individual concerned is still fired and has a harder time surviving than the company that fired them.

There's a duty of care* that doctors have. If there's no one else to care for your patient, you're required by law to care for them. (I'm not a doctor, but it's a real thing) It's one thing to risk being fired. It's quite another to lose your profession.

*google "duty of care" for more info

If you don't have your own practice, yes, they might fire you. If you're only working "part time", you're bringing in less in patient associated payments for the owners compared to people who work more.

There's also the fact that doctors might prefer $700k/yr working 80 hour weeks vs $350k/yr working 40 hour weeks. A lot of people who become doctors are workaholics and were behaving in a similar manner throughout their schooling.

> If your operations have a 90% survivability rate it could still be considered a success despite those 10% they end up killing, because 90% is a lot better than 0%.

> Meanwhile a tired pilot is more binary, it either can have 100% passenger survivability if things go well or 100% fatality if things go tits up, meaning the risk are too high to take chances.

This isn't how the math works. A tired pilot either kills or doesn't kill their passengers on a given flight the same way that a tired doctor either kills or doesn't kill their patient in a given operation. In both cases it's 100% survive or 0% survive.

Pilots aside, we also have laws about keeping truck drivers from driving too many hours, and accidents involving drowsy truck drivers are unlikely to have fatality counts measured in the hundreds.

The difference between doctors and pilots/truckers isn't in the amount of risk involved, it's that surgeries are expected to have a non-zero fatality rate. A doctor can do their job perfectly and still lose a patient, so it's harder to prove that the fatality rate would be lower if we gave surgeons more rest. When a truck driver falls asleep at the wheel and kills someone it's obvious because they did something provably illegal or unsafe right before the crash. When a surgeon fails it's a lot harder to prove it was preventable.

It's a little different because an unflown airplane doesn't kill people, but an untreated medical condition does.

Sometimes it can happen extremely quickly, but also be largely preventable with proper and timely intervention (like with a burst appendix).

but the alternative isn't having no doctor at all, but to get more doctors, so the "basic game theory" is about why the limits on more doctors stay in place despite the higher risk of death etc.

> but to get more doctors

Have you found that magic fountain of endless doctors?

Sure, it's very easy! Just do things that prevent burnout (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8834764/) and the job gets more attractive, drawing more students and producing less attrition:

- Valuing work gives meaning (money, appreciation)

- Autonomy gives feeling of control

- Managing burden prevents overwork, exhaustion and fatigue

> Sure, it's very easy!

I have issues when someone says a complicated issue can be solved easily…realistic expectations…

The answers to some problems may be easy to know but difficult to implement, due to political/financial will etc. For eg we know how to reduce emissions, but it's still a challenge. In such cases advocacy and raising awareness can be helpful.

"Easy to describe" is very different from "easy to do".

It reminds me of the famous "just eat less and exercise more", the alleged simple solution to the global obesity epidemic.

Sounds good, but healthcare already constitutes 17% of US GDP. And with an aging population, spending has been growing faster than the rate of inflation. Most of the funding ultimately comes from governments, self-insured employers, and individual patients. Those groups have no appetite for spending more.

https://savegme.org/

The entire medicare residency slot system seems a bit self inflicted, why hasn't an alternative system popped up?

Also this is a global problem, not just the USA. You look at videos of student doctors in the UK for example and there are similar abusive schedules. https://www.youtube.com/watch?v=KE1XwEMGm0I

Read Adam Kay's "This is going to hurt" [1]. It was made into a miniseries. I read the book and it was so horrifying that I couldn't face watching the dramatisation.

It doesn't seem to be such a big problem here in Norway where things like working time directives are taken much more seriously.

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

Yeah it’s called correct incentives - I look at the over work, and insane stress levels that doctors suffer and I say “NO THANKS”

I am definitely not the only one

The AMA only allows a fixed number of seats in medical school.

There also can be tiers of medical doctors. Most doctoring work is routine, and can be handled by a more of a medical tech.

False. The AMA has no regulatory or accreditation authority over medical schools. Schools can admit as many students as they want.

The bottleneck right now in producing more US physicians is lack of Medicare funding for residency slots (graduate medical education). Every year some students graduate from accredited medical schools with an MD but are unable to practice because they don't get matched to a residency program. Congress hasn't significantly increased funding in years. At one point the AMA did lobby Congress to limit the number of slots but they have since reversed that stance and are now lobbying for higher residency funding.

https://savegme.org/

There are already tiers of clinicians. Much routine care can be delivered by Physician Assistants or Nurse Practitioners working under a Physician's supervision. Specific limits on their services are set at the state level.

Why do residency programs require subsidies, are resident doctors each a large net financial loss to a hospital? I can't think of many other career paths where someone out of school is so underprepared for the job that the business could not employ them without someone else footing the bill, doesn't seem like a reasonable system that will sustain itself in the long term. I suppose pilots are a bit like this but they typically take the financial risk on themselves to some degree or get the taxpayer funded training via the military.

Hospital accounting is always messy. There's no simple way to determine whether a particular program is profitable or not; it comes down to how the accountants allocate overhead costs. But the fact that publicly owned and non-profit teaching hospitals aren't voluntarily expanding their residency training programs is strong evidence that they operate at a loss.

Very few other career paths have such an extensive body of knowledge, licensing requirements, and low tolerance for errors. Law is maybe a bit similar in that new associates in most firms are worse than useless, and training them sucks up a lot of time from senior associates and partners. But law firms aren't subject to price fixing, so they have more freedom to raise their rates in order to cover those costs.

Do residency slots mandate public funding?

Aren't they doing actual useful work same as regular doctors? (albiet with a higher error rate)

So they could be funded through via charging for services rendered.

Of course their effective pay may be close to zero, after malpractice insurance, but it will still attract some number of med school grads who can't get in otherwise.

Residency slots don't mandate public funding. The majority of funding comes through the Medicare program but private foundations also contribute some. Private payers (insurance companies) also indirectly subsidize residency slots by paying teaching hospitals higher rates.

Some services performed by residents are billable, especially the more experienced ones. But the programs as a whole run at a loss after accounting for overhead so hospitals won't add more slots without a matching funding source.

Presumably it will only happen in hospitals that charge high enough rates to fully cover the cost of overhead, I.e at one of those luxury hospitals

What "luxury" hospitals? I've never seen the word "luxury" used to describe the teaching hospitals which train most residents. Most of them have high proportions of Medicare/Medicaid patients where rates are set by the government and hospitals have zero ability to charge more. I don't think you understand the reality of healthcare economics; this isn't a free market where sellers can change prices and supply to meet customer demand.

Colloquially, from the folks I've spoken to, luxury refer to those hospitals that offer high-end rooms, fancy furniture, concierge service, and so on, for a higher fee. I.e. Places where the differences are immediately obvious to the layman

If it's indeed the case that most hospitals can't cover their overhead then by default it must be limited to the high end, if it ever does happen.

> The bottleneck right now in producing more US physicians is lack of Medicare funding for residency slots... Congress hasn't significantly increased funding in years. Much routine care can be delivered by Physician Assistants or Nurse Practitioners working under a Physician's supervision

We should all accept a lower standard of care because hospitals can't find more funding to train doctors? What are all the $20 aspirin paying for? How does every other profession manage to train new members without needing a literal act of Congress?

Where would you suggest that teaching hospitals find more funding? Most of them are non-profits, or operate as part of state or local government agencies. They have no ability to negotiate higher rates with Medicare/Medicaid and only limited ability to negotiate higher rates with private payers (typically set as a multiplier to the Medicare rate). Voters generally haven't been willing to raise taxes. There is probably some waste that could be trimmed but it's tough to figure out where to cut without impacting patient care quality. Much of the administrative overhead is forced upon them by unfunded government mandates around reporting, quality, security, credentialing, and interoperability.

Private donors are always welcome. If you have a few million to spare then you can personally fund a residency program expansion at your favorite teaching hospital.

I won't attempt to defend ridiculous charges for certain basic medical services. Hospital accounting is a funny business, and almost entirely artificial. The teaching hospitals tend to deliver a lot of charity care (including writing off a lot of bad medical debt) and some Medicare/Medicaid reimbursements don't even cover their costs. So, they attempt to close the gaps by jacking up other prices as high as they can.

You should accept a lower standard of care because as a society we have limited resources and can't afford to waste them. If you have a boo boo then a NP can clean the wound and apply a bandage. That's what happened to me when I crashed my bike last year and it was fine. Physician time should be reserved for more complex cases.

Are you talking about the same hospitals that tripled the administrators to doctors ratio in the last 50 years (don’t remember exact numbers)? Is that why we need to accept a lower standard of care?

P.S. wait, you went to a hospital to apply a bandaid after you fell off your bike? Are you serious? Perhaps that’s the real problem…

The AMA doesn't have direct control over it, I was wrong about that. But they heavily influence it:

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

That's a straw man. We do not need "endless doctors" just more (or some way to use them more efficiently).

The number of doctors are limited by the pipeline to educate them.

Most countries I know, the number of people admitted to study medicine exceeds the number people wanting to study medicine vastly exceeds the positions to do so, and admissions are highly competitive. To a point, I'd say, that it is becoming ridiculous.

So, there is not a lack of people wanting to become doctors, but a lack of people allowed to even start to study to become one.

If you didn't cut the "limits" from the quote, you might've found a hint on how to answer your question without any magic involved. For such a small profession the general talent pool is endless indeed unless you... limit

Not so sure about that. According to a few studies, medical error is the 3rd leading cause of death, behind heart disease and cancer.

Many operations are elective. In such cases, having a tired surgeon or nurse may be worse than delaying the procedure, or even skipping it.

https://www.bmj.com/content/353/bmj.i2139

https://pubmed.ncbi.nlm.nih.gov/28186008/

https://journals.lww.com/journalpatientsafety/Fulltext/2013/...

This has been extensively debunked. Read the original methods of the BMJ article that you linked. They took every single minor error, like prescribing medicine 15 minutes late, and if the patient died, even of an aggressive cancer that they had already, it would be counted in the 'medical error that caused the death' statistic.

https://www.nytimes.com/2016/08/16/upshot/death-by-medical-e...

https://www.medscape.com/viewarticle/863788?scode=msp&st=fpf...

https://sciencebasedmedicine.org/medical-errors-2020/

Of course practicing doctors and nurses are going to swear up and down that it isn't true. They are the perpetrators. Ask any person who has had to spend time in a hospital recently, and watch your "de-bunked" turn back into a "re-bunked." These jokers can't even keep the charts straight. It is fast-food-tier service for a life-and-death commodity.

…but if you postpone a procedure, the medical facility they work at isn’t able to keep up with their revenue targets.

I think someone also did the math and figured out that having fewer handoffs side a patient led to better outcomes so now there’s pressure to have two doctors per24 hours instead of three or four.

That's a very good point. I think 12 hour shifts aren't necessarily bad, but even EMTs/firefighters (in some places, afaik) have downtime after their shift. Maybe work one on one off, or maybe 2 on 3 off. I suspect that's still much better than the practice of 24 hour shifts.

Did they really study how doctors and other staff work in enough countries?

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