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Comment by maxerickson | Hacker News Reader

A lack of government funds is not a cap!

What would they do if the government didn't fund any slots, just shrug and decide they didn't need doctors?

Note that I'm not opposed to the government funding lots more slots, I am objecting to the presumption that government funding is the only possible way to make a doctor.

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If the government didn't fund any slots then graduate medical education programs would charge the residents themselves instead of paying them a salary. Then physicians would finish their education $1M in debt instead of $500K (or whatever) today. World that be an improvement?

There are a small number of residency slots funded by non-profit foundations but those are a drop in the bucket. None of the other major players in the national healthcare system have an incentive to pay for this stuff.

> World that be an improvement?

Unpopular opinion: if the student will be able to pay that loan off in 10-20 years and maintain a good standard of living while doing so, then it is probably fine.

> None of the other major players in the national healthcare system have an incentive to pay for this stuff.

I'm pretty sure the entire system's revenue model breaks without physicians, so there are plenty of businesses (hospitals, labs, practices, etc...) with an incentive to have more billing capacity.

Out of curiosity, how were new doctors being trained before Medicare existed?

AFAICT, way back in the day hospitals and clinics did residencies out of a desire for free/cheap labor, the same reason that some firms provide internships in other fields today. Nowadays the costs and obligations of providing a residency far exceed the benefits of the lower cost labor.

Perhaps, then, those who have graduated into practice and who are now earning big bucks ought to absorb part of the cost. For example, training residents at some reasonable frequency could become a requirement of license renewal.

Not all physicians live and work near a teaching hospital where residents are trained. This isn't something that can be done just anywhere. And not everyone makes a good teacher; forcing people to teach who don't want to do it will guarantee bad results.

I really don’t understand how the average resident could be a cost center for a hospital. At least over the course of their 4-6+ years.

There are some hospitals you will go to (big names!) where you will never actually see an attending physician most of the time. Your entire care team are residents.

How a hospital can’t turn a profit off $60k/yr “junior doctors” doing all the actual work is beyond me. I’m sure there are costs I am not considering, but my immediate gut reaction is that it’s nearly all creative accounting to pretend residents cost more than they bring in - to keep that sweet government subsidy coming in as well as limiting the number of slots.

Some programs of course this makes sense, but on the whole it doesn’t seem to pass a smell test to me.

I've always wondered the same.

For the math to work, the fully qualified attending would have to be ~10x more efficient than the residents ($600k salary vs $60k salary - very rough, obv).

The current state seems to be "a single attending is more efficient practicing solo than the same attending overseeing five residents"

Some of this is an internal accounting problem. The net income (or loss) from operating a residency program depends on how you allocate associated revenues and fixed costs to it. But empirically the fact that teaching hospitals aren't all rushing to expand their residency programs indicates that they probably aren't profitable.

The value of residents varies a lot by experience and specialty. Like a 1st-year neurosurgery resident might be worse than useless and a huge burden to everyone around them. Whereas a 3rd-year family medicine resident can do a lot with minimal supervision.

While residencies have existed since well before Medicare was passed, they were mostly something elites pursued. Overall, residency wasn't an absolutely necessary practice until the mid-late 20th century. By the 70s, with the tailwind of the baby boom, the practice became normalized.

https://en.wikipedia.org/wiki/Residency_(medicine)#:~:text=B...

Our demographic makeup means we have more elderly in need of care and fewer to care for them, which means we will need to revert our requirements. The UK is already discussing/planning-for this in their healthcare system: https://www.independent.co.uk/news/health/nurses-doctors-deg...

I understand that it's scary that care quality may be lower, but that argument is similar to demanding that every road worker and civil engineer have a PhD. Our bridges and roads would likely be better if all participants were so educated and qualified, at least for the horrifically expensive and few roads/bridges we would be able to build.

What will probably happen in most US states is that physician education will continue to require residency. But routine primary care will increasingly shift to Physician Assistants and Nurse Practitioners. Real physicians should be reserved for the more complex cases.

I agree with this as a possibility for general doctor visits.

I already mostly see NPs for my checkups. If they aren't sure, then I can jump through the hoops to get a Physician.

It works well and I get plenty of time to discuss things during my appointments.

EDIT: I still think my original point may stand for specialists however, we'll have to see how it shakes out and what healthcare systems under more stress than ours decide to do in the near future.

Exactly. If you create a regulatory system so strict that you cant make doctors, you end up with a shortage, and creating a new class of professionals that do what doctors did before.

I think there are parallels to nursing as well, with increasing credentialism and then creation of new classes. 30 years ago nurses entered the workforce with a 2 year associates from a junior college. Heck, my highschool had a nursing occupational program.

Presumably the government could at least try to change the incentives that they are already heavily involved in shaping.

There are also residency slots not funded by Medicare or any foundation. They pay the same as the funded slots. These slots exist because it's usually profitable to pay a resident physician to deliver care at a fraction of the salary of an attending physician.

Running surgical residents ragged for 80-100 hours per week for several years and only paying them $70k/yr seems extremely lucrative.

> Then physicians would finish their education $1M in debt instead of $500K (or whatever) today. World that be an improvement?

Maybe the graduate medical education programs would have to compete on price as well as quality and reputation?

You're correct - a hospital could indeed find alternate funding for residency slots. Medicare funds something like 70% of them today, the rest are funded by state/local government or non-profits.

But, the fact that hospitals don't fund their own seems to prove the underlying assumption - that offering a residency is a net loss to the hospital. If that weren't true, they'd fund the slots on their own.

Perhaps we could consider making it less burdensome?

It's bizarre that these discussions seem to start from the assumption that we got here intentionally by only making good decisions.

The people have "decided" that they prefer extremely high quality and cost doctors to a high supply of doctors.

Regulation, left unchecked, favors constant indirect damage from shortage to more visible direct harms.

This is why it takes 3000 hours of training to cut someone's hair.

The status quo might be more profitable for hospitals though.

The lack of doctors allows hospitals to charge more money for access to the ones they have. And right now the government foots the bill for training new doctors.

If they funded new residency slots they'd simultaneously increase their expenses, and reduce long-term revenues. Even if the resident's work is profitable by itself - in the sense of generating more in billings than the costs in salary, benefits, and teaching time - it could be bad for the hospital in a decade or two.

If the government simply ended the practice of funding residencies then hospitals and the rest of the medical establishment would be forced to come up with a new approach. Until then they're content to ride the gravy train.

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