Already ML algos are more accurate at diagnosing melanomas from an image than dermatologists - but we will never get that tech because doctors are fiercely protective of their salaries and have captured the arm of the state to help them do so.
In the US you need a prescription within the last year to buy contact lenses. European countries do not require this. Not only does this mean contacts are more expensive and come from fewer suppliers, but demand for appointments with eye doctors would never go down, even though a test of vision could easily be done now by an automated machine where you choose a series of A/B options.
Forcing people to do it just to get a contact prescription is indeed a cash grab.
But yes, they will sell it to you as being for your own good.
Those sellers are incentivized not to look too closely at your prescription and whether the year has been altered.
Obviously breaking the rules doesn't make it less of a cash grab but at least one can work around it.
Same here in Japan. I just buy my contact lenses from a shop online; I don't need a prescription at all. The only reason to go to the optometrist is when I feel my lenses are no longer the correct prescription (since your eyes change over time).
And for the eye-health tests that eye doctors try to use to justify yearly visits, that's done for free at the annual health check that everyone gets. Unlike the US with its weird system that considers eyes and teeth to not be necessary for health, those are all covered by the same single health insurance that you normally get, either through your employer or from the government.
I was told you even need prescription to buy glasses, which is ridiculous.
Even many places online require it, but some just let you input the values.
When I said this to an overnight glasses website's customer care they basically said if I ordered without a prescription I'd be committing a crime.
You really can't make this up!
In my experience, the cost for glasses/contacts is mostly in actually buying them anyways. Therefore, I just go get my eye exam done and then just buy them online for much cheaper than any retail store. Supposedly the cheap online glasses aren't as good, but they're good enough in my experience and then I don't feel quite so bad when I inevitably lose them somewhere.
The UK is bad at creating a pro-business/pro-investment environment, so we have to buy in stuff from elsewhere, even though it's not well-suited to our needs. Or best case we find US-based investment for our companies.
> The UK is bad at creating a pro-business/pro-investment environment
I've discussed with a number of people who work directly on DL for imaging at a major hospital system in Boston. They say that (outside of the doctors they work directly with) fear over competition and losing out on the pricier billings are one of the largest barriers to getting their (very accurate) tech deployed more widely.
If 'additional mouse clicks' is a major barrier to physicians using a tool that leads to far better diagnosis outcomes of a fast-progressing and deadly disease, I'm not sure why that is an argument for why things should continue to be as physician-gated as they are.
I will happily perform the 30 extra clicks myself if it is my potential melanoma. But if I were to offer it as a self-serve app ($2 for melanoma diagnoses too cheap to meter), I would be thrown in jail.
Apologies if the link to that article is one mouse click too many for you.
[0]: https://med.stanford.edu/news/all-news/2024/04/ai-skin-diagn...
You're just too sour, man. I'm not saying it won't work, not even saying with certainty it doesn't work now. I'm not refuting protectionism plays a role either. What I'm saying is just that clinical integration of new tech, especially involving computers, is much more difficult than you seem to believe. And that the primary reason for that is not the greed of docs, which in my experience holds far less political influence than you think. I'm all for new tech, so chill out a bit.
Thank you for your sacrifices, including to the oncoming ML "clinicians."
Every working stiff at all income levels sacrifices disproportionately to their income, and if I were a high school teacher, I'd belly laugh at this doctor pity party.
The front line primary care doctors and nurse practitioners dont make as much as IT people quite often.
Data on doctor salaries is very difficult to come by publicly, however H1B salaries indicate the average pay for H1B PCPs is $200k [0]. These are the lowest paid physicians. If you look at the data, many many physicians are making much more than that - with many specialities averaging $300k+. Generally H1B workers make less than comparable native-born (even though that's illegal) so we should view this as a lower-bound.
That puts hourly pay for average PCPs lower than the top SWEs, but comparing average with average or specialty with average and you're already quickly outpacing large majority of SWEs.
An OB/GYN or anesthesiologist is closer to $200k+
Of course, there is a typical shortage of doctors prying for this coveted physicianhood /s
I have no clue if that's improved (with another decade of training, since I dropped out), but an even larger majority are miserable.
Anecdotally, I'm a software engineer. My wife is a physician. We'll be in our 50's before my wife's career out earns mine. That financial hole of med school and residency is so deep and the salaries on the other side just aren't _that_ much better than other paths. I didn't even pursue FAANG level salaries, either.
That being said, job security and availability is far, far better for my wife. We can basically live anywhere we want and she can find a job.
You mean it's not us tech workers? :P
Seriously though, I've seen the pay scales in some countries, they're nice and all, but they come with many extra years of training (expensive plus limited income while you do that), plus shift work and overtime that is bad for everyone (staff and patients) and which shouldn't be necessary — and wouldn't be necessary, if most nations all hired about twice as many of them… but that would require us to also train twice as many and politicians who do that get the budget shortfall today while their successors (possibly in other countries) get the reward for the benefit of their being more trained doctors and nurses.
I'd pay them the same for less hours. Mandatory less hours — go home and sleep, let someone else tend to this patient while you rest.
Do you accept the criticism that the US simply artificially limits the supply of doctors, which leads to overwork for physicians, and worse health outcomes for patients?
Do you think most doctors would take less hours for a somewhat lower salary if you it was possible?
Young docs would absolutely work less for less if possible, I think. Old docs wouldn't. IMO, that's reflected in the rise of big network providers such as Kaiser and friends.
In Europe, access to care is better IMO mainly because both patients and docs are far less aggressive, and often quite happy just doing nothing. Which is in fact the true problem about US healthcare: the culture of absolutism.
To pretend that the restrictions in other countries like Germany are at all comparable to the restrictions in the US is laughable. Just look at the work involved for a German doctor to legally practice in the US vs the reverse if the controls are so similarly strict (they're obviously not).
You are very clearly engaging in motivated reasoning in this thread.
> cultural issues
Within the US, the limitation of admission of US students into med school is another matter. And I think people are probably right to call out protectionism in this case. But I have no first hand experience, being a foreign graduate myself.
I'm just a random bloke having worked in Boston, though. So YMMV.
High doctor-per-capita could be a sign of inefficient use of resources rather than being a good thing.
Examples: Do you need a prescription for stuff that's otherwise over-the-counter elsewhere?
Is over-the-counter stuff paid by (state) insurance if you get a prescription for people that don't value their time?
Do people go to the doctor anyway for every possible matter (e.g. cough/cold/flu in otherwise healthy people)?
Do you have to make a pointless appointment with your GP every year to confirm you still have that incurable disease in order to keep seeing your specialist? Or renew that allergy med prescription every allergy season? Or go once for a lab test, and then again in-person just to find out the results, even if they're negative?
Who puts in most IV lines? In some places it’s a doctor, other places, nursing staff.
In Europe, they somehow get through medical school without them.
(Not that any of this would matter because the incentives of the residency system are perfectly set up to make it impossible to train any more doctors.)
It's also a meritocratic matter: you have to take a lot of risk to make a go for medical school, and the best candidates may not be able to afford the risk of failing to achieve their med school goal and ending up with a degree with ??? value, so the best may not take that path.
Or worse, taking an easier degree program (to beef up their grades and have time for other application-enhancing activities) and not getting themselves educated to their full potential.
> Do people go to the doctor anyway for every possible matter (e.g. cough/cold/flu in otherwise healthy people)?
26.1 / 10000 * 336M Americans = 876960 active physicians, and the error is probably a measurement artifact (how do you define 'active physician') and the fact that both the population and number of doctors vary over time.
https://www.who.int/data/gho/data/indicators/indicator-detai...
> Do you think most doctors would take less hours for a somewhat lower salary if you it was possible?
It is possible. Lots of doctors work fractionally. It's one of the easiest fields to do it in. Given the artificial shortage, hospitals essentially have to accept it.
The reality is many doctors are simply driven people. They don't really mind the hours, but they do mind the type of work. A lot of it is just terribly unfun.
> US supply is artificially limited. There's literally no arguing this. There are essentially a fixed number of residency spots and that's basically the only way to become a physician.
I was under the impression that the limitation is a bit different in other countries. There is no hard, fixed limit. However, there is still practical limitations around how many institutions want to go through the accreditation process and support the education system. "Anyone" (hand waves a little bit) can start a program, as long as they meet the requirements.
In the US, it's a hard limit set by Congress. Even if you want to run a residency program, you can't.
Technically, there are ways around the hard limit, but they're extremely challenging to implement.
I will be honest, I've had better luck with google than most doctors. I've had doctors say things which were completely incorrect. I've had doctors prescribe unnecessary and not advised meds for what they diagnosed me with(incorrectly).
I have friends who are pharmacists and they agree with my opinion, and they interact with doctors daily.
It'd be nice to have this decision tree being built out in the open, ultimately everyone needs it.
I know a few surgeons who are nerds about surgery like many on HN are about technology. But they are also the first ones to tell you not all doctors are the same.
Grant the status of their profession to their opinions.
Even worse with lawyers. AI will never make a real difference in that field.
If you have enough time, read this 5-page article. Can this be explained by anything else but naked greed?
https://digitalsmiledesign.com/files/Old-Website-Assets/PDF/...
You can explain all you want, but the US is the only country that has exorbitant bills for healthcare culturally normalized for some reason, despite outcomes being roughly the same as other developed countries.
Unless your explanation sufficiently addresses that (which I doubt, since you are not an economist), no one will care to listen.
So maybe a little less confidence and a bit more humility and empathy (for those that need healthcare and can't afford it).
Though, I do largely agree that the actual assessment by an optometrist is literally unnecessary. I've personally had to adjust my prescriptions because the optometrist pushes me to something that strains my eyes.
It's interesting that we have all these RCTs for drug interventions, but never conduct the RCTs on policy like letting NPs do more procedures, etc.
My wife is a physician. Actual, scientific diagnosis is a ridiculously small part of her job.
Most of her time is taken up on "soft problems". Writing notes for continuity/quality of care. Justifying medical decisions for billing purposes. Advocating with insurance and healthcare administrators. Discussing treatment plans and options with patients. More notes. Well, really, most of her time is taken up with notes. It's really the only way for her to capture all of the soft variables.
Writing notes is a bit like coding. LLM/AI can help solve the problem, but ultimately you still need to go through them piece-by-piece to ensure they're correct.
However I do think that in the process of engaging in wage protectionism (and there is absolutely no question that doctors do this) there is a ton of consumer surplus that is being lost and not captured by either patient or provider. For instance, in the case of the melanoma AI, that is a casualty of the wage protectionism (+ medical conservatism + FDA failure) - the value there isn't being captured by doctors, it is just disappearing into thin air and tons more people will just have undiagnosed melanomas.
I actually think this is the only way to bring costs down. Most providers, equals more competition. More competition leads to innovation and all around better outcomes.
Interestingly, a lot of states are starting to express their frustration with physician supply shortages by expanding rights for NPs and PAs. I think over the next 20 years, we're going to see MD/DO roles transition to largely supervisory roles with NPs and PAs doing most of the work. Much more akin to manager/IC type of roles we see in STEM type fields.
That is higher than the 8% the NYTimes quoted in this 2021 article (which I was basing my argument on): https://www.latimes.com/opinion/story/2021-09-14/dont-blame-...
That AMA-ASSN article has a nice pie chart breaking down the high level categories of total health care spending. Though, this isn't particularly useful for understanding why your individual healthcare might cost so much. This article is looking at nation-state level trends, including things like public health activities and nursing home costs.
Labor does make up a massive part of healthcare costs (I've seen it quoted as much as 60%), but that includes every person in the healthcare field. Physicians, nurses, techs, administrators, billing, construction/maintenance staff, security, etc, etc, etc,
That's sort-of what a NP is, but without the doctor in the room and only if she were reviewing their notes after.
(I know some doctors who this is a sensitive subject so I haven't asked them yet).
A lot of patient care centered specialties (as opposed to surgery or technical specialties, like radiology) are seeing a shift towards NP and PAs. The physician will be legally responsible for the actions of one or more NPs. They'll review their work and ensure their plans are correct.
I don't think that some regulations ensuring the tooth drilling robot isn't going to explode teeth is unwarranted even though that drives up cost of development.
A freshly-minted dermatologist isn't making that much, though they will be in the long term. As a whole, physicians aren't very organized to deal with these types of technological "invaders." The AMA and similar organizations' core competencies have traditionally been limiting supply and creating personnel exclusivity (limiting residency slots, limiting the usefulness of foreign-obtained credentials, etc.)
I promise you can find an endless supply of freshly-minted dermatologists who will sign off on these ML-identified melanomas, bypassing the old guard with their rubber stamp. Once the tech is proven, that rubber stamp is worth nothing and may be removed. It's just too easy to chip away at these types of schemes where "assistance" can be rendered to a licensed professional and eventually completely relied upon.
Despite being poorly-organized, the medical field is collectively quite conservative and moves slowly - "first do no harm" is kind of the name of the game.
The medical profession seems to hold on too dearly to the action/omission distinction. Preventing life saving tech from becoming prevalent, arguing against challenge trials, advocating against NP responsibility expansion, etc. etc. -- all of these things do tons of measurable harm.
But yes, I agree that the US needs major tort reform regardless. I just don’t think tort is the major barrier compared to occupational licensing & the FDA though.
The medical world moves at a glacial pace compared to tech. Complaining that ML algos haven't swept the industry ignores all of the factors pushing it in that direction.
"Best medicine" operates on a consensus model of the most prudent decision-making given present knowledge and evidence. That takes time. Pushing boundaries as a doctor outside of a research environment doesn't earn you brownie points. It increases your chances of getting sued.
You also dramatically overestimate the amount of autonomy any given doctor has over the tools they are able to use. The vast majority are employees. It is like if you worked at Google as a SWE, and I came on HN ranting that you don't want to use the most recent release of Sonnet 3.5 to help you write features faster for Gmail, because you're "fiercely protective of your salary." You would laugh at how ignorant the complaint sounds.
> You also dramatically overestimate the amount of autonomy any given doctor has over the tools they are able to use.
I'm not saying that doctors are mostly choosing not to use these tools - but that lobbying organizations involving collectives of doctors would lobby against it if it ever tried to do a DTC approach or something like that. Please, steelman what I'm saying - I am very aware that doctors who don't own their practice (vast majority of them) cannot simply choose their tools and even those with their own practice are often limited by what they can bill. I know lots of doctors personally.
While I think doctors are paid handsomely and there are critical shortages, I don't think regulatory licensing requirements per se limit access to new and cheaper care.
Healthcare, similar to government, shouldn't be a move fast break things situation. If your service breaks, you just roll back. False or incorrect cancer diagnoses...that's a huge deal.
Imagine your tumor getting missed because of a bug in software, one which a human might have caught. Peoples' lives are on the line here. It's not a game.
as in losing jobs to ML algorithms ? What would the point of a union then :)
No. we are talking about doctors in specific.
Your original point won't stand if everyone in the world is replaced by AI.
> If only you guys had universal healthcare
There would be no private insurance through their employers if no one has a job in first place.
To be clear, I think you're right up to a certain point, but it makes some sense to be very elitist about who can practice in what you'd like to be the medical 'pride of the nation'. Now, scarcity in other regions is another matter, where it makes sense to relax standards. How much you relax the standard is a matter of how low you accept to go in terms of quality.
For example, see [1] where a general surgeon made an average of $118,689 in 1984 and a family practitioner $84,256. This would be $358k and $254k in 2024 dollars. Today in 2024 they make on average $423k and $272k respectively [2].
[1] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4192917/ [2] https://www.whitecoatinvestor.com/how-much-do-doctors-make/
https://www.ama-assn.org/about/research/trends-health-care-s...
Nursing care added another 4.3%, and other personal health care expenditures (dental, medical equipment, and other professional services) added another 16.5%, or about 2/3 of total costs when all taken together.
By the way, an average salary of $423K is pretty good, and a six month wait to see a specialist amounts to denial of medical care. Serious reform is needed.
All the rest of the logic you supplied yourself.
Since you seem intent on sticking words in my mouth, I don’t think doctor are necessarily paid too much, and don’t think limiting their salaries will substantially affect health care costs. I do think doctor salaries probably will go down if their ranks weren’t artificially limited, but society would benefit, and doctors might too with a reduced workload. In fact, the overall proportion of medical costs given to physician salaries will likely go up if their ranks weren’t limited, albeit with each individual doctor making less.
Cutting their salaries in half would have almost no perceivable impact on the cost of care.