
The Problem of Doctors’ Salaries - sus_007
https://www.politico.com/agenda/story/2017/10/25/doctors-salaries-pay-disparities-000557
======
seibelj
Doctors are part of a guild. They artificially limit the number of doctors
available by capping the number of medical schools, which also allows the
existing schools to crank costs to astronomical levels (“don’t worry, you’ll
make enough to pay it back”).

One thing that would help is letting non-MD’s, such as nurses or physicians
assistants, do more “doctor” things. Dentists, a similar profession, is going
apeshit that states are trying to let specially licensed assistants (but non-
DMDs) do slightly more advanced work like fill cavities.[0]

The entire health system from top to bottom would benefit immensely from free
market forces.

[0] [http://www.mercurynews.com/2017/07/01/dental-lobby-bares-
tee...](http://www.mercurynews.com/2017/07/01/dental-lobby-bares-teeth-on-
care-laws-2/)

~~~
chimeracoder
> Doctors are part of a guild. They artificially limit the number of doctors
> available by capping the number of medical schools

They do not. You may be confusing the AMA (which less than 25% of doctors even
belong to) with the AAMC. The latter does cap the number of medical school
positions nationwide, but they've also made a concerted effort over the last
ten years to increase that number steadily.

But even if they eliminated that cap entirely, it wouldn't matter, because the
number of medical school slots isn't a bottleneck for the number of practicing
physicians. The number of _residency_ slots is, and the funding gap for that
comes from Medicare, which is responsible for funding them.

Unless more residency programs are funded, increasing the number of medical
school positions would simply increase the number of people who have medical
school debt and aren't licensed or trained to practice medicine, which would
be even worse,

> which also allows the existing schools to crank costs to astronomical levels
> (“don’t worry, you’ll make enough to pay it back”).

Hardly - in fact, there's already been significant downward pressure on these,
because the debt level is already at the tipping point. Today, the typical
person who enters medical school can expect to pay off their medical school
debt in their 40s. That level of debt load is already having a negative impact
on qualifications for medical school applicants (who wants to be past child-
bearing age by the time they've paid off their debt, when they can just go
into another better-paying field without any of that)?

~~~
zellyn
Is this part of the article incorrect?

> In recent years, the number of medical residents has become so restricted
> that even the American Medical Association is pushing to have the number of
> slots increased. The major obstacle at this point is funding. It costs a
> teaching hospital roughly $150,000 a year for a residency slot. Most of the
> money comes from Medicare, with a lesser amount from Medicaid and other
> government sources. The number of slots supported by Medicare has been
> frozen for two decades after Congress lowered it in 1997 at the request of
> the American Medical Association and other doctors’ organizations.

~~~
sjg007
Or you know, hospitals with residency programs could just use of the massive
insurance money they make to fund residency positions. It's not like the
residents aren't employees or something.. Even the medicaid/medicare
procedures are reimbursable.

~~~
chimeracoder
> Even the medicaid/medicare procedures are reimbursable.

Medicare reimburses rates below-cost. About 7% below COGS, which means they
lose money _per-patient_ , even before they have to pay doctors, nurses,
janitorial staff, etc.

> Or you know, hospitals with residency programs could just use of the massive
> insurance money they make to fund residency positions.

The "massive insurance money" is used to subsidize the losses that hospitals
make on Medicare patients.

> It's not like the residents aren't employees or something

Great point. And that's why companies generally don't hire employees unless
they work they do is profitable for the company. As it turns out, residents
are _not_ profitable for hospitals, which is why hospitals don't "just hire
more of them".

~~~
jzylstra
> As it turns out, residents are not profitable for hospitals, which is why
> hospitals don't "just hire more of them".

This isn't quite in line with reality. If you familiarize yourself with
specific hospital system figures, you find gems like this: Of Beaumont
Hospital's 395 residents, 91 are not covered by Medicare and so are paid for
by Beaumont. The $57 million for GME represents 4.73% of Beaumont's net
patient revenue in 2013, or about $189,368 per resident. [0]

The 91 residents that are trained within the hospital system without medicaid
funding speaks to the fact that residents are in fact employees. [0]
[http://www.modernhealthcare.com/article/20150719/news/307199...](http://www.modernhealthcare.com/article/20150719/news/307199999)

~~~
chimeracoder
> The 91 residents that are trained within the hospital system without
> medicaid funding speaks to the fact that residents are in fact employees

...nobody ever said that residents weren't employees? The point is that they
_are_ and hospitals aren't going to go out and hire more unless it's
profitable for them to do so. (Which it isn't, or else they would have done
so, and that article even says as much).

------
acconrad
All of my close friends are doctors and the toll that school and residency
does on the body and mind is honestly shocking. I'd want to open up the
residency and med school programs for nothing else but to not force our young
doctors into 24 hour shifts. They're treating these young doctors like it's
Hell Week in a fraternity, and the main excuse you'll get from the AMA is
because that's what they (the older doctors) did so all of this fanfare is a
right of passage towards full membership (attending physician) which unlocks
all of these riches to justify sacrificing your youth for.

To me, that's a much better narrative to support increasing the number of
doctors than "they get paid too much." Instead, this article reads like a con
artist who is using slight-of-hand to distract you from the watch he's taking
from your pocket. The trick is the doctor's salaries, but the real stealing is
happening from the health insurance companies.

The article mentions how many billions of dollars this "problem" impacts the
Federal budget. "Billions" \- it's a large number in absolute terms, but
relative to the problems with our inflated military budget ($850B), it's a
pittance.

What I'm trying to get at is this feels like the kind of thing a propaganda
outlet would do to give you a false enemy to hate. Even if the premise is
grounded in truth (that US doctors are paid twice as much as everywhere else),
it just feels like the wrong villain.

~~~
0xB31B1B
The 24 hour shifts are there because it results in a higher standard of care
for patients with life threatening and time sensitive treatment schedules. If
they worked in 8 hour shifts, there would be a handoff and loss of information
at each shift change that resulted in worse outcomes. It’s a fairly well
studied phenomenon. My SO is in med school right now and they just changed the
regs from 16 hour shifts back to 24 hour shifts.

~~~
crimsonalucard
But there would still be a loss of information after 24 hours. Improving
quality means upping the shift to 96 hours. We should encourage doctors to not
sleep as sleeping means loss of information.

This totally makes sense.

~~~
yequalsx
So it's not reasonable for a person to work 96 hours. But apparently it is
reasonable for 24 hours. The goal is to minimize information loss while
maximizing performance. There's a tradeoff. Apparently 24 hours is a local max
in this tradeoff.

------
unionjack22
[https://www.cdc.gov/nchs/fastats/health-
expenditures.htm](https://www.cdc.gov/nchs/fastats/health-expenditures.htm)

The US spent 3.2 trillion on health care in 2015. 100 billion is 3.12%. It
doesn't seem like that big of a problem. This article is just capital
scapegoating labour as the source of the inefficiency and insane costs that is
particular to the American Healthcare system. If you want an honest
discussion, look to the heart of the issue, which is the fundamental
incompatibility with effective healthcare and America's fetishism of
libertarian market dynamics. I mean even in the Swiss healthcare system which
maintains private insurance participation, family doctors on average earn CHF
198,000/USD 201,732.

This is just a hit piece by big Pharma trying to squeeze dollars out of labour
and we in tech who went through 4 years of schooling to collect comfy salaries
for a few hours a day of productive work, we in tech who love to bash H1B's
and foreign grads for increasing our competition, and we in tech who seldom
reckon with real human suffering, fear, and death in our line of work, are
absolutely eating it up. I absolutely look forward to the time when the
squeeze comes and companies pivot to blaming us as the reason for the high
costs of goods or as the limiting factor stopping execs from achieving the
revenue gains they promised investors.

~~~
cjlars
If we spend $3.2TR on medicine and roughly 50% of that is 'overspending', as
the article suggests. Then we have roughly $1.6TR in systematic
inefficiencies. If the misapplication of occupational licensing for doctors
are $100BN of that or 1/16th. What, specifically, is the other 15/16?

I think that author makes a good effort to itemize at least one of the
components, now we should be asking what the rest are.

~~~
chaostheory
Could be wrong but I have a feeling that most of the other costs are related
to either mitigating or fighting malpractice lawsuits. Do any other countries
have a lot of medical malpractice lawsuits besides the US?

~~~
cjlars
Unlikely. Some quick googling gives an annual cost of $55BN for malpractice.
Still, including the above, we're now at 1 / 10 of the overage.

[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3048809/](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3048809/)

------
ryandrake
Software practitioners could learn a lot career-wise from our counterparts
over in medicine. Here's a profession with salaries more consistently high and
more commensurate with the value they provide, where they're not as worried
about global competition, and where ageism is not a factor. They have strong
professional organizations who not only set competence standards and control
labor supply. They lobby the government to mitigate competition and legislate
who-can-do-what, with results very friendly to M.Ds. This is in stark contrast
to the free-for-all race-to-the-bottom that characterizes tech labor.

I'm not sure what an "AMA for software developers" would look like or do, but
I'm pretty convinced a strong organization would be overall beneficial.

~~~
hackinthebochs
This will never happen as long as we continue to have a broad distrust of
academics and fetishize the hacker with no formal training. We don't value
ourselves as a profession and so we reflexively reject the idea of forming a
professional organization. There's also the fact that a significant portion of
software developers have no or sub-par formal training and are insecure about
their ability to pass any rigorous standardized testing, and so there's some
measure of self-preservation involved in rejecting a formal licensing body.

~~~
psyc
I’ve been repeatedly denied by gatekeepers disinclined to let me inside

They say stay at the perimeter. Keep to the outer limits. They’re the ultimate
limiters. Competitors can’t get in it.

If we can’t even begin, they keep taking the win. We stay thin like we’ve
been. They keep raking it in.

Good luck plucking a chicken or an egg from nothing. Success flows to success,
and so far I hear no clucking.

I’ve jumped through enough hoops in my lifetime. More exclusion? No thank you.
If we take cues from anyone, let it be tradespeople, e.g. apprenticeships.

------
bkovacev
Going against the popular opinion.

Sure, but when the salaries are too low like they are in Southeastern Europe
doctors don't want to schedule surgeries($500+), do a proper look-up ($50-100)
or even bother to check on you or when an inadequate doctor/nurse/practitioner
checks on you or does a procedure and screws up what happens? Nothing. Tough
luck pal. Healthcare is public, you're required to pay for it and it's
deducted from your salary. What do you get in return?

Two nights ago I brought my girlfriend's sister to the ER, her appendix was
inflamed, she couldn't walk, talk or move due to pain and was left waiting for
an hour. They did blood work and gave her an IV and sent her home, told her
"we cured you" after another blood work was completed and her leukocytes
dropped a bit. No ultrasound, ct or anything advanced, they haven't even
properly checked her stomach. Her leukocytes were >19000.

I was later told by a friend that I need to give a 50 to the nurse to push her
through the line and another 100 to the doctor. Great world we live in.

Don't get me wrong, but I think you should not fix something that is not
completely broken. Your doctors still do their work and don't expect money,
expensive gifts, bottles of whiskey and roasted pigs like they do in my home
country.

In my country number of doctors you're allowed to have in a Clinic/ER/Urgent
Care is proportional to the number of people living in the region. There is
1.3 gynecologist on a region of 10,000 people. Is that normal? My grandmother
has to schedule a month and a half in advance to get her prescription
medication and check ups are every two-three months. Not sure how it is in the
States now, but in my 10 year tenure there and 10 times I was in the hospital,
I never waited for more than 10-15 minutes after my scheduled time.

~~~
1stranger
> Going against the popular opinion.

> Sure, but when the salaries are too low like they are in Southeastern Europe
> doctors don't want to schedule surgeries

Nobody is saying to pay doctors according to undeveloped country standards.
We're talking about developed countries with similar if not better health
outcomes.

~~~
bkovacev
You're not getting my point.

Salaries for doctors are too low for the Southeastern Europe standard. The
whole point I was making is that you should not lower it as per your
standards. It's good as it is.

~~~
thinkcontext
The point the article is making is that the US is getting significantly lower
value out of their doctors than other comparable countries. They pay doctors
more and get worse outcomes, which points to the conclusion that the doctors
are overpaid for the value they provide.

~~~
bkovacev
The point I am making is that you can pay less and get the value I mentioned
in my original comment.

------
eric_b
It's too bad this is the case. My experience with the medical professionals in
my area isn't particularly positive. Many of them just look up symptoms on
some kind of medical Google and regurgitate what the screen says.

I had RSI in my wrists for years. I had several different diagnoses, and none
of the treatments worked. Finally I found Dr. Sarno's book and my RSI has been
gone since then.

I guess my point is - we pay these people a lot, and they aren't even
particularly competent at what they do. I'm sure the Mayo Clinic specialists
are, but those folks are making more like 500k a year. To be competent.

~~~
dan_quixote
I understand that feeling of incompetence when you watch them look up symptoms
in front of you. But think of it like a programmer digging into a language’s
documentation or a structural engineer looking up calcs in a load table. You
can’t be expected to remember every single detail. And it requires tons of
experience to trust the result you’ve chosen. In other words, would you rather
have a practitioner that works purely from memory, or one that checks their
assumptions against the corpus before making a diagnosis?

~~~
eric_b
If I hire a web application developer who says they are proficient in
JavaScript, I expect them to be able to get moving without checking
documentation constantly. Certainly they should check it to confirm a
hypothesis or to jog their memory on individual API calls, but any decent
senior programmer need not check the docs for simple things, or at least they
will start with an idea of what they are looking for "I know there's an API
that does this..."

The doctors I encounter are the equivalent of a junior developer right out of
code school, checking the docs for everything. That might be OK, if we were
paying them commensurately with their value add.

~~~
upvotinglurker
To be fair, the web developer's work probably doesn't lead to someone else's
health decline or death if they misremember something.

~~~
xkcd-sucks
Yeah, if my bugfix was scheduled three months out and had to be figured out,
implemented and merged during a half hour appointment without making things
worse-- I would read the docs for literally everything, and probably copy-
paste from them to avoid typos

------
jhas78asd
The article failed to mention the high cost of medical school, high interest
rates for loans, and being phased out of interest deductions from earnings
(which are capped quite low IMO to being with). My wife attended a Big 10
university medical school, costing around 50K/year, graduating with around
200K of debt, added to her 50K of undergrad debt, deferred through most of
training, making 50-60K as a resident and fellow, looking at a 2000+/month
expense for P&I on those loans. We've re-financed it, but the rates are still
quite high relative to car loans, home mortgage etc., so of course this
reality of essentially carrying a second mortgage of debt, was a factor in her
choosing to go into a specialty, with additional training (fellowship), and
moving to a lower cost, higher demand (higher wage) area. We pay 15K+ INTEREST
annually on those loans and we are phased out from deducting any of that. If
undergrad was less expensive, or free as it is in other countries, if med
school was less expensive, doctors could enjoy the same quality of life with
less salary.

~~~
s0rce
Isn't the important statistic when break even with someone who makes less but
started saving earlier with less debt (say only college debt). I haven't run
the numbers but 250k in debt doesn't seem so bad if you make 300k after you
finish at 32, compared to making $100-150k with 50k debt starting at 22.

You could also compare the opposite, if you have 250k at 19 is it a good
investment to go to medical school or take a less lucrative job and just
invest the 250k in index funds, I'm guessing medical school still comes out on
top, maybe after 20 years.

~~~
potatote
I agree with your point. I never understood why making >150K starting at the
age of 32 with a debt of about ~300K is an insurmountable burden. I have a
close friend who fits the above profile. She actually makes about ~200K/year
(after tax and everything, she nets about 100K); her work hours are nothing
unusual--~9-10hours. With this rate, she can comfortably pay off her debt in
~10 years top.

~~~
fjsolwmv
1\. Because they might burn out or change career to homemaker before they make
that money.

2\. Because when they make $300k/yr they feel entitled to spend $250/yr or
more

~~~
s0rce
Changing careers is definitely an issue when you end up with 200k+ in debt.
Although, even without the debt 10 years has a large opportunity cost.
However, not saving because you make money is up to you, if you want to live
lavishly to make up for the 2 decades living like a student who is to say
thats wrong. You'll obviously end up with less savings but if your a doctor I
think you can figure that you.

------
electriclove
"The number of slots supported by Medicare has been frozen for two decades
after Congress lowered it in 1997 at the request of the American Medical
Association and other doctors’ organizations."

Wow, just wow..

~~~
priam
More students are accepted to medical school than there are residency spots
available.

See "Figure 1" [http://www.nrmp.org/wp-content/uploads/2017/06/Main-Match-
Re...](http://www.nrmp.org/wp-content/uploads/2017/06/Main-Match-Results-and-
Data-2017.pdf)

~~~
giarc
That's by design, and not in some secretive, nefarious way. People will drop
out of med school.

There is also a lot of residency spots that go unfilled. I know infectious
disease is struggling to get bodies into spaces.

~~~
sxg
The drop out rate for med school is under 5%. Infectious disease is a 3 year
fellowship that's done after completing a 3 year internal medicine residency.
Oddly, the average salary for infectious disease specialists is lower than
that of internal medicine physicians. Economically, it doesn't make sense for
internal medicine physicians to spend 3 years doing a fellowship only to make
less money on the other end. On top of that, these physicians are missing out
on an attending's salary during those 3 years of fellowship.

------
assblaster
1) Physician salaries have been decreasing relative to inflation for the last
30 years. Decrease it further, and opportunity cost will drive smart talented
people away from healthcare.

2) Physician education and training are fundamentally different from nursing
education. Not just in duration, but also in mindset. Doctors think through
medical problems through a physician mindset, and nurses think through nursing
problems through a nursing mindset. Simply letting nurses make medical
decisions without the proper frame of thinking has been proven to have higher
rates of complications and misdiagnosis and physician consultations.

3) The main driver of healthcare costs is not physician salary. More attention
needs to be paid to equipment, capital infrastructure, nursing staff,
administrators.

------
krishanath
One problem not covered by this story: it takes too many years to acquire a
medical degree. In India, you can go to medical college right after graduating
from high school. It only takes 5 years in the medical school to become a
doctor. By age 22 you are a doctor. Compare that to the US: you have to get
degree from a 4-year college before going to medical school. This is wasteful,
unnecessary, and increases the cost of medical education, which in turn
increases cost of medical care.

~~~
dugmartin
You don't always have to have an undergrad. A good friend's Dad earned an
MD/PhD from the University of Chicago without an undergrad. This was in the
1960s though and he entered after doing a stint in the Peace Corps.

~~~
sjg007
This is less likely now since competition is so high so undergrad courses/GPA
is a filter, but it does speak about how an undergrad degree is strictly
orthogonal to the job. You could probably get away with it today based on the
MCAT as proof of pre-qualification maybe...

------
haaen
I'm aware that that many of doctors' high salaries are due to the government
creating artficial shortages and I support less government regulation in order
to make helathcare better and more affordable.

That having said, I don't think high doctors' salaries are the most important
societal problem in healthcare. Years and years of studying, long working
hours, great responsibilities, saving lives and healing patients: doctors are
welcome to their high salaries.

~~~
conanbatt
I read once that doctor salaries account for 30% of the cost of healthcare.
Its significant.

~~~
lazerpants
Nope. 8%.

Source: [https://www.jacksonhealthcare.com/media-room/news/md-
salarie...](https://www.jacksonhealthcare.com/media-room/news/md-salaries-as-
percent-of-costs/)

~~~
conanbatt
Thanks! Had that wrong, or remembered it incorrectly. NYT says 10% in another
article.

Its still considerable. Have to take into account that a 5% reduction in price
can lead to a much higher increase of consumption than 5%, particularly on
things like healthcare in the us that have clear excess demand.

~~~
fjsolwmv
How is it possible for 5% decrease in price to cause ore than 100/95
consumption, if medical care is already a top priority for spending?

~~~
conanbatt
Because there are people that do not get healthcare today because it is above
their affordability.

If net income for a large amount of people is 100 U$S, and healthcare service
costs 101U$S, the jump from 101 to 96 would surge in demand.

Medical services have low elasticity but there are millions of people in
america not getting medical service.

------
SkyPuncher
My wife is in medical school and we often talk about these types of issues.

I think this article is a bit misleading in suggesting that the limitation of
spots in residency programs are intentionally and disingenuously imposed.

The reality is training doctors is very, very hard and there simply enough
resources to do it properly. This is not an issue with medicine alone.

We're seeing similar trends in the tech industry where developer salaries are
sky-rocketing because there is a lack of highly qualified talent. Even with a
slew of "bootcamps", "code universities", and a general influx to the industry
the tech industry still doesn't have enough highly qualified individuals.

The medical industry is facing a similar issue, but everything has even higher
standards because medicine involves human life. The medical industry is trying
to keep up (my state has opened 3 new medical schools in the past 5 or so
years), but it takes a very, very long time for organizations to find the
proper resources and build a proper program. I believe my wife's school was in
works for 10 to 15 years before opening its doors 4 years ago.

Opening more spots requires finding qualified doctors who not only understand
the subject well, but can actually teach it. This severely limits the sample
size. On top of that, these programs also require doctors who are willing to
put up with medical students and residents on a daily basis.

Could you imagine if you were paired with the new development intern every day
of your working life? You'd go crazy.

\----

I do think something needs to be changed, but I don't think medical schools
and residencies are really the place to make an impactful change. I see a lot
of value in doctors becoming "supervisors" and managing a team of nurse
practitioners or physician assistants. Then again, we're seeing similar
training issues in both of those fields.

~~~
fjsolwmv
Programmers are making a fortune because they are critical to generating
massively superlinear business profits, and the market is winner-take-all
competitive

My doctorcan't generate superlinear profits for curing me better than your
doctor cures you.

~~~
SkyPuncher
I'm a programmer so I see both sides.

The reality is both programmers and doctors have a highly technical skill. A
high school can build an "app", but they likely don't have the depth of
knowledge to build it properly and reliably.

The same goes with medicine. A nurse, WebMD, or other resource might get you
the correct answer, but that's not really the name of the game. Medicine is
about both getting things right and not getting things wrong. It's easy to
teach the first, it's very hard to get the second.

------
chimeracoder
A big point people often forget when comparing doctors' s salaries to other
fields: physicians are expected to cover a large number of their own work-
related costs, like continuing education, insurance, or even medical equipment
and (sometimes) overhead like office space. Because physicians almost always
pay AMT, these work-related expenses are _not_ tax-deductible.

$250,000 sounds like a lot, but it's really not once you take into account how
much of that goes towards insurance, licensing fees, equipment, supplies, and
all your normal business expenses. (The article linked says that this is "even
after malpractice insurance and other expenses", but that's clearly _not_ what
the underlying source data represents.)

~~~
mljoe
Their gross pay is way higher then $250,000. Actually $250,000 is the net
salary after all expenses, and that's about right for not particularly
enterprising doctors (ie. internal medicine, no surgery).

~~~
chimeracoder
> Actually $250,000 is the net salary after all expenses

It's _not_. The article says that, but it's flat out wrong - even the source
that the article links contradicts this claim.

> For employed physicians, patient-care compensation includes salary, bonus,
> and profit-sharing contributions. For partners, this includes earnings after
> taxes and deductible business expenses but before income tax.

The author of the article clearly doesn't know that "deductible business
expenses" covers only a tiny fraction of the business expenses that physicians
are expected to pay - most are _not_ deductible.

~~~
mljoe
What business expenses are not deductible?

~~~
SkyPuncher
deductible != credit

A 100k expenses does not translate to 100k of tax savings.

------
csulmone
I don't think it is fair to compare physician salaries from countries where
education is heavily subsidized by the government. Are new doctors in the UK
or the rest of the EU starting their careers $200k+ in debt?

~~~
doctorslol123
So American taxpayers should fund the absurd cost of medical school instead?
Genius

~~~
csulmone
Either that or you will have even fewer doctors with much higher salaries. How
would a doctor be able to afford any sort of life working 80hours a week to
barely pay back loans accumulated over a decade of education. Supply/Demand

~~~
doctorslol123
I have doctors in my family. They would be sad to know the truth, just like
you. There's nothing special about American doctors... the education, the
quality. It's just another classic example of the fat needing to get cut. And
there's a juicy chunk of fat to cut here

------
rtx
Personally I believe that the good doctors are underpaid for the skill and
training they have.

~~~
albertgoeswoof
Are they really that super skilled?

If medical school was free and had unlimited places, do you think we would
have the same number of doctors that pass the bar?

~~~
nullspace
Honestly, while cost is a real factor, I don't think the number of doctors
that pass the bar would increase by as much as you think. The amount of
knowledge, skills, experience in that practicing physicians possess dwarves
what people in many other specialized professions have. I doubt most people
would have the grit and patience that it takes to cross that bar.
(Disclosure/source: my partner is a physician, I am a software engineer).

That said, (only) one of the reasons for compensating physicians more is the
time and money they put into their education. At least 2x - 3x more than other
professions. Reduce this time / money commitment, you will be able to reduce
the salaries.

------
notliketherest
most of the health care cost is NOT due to doctors salaries. the reason health
care costs are so high in America is due to the way Providers (Hospitals,
small clinics, and large Systems) charge insurance companies. Several decades
ago when insurance really started getting big, they realized they had huge
groups of people they could send to "in network" hospitals. they choose which
Providers are in their network. therefore they have leverage over the
Providers, and use it to negotiate the price they pay for all claims (the bill
the provider sends the insurance company). They negotiate huge discounts on
the "listed" price for a claim. Therefore, every year for decades, hospitals
have been jacking up their prices in order to actually be able to stay in
business (given that the large majority of costs are paid for by insurance
companies, who are getting a huge discount). So 2 tylenol go from $3 to $10 to
$100 to $500 over time, as the insurance companies negotiate bigger and bigger
discounts. This is why the "cost of healthcare" is so high, even those it's
not really the true cost. Unless you're not insured, in which case you have to
pay the "actual" rate (ie $500 for 2 tylenol).

Here's an article that explains further [http://www.npr.org/sections/health-
shots/2014/11/15/36406408...](http://www.npr.org/sections/health-
shots/2014/11/15/364064088/they-paid-how-much-how-negotiated-deals-hide-
health-cares-cost)

~~~
QAPereo
Salaries make for a great distraction though, like hosepipe bans in California
when 80% of the water use is agricultural.

~~~
jhowell
$500 Tylenol anecdotes make for an even better distraction. The likely problem
is a little of both.

~~~
jessaustin
Do you mean to suggest that physicians' incomes should be several orders of
magnitude less than what they are currently? If not, I'll continue to be
"distracted" by the Tylenol.

~~~
vonmoltke
No, it means to suggest that the number of people who have actually paid
anywhere near $500 for a couple Tylenol pills is so small as to be an
irrelevant rounding error in the grand scheme of things.

Note I said _paid_ , not _billed_.

------
oxymoran
It blows my mind that people can’t see this is as one of the glaring issues
with out healthcare system. In addition to the outrageous costs of higher
education and the litageous nature of our judicial system, it’s pretty obvious
why healthcare costs so much. We can talk about insurance and Medicare until
we are blue in the face, but those are just symptoms of a system that was
broken from the start.

------
hristov
There should definitely be more med school slots and more residency slots in
the US. The idea of nurses prescribing pills is very bad though.

The shortage of doctors is a problem, but we should not kid ourselves -- the
biggest problem in America's health care is out of control drug costs. Even
with the shortage there has not been a massive inflation of doctors' salaries.
In fact all of my doctor friends are constantly complaining about how they are
paid less than the previous generation.

But there has been a massive inflation of drug costs.

~~~
albertgoeswoof
Why are nurses unable to prescribe? Nurse practitioners (mid-senior nurses)
have been able to prescribe a limited set of drugs in the UK for quite some
time now, quite successfully.

~~~
RandallBrown
Nurse practitioners can prescribe in the US as well.

~~~
mljoe
This right. In fact CVS MinuteClinics are usually manned by nurse
practitioners. They can do many things typically associated with
internal/family medicine.

------
chriskanan
I feel like doctors should at least be paid as well as programmers. My wife is
a physician with $500k in debt and she completes residency next summer. That
took 4 years of undergrad, 1 year to burnish her credentials, 4 years of
medical school, and 6 years of residency. Her job offers are all under $200k
for pediatric neurology. With that enormous amount of training, debt, and
responsibility, I feel like she should be making a lot more than your average
AI programmer.

In other countries the education process is much shorter. For example, in
Columbia, I'm told, you skip undergrad altogether to be a physician. Some
other nations make training free, which encourages more general practitioners.

Can anyone explain why Medicare subsidizes residency slots? Moreover, why do
they need to be subsidized? Residents earn about $40-60k per year and work 80
hour weeks.... If you think PhD students are slave labor, talk to residents.

~~~
Cd00d
I don't understand the reasoning that because one opts for expensive training
that incurs debt then a high salary is necessary. What other forms of debt
behave that way, where the more you take on the more compensated you should
be?

I did a physics PhD, which took roughly 8 years of graduate training. My
stipend was ~$12k per year for 80 hour weeks, and from that I still had to pay
student fees. It's possible to graduate debt free in that situation (I did
not), but does that imply that my working salary should be less? Or, because I
did take on debt, I should get paid more?

------
Quarrelsome
I sorta figure if you spend around about a DECADE of your life training in a
profession then that profession should give you that sort of salary. The
amount of education doctors have to do compared to the other routes to getting
$200k p.a. makes me much more sympathetic to this outcome than say investment
banking.

~~~
conanbatt
Thankfully, it is not up to the individuals to gauge what the value of other
peoples labor is.

Any decision that strays from what people want to pay is going to be either
more expensive than it should, or lead to supply shortage. In this case, both
are happening.

------
wpietri
For those interested in the broader picture, I recommend Aaron Carroll's
series "What makes the US health care system so expensive":

[https://theincidentaleconomist.com/wordpress/what-makes-
the-...](https://theincidentaleconomist.com/wordpress/what-makes-the-us-
health-care-system-so-expensive-introduction/)

Physician salaries are a part of the problem, but by his numbers they are a
pretty small part (as shown in his pie chart at the bottom):
[https://theincidentaleconomist.com/wordpress/what-makes-
the-...](https://theincidentaleconomist.com/wordpress/what-makes-the-us-
health-care-system-so-expensive-conclusion/)

~~~
bootsz
> _Much of what we choose to spend money on is stuff that we as Americans seem
> to value. Much of that value, unfortunately, isn’t all it’s cracked up to
> be._

This speaks volumes, far beyond just the healthcare system too.

------
nilkn
Most other wealthy countries subsidize the cost of medical education to some
extent. This article didn't touch on the possibility that the extra $100
billion the US spends on doctor salaries is just being spent on education
subsidies in other countries.

Many professions in the US are paid more than their counterparts elsewhere.
Software development is a good example, where the salaries I see in the US are
often _twice_ as high as what I see in Europe. But Americans have basically no
rights as employees, very little time off, no access to universal healthcare,
no access to high quality public transportation, etc.

------
taurussai
So lets just say the savings as described in the article by not paying doctors
as much would be $100billion (cut doctors salaries by half). Spending on US
Healthcare was in 2015-16 was $3.2 trillion. Assuming there are no side
effects in the market (such as number of students entering medical school
would decrease etc) the $100 billion in savings is 3.1% which is a very small
figure.

------
d7
Medical education in Europe is free. In the US, it costs hundreds of thousands
of dollars, on top of 4+(1-9) additional years of training with grueling hours
during the prime of your life. 80% of doctors are burned out. The emotional
toll of watching innocent people die, telling their families, and doing your
best with variable levels of success is indescribable. Doctors in the US are
not overpaid - the pay is the only thing keeping them in the profession. The
real money is going to hospital administration (non-profit hospitals with
executives paid more than 6 million per year), malpractice insurance which can
go up to 30% of a doctor's salary (a single malpractice case can cost $1M to
defend, whether you are guilty or not), and most importantly, tests that have
to be done, not out of necessity, but because there is a 0,1 chance of a rare
condition that can get caught by it, and the doctor can be sued if they miss
it.

------
qaq
And now let's look at the size of US drug market and it's 4.6x the size of
estimated salaries from the article. Almost looks like article was sponsored
by Big Pharma

------
sbov
[https://www.cdc.gov/nchs/fastats/health-
expenditures.htm](https://www.cdc.gov/nchs/fastats/health-expenditures.htm)

The US spent 3.2 trillion on health care in 2015. 100 billion is 3.12%. It
doesn't seem like that big of a problem.

------
beisner
Before making a judgement on whether doctors are overpaid or not, I’d kinda
like to see an analysis on the value doctors provide. For instance, how much
does an average doctor’s treatment affect the economic productivity of all her
patients in aggregate? If patients would produce substantially less without
treatment, and she sees many patients, a high salary is much more justifiable.
If you’re not keen on analyzing things strictly in terms of GDP, how much does
an individual doctor influence quality of life, happiness, lifespan, etc?
Again, an outsized effect warrants an outsized compensation. Of course, value
is quite difficult to assess - especially added value versus alternatives
(I.e. online self-diagnosis) - but it’d be interesting to see.

~~~
hn_throwaway_99
But the main argument is that US health outcomes, with their much higher
costs, are not better than the outcomes in other developed countries with much
cheaper costs, and there are lots of studies to back that up.

Seems like you can skip all the analysis you are asking for, at least as long
as salaries in the US are much higher than elsewhere without commensurate
improvement in health outcomes.

~~~
beisner
I think comparing salaries across the world isn't really a good way to measure
whether a provider is "overpaid" or not. If you're just looking at
contribution to well-being and human happiness, that way of looking at things
might be valid, but even if well-being/happiness outcomes in different
healthcare markets are equal, productivity outcomes might be quite different.
Americans work longer hours than in the countries outlined in the article,
resulting in significantly higher annual productivity per capita compared to
other countries. From a labor economics perspective, doctors in the US
therefore might (again, depending on real metrics that I'd like to see)
contribute more in absolute terms to GDP than doctors in other countries.

Additionally, it might be the case that, relative to their productivity,
doctors in other countries might be significantly underpaid. This sort of
distortion happens in many other industries. Software, for instance, is
notorious for this. Internationally, people might look at US software
engineering salaries and balk at how high they are compared to the rest of the
world, and might make the judgment that US software engineers are underpaid.
But if you look at the profit per employee at leading tech companies, that
figure dwarfs engineer salaries (e.g. Facebook's profit per employee is north
of $400,000/year, Google's is similar). So, relative to value delivered, many
software engineers in the US are actually underpaid. This implies that
software engineers abroad are significantly underpaid, as they often work for
the same multinationals doing the same sort of work.

At the end of the day, salaries are determined by all kinds of factors,
including competition, regulation, value generated, etc. I think that real
value added is the only way to determine if a position is overpaid, and
comparing to other systems doesn't really help us evaluate that.

------
MBCook
This featured pretty promenantly in the most renecent episode of the
Freakonomics podcast:

[http://freakonomics.com/podcast/nurses-to-the-
rescue/](http://freakonomics.com/podcast/nurses-to-the-rescue/)

------
jondubois
I do think that there might be too much regulation in medicine. It seems
strange that someone should study for 20 years to learn how to perform the
same operation on a specific human organ...

Most doctors tend to specialize anyway so why should a heart surgeon spend so
much time learning about other organs which they're never going to sink their
scalpels into?

Doctors are extremely well rounded these days, maybe they don't need to be.
There are plenty of very good software engineers who never went to university,
could it be the same for doctors; if we allowed it?

~~~
protonfish
I don't think "less" and "more" should ever be used when discussing rules,
regulations, and laws. Only "better" and "worse".

As for "specializing" in a type of medicine, this is naive. The human body is
not separated into discrete modules; every part is extremely interconnected to
many others. Doctors must understand general medicine because treatment can
effect all body systems.

~~~
jondubois
Maybe you do need at least one person who understands everything to oversee
treatment but does the person who actually does the 12 hours of precision
meat-cutting need to be that person? I don't know, it's just a thought.

Master jewelers can do very fine work and handle lots of variation in the
materials they work with but they don't need to know anything about the
chemistry of gold in order to actually make the jewelry... They just need to
know the right techniques and potential issues that can arise.

------
carewolf
The problem are not doctors salaries, it is everybody elses. Double the salary
of everybody else, to where it would have been if they hadn't been fooled into
dropping unions.

~~~
conanbatt
Oh my. That's not how it works. Thats not how any of it works.

There are less people getting health services than there would be if it
weren't a constraint field. Also, the total amount of money paid to doctors
would be much higher if more doctors would join: it just would be a lower
average.

The doctor community makes less money by contraining supply the same way a
bagel shop makes less money if it doesnt satisfy its demand. This is
absolutely basic microeconomics.

------
nemo44x
The next great thing tech can do is to automate and streamline as many
procedures that currently require a physical doctor. We will need to lobby
Congress to change regulations and possibly even torte reform for automated,
computer based health care.

I believe it's the best way we can scale health care. We need machines that
can do the majority or tests and diagnosis to at least flag things as
suspicious and then send the person onto a human doctor for further analysis.

------
hanklazard
The article fails to mention the debt-load that doctors acquire through their
lengthy schooling. I agree that it seems ludicrous to pay (some) doctors the
outrageous salaries that they are paid, but most professions don’t require a
couple thousand dollars of _post-college_ debt to practice. That may be fine
for a specialist surgeon pulling in 600k annually, but it’s quite different
for academic primary care docs making more like 120k$ in major metropolitan
areas.

Disclosure: doctor

------
qaq
OK considering the time it takes for someone to start making that amount of $
in medical field to be honest we in IT should really be the last to complain.

------
dijit
I'm a big fan of the NHS in the UK and I live in Sweden now which also has
national healthcare services that are heavily subsidised. There are some
things that allow the system to be cheaper- for sure. As one hospital buying
cotton balls might be more expensive per cotton ball than if you decide as a
country to produce or procure millions of them at a time.

But RE salaries; Is it the USA who pays too much? or is it those other
countries which pay too little?

The NHS in the UK and the Vardcentralen in Sweden are both having intense
crisis' at the moment due to funding and are overstretched to say the least.
In Sweden in particular Doctors are more keen to be contractors and hire
themselves out to hospitals and offices, mostly due to the fact that
Vardcentralen has limits for how much it will pay permanent staff Doctors. And
since that's so ubiquitous the Vardcentralen cannot avoid paying these
contracting rates, else it would not have Doctors for people.

So, are they greedy? or are they just getting what they should really get?
Eitherway we end up paying the Doctors the full amount out of tax money-

~~~
nyreed
>In Sweden in particular Doctors are more keen to be contractors and hire
themselves out to hospitals and offices, mostly due to the fact that
Vardcentralen has limits for how much it will pay permanent staff Doctors.

This is much the same in the UK. Hospitals struggle to fill rota gaps, so
offer locum shifts at sometimes 2-3x the normal rate to fill gaps at short
notice.

However staffing is so tight now, one can sustain a workweek solely on locum
shifts.

Most doctors at junior level have taken notice, and many (more then half
afaik) defer entering specialty training after their first two years to spend
a year (or three!) solely filling these shifts.

At the cost of job progression and workplace continuity, you're getting paid
way more for the same work, but with way more shift flexibility and less CPD
paperwork.

Sounds pretty good to me!

Are docs greedy? Hard to say. If locum wages are what fills rota gaps, is that
the market dictating the true price of medical labour?

The feeling among a lot of my friends is that if regular and locum wages met
in the middle, it might help things. Can't really account for that flexibility
of what is essentially taskrabbit for doctors though.

------
test6554
If you want to reduce doctor salaries, then you need to reduce the exclusivity
of their skillset. You need to reduce their working hours, their student
loans, and you need to automate the detection of issues/mistakes.

Their hours need to be limited to sane levels. Medical schools need to get
cheaper. Robots, IoT health and fitness devices, and nurses need to take over
more functions that Doctors perform.

------
purplejacket
Yup. As unionjack22 says, this is just a hit piece. For instance, hospital
bureaucrats can make way more than doctors. This from a 2014 NY Times article:
"The base pay of insurance executives, hospital executives and even hospital
administrators often far outstrips doctors’ salaries, according to an analysis
performed for The New York Times by Compdata Surveys: $584,000 on average for
an insurance chief executive officer, $386,000 for a hospital C.E.O. and
$237,000 for a hospital administrator, compared with $306,000 for a surgeon
and $185,000 for a general doctor." \--
[https://www.nytimes.com/2014/05/18/sunday-review/doctors-
sal...](https://www.nytimes.com/2014/05/18/sunday-review/doctors-salaries-are-
not-the-big-cost.html)

------
curun1r
The first step is to actually start spending more money, specifically on
grants for med students. One of the reasons we have to pay doctors so much is
because they have so many loans to repay. I've been told that between med
school and the low pay during residency, a doctor's break even point can be
around age 40. If we paid them less, they might not get out of the hole with
time left to save for retirement. But if we can keep them from going so far
into debt to become a doctor, it'll be more reasonable to pay them less. Other
countries have programs to help or even fully subsidize their training...we
should have something similar. Because the way it is now, they get bitten by
interest twice, on their loans and on their inability to save for retirement
during their 20s and 30s.

------
darawk
Totally agree with this article. All excellent points. I think these sorts of
improvements to a free market medical system need to be fully explored before
we turn to socialized medicine. I'm not opposed to socialized medicine if it's
necessary, but I think all else equal, market-based systems are better. If we
truly can't make a market based system work, then i'm all for it. But I think
there are a lot of ways to improve competition and drive down costs without
making that leap.

Just to pile on a few other things:

\- In order to open a new hospital in the US, you need to demonstrate 'need'
for it. Who certifies that there is a need? A panel of the other hospitals in
the area.
[https://en.wikipedia.org/wiki/Certificate_of_need](https://en.wikipedia.org/wiki/Certificate_of_need)

\- A large percentage of the things people go to the doctor for right now
could be handled by a nurse, or someone substantially less qualified. You
don't need to see an MD to get diagnosed with a cold. Making it easier for
people with lower tiers of qualifications to provide basic types of care, and
even write prescriptions for simple issues would dramatically increase access
and reduce costs. There has been some movement in this direction, but not
nearly enough.

\- Breaking the doctor-pharma company relationship. This is a tricky one, and
i'm not sure how to go about doing it in a way that doesn't overly trample
either entity's rights. However, there is an enormous problem in the US of
drugs being prescribed to patients without regard for cost. Often there are
many nearly equivalent pharmaceuticals to address a given problem, but doctors
will prescribe the latest and greatest one, because they are incentivized to
do so by the pharmaceutical companies. Since that drug is still under patent,
it costs substantially more than many 'nearly as good' alternatives. Patients
don't have the information or education to know this usually, and so they just
follow their doctor's recommendation.

------
mavhc
1\. Someone's paying for those mansions Doctors live in. 2\. Someone's paying
the people selling drugs to doctors, advertising on tv etc 3\. Someone's
paying to run the insurance business

According to my uk taxes I'm paying £800/year for the NHS

~~~
sjg007
And that's cheap! With employer health insurance I pay $4k in premiums.

~~~
vonmoltke
How much coverage do you have? My coverage is only for myself, but I would pay
a bit less than $4k in premiums if I paid for 100% of my insurance.

------
rcpt
My wife is applying for family medicine residency right now.

There are 20 slots for the entire Bay Area. 6 at UCSF, 6 at Kaiser San Jose,
and 8 at Stanford.

Family medicine isn't neurosurgery or radiology but the artificial limitations
on residencies still lead to hyper competition, long hours, and an insane
"match day". When graduating med school it doesn't look _that_ much harder to
push a bit more for a specialty and get paid twice as much.

And now we have too many specialists in the United States. It seems like we
could solve this pretty easily by simply increasing the number of residency
slots for GPs.

------
msaltz
One thing not mentioned is the cost of medical school (both in time and money)
in the US vs. other countries. I’d imagine that a decrease in doctors’
salaries in the US could cause a significant drop in the number of people
willing to spend the amount of time and money necessary to become a doctor. If
we want to decrease the pay to match other countries, I think we’ll also need
to decrease the investment required to become a doctor in order to maintain a
reasonable level of supply.

------
Brakenshire
This is a big reason why the NHS is a lot more affordable, average wage for a
GP is still something like £90k, but it's not in the hundreds of thousands.
Staff costs are just a really big part of the total cost of providing care.
The rest of the benefit is making clear cost:benefit decisions on buying
drugs, reducing bureaucracy from the insurance system, the ability to
centralize and scale care without so much replication, etc. But doctors
salaries are still a big part of it.

------
wdn
The issue here is we don't directly pay for the services. It is handle by 3rd
parties, AKA health insurance companies. Health insurance company is not true
insurer. They pay for everything. I meant, do you call your car insurer to pay
for oil change?

Since health insurance companies merely handle the payment and get a cut for
this services, they have the incentive for the cost to go up. High cost equals
to higher profits.

Insurance company should be insure on highly unlikely illness, such as
cancers.

~~~
criddell
> Insurance company should be insure on highly unlikely illness, such as
> cancers.

I get what you are trying to say, but I think it's worth looking a little bit
deeper. It's possible that it could be more cost effective to also cover some
preventative care.

------
shams93
As an engineer my salary is frozen in 1998, technical salaries have been
effectively frozen so long that my salary thinks Biggie and Tupac are still
the big thing. It doesn't matter how rare the technical skills there's a hard
ceiling on income coupled with high cost of living and you work 100 hours a
week but still have to go hungry on some days. Salaries are frozen in time for
the benefit of the thin layer of people who own other people for a living.

------
aabajian
I'm a surgical intern right now, it's not fun. I'll be doing radiology next
year, and very much looking forward to it.

I'm biased, but I don't agree with the premise of the article; Doctors
_should_ be among the highest earners in any country, it's the price you pay
to ensure the brightest students are attracted to medicine despite the long
training. I do agree with the following:

 _A second route would be to end the requirement that foreign doctors complete
a U.S. residency program in order to practice medicine in the United States.
This means setting up arrangements through which qualified foreign doctors
could be licensed to practice in the United States after completing an
equivalent residency program in another country. The admission of many more
doctors would put downward pressure on the pay of doctors in the United
States, as insurers would have a new pool of physicians to add to their
networks who will accept somewhat lower compensation._

I've met many foreign-graduates who have already completed residency. In makes
ZERO sense to have these individuals repeat a residency in the U.S. They have
already undergone 12+ years of training, actively treat patients in their home
countries, and there's a need for physicians in the U.S. This is very much
cartel-esque of the AMA. I know it would result in lower salaries, but this
would (hopefully) translate into lower-cost medical school in the U.S.

This is a situation that may benefit from tech solution. There are already
certain states allowing foreign medical graduates to practice in the U.S. If
you're looking for a "startup pain point", let me present you with the two
sided market:

1\. There were ~7,500 international medical graduates who applied to residency
in the U.S. ([http://www.nrmp.org/wp-content/uploads/2016/09/Charting-
Outc...](http://www.nrmp.org/wp-content/uploads/2016/09/Charting-Outcomes-
IMGs-2016.pdf)) Presumably, these are individuals who want to practice in the
U.S., but must undergo a U.S. residency. I don't know how many of them have
already completed a residency in their home country, but let's conservatively
say 25% or ~1,800.

2\. The AAMC is estimating a physician shortage of 30,000 by 2030
([https://news.aamc.org/medical-education/article/new-aamc-
res...](https://news.aamc.org/medical-education/article/new-aamc-research-
reaffirms-looming-physician-shor/)).

Even if _all_ of the foreign train medical graduates were allowed to practice
in the U.S. w/o residency, it still wouldn't be enough. Maybe there's a
startup opportunity that matches foreign MDs to positions in the U.S. As I
mentioned, states like Missouri have already allowed some non-residency-
trained physicians to practice ([https://www.statnews.com/2017/05/15/missouri-
doctor-dearth/](https://www.statnews.com/2017/05/15/missouri-doctor-dearth/)).
My preference would be to have a foreign doctor who has undergone residency in
his or her home country rather than a U.S. grad with no residency.

------
tryingagainbro
I remember in one clinic...7-8 nurses at one docs office. 4-5 minutes time
with the doctor and probably a $150 bill.

A lot of money also goes for people to process insurance claims

------
inopinatus
This article is founded on bad research. Research that considers only what it
costs to have a consult with a doctor. The same research does not consider
what it costs that doctor to _become_ and _remain_ a doctor. Those costs are
borne much more directly by the physician in the US, whilst in the other
countries discussed it is far more diffused into the public tax burden.

In other words, the entire article is built on sand.

------
kwhitefoot
You have a similar number of doctors per capita as other comparable countries
so it seems unlikely that the mere supply of doctors is the problem, Patients
per doctor Norway: 320, US: 390, UK: 440. ([http://bigthink.com/strange-
maps/185-the-patients-per-doctor...](http://bigthink.com/strange-maps/185-the-
patients-per-doctor-map-of-the-world)).

------
cmurf
Some hospitals certainly are making a lot of profit, and quite a few of the
most profitable are non-profit hospitals.
[https://www.bizjournals.com/denver/news/2017/11/15/denver-
ho...](https://www.bizjournals.com/denver/news/2017/11/15/denver-hospitals-
increase-profits-with-some.html)

------
IanDrake
I’ve been expecting this type of discussion for a long time. It’s part of the
march toward socialism.

We are now starting the price fixing phase of the march. Now that enough of
the nation’s healthcare bills are being paid by tax payers, it will be popular
to blame overpaid doctors.

Forget all the government involvement that got us to this point and just blame
the free market. Things like this make me sad for our future.

------
vasilipupkin
Hmmm, shouldn't you compare doctor salaries not just with doctor salaries in
other countries, but also salaries relative to other professions that require
similar level of IQ and schooling in the US? 250k doesn't seem that high in
that context. A mid level manager in a company can make that much

------
yellowapple
I feel like the most obvious explanation here (one which the article doesn't
really cover all that well) is that college tuition is disproportionately high
in the US. This means doctors (and other professionals) have to be paid more
just to be able to pay off student loans.

~~~
sjg007
Doctors that work at qualified non-profits can get loan forgiveness. Also
there are special programs to pay off medical school debts.

------
mar77i
Not-yet-so-famous musicians should be able to hang out at a doctor's office or
house for free. I even see room for mutually beneficial symbiosis, as music as
something cheerful in and on itself can help enhance medical treatment.

But I digress... :)

------
sodosopa
Isn't politico a fairly conservative news hub now? I don't see paying
physicians less as a good thing, do we really want the lost cost physician
operating on us?

------
pers0n
Medical tourism or maybe get an medical intern, they can do it for sweat
equity and stocks

------
killjoywashere
Paul Starr's The Social Transformation of American Medicine is the standard
text on these issues.

------
jamiesonbecker
Correlation is not causation, but this basic principle is sometimes lost on
political journalists.

------
arikrak
> Doctors and other highly paid professionals stand out in this respect. Our
> autoworkers and retail clerks do not in general earn more than their
> counterparts in other wealthy countries.

You need to compare doctor pay with pay on other skilled careers like software
engineers and lawyers. A software engineer earns considerably more in the US
than in Europe.

------
qxmat
So... adopt the UK model then?

------
jprafael
Disclaimer: I'm not a doctor nor do I work in the US. My prespective is as a
software engineer who contacts daily with doctors.

In order to get into med school you must sure that your high school grades are
on the top 5%.

You must ensure that the hospital(s) you work in are able to function 24/7\.
This means you don't really control your vacations, you must work nightshifts
and you will work on special holidays.

You don't get to clock out when your shift ends. You are medicaly responsible
for your patitients until someone else takes over. If the patient starts
having problems just before the end of your shift, you have to handle it. Its
frequent to only actually leave the hospital 2h after.

Your work doesn't end when you come home either. You are supposed to study for
exams, to refresh your knowledge over the diseases you are currently working
on. You need to build your curriculum by publishing research papers and
attending expensive conferences. Your hospital rarelly pays for this. You
either lobby with pharmaceuticals in exchange for favours or pay out of your
pocket.

In order to get a specialization you have to go through 4-6 years of
training/evaluation. That is, if you can get into one in the first place. Due
to the limited amount of positions available, doctors have to compete against
each other. Only the top 2% will get to the prestigious/high paying positions
such as neurology or plastic surgury.

The pressure is huge. People will die or live depending on your decisions.
You'll make 10s of those every day.

People will still die everyday regardless of what you do. Its not cost/health
effective to try every procedure on all patitents. You will have to come home
to your family knowing that you could have saved someone but you decided not
to. You will be the one informing their relatives.

They might sue you or the hospital over malpractice. The hospital has
insurance for this but its there to cover the hospital, not its workers. You
are expetected to have your own insurance if you work in high risk zones (e.g.
ER).

Being a doctor is a high risk profession. There are plenty of infectious
diseases just lying arround. You never know what the next patient might have.
You have to be wary of criminals trying to steal drugs, criminals comming in
to finish of someone, patients with mental issues trying to hit you. Not to
mention people that have received bad news or have simply been waiting for too
long, wanting to take some frustration out on the next person they see.

The 200k _average_ is most likelly misleading. Where I live doctor salaries
are very skewed. Most high profile doctors also have management positions and
can make 10x than regular doctors.

Sure they get more money at the end of the month, but for what its worth, I
wouldn't trade my salary/responsabilities/perks over theirs.

~~~
crimsonalucard
Increasing the supply of doctors will not only lower their salaries but it
will alleviate a lot of the issues you talk about which is largely caused by
the fact that we don't have enough doctors because it's so hard to get into
med school.

Paying doctors humane salaries to work humane hours leads to better doctors.

------
dustinmoris
This article is total bollocks. Doctors are not overpaid in the US, the ones
in Europe are massively underpaid and overworked because they are funded by
tax payers.

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vbezhenar
In Russia most of doctors getting very low salary, less than MacDonalds
employee. It doesn't work very well, talented people moving to other
professions.

------
grandalf
When you start with the premise that a price is too high (or too low) the
resulting reasoning is bound to be sloppy and fraught with bias.

This article is no exception. It is embarrassing to read this article, because
it is full of small, emotionally-potent morsels for those who don't like
doctor salaries being high. It's as if the article were read as ASMR but the
excitement is instead induced by those potent "the price is bad" morsels.

The truth is that not all doctors make even $200K and many struggle for years
to pay back their med school loans once they finally are able to earn a salary
after years and years of training.

But it's only by a slight of hand that we are even focusing on doctor salaries
instead of the broader issue of the cost/benefit offered by the healthcare
system as a whole.

Doctors combine a form of scientific authority with both social and moral
authority. They have scarce knowledge, they judge whether or not we deserve
workers comp, a paid sick day, a sticker to park in a coveted parking spot,
permission to take a pill that takes the pain away, etc. They tell us which of
our symptoms we are to blame for vs which we can blame on others, and they
offer us hope when our loved ones are at death's door.

This makes doctors the closest thing modern, mainstream (secularized) culture
has to priests and priestesses. The status held by doctors goes far beyond any
financial rewards.

We must ask ourselves the difficult question of why we (as a society) need the
absolution and authority offered by doctors. Why can't we just (as the article
suggests) make pragmatic decisions that would lower the bar for entry into the
profession?

To do this, we must appreciate that there is a uniquely American view of
health that differs from the view held in many other places. Health is
something we deserve. Health is understood as something that can be restored
or improved through science. Disease is understood in a way that is analogous
to "evil forces" that can be successfully eradicated from the body. The social
and psychological aspect of disease is minimized, and the physicalization of
mental health challenges is nearly completely denied.

Death too is treated differently. Death must always have one cause, and the
implication is that were it not for that cause life would have gone on much
longer.

In such a view, it is only through the perfect knowledge and/or perfect
technical performance that we can overcome disease and stave off death, so
doctors must be close to perfect. This is why the bar is set so high for entry
into the profession. Those who are selected into the profession are typically
very highly skilled. Medicine is among the most popular career plan for
college freshmen, but only a small percentage manage to be admitted into
medical school. The rest wash out either because they don't want to work that
hard or because they can't make the grades.

This pressure on perfect outcomes (and all the fallacies the notion entails)
results in expensive malpractice insurance and far too many costly
interventions that have little chance of significantly benefitting the
patient.

A massive amount of lifetime healthcare spending occurs in the last two months
of a person's life. The author seemingly blames this on doctor salaries. This
is false. The problem is that patients and their families expect the 80 year
old with pneumonia to miraculously recover and live to be 100. The fact is,
when an 80 year old gets very sick and ends up hospitalized, it's quite likely
that a cancer or two might be discovered, as well as all sorts of other
impending problems. But the family still thinks of the person as a healthy 80
year old. Most of the cost of our healthcare system comes from this adjustment
process during which we flush money on useless tests and interventions, all to
help a patient and family adjust to the reality of old age and impending
death.

Yes, there are some docs who profit from largely elective and arguably
wasteful surgeries, but many of those are also the optional "lifestyle"
surgeries that the public demands most (arterial stents, plastic surgeries,
many cosmetic derm treatments, etc.).

------
wife_is_md
Until I met my MD wife, I would have agreed with most of the points in this
article. Doctors in the US are certainly well compensated relative to Doctors
in other countries. Also, the story of physician credentialing as a means of
restricting labor supply appeals to my economic rationale.

However, there are some weaknesses with this argument. To start with,
physician compensation makes up just 8% of total healthcare costs in the US:

[https://www.jacksonhealthcare.com/media-room/news/md-
salarie...](https://www.jacksonhealthcare.com/media-room/news/md-salaries-as-
percent-of-costs/)

So, if they were somehow cut in half, that would net a savings of just 4%.
That assumes there wouldn't be a corresponding drop in quality as a result of
loss of physicians from the occupation. Keep in mind that this is an
occupation whose supply is so tight that one of the primary ways being
discussed to increase supply is by lowering the credentialing requirements for
primary care by having Nurse Practitioners and Physician Assistants provide
primary care, unsupervised by a Physician.

I think that's really the rub in terms of talk of lowering physician pay. The
barriers to entry in the field (in the US) are so high that if physician pay
were significantly reduced without a corresponding reduction in the barriers
to entry, it would disincentivize our smartest, and hardest working people
from becoming physicians. Which would lead to a significant decrease in the
quality of healthcare in the US.

In the case of my wife, she is both smarter and harder working than I am. She
spent her 20's and early 30's working 60+ hour weeks doing work that is very
taxing mentally and emotionally. She went through four years of undergrad and
four years of medical school. She exited medical school at 26 with a
significant amount of student debt (though less than many, and at a lower
interest rate due to smart decisions on her part) that started capitalizing
immediately. She then spent four years in a residency program, making $50,000
a year, and then another four years in two different fellowship programs also
making $50,000. When she finally got to a point where she started making a
Physician's level of compensation, she was almost 35 years old with $240k in
student loan debt and a small amount of savings and retirement built up. She
could have dropped or failed out at any time and, if she had, she would have
taken on the full cost of the student loan debt without the ability to repay
it. This level of debt represents a significant personal risk for physicians
that shouldn't be discounted. If you were to compare our financial situations
independently, as a software developer, I'm in a better position financially.
I've had the opportunity to invest my earnings in my 20's and 30's and haven't
had to forfeit so much of my later earnings to debt. As a result of this
financial head start, even though she makes more than twice what I make, she
doesn't have a chance to catch up with me in terms of wealth accumulation
until she's in her 40's, assuming she's financially disciplined and doesn't
succumb to physician lifestyle inflation.

If she had instead aimed to become Nurse Practitioner or Physician Assistant,
she would have been looking at a low to mid 100k job in her mid-20's with
maybe 40k in debt. This would have been a much lower risk in terms of debt,
it's much less work to go into one of these fields, and I would argue it may
be a better move financially because of the ability to put her money to work
earlier from an investment standpoint.

So, if the carrot of higher compensation later down the road is eliminated, I
think we will see less quality people entering the field. Physicians are some
of the smartest and hardest working people in the US. They'll be able to weigh
the cost benefits and will choose alternative fields that have better
financial renumeration or lower risk. If the student loan burden were reduced
for physicians, you might be able to get away with lower pay without
disincentivizing becoming a physician. But I don't see the government
providing more assistance to cover the cost of medical school.

If we really wanted to cut down costs for healthcare in the US, the first
place to look is administrative costs. We pay more than twice what other
countries pay in administrative costs as well. And administrative costs make
up a greater percentage of the total money spent on healthcare. Administration
costs are mostly waste in that the reason it exists is to keep the gears
turning so people can receive healthcare. One of the reasons administrative
costs are so much higher is b/c of the complexity of the private insurance
system in the US. As others have noted, some of the administrative burden
would be simplified by a universal healthcare system.

[http://www.commonwealthfund.org/publications/in-the-
literatu...](http://www.commonwealthfund.org/publications/in-the-
literature/2014/sep/hospital-administrative-costs)

