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Comment by otterley | Hacker News Reader

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.

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