Comment by 1980phipsi | Hacker News Reader

Comment by 1980phipsi | Hacker News Reader

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"Are you sure you can find that many more doctors? That they'll be any good? Speaking from Romania: ..."

The prior post was specifically talking about the US. (I assure you, arrogant dismissive doctors are also a thing in the US)

In the US, there are a number of things that artificially increase the barriers to becoming a doctor.

1) You typically need a four year college degree to apply to medical school

2) Medical schools are accredited by the AMA, which is controlled by doctors. The AMA makes it very difficult to start a new MD-granting medical school.

3) Medical school in the US is very competitive to get in. They are likely turning away a lot of people who could complete the degree.

4) Since 1997, the federal government has a fixed number of Medicare (Medicare is a federal health insurance program for people over 65) supported residency positions. That number was basically flat for 25 years. We lost about 20% per capita of doctors being trained with support from this program. The caveat to this is that the total number of residents per capita has increased over time, particularly the past 15 years or so. My understanding is that they are less likely to be fully funded, so they spend more money getting trained, and then have higher students loans (on average graduating with debt above 200k going back to the late 2000s) that they need to pay off, so they charge more.

And you can add to this that it can be very difficult to be a doctor in another country and come to the US to practice here.

On top of these, a few things with the training process also jump out to me from a "can we attract smart and motivated people to this work" point of view: the sheer cost of medical school that creates an imperative for high pay down the line, coupled with a real chance that you can wind up without a residency match but still owe all that money for school, and in particular the grueling nature of the residency system, currently capped at only 80 hours/week since 2003, because people were working >100 and making mistakes.

There are arguments that these are factors that filter out the people who are not sufficiently motivated, but it's hard for me to imagine there aren't a lot of bright young people who might be interested in medicine, but see one of the various paths that exist today to making doctor-level money with only an undergraduate degree and in an environment that doesn't require a working schedule that actively harms your health.

Yep, it's a huge risk. If a student enters medical school and realizes halfway through that they don't want to be a doctor then they're still stuck with a huge debt and no way to pay it off. It's not like undergraduate education where you can fairly easily switch majors from chemistry to mathematics or whatever.

I totally dont by the "no medicare funds for training". A doctor will see you for 10min (perhaps another 10min prep) and bill $1000. If you doubt this, just check your EOB statements from the insurance company or check your deductible history.

The entire salary for the resident can be earned back in 3-4 days. You still have 360 days left to pay back admin overhead, facility overhead, supplies, etc. That is earned back in the next several weeks. After that, the next ~300 days of the year are profit.

In states with balance billing, the doctor can set any price and bill you for the remaining figure with a balance bill. In NY and NJ these can be thousands or tens of thousands. If you dont pay, it goes to collection and the provider still gets 10 to 15 cents on the dollar. So no...the $75k annual salary of a resident is not a barrier to training more doctors according to any math i'm seeing. What am I missing?

What seems more likely is that supply is artificially constrained to increase scarcity and prices.

It is not in the interest of the members of a cartel to add new members. What's so hard to understand?

Anyone here should be familiar with the ""sAfEtY"" argument at this point.

> What am I missing?

Several things.

First, private practice docs see patients with very good employer provided insurance, but residents are largely seeing patients that private practices wont see - patients who are far too medically complex to fit into a 10 minute slot and who also have particularly stingy insurance.

So as opposed to a private practice doc who is seeing 30 patients per day and billing an a average of $250 to $300 per patient (certainly not $1000 - that is unrealistic in my experience), a resident is seeing more like 10 to 15 patients per day (30 minute slots) and billing less than $100 per patient.

Second, residents have to be supervised. You have not included the salary of the physicians supervising them in your calculation.

Third, and I have mentioned this many times before on HN, training is limited by chiefly by the number of training sites that can offer quality training. For example, most hospitals will not see a single case of Guillan-Barre in a single year. Would you want to be treated by a nuerologist who trained at such a hospital? This is why neurology training is generally limited to places with a high volume of neurologic cases that would be considered rare at the average hospital, and these hospitals can only accommodate so many residents. Even for general medicine, you probably do not want to be treated by a doctor who trained at a hospital where any case that passed a certain complexity was transferred out to a bigger center.

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