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Comment by Telemakhos | Hacker News Reader

This is a symptom of a deeper problem in medicine, the subjugation of doctors. It used to be that doctors ran their own practices and were the Götter in Weiß, the gods in white lab-coats. What they said was what happened, and healing patients was their purpose. Now, however, doctors are cogs in a much larger healthcare system run by suits for purposes that one suspects have more to do with money than medicine. If computer workflows are optimized for the suits rather than the doctors, that’s a symptom of a problem whose other symptoms, like rampant price inflation, are yet worse.

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My company builds software for medical office assistants, and our clients are typically doctor-owned clinics. We have literally the same problem, but one step down the ladder. The doctors are making the purchasing decision, but MOAs are the direct users. And ironically enough, we have often run into the same problem. Doctors often don’t see the value in software that solves their subordinates’ problems.

>"Doctors often don’t see the value in software that solves their subordinates’ problems."

This was such a huge problem at my former company, Billit (getbillit.com), that our number 1 method on achieving clients was making such steep referral incentives for doctors, to their colleagues. We only needed one to make scale eventually happen, but the organic clients couldn't empathize with the workflows of their front desk - they didn't care.

At least in the US, many doctors (at least specialists) split off and created their own companies that then contract with the hospitals.

A large chunk of people working in healthcare are all contractors, now, with all the overhead and friction that comes with that.

The only true employees of most hospital systems are the finance people.

and facilities, cops, 'environmental services' etc.

Hospitals employ plenty of people to keep the machine running. No one wants a localized rainstorm in a surgery bay.

Indeed, and something else many people don't know is that a lot of (mid to senior) doctors have ownership stake in the hospitals, or are part-owners of the building that the hospital leases, etc. So it's not a direct "owernship" relationship anymore, it's more like a stockholder who works (contracts) for the company, sometimes with a hop or two in the way. I'm not saying this is good or bad (it doesn't seem at all clear cut either way to me), but it is something I found really interesting

A lot of that is to get around laws that say corporations can't practice medicine. These are state-laws, not federal so in every state it's different.

>doctors are cogs in a much larger healthcare system run by suits for purposes that one suspects have more to do with money than medicine.

Is that actually accurate? The American Medical Association (the Physician cartel/trade association) bribes/lobbies about equal as hospitals/owners.

They also legally reduce supply using their private, unelected, ACGME.

If we use lobbying numbers, they are just as obsessed with money as the owners.

I am a doctor and I run a graduate medical education program. The constraining resource is generally funding, not limits imposed by ACGME. For example, my program is ACGME-approved for two trainees per year, but we have funding for one.

Who decides the funding?

Funding is mostly controlled by the federal government, via Medicare and Medicaid, and if I am not mistaken the funding levels are set by Congress.

You are not mistaken. Contrary to the conspiracy theories you see on here about the AMA, lately they have been lobbying Congress to increase funding for residency programs because that is the primary bottleneck to producing new physicians.

https://savegme.org/

So after studying for a decade a soon-to-be physician needs to go through a government funded job in order to qualify as a physician?

Why don't the hospitals just pay the cost of their staff like every other apprenticeship program? (or add it into the list of student debt that doctor requires).

Anyone who graduates from medical school with an MD / DO degree needs to complete several years of graduate medical education (residency) at a teaching hospital in order to become a physician legally authorized to practice medicine. Most residency slots are funded by Medicare, although some are funded by other sources. Teaching hospitals are usually run by non-profit corporations, or by state or local governments. While internal accounting is always a bit fuzzy and opaque they simply don't have the money to pay residents directly. Most residents generate less revenue than they cost to train. And hospitals don't have the freedom to raise prices to cover the cost of running residency programs. Thus the need for subsidies.

If we force prospective doctors to take on even more debt then we'll likely end up with an even worse shortage. Current levels of student debt are already unsustainable, at least for many specialties.

> Most residents generate less revenue than they cost to train.

Is this just a thresholding issue? What substantially changes about the resident from year 1 to 3? Can you chop residency up into different tiers where they don't need somebody watching them do stitches once they're no longer the lowest tier?

I find it extremely suspicious that a sector with so much money in it can't figure out how to make apprenticeships profitable but an electrician can.

You seem to be confusing amount of money with actual control. Electrical contractors can charge any price they want (subject to customer demand). Hospitals, especially teaching hospitals, have no such freedom. Medicare reimbursement rates are fixed by government fiat. This is not a free market.

Residencies are already chopped up into tiers. Those with more experience have more clinical and administrative autonomy. But for the most part, Medicare doesn't allow hospitals to directly bill for work done by residents. With a few limited exceptions, all of their work has to be supervised and signed off by a qualified attending physician. This training and supervision is extremely expensive.

Any major reforms will have to come at the federal government policy level. This is not a problem that medical schools and teaching hospitals can solve by themselves.

I think it is primarily a matter of insurance expectations and regulation of residents. It dictates what services they can bill for and the amount of redundant oversight required.

It is a self imposed problem.

The problem is largely imposed by Congress in terms of strict rules about what hospitals are allowed to bill Medicare for. This is not something that teaching hospitals have imposed on themselves.

correct, I didn't mean to imply it was by the hospitals, although the teaching hospitals may still benefit from the current arrangement.

Uh... You are talking about the highest paid profession in the US.

There is no debt problem.

I joke about how bad doctors are at math, but this is a pretty obvious case when Physicians are making 200-500k/yr and complaining about 300k of debt.

300k of debt sounds kinda low.

https://www.bls.gov/ooh/healthcare/physicians-and-surgeons.h...

> 2024 Median Pay This wage is equal to or greater than $239,200 per year or $115.00 per hour.

> Physicians and surgeons typically need a bachelor’s degree as well as a medical degree, which takes an additional 4 years to complete. Depending on their specialty, they also need 3 to 9 years in internship and residency programs. Subspecialization includes additional training in a fellowship of 1 to 3 years.

So on ~240k you pay ~50k takes just to the federal government and we'll say 12k to the state. 178k is still pretty good, knock out 80k for living expenses (better not live on the coasts) and you're left with 90k which would (naively) pay down 300k debt in 4 years. That said, you're also probably 30 with a net worth of 0$ and could've done a different career path to make ~240k per year without a decade of education.

Hahahahahaha 4 years to pay off education for the most lucrative profession in the US. (And you assumed 80k/yr for living expenses... whats the median income in the US? 50-60k? hahahahaha)

Yeah thats a steal.

You can't really paint this in a negative light.

Median household income is 80k [1].

It's really easy to paint this in a negative light. You can go study for an extra decade to be a doctor to make as much money as not studying for a decade and working in fang. Becoming a doctor over many over professions puts you literally millions of dollars behind. Doctors are not the most lucrative profession.

[1]: https://fred.stlouisfed.org/series/MEHOINUSA672N

You're really missing the point. There is a huge variance in physician wages based on specialty and location, to the extent that looking at averages is mostly meaningless. We already have a growing shortage of physicians, especially primary care providers in rural areas. Asking prospective doctors to fund their own residency slots will only make that problem worse.

>shortage of physicians

>Asking prospective doctors to fund their own residency slots will only make that problem worse.

Its literally the opposite.

If you have them fund their own spots, there would be potentially unlimited spots.

The limit is caused by the boogeyman of not getting government funding, not that people can't afford the temporary debt.

There was some stat that 1 in 4 qualified people become doctors. The problem is not supply. The problem is the cartel legally reducing supply to prop up wages.

Why is the government paying for graduate education? I paid for my own graduate education.

The costs would be utterly extortionate otherwise.

No. Don't let the cartel propagate this lie.

> Now, however, doctors are cogs in a much larger healthcare system run by suits for purposes that one suspects have more to do with money than medicine.

Just one more way that private equity ruins the world.

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