
Why doctors are sick of their profession - roye
http://online.wsj.com/articles/the-u-s-s-ailing-medical-system-a-doctors-perspective-1409325361?mod=WSJ_hppMIDDLENexttoWhatsNewsSecond
======
toasted
Non-US anaesthesiologist here. I love my job and relish going to work each
morning. I spend almost no time on non-clinical paperwork. I work reasonable
hours, have some busy on-call shifts but am generally well supported by my
department. I earn good money in the state system - enough to raise a family
comfortably and have a nice house, but not silly money. I pay no malpractice
insurance, but pay $400 annually to a non-profit society for medico-legal
cover. If I want to I can do additional private sector work to earn more (but
I don't). I live in a country where a high standard of medical care and longer
life expectancy is provided for less than half the per capita health spend of
USA, and the public health system is so good that the private health sector
really does struggle to offer much additional benefit.

There are many great examples of socialised health systems in the world, I'm
not sure why the US ignores them? Some of the WSJ comments list all the
problems inherent in the US system and then blame socialism for them when the
problem is completely the opposite?

~~~
jval
The problem is that the United States isn't a 'country' in the way the UK, or
Denmark, or Australia is. The entire population of Denmark is 5.59 million,
the size of a single second or third tier city in the US. Australia is 22
million, the size of the NYC metro area. You can socialise and centralise
healthcare in countries on such a small scale, but it becomes exponentially
more difficult to do in a country like the US (pop: 313 M).

The United States is an enormous country comprised of 50 separate state
governments, where the powers of the federal government are extremely limited
(both by the constitution itself, and by the fact that it is practically
impossible to do anything at that kind of scale).

As a result, it is extremely hard to pass any sort of massive reforms. Can you
imagine how difficult it would be to pass one single, uniform system of health
care for all Europeans?

Talking about solutions that work well in smaller countries is all well and
good, but the reality is you need different solutions if you want them to work
at scale. It's the same reason why most of Facebook's backend is now written
in C++ instead of PHP. It is much more painstaking to work with and harder to
pick up but when you're building a huge system of interconnected parts you
want something that isn't going to fall over and die suddenly.

The supposed chaos and gridlock of the US political system is a feature, not a
bug. It's the reason why if you look at a list of the world's oldest nations
the United States is right at the top, and is one of the largest.

EDIT: Sorry - not saying the US's healthcare system is the best it can be and
didn't make that clear enough. Just saying that comparing it to other
countries won't help as the US has a unique political reality.

~~~
ThomPete
I agree that Denmark don't scale. But that doesn't mean that the current
system we have in the US is good or that the insurance based version is by any
metrics the best possible solution for the US. You could also think in states
instead.

If you look at it from a purely financial point of view the problem of the US
system is that when given the choice, younger people don't insure themselves
because they are healthy and so don't participate in financing those who are
sick by costing the system less.

As they grow older and get sicker they end up paying insane prices unless they
are paid by employees and even there the quality of the insurance varies and
you still have some really absurd pre-existing conditions rules etc. If you
don't have an employer to back you up you are basically screwed.

Obama Care is an attempt at solving this issue. It's not single payer but it's
closer and hopefully it will help improving the healthcare system for millions
of those without either healthcare or proper healthcare.

Now in my mind there is a middle ground where you pay most of your healthcare
yourself (the checkups, the sinus infection etc) but you don't end up in
endless debt because you become sick, your kid gets born to early and have to
stay at a neonathal facility, for a longer period of time and don't have the
right insurance.

And having been through the system I must say that if people think it's less
beucratic than say they Danish system (which is much more social in its
approach) then they would be mistaken. The sheer number of interests involved
in any single episode creates complexity way beyond what seems reasonable.

So agree it's not possible to take a small nation and apply what they do, but
it is possible to look at the current system and realize that the healthcare
system in the US is def not a feature but rather a system with plenty of room
for improvement.

~~~
jval
Sorry - edited my post to make clearer the fact that I'm not saying the US's
healthcare system is good. I just think that comparisons with other countries
are futile. My comment was intended to be a general one about the way politics
works in the US.

~~~
ThomPete
The countries in the EU which is 400mio serms to be handling this ok and thats
even with national laws. You might say the realpolitics will nok make it
possible but its not a scale problem but rather a political one.

------
2mur
I'm a physician. I love the value I bring to patients, and I enjoy what I do
(most of the time). But the industry is disgusting. The people who are
creating the real value for patients (nurses, technicians and doctors) have
been saddled with increasing regulations and there are incredibly levels of
administrators and belt-phone business guys riding them to extract every
profit out of the environment.

There is no chance I would do it again.

~~~
dmfdmf
The doctors lost the argument decades ago when they agreed that people had a
right to medical services. It was self-imposed slavery (because they agreed)
and now we are just discussing the details (e.g. Obamacare, medicare, etc.)
and the govt programs that steal from people to pay for medical services are
just windows dressing to make it look civilized and moral.

The good news is that your rights are inalienable, you can reclaim them at any
time. The doctors should go on strike and reject the assumption that anyone
has the right to their work. As a patient I would support the doctors 100%.
Let's see how long medical services last without doctors or how laughable it
will be when the govt tries to force doctors back to work. LOL.

Health Care is Not a Right.
[http://www.afcm.org/hcinar.html](http://www.afcm.org/hcinar.html)

NB: I recently dropped all my medical customers at significant drop in revenue
because of HIPPA. You think things are bad now wait until that monstrosity
becomes strictly enforced.

~~~
tim333
>when they agreed that people had a right to medical services ... It was self-
imposed slavery...

We've had rights to medical services in most of the developed world outside
the US for decades. Doctors have high salaries and reasonable conditions for
the most part. Funny version of slavery.

~~~
jasonisalive
The use of the term "slavery" here is pretty standard rhetoric used for
emphasis by the American libertarian movement; its use descends from the
vocabulary developed by the body of anti-Socialist thinkers in the early to
mid-20th century.

A more sophisticated rhetorician would argue that the various bodies of your
society (those who pay for the universal medical services via taxation, those
who partake of the medical services offered, those who actually provide the
services (i.e. the doctors), and those who administer and regulate the
provision of service) have all internalised and unconsciously accept a
worldview which debases and discredits the right to free action of individuals
in society. You may not be slaves in the classical sense of being enslaved by
a third party, but from the perspective of someone with a "strong" view of
personal liberty, you are in a sense enslaved to your own lowered expectations
and faith in liberty.

So while you might all claim that you are perfectly content with your current
system, your critic would view your opinions as hopelessly biased, and point
to what they would classify as numerous instances of the poor results of
socialised healthcare (incessant arguments about over-spending and budget
problems, claims of corruption in service administrators, complaints of high
wait time and low quality of service, low morale and satisfaction among
service providers) as evidence to strengthen their claim.

~~~
jasonisalive
Wow. It absolutely astonishes me that someone would downvote this. Since when
is clarifying a use of a term, then demonstrating what a contrary point of
view would look like - without once stating my own personal opinion -
downvote-worthy?

This is just disgusting behaviour to see on Hacker News.

~~~
nitrogen
Sometimes downvotes are accidental, especially on phones.

------
727374
I think it's funny that the first picture in the article is of a doctor taking
a patient's blood pressure. It's a little ironic because I've never actually
had a doctor take my blood pressure (in the US). I'm not even sure if I've had
a nurse do it, but more likely a physician's assistant or phlebotomist. Just
like other industries medicine has been turned into an assembly line where
patients are herded through the system with professionals at each level of the
training pyramid doing their part. We do this to be efficient and cost
effective, but speaking from personal experience, the side effect is that
information gets lost from transfer to transfer and a patient has less time to
bond with a doctor. I'd like to believe that many doctors would be happier
working with a patient from start to finish like in the old days.

~~~
wirrbel
What has always confused me is that the perceived gap between doctors and
nurses is so big. I have the impression that nurses could benefit a lot from
better training and there could be a good case for positions somewhere between
a nurse and a doctor. Considering the effect that _care_ (time with patient)
has on patients the current model with a demi-god in white just does not
scale.

My optometrist (the guy selling glasses) measured my eye sight and found that
I needed a correction for some corneal irregularity (pardon me if I did not
translate the terms right). I had never been given such a reading from my
ophthalmologist (eye doctor) who just wrote down dioptry corrections. My
optometrist then told me that the specific doctor never wrote down these
numbers (i.e. ignoring a condition). This tought me a lot about medical
professionals and highly educated doctors. My doctor probably is just a little
bored to measure and monitor visual acuity changes in a person with small
eyesight issues. That ophthalmologist also had very good reputation working
with accident victims, etc.

~~~
jkestner
> positions somewhere between a nurse and a doctor

They call that a physician's assistant or nurse practitioner. The latter has
the nurse's more user-centric approach but can do pretty much everything a
general practitioner does, including writing prescriptions (though not in
Texas, yeehaw).

~~~
seanstickle
Not to be too pedantic, but the profession is "physician assistant", not
"physician's assistant." They typically have master's degrees (and all will be
required to have master's degrees by 2020), can practice medicine in most
specialities (including surgery, pediatrics, etc.), and can prescribe medicine
in all 50 states.

Note: I work for the Physician Assistant Education Association.

------
jseliger
This resonates with what I've observed, and in 2012 I wrote an essay that fits
this genre: "Why you should become a nurse or physicians assistant instead of
a doctor: the underrated perils of medical school"
([http://jseliger.wordpress.com/2012/10/20/why-you-should-
beco...](http://jseliger.wordpress.com/2012/10/20/why-you-should-become-a-
nurse-or-physicians-assistant-instead-of-a-doctor-the-underrated-perils-of-
medical-school/)), which explains everything my girlfriend wishes she'd known
before she started.

~~~
cloverich
I've read this before, and feel obligated to state I couldn't _disagree more_.
And this is coming from someone who quit the profession (physician).

Be a nurse or PA because you have shadowed one, and enjoy the work. Their job
is different than a Physicians, and personality (etc.) plays a part in which
you'll enjoy. Additionally, the available specializations in medicine are
something thats simply not available outside the profession. Don't settle for
one or the other, choose the one that suits you.

------
BenoitEssiambre
Demographics is huge headwind for doctors. In the past 30 years, median age of
the population in North America went from about 27 to almost 40 and is still
rising.

Doctors are usually on a fixed fee for service arrangement but every year as
people get older, the length of time it takes to perform the average "service"
goes up. The amount of time and ressources needed to treat older patients is
almost exponential with age. Older patients' state of health is often very
complex with all kinds of interactions between illnesses and medication side
effects to manage. Sick people get more "services" but also each service takes
significantly more time to perform. Yet doctors are expected to be able to
perform as many of them each year.

There is an oversized population of people in their fifties right now. This is
the age where people start to get sick but are still young enough that they
are often the main income earner for their family having one or more
dependents.

Doctors have to work more hours for less money trying to help families cope
with increasingly common and tragic medical conditions. When a family is
collapsing because of an illness and people pile up in the doctor's office
(justifiably) in tears, there is no ethical way to "process" these patients in
the time that is supposed to be allocated to them.

------
jprince
I think we're the new independent professionals. Nobody has required a license
to "practice technology" (yet, but I suspect California will find a way
eventually...) and so we can do our job anywhere, for any hours, for any pay.
Until bureaucracy swallows us up(as it does all professions ultimately) we'll
have our golden age too.

~~~
jjoonathan
It won't be bureaucracy that kills us but rather the inevitable grind of
economics. Once our industry stops growing and the supply of programmers has a
chance to catch up with demand, our bargaining position weakens and the impact
will be felt across the board. Those in corporations will find higher
expectations (even longer hours), less respect, lower pay, and fewer benefits.
Those who are "independent" will find it more difficult to acquire funding, a
higher probability of failure on launch, and lower returns even when they do
manage to "crush it."

This has already happened to older engineering professions and it has already
happened to sectors of the software engineering world that have a different
supply/demand balance than the mainstream (see: game developers). It will
happen to us too. Hopefully not in the near future.

~~~
tomjen3
I work in game development and the issue isn't that there aren't enough work,
the issue is that there are too few people willing to buy games.

However I seriously doubt we will run out of work for programmers across all
sectors - if we can code some business app to do something ten times as fast
as a normal person takes to do it (likely a low bar) then there will always be
businesses willing to pay for that.

~~~
jjoonathan
Demand is too low, supply is too high... potato potahto.

We won't run out of work across all sectors. EEs still have work. Chemists and
Biologists still have work. Aerospace engineers still have work. And lots of
it! But the supply/demand balance has shifted enough in their respective
sectors to have a very concrete impact on their compensation.

------
praptak
All this sounds quite a bit like Marx's theory of alienation:

 _" The theoretic basis of alienation within the capitalist mode of production
is that the worker invariably loses the ability to determine his or her life
and destiny, when deprived of the right to think (conceive) of himself as the
director of his actions; to determine the character of said actions; to define
their relationship with other people; and to own the things and use the value
of the goods and services, produced with their labour."_

[http://en.wikipedia.org/wiki/Marx's_theory_of_alienation](http://en.wikipedia.org/wiki/Marx's_theory_of_alienation)

~~~
grimtrigger
The article makes the opposite point - that government bureaucracy (and the
mal-incentives it creates) is what is killing the relationships between
doctors and patients.

~~~
esfandia
I didn't see any discrepancy: both the article and Marx are criticizing the
alienating effect of the added bureaucracy and the lessening of the doctors'
autonomy.

------
mikeleeorg
Many friends of mine are doctors and they've expressed the same feelings.
There are days when they absolutely love what they do, but as an outsider, I
see them experiencing more low days than high days.

Just as an anecdote, part of it is the expectations of the patient population
in the Bay Area - and I'm only referring to the high income neighborhoods
here; the situation differs significantly in low income neighborhoods.

Patients from high income backgrounds tend to be much more demanding than
patients from low income backgrounds. At Stanford, the doctors in the
emergency department are (informally) expected to stop what they're doing and
sing Happy Birthday to certain high income individuals.

A lot of doctors translate this to a lack of respect, which echoes the quoted
statement in the article.

Here's another anecdote. While sites like WebMD are fantastic for educating
the general public about health issues, it also makes some people falsely
believe they know more than the doctors treating them. And I don't mean they
simply question their doctors - that is a good practice and everyone should be
as educated as they can about their own health. But apparently many people
argue and flat out ignore their doctors, even when their own knowledge is
tragically incorrect. As one doctor put it, "Why did they come and see me at
all, if they are already convinced of what they have? Just to waste their own
time and money, not to mention my time?"

Again, there are times when one should definitely question their doctor and be
as educated as they can. Second, third, and additional opinions can be very
useful. But I'm sure many doctors would appreciate less arrogance and
animosity in their attitudes.

One more note. Apparently a very high number (between 75-99%) of all doctors
will have faced a malpractice claim at least once in their career. Most of
these claims are frivolous, but going through something like this is extremely
demoralizing. A couple of doctors I know came close to leaving the profession
because of it, even after they were cleared of all wrongdoing.

I once described the job of a project manager to a doctor friend as a
"thankless profession," and he immediately said, "that sounds like my job
too!"

~~~
a3n
> A lot of doctors translate this to a lack of respect, which echoes the
> quoted statement in the article.

Does this mean a lack of general respect, the type that all people deserve? Or
is this some kind of extra respect and dererence due to their education or
profession, which no one deserves?

Because I am constantly disrespected by the medical profession. I am sent
email a day or two before each appointment, reminding me that late or canceled
appointments are subject to cancellation fees, yet I have NEVER been seen on
time by any doctor ever.

~~~
mikeleeorg
Just a general level of respect, from what I can gather. This is all second-
hand info of course. But the stories they've told me seem to indicate this.

I should have added that my friends are specialists, not general
practitioners. I've heard lots of complaints about general practitioners too,
in terms of late and canceled appointments, little to no interaction, being
rushed out the door, etc.

------
joelberman
I love my primary care doctor who is also my cardiologist. He is amazing.
Explains everything, and is never rushed. The only negative is sometimes he is
off schedule. I just had open heart surgery and that was also wonderful. The
techs, nurses, PAs, and doctors were great. In simple terms, I am thrilled
with the care I got and except for one nurse from hell, I have no complaints
about care and I have the utmost respect for those who helped me.

Now the dark side. I cannot imagine how many people are preparing bills,
sending them to Medicare and then to my supplemental insurance. And how many
questions I have about billing and how many phone calls I have to make. I am
sure that the cost of administering payments is much higher than the cost of
care. And yet none of that administrative work prevents disease or cures me.
We need a single payer system and need to reduce the non-care-related
paperwork. And let the healers heal.

------
ArkyBeagle
The business model for doctors works out to is surviving a grueling
educational process to gain a license against which they charge rents.

The business model for professional athletes devolves to surviving a grueling
selection process in the service of building their brand as a performer
against which they can charge rents.

The business model for performing musicians devolves to surviving a grueling
selection process in the service of building their brand as a performer
against which they can charge rents.

This has a personal cost.

------
ericHosick
I think another frustration doctors are feeling today is due to a lack of
patient-doctor relationships.

Society views doctors as tools that society has a legal right to.

------
dobbsbob
Surprised the average income for a GP is $161,000 in the US, thought they
would be paid more than Canadian MDs who's average is $300k
[http://www.theglobeandmail.com/life/health-and-
fitness/healt...](http://www.theglobeandmail.com/life/health-and-
fitness/health/how-much-are-canadian-doctors-paid/article7750697/)

Canada also heavily relies on US medical labs in Houston. I had to have a
blood analysis done as part of a health check for a work contract years ago
and my provincial health authority shipped my samples there for testing. It's
cheaper for Canada to outsource all this work to Americans wonder what they
are paying lab technicians.

~~~
djokkataja
A little strange to be comparing American GP average income to the average
income of all Canadian MDs given that GPs are paid much less than average.

"Geoff Ballinger, manager of Health Human Resources for CIHI, said the figures
represent averages and vary significantly depending on a doctor’s specialty.
For instance, the average family practitioner would earn less than a
neurosurgeon or cardiologist."

[http://www.theglobeandmail.com/life/health-and-
fitness/healt...](http://www.theglobeandmail.com/life/health-and-
fitness/health/mds-gross-income-307000-report-finds/article7640498/)

------
analog31
We've all read about how much health care costs in the US, but I'd like to
know: Into whose pockets is that money actually flowing? My guess is that
those people will be doctors, even if directly caring for patients isn't how
they make their money. From what I've gathered by reading about this over the
years:

* More than half of doctors are self employed, meaning that their salaries don't tell the whole story about their incomes.

* Doctors are heavily invested as stockholders in provider businesses (insurance, HMO's, etc.), and the malpractice insurance industry. Until recently, my employer-provided health care was delivered by a large organization that was entirely doctor-owned.

Sorry, no links or evidence for either of these, and I think the gathering of
that evidence may be difficult due to the complex financial relationships
involved. But it makes me skeptical when I read about doctors struggling
against "the system." Who owns the system? It may very well be that medical
care costs less overseas simply due to a simpler system where costs can
actually be tracked. Medicine might become a better profession in the US if
med school were free, doctors worked for a salary, and everything else was
owned by the government.

To be fair, it may be doctors exploiting doctors, and your career prospects
upon finishing medical school may have a lot to do with how much investment
money (e.g., inheritance) you have at your disposal to buy into the portion of
the business that ultimately profits.

------
marincounty
1\. I understand their frustration! 2\. Yes--you are fighting with insurance
companies; So are your patients. 3\. No--you are not the "pillars of society"
anymore. (That's change has been slowly taking place. Patients educated
themselfs, I don't know, but patients wised up; they realize when when they
are dragged in for unnecessary office visits--just to invoke another billing.)
4\. O.K.--You are not making the money your father did--neither are most of
your patients; the world changed. Hopefully, things will get better. You guys
deserve Tort Reform--I think, but then again I sometimes feel the only reason
you guys pick up the phone, or refill a prescription is because you you don't
want a lawsuit. (It pathetic I'm even thinking like this?) 5\. In the end, we
are all in this mess together, and one day You will be a Patient. 6\. I swore
I would never comment on HN again. (The political Correctness is stifflling,
but I needed to respond to this article.) 7\. Goodbye again. That said, if you
have realatively good genes, and you eat somewhat healthy; I would steer clear
of most Doctors. I never thought I would say that about allopathic physicians.

------
healthisevil
I am a physician in Australia. Being a doctor sucks here too.

I encouraged my son to avoid medicine. He followed my advice and is enjoying
himself in private equity.

Anyone bright enough to do medicine would do far better in another profession.

~~~
mariodiana
"Anyone bright enough to do medicine would do far better in another
profession."

Just as a point of reference, I'm in the U.S. and not a doctor. But I've
always seen careers in medicine as a kind of social scam. Not necessarily a
bad one, but there is or was something funny going on.

A person smart enough to be a doctor could be many things and earn a lot more
money doing one of those things. The only thing society can really offer
doctors is independence and respect. That's why -- for the longest time in
this country -- doctors often owned and ran their own practices. That's why we
addressed doctors with the honorific "Doctor." But the first is all but dead
in this country and the second, because of some kind of unwashed, egalitarian
ethic that only gets worse and worse, is starting to die out too.

We've really fucked up, as a society. No one in his or her right mind is going
to want to spend life kow-towing to pervasive regulations and third-party
bureaucrats second guessing them and tying their hands, while rushing to and
fro like a retail clerk in an understaffed big box store, and all the while
having to protect the egos of patients by introducing oneself as Bob or Sally.

Doctors need prestige and independence. Without those, the lure of "doing
good" just isn't enough to convince anyone to become one -- at least, not
anyone I'd want to have to trust as a patient.

~~~
ForHackernews
> A person smart enough to be a doctor could be many things and earn a lot
> more money doing one of those things.

Is that really true? Doctors are most of the best-paying jobs in the US [0] It
seems to me that if you're bright, and care about making a lot of money,
medicine is absolutely the way to go. Yes, there are some people who strike it
rich with startups or high finance, but that's essentially buying a lotto
ticket.

[0]:
[http://www.bls.gov/oes/current/oes_nat.htm#00-0000](http://www.bls.gov/oes/current/oes_nat.htm#00-0000)
(sort by annual mean wage, Anesthesiologists, Surgeons, Oral and Maxillofacial
Surgeons, etc.)

~~~
mariodiana
I read this years ago. Google is a wonderful thing:

"Gilded Paychecks: Lure of Great Wealth Affects Career Choices." NY Times.
November 27, 2006.

[http://www.nytimes.com/2006/11/27/business/27richer.html](http://www.nytimes.com/2006/11/27/business/27richer.html)

~~~
ForHackernews
The first step of that career path is still "Become a doctor"

~~~
mariodiana
Yes.

    
    
      * Get your M.D. 
      * Do anything afterward, except practice medicine 
      * Profit
    

That's what that article is saying.

I think being a doctor is about more than making money. But it isn't simply
about helping people and making a good living. Smart people want to be able to
exercise their own judgment and initiative. We need to be careful as a
society, or the people we want as doctors are going to be the people we chase
away.

------
cashoil
Is Obamacare going to be the first step towards making the U.S. a socialist
country ? Is the true goal to reditribute wealth ? It is meant here,
[http://www.mymustardseeds.com/ultimate-goals-of-
obamacare.ht...](http://www.mymustardseeds.com/ultimate-goals-of-
obamacare.html).

Or is it just verbiage to shine for the next election ?

Will people suffer from Obamacare ? Are consequences to the whole system
really under control (increase of the premiums, ...) ?

------
pessimizer
Most important takeaway (other than a series of anecdotes, a general history
lesson, and a few random undefended policy suggestions):

"In 1940, in inflation-adjusted 2010 dollars, the mean income for U.S.
physicians was about $50,000. By 1970, it was close to $250,000—nearly six
times the median household income."

------
kelukelugames
Do you know what's incredible?

Plenty of SDE 2s make more than 200k a year, and plenty of doctors don't.

I'm not sure if we are overpaid or they are underpaid.

~~~
ntkachov
we've got the market playing for us. Once supply catches up, there won't be as
high of a salary.

------
ch4s3
More work for less pay huh? Being squeezed by profit taking business people at
the top... surely no one other than doctors can relate to such changes in the
economy.

*Edit I am of course being a bit sarcastic. It's interesting to see how shifts in the general economy are changing the medical profession.

~~~
chubot
That's not a helpful comment. It's already addressed in the article anyway:

 _Of course, doctors aren 't the only professionals who are unhappy today.
Many professions, including law and teaching, have become constrained by
corporate structures, resulting in loss of autonomy, status, and respect._

Personally I think the history lesson in the article was great. It makes me
wonder about programmers. We are riding high now. But if we keep producing
software that neglects user intent, then perhaps we will also find ourselves
regulated. I'm actually happy that the FTC has stepped in and constrained
certain companies.

~~~
rayiner
> But if we keep producing software that neglects user intent, then perhaps we
> will also find ourselves regulated.

Regulation is why those professions had autonomy, status, and respect in the
first place. Without legal protection, a "professional" is just a laborer, and
capital always wins out over labor in the end. Temporarily the software
industry is growing so quickly that programmers have a lot of leverage, but
that will end. The "corporate structure" will absorb more and nore of the
value created by the professional.

And that's a good thing, right? Protectionism is bad, leads to higher prices
for everyone. Why should doctors or programmers be protected more than Wal-
Mart shelf stockers?

------
exstudent
You can definitely feel this as a patient. If I could give my vitals to an app
and have it diagnose and prescribe remedies, I would do it in a heart beat and
never visit a doctor again (of course you would need robot surgeons too :).

I've never seen a doctor research anything either (although I'm sure they do
behind the scenes). They seem to be pulling from whatever information cache
they have in their head which I often suspect is horribly outdated.

I'd take a crowd sourced db of health info over a doctor's personal knowledge
any day of the week.

~~~
khungus
> I've never seen a doctor research anything either

That's a little surprising to me. One of the coolest things about practicing
medicine today is that I can pull out my phone in front of a patient and find
guidelines that I'm not familiar with, medication side-effects, and other
point-of-care resources that really do enhance my clinical ability in real-
time.

Granted, I work in a hospital setting. Maybe it's different in the clinics.

BTW, though I feel I'm underpaid for what I do (which many outsiders would
find ridiculous), I'm overall pretty happy with being a physician.

> I'd take a crowd sourced db of health info over a doctor's personal
> knowledge any day of the week.

So would I. But what you'd learn in the first week of hanging out with a
doctor in a typical clinical setting is that most patients are frankly too
uneducated to be able to use that kind of tool. When I did residency, I
suspect most of the patients I saw didn't have internet. Many were illiterate
and a disturbing number simply didn't care about their own well-being.

I'd love to build up a practice with patients like you, but people like you
tend to be pretty healthy.

~~~
w1ntermute
> When I did residency, I suspect most of the patients I saw didn't have
> internet. Many were illiterate and a disturbing number simply didn't care
> about their own well-being.

> I'd love to build up a practice with patients like you, but people like you
> tend to be pretty healthy.

There's also the factor that teaching hospitals tend to get a lot of poor and
uneducated patients. Private clinics have a different clientèle, and there are
definitely plenty of individuals out there who are not in perfect medical
condition, yet are educated/informed enough for doctors to interact with on a
higher level than they currently do.

------
ihsanyounes90
In my opinion(and general opinion), this is the most important job. Maybe we
can find someone depressed(like in the article), but come on they save lives.

~~~
nhstanley
> but come on they save lives.

I'm going to say something controversial here, but please bear with me. Your
statement sort of encompasses several parts of this problem.

Some doctors are miracle workers (see [1] below), but most doctors are
glorified auto mechanics. I don't say that to downplay the amount of
intelligence/skill required for the job, but if you think of most doctors as
"saving lives", then you obviously haven't spent a lot of time around
doctors/clinics/hospitals.

Most doctors rarely save lives, and often when they do it wasn't them that
really did the critical life saving steps, they're just the interface the sick
person is interacting with. Most doctors deal with a series of inputs
(symptoms and circumstances) and output a solution (diagnosis and remedy),
which requires very little critical thinking on their part. Sick kids with the
flu. Idiots that took too many drugs that need fluids, benzos, cypro, or an
ice bath. People at mid-life who made shitty decisions for most of their lives
and now need Lipitor/Coumadin/a treadmill/a gravestone.

The truth is most doctors get paid a lot because people erroneously assign to
them the ethos of miracle workers, when most of them aren't. In fact, they
often can't even do anything for their patients (see above, such kids with the
flu, old people who've made shitty decisions their whole lives). The cures
really come from researchers and pharma companies that come up with drugs and
treatments for these incredibly difficult problems. If doctors deserve their
paychecks, it's because they keep alive the illusion society wants. The
illusion that when something is wrong, the doc will fix them up good. And
indeed that's basically what the article is about. Doctors demand respect and
to be paid to keep up the illusion and to deal with the bullshit.

[1] Obvious and important exceptions to this are ER docs and trauma surgeons,
who indeed save lives. There are also clinical doctors, who work tirelessly
with armies of researchers to try to find new cures for cancers, autoimmune
and genetic disorders (among many other things). There are surgeons who come
up with new procedures to reduce the invasiveness and trauma of procedures.
These are the people that deserve the lion's share of the praise that goes
towards doctors, and they should get the lions share of the money as well
(some certainly do).

In this whole rant, I'm not trying to lay blame on doctors for the whole mess,
because problems come from all sides, as I've hinted. Patients have
unrealistic expectations of what doctors can do, the health industry is trying
to low-ball doctors (not always without reason) to maximize profits, and many
doctors who thought they would be genuinely helping people are realizing in
reality that fate is largely decided before they even meet their patient (as a
criminal lawyer friend put it, "90% of my client's case is decided before I
ever meet him, but he wants me to work miracles!").

This is specifically why I didn't continue into medicine like so many of my
friends. If you really want to help people, you don't become a regular doctor.
You become a thoracic surgeon, or you do basic research, or you work in
pharma, or you start a biotech. That's how you cure people. But no one will
praise you for it.

~~~
jrapdx3
Practicing medicine for decades gives me some "perspective" on the subject. No
one in medicine is a "miracle worker", though many of us work hard to the job
responsibly.

You are wrong. We do "save lives", and not just in the ED. Every day, if not
as dramatically, immediately or even noticeably, our incremental toil helps
patients progress bit-by-bit toward better health. Managing chronic,
debilitating conditions really does enable patients to live longer and more
fully.

You are also wrong regarding income. Doctors in the US are getting paid less
and less, while expenses of practice go ever higher. My own income is probably
less than most of the people I know in other professions.

The "mess" of the health care system (to the extent it is even systematic) is
the result of the constant assault of corporations and governments at all cost
to "reduce costs", but the result has been the degradation you and others
notice.

The most conspicuous evil has been perpetrated by the insurance industry. For
example, amazingly short-sighted insistence on paying for a "generic"
medication $3/mo cheaper than the drug already working is an every day
challenge. If patients don't get what is really needed, they wind up getting
sicker, need more care, the result is more money spent, not saved.

The problem is that the industrialization of medicine makes it increasingly
difficult to be helpful. People are not neat little uniform units produced in
factories. People are enormously complex organisms that defy all rules we
invent to "explain" illness and treatment. People are unique entities that
require individual attention and customized approaches if true "health care"
is going to be provided.

If doctors are given the resources, time and respect to do their work, I
believe almost all will strive to do it right.

~~~
pinkyand
> The problem is that the industrialization of medicine makes it increasingly
> difficult to be helpful.

Atul gawande, which is a doctor and a healthcare journalist ,and knows the
medical system from inside, thinks that industrialized medicine is exactly
what's needed:

[http://www.newyorker.com/magazine/2012/08/13/big-
med](http://www.newyorker.com/magazine/2012/08/13/big-med)

And in general the positive results from decision support systems seem to
agree with him.

~~~
jrapdx3
Of course, talking about the US health care "system" is hazardous given the
enormous diversity of systems within it.

No doubt there are instances whereby particular "industrial" implementations
function well. But there are also many that function poorly.
"Industrialization" is a term that can be applied to mean numerous and
distinctly different things.

I was referring to situations I've observed where doctors are restricted from
taking time when necessary to evaluate complex cases. Facing a patient with
several serious conditions interacting and combining is far different than
dealing with a patient having one condition.

It's impossible to do the job well when "bean-counters" insist on scheduling
tightly and emphasis is on "production". This is particularly problematic in
primary care settings.

Having been involved in quality assurance activities for many years, I fully
understand the value of consistency, adherence to rational protocols, etc. But
the ability to deal with "outliers", especially when the exception is the
rule, is where "industrialization" is at risk of failing.

~~~
pinkyand
Yes i agree, sometimes "production" goes too far. In some of those complex
case it's even wiser to allocate much more time in advance from doctors and
nurses, to prevent future complications - which are much more costly.

But i wonder:

On what sources do you rely when it comes to managing complex cases ? is it
only known hard coded medical data in books and databases ? or also some
intuition ?

And if it's intuition , how can you form intuition for such complex cases
where really each case is pretty unique , as you said ?

~~~
jrapdx3
The ancient wisdom is the practice of medicine is as much art as science.
There is "evidence" supporting many practices. As in every complex endeavor,
evidence is not static, but evolving constantly.

Evidence is necessary but by itself insufficient. We must use our own power of
observation combined with what we know and what we've learned to decide what
to do.

So your question is indeed profound, cuts to the core of the issues. Intuition
is one way to phrase it. I once heard a colleague say we're not paid because
of what we know, but for the judgement we exercise about advice or treatment
to offer.

Each human is indeed unique. Even identical twins are in fact not exactly the
same. Rules have limits when no two cases are precisely the same, it always
comes down to that very intuition you are intuitively aware of.

After all, we frequently wish to have a second opinion. I do often enough too.
I like the saying, get 5 experts in a room, and you're likely to get at least
6 opinions on any subject.

Who said decisions should be easy? I sweat over each and every one.

~~~
pinkyand
> Who said decisions should be easy? I sweat over each and every one.

True medicine is a really hard job.

So maybe the way decide in medicine should be changed ? maybe they be done
remotely but through a recommendation system so that each doctor would get
plenty of nearly similar cases - so he could practice and hone it's intuition
?

Or since the complexity is really too great (and as a patient hearing that
"this is art not science" isn't that encouraging , even if true) maybe the
overarching goal of medicine should be to remove the art, and we finally have
the tools to do it(watson, machine learning ,remote diagnosis , etc...) ?

And if we agree that that's a good goal, maybe the current way we try to do it
(evidence based medicine) , is a bit clumsy due to both the science and the
resistance by doctors , but at least it's going in the right directorion.

------
prestadige
Going into a career because it's noble, rewarding or because it "helps people"
seems like a mistake.

~~~
StavrosK
Going into a career because it's rewarding seems like a mistake?

~~~
adamnemecek
I think he meant financially.

~~~
prestadige
I think it's a mistake whether for financial reasons or in terms of personal
satisfaction. You go into a field because you are interested in learning and
engaging with the problems in that field. Not for status or rewards.

You can't _enter_ a profession on the basis that it will be personally
rewarding. You can only leave because it turns out not to be.

